#FA Nutrition

[bunnis-monsters]

Experimenting

Male!Vampire Scientist x Fem!Experiment Reader

Bunni’s Monstertober Event

Oct 18th

Oct 17

Oct 19

summary: when a vampire needs a source of unlimited blood, he turns to science. You’re his experiment, and a bit spoiled…

warnings: blood drinking, cock warming, male lead is a bit manipulative

a/n: shut up if I have any spelling mistakes 🙏 I’m trying to catch up

You let out an annoyed whine as he poked his head into your room. You were in the middle of a movie, eating a snack.

“Darling~”

He walked in, throwing his lab coat aside and jumping into your bed. The man had a habit of coming to you after a long day in the lab, being clingy and over baring.

“H-hey, don’t jump in my bed before you wash up!”

You pouted, squirming as he pulled you on his lap and rubbed his cheek against your neck.

“Oh, don’t fuss my dear… you know I just adore you, it’s hard to stay away for long.”

Before you could whine anymore, he moved his hand between your thighs, pressing against your wet panties.

“Don’t you remember who saved you? Who’s spoiled you rotten?”

You did remember.

Before you had been living on the street, hungry and barely hanging on. One night you were caught in the middle of a shoot out, and nearly died from blood loss,

He found you curled up in an alleyway, buried beneath trash and filth. You had already died, not even turning you into a vampire could bring you back…

So he used the knowledge he had gained from his research so far from both science and witchcraft to give you life.

One of the side effects was that you overproduce blood, and had to be drained daily. It was a happy surprise, and he decided to keep you for himself as his blood bag.

You were kept in a sterile section of his lap, your bed a plain cot and your food some sort of nutritional mush.

It was hardly the place for a girl… but it would do. You were just an experiment, after all.

That had been his idea at first, to keep you in his laboratory and feed from you every once in a while… but he grew fond of you quickly.

A room was decorated with your interests in mind, and he made sure you were comfortable and had everything you could ever want.

You were almost like his doll, something he could play with when he was bored. He dressed you up, kept you in a pretty room… you were his perfect, pretty little doll.

That’s what he told himself. In all reality, he truly cared for you. Once you bring someone back from death and care for them for months while they recover, you become fond of that person and want to see them thrive.

As he thought this over, your memory was a bit different.

You reached out for him to help you, and he carried you back to his lab himself, not caring that you were dirty and smelled of decay.

Your spirit watched as he carefully cleaned and stitched up your broken body, his hands gentle and caring. Even though you were simply a corpse, he still dressed you and placed a pillow under your head while he researched ways to save you at his desk.

When you woke up in your body, you were in something much softer than the ground you slept on every night. Every day you ate until you were full, and always had energy to walk around.

You weren’t hungry or cold or dirty anymore… that was enough for you, but he gave you even more! A room just for you, dressed and games and books and all the attention and love you could ever ask for…

But it was so hard to accept all of this, to really give in to being spoiled. Especially when you were crushing this hard on him…

His fangs brushed against your neck as he slipped the silk panties he bought for you aside. Lately his affections had turned from platonic to sexual, and he had been toying with you a lot.

Experimenting.

“I see… this is how wet you get when I rub here, hmm?”

He licked along your neck, eyes on your fat cunt as he flicked your clit, causing you to yelp and your hips to buck.

“H-hey…”

His cock hardened when you squirmed, your plump ass moving against his hard on. “That hurts…”

You were pouting, your face warm and flustered.

“So cute…”

He lifted your hips with ease, his cock rubbing against your cunt before he slowly lowered you into it.

Though you’d never taken cock before, he had been slowly stretching you out for weeks now, pumping his fingers in and out of you, getting you ready to take him.

You could only whine and whimper, embarrassed that it felt so good. You attempted to move, but he kept you still, his fingers toying with your clit.

“Relax, love…”

His fangs sunk into your neck, causing you to wiggle and writhe in mild discomfort, which made his cock twitch inside of you. The man continued to stimulate your clit as he fed from you.

Your soft body felt warm against him, and having your blood flowing through his felt intimate. You were connected in a way no one else could be.

As he finished up his feeding, he began lightly bouncing you, letting you ride out your orgasm as his cum spurted into your womb.

Afterwards you were tired and a bit cranky from the blood loss, so he carried you to a bath and washed you up before tucking you into bed.

Why did he do so much for you? He wasn’t sure… but you knew.

He loved you, his little experiment had become his mate and he hadn’t even noticed yet.

want more of this? my commissions and kofi are open!

——————

NSFW TAGLIST: @sunset-214 @strawberrypoundtown @avalordream @icommitwarcrimes @bazpire @im-eating-rn @anglingforlevels @kinshenewa @pasteldaze @unforgettablewhvre @yoongiigolden @peachesdabunny @murder-hobo @leiselotte @misswonderfrojustice @dij-ology @i8kaeya @lollboogurl @h3110-dar1in9 @keikokashi @aliceattheart @mssmil3y @spicyspicyliving @namjoons-t1ddies @izarosf1833 @healanette @lem-hhn @spufflepuff @honey-crypt @karljra @zyettemoon1800 @exodiam @vexillum-moeru @imperfectlyperfectprincess1 @binnieonabike @enchantedsylveon @mysticranger575 @readeryn68 @danielle143 @kittenlover614 @filthybunny420 @annavittoria-mm @makimamybelovedwife @blubearxy @omglovelylaila @toocollectionchaos-universe-blog @fruk-you-usuk-fans @wil10wthetree @hammerhead96-blog @slightlyusedfloormat

[ipreachbeautyandfitness]

How can I lose belly fat fast?

Losing belly fat is a common goal for many people. However, it is important to note that there is no magic formula for spot-reducing fat in specific areas of the body. To lose belly fat fast, a combination of diet, exercise, and lifestyle changes is necessary.

Cut down on calories: To lose belly fat, you need to create a calorie deficit by burning more calories than you consume. Focus on eating whole, nutrient-dense foods and limit your intake of processed and high-calorie foods. Aim to consume fewer calories than you burn each day.

Increase protein intake: Protein is important for building and repairing muscle tissue and can help you feel fuller for longer. Aim to include a source of protein at every meal and snack, such as lean meat, fish, eggs, beans, or nuts.

Incorporate strength training: Strength training can help increase muscle mass, which in turn can boost metabolism and aid in fat loss. Incorporate strength training exercises such as squats, lunges, push-ups, and planks into your workout routine.

Cardiovascular exercise: Cardiovascular exercises such as running, cycling, or swimming can help burn calories and reduce belly fat. Aim for at least 30 minutes of moderate-intensity exercise most days of the week.

Reduce stress: High levels of stress can contribute to weight gain, particularly in the abdominal area. Find ways to manage stress such as meditation, yoga, or deep breathing exercises.

Get enough sleep: Lack of sleep can disrupt hormones that regulate appetite and metabolism, making it harder to lose weight. Aim for 7-9 hours of sleep per night.

Stay hydrated: Drinking enough water can help reduce bloating and aid in digestion. Aim for at least 8 glasses of water per day.

Are you struggling to lose weight and looking for a solution that works? Look no further! Download our free book on weight loss tips and tricks that will help you achieve your goals fast.

Inside the book, you will find practical advice on how to make healthy lifestyle choices, how to create a calorie deficit, and how to incorporate exercise into your daily routine. You will also discover effective strategies for managing stress and staying motivated.

Don't let another day go by feeling unhappy with your body. Take action now and download our free book on weight loss. With the right tools and support, you can achieve your weight loss goals and live a happier, healthier life.

So, what are you waiting for? CLICK HERE to download our free book and start your journey toward a healthier you today!

[francesca-70]

DOVE VA A FINIRE L’ amore QUANDO FINISCE?

- Come faccio - mi chiese -

A lasciarlo andare ? Non vederlo piu’, non sapere piu’ niente di lui .

- perché devi figlia- rispose la curandera guardando verso l’antica quercia .

- vedi , nulla davvero ci appartiene ma chi abbiamo amato ha mescolato con noi il suo corpo astrale .

- che significa?

- che vi siete intrecciati come i rami dell’edera , ma non nel corpo , quello e’ momentaneo, nello spirito .

- ma a me non basta .

Sto male , voglio ancora vederlo e toccarlo e parlargli .

Non ce la faccio .

- non ce la devi fare - rispose sorridendo la donna di cui nessuno conosceva l’ eta’ .

- non ce la devi fare perché non sei tu a decidere : l’amore improvvisamente e senza merito arriva , come un canto di uccelli a mezzanotte .

E cosi’improvvisamente e senza motivo se ne va .

Ma non finisce mai.

Continua in quest’ altra dimensione .

- quale dimensione ?

Chiede la ragazza soffiandosi il naso avvolto dalle lacrime .

- la dimensione dell’invisibile. Dove vivono i maestri, i sacri spiriti, gli esseri di luce e le forze superiori .

I vostri spiriti congiunti e intrecciati salgono su fino a li , fino a diventare impercettibili e tuttavia continuano a vivere .

Vedi cara : l’umano non accetta che cio’ che può vedere e’ pari a un granello di sabbia a confronto dell’oceano.

- sto iniziando a capire ma fa ancora male .

- lo so bambina .

Non scacciare il demone del dolore : ogni volta che il cuore si spacca, si allarga un po’ di piu’ ma solo se lo lasci fare.

Se respingi, fingi , rigetti indietro, ti stordisci con le frivolezze , ritornera’ piu’ forte e ti chiudera’ il cuore .

E un cuore chiuso, e’ cio’ che di peggio puoi dare al mondo .

- gia’ in passato , Signora ho chiuso il mio cuore per non soffrire piu’ ed e’ stato sempre peggio !

- certo! Dimorare nelle tenebre e nella paura non e’ mai bene cara .

Non cercare di capire il dolore , lascia che ti travolga come un’onda, fatti lieve come piuma , lasciato attraversare come burro , ma se chiudi il cuore allora i demoni danzeranno sul tuo petto e ne’ gioia ne’ dolore toccheranno piu’ il tuo ventre .

E questo equivale a morire .

- si , ho capito .

Ho capito che essere forti significa stare 5 passi indietro.

Lo lascero’ andare ...

- domani sera , con la luna piena, da sola , vai in collina e pianta un ulivo .

Le sue foglie argentate saranno nutrite dalla tua leggerezza .

Qualcosa crescerà da questo strappo ma solo se lasci che la luce lo disinfetti .

E cosi sara’ per la pianta .

E la ragazza ando’ .

Con la luna calda di agosto a piantare il suo amore finito tra o cespugli di ginestra .

Scivolo’ dentro se’ per un po’

E la curendera non la perse mai di vista .

Da lontano, la vedeva con l’ occhio interiore e lei inviava ogni sera gli spiriti del bosco a vegliarle il sonno ...

Testo originale di

ClaudiaCrispolti

[lunamagicablu]

Altre cose da fare giornalmente se si pratica yoga: 6. Se viene in mente un’azione gentile, farla Se l’hai pensata vuol dire che è fattibile. Uno yogi non si tira indietro perché “può sembrare brutto o strano”. Yoga è azione. L’azione gentile è un seme nel cuore di chi lo riceve.

7. Rispettare lo spazio che ci circonda Uno yogi lascia un luogo migliore di come lo ha trovato riuscendo a renderlo sempre più bello. Lo abbiamo già scritto, ma ci teniamo a ribadirlo.

8. Pulire spazio ed energia dietro di sé La pulizia di un corpo è igiene. La pulizia di uno spazio è amore. La pulizia dell’energia è un regalo.

9. Dire Grazie Questa parola così piccola e piena di significato è sempre sulla bocca di uno yogi. Qualsiasi cosa accada è un insegnamento. Rafforza le emozioni, il carattere e tutte le relazioni in generale.

10. Lasciare la tecnologia per 10 minuti al giorno Uno yogi vero sa apprezzare un panorama senza doverlo fotografare. Prova a staccarti dagli altri e ricollegarti a te stesso.

Senza dimenticare un’altra cosa da fare se si pratica yoga. Una importante… 11. Mangiare sano Uno yogi si prende cura degli altri, dello spazio, delle relazioni, e tra tutto questo lo spazio interno e la relazione con se stessi gioca un ruolo molto importante. Mangiare sano, quello che ci fa sentire bene ha un alto valore non solo per la salute, ma anche per come ci muoviamo nella vita.

Un radicale cambio di alimentazione per stare meglio porta con sé la consapevolezza dei limiti e delle potenzialità del proprio corpo. Un’alimentazione sana ed equilibrata è componente fondamentale per una pratica olistica come lo yoga: il cibo che fa bene a chi pratica yoga deve dare il giusto apporto energetico ai muscoli coinvolti negli esercizi e, nel contempo, secondo i principi dell’alimentazione ayurvedica, influenzare positivamente le emozioni. eventiyoga.it art by_detelina_ ************************ Other things to do daily if you practice yoga: 6. If a kind action comes to mind, do it If you have thought of it, it means that it is doable. A yogi does not hold back because "it may seem bad or strange". Yoga is action. A kind action is a seed in the heart of the one who receives it.

7. Respect the space around us A yogi leaves a place better than he found it, managing to make it more and more beautiful. We have already written this, but we want to reiterate it.

8. Clean space and energy behind you Cleaning a body is hygiene. Cleaning a space is love. Cleaning energy is a gift.

9. Say Thank You This small and meaningful word is always on the lips of a yogi. Whatever happens, it is a teaching. It strengthens emotions, character and all relationships in general.

10. Leave technology behind for 10 minutes a day A true yogi knows how to appreciate a view without having to photograph it. Try to detach yourself from others and reconnect with yourself.

Without forgetting another thing to do if you practice yoga. An important one… 11. Eat healthy A yogi takes care of others, of space, of relationships, and among all this, internal space and the relationship with oneself play a very important role. Eating healthy, what makes us feel good has a high value not only for health, but also for how we move in life.

A radical change in diet to feel better brings with it the awareness of the limits and potential of your body. A healthy and balanced diet is a fundamental component for a holistic practice like yoga: the food that is good for those who practice yoga must give the right energy supply to the muscles involved in the exercises and, at the same time, according to the principles of Ayurvedic nutrition, positively influence emotions. eventiyoga.it art by_detelina_

[pollicinor]

L'attività fisica i cui benefici per il cervello sono universalmente riconosciuti dagli scienziati è, paradossalmente, la più semplice di tutte: camminare. «Rafforza le connessioni tra i circuiti cerebrali, che sono importanti per l'elaborazione delle emozioni, la risoluzione dei problemi e la memoria», fa notare Nas. La sincronizzazione di queste reti cerebrali è stata associata a una riduzione del rischio di Alzheimer. Secondo un recente studio condotto dal Programme National Nutrition Santé francese (PNNS), 20 minuti al giorno a passo moderato possono addirittura modificare in meglio la struttura del cervello. «Camminare tre volte alla settimana per 20 minuti ispessisce il tessuto che collega la parte destra e quella sinistra del nostro cervello», conferma Nas. «Questo cambiamento porta a un potenziamento della memoria». Una passeggiata di 20 minuti, inoltre, può accrescere notevolmente l'attività cerebrale, l'attenzione e la concentrazione e migliorare i tempi di reazione, spiega la dottoressa Swart, secondo la quale, ogni volta che siamo a corto di concentrazione, dovremmo fare una breve passeggiata, anziché bere un caffè. Infine, camminare ha un effetto benefico sulla salute mentale, in quanto rallenta l'attività delle parti del cervello coinvolte nella risposta allo stress.

Dall'articolo "Mantenere il cervello giovane e attivo? Bastano 2 facili attività quotidiane. Lo dice la neuroscienza" di Marie Bladt

[anco-writes]

Initiation

Have I mentioned that I set up a patreon? It's live now! You can sub! there's only 1 story uploaded there at this time, but I plan on having at least 1 paywalled story a month, as well as additional lore tidbits for the Demesne here and there.

Additionally, if you'd rather just see the story without subbing, I'll be uploading a preview on my FA page, and you can just leave a tip on my ko-fi and I'll email it directly to you.

Imitation is a story of a collegiate warrior trained on theory, thrust into the world of his personal heroes. When he finds out that the long standing company has little regard for the nutritional concepts he had drilled into his head during his college days, friction grows as he tries to figure out the secrets of the company of champions. Surely they're not so strong because they're so... bloated, right?

[stella-rose-love]

annual recurrent flight attendant training day 1/2 [08-19-24]

day 1 of my annual FA training is complete.

• first aid [practical]

• first aid [written]

• opening/closing exam of the eight aircrafts in our fleet [practical]

• emergency evacuation procedures [practical]

• standard operational procedures exam open/closed book [written]

• location/safety/security aircraft knowledge exam [written]

• fire extinguisher / drager smoke hood firefighting exam [practical]

• unruly passenger restraining exam [practical]

• oxygen bottle & mask application & usage exam [practical]

• medipak usage exam [practical]

all passed 90% or over.

highlights

• have the same training days as a colleague who I got hired with last year, who is one of the funniest people I've ever met. Helped ease any nerves I had

• during first aid in pairs, one of my friends/colleagues was committed to his role of "the injured patient". It was so painfully overly dramatic, I cried tears of laughter

• ran into my role model at the company ! hadn't seen him since 2023 and missed him dearly. he is currently climbing the corporate ladder with no sign of slowing down, was so nice to see him. Had a huge smile on my face the whole interaction

• got the taste of healthy stress again in an educational environment. It is great fuel

• made me that much more excited to go back to college in a couple of weeks

what I ate

• breakfast - yogurt & granola bowl + ginseng stick

• lunch - grilled cheese

• dinner - falafel veggie wrap

final thoughts

overall a packed day, but was happy to get the more difficult exams out of the way. It's a lot easier to be friendly and sociable in a classroom environment, than on the actual job, due to the trainings calm nature.

I am grateful for the way FA training is formatted, and allows me to cram for many exams within one day. It makes going back to college feel a lot less daunting.

I want to do some research regarding how nutrition can positively impact female hormones throughout the day. I always feel lethargic when I have to attend a class after lunch (12:30-3:30), even if I haven't eaten right before. I'd love to converse with people who study these subjects, or possess this knowledge due to their field of study.

I am a bit nervous for tomorrow, because we blend with the pilots for training for "crew resource management". It helps to enhance the quality of communication amongst each other, so we will be able to work together more efficiently. It's a bit intimidating !!

Im going to do my review for a couple of hours, then go to bed early so that I can complete most of my review after a solid rest.

have a good night every one :)

[doaa92]

Hello 👋

I am Doaa from Gaza 💔 I live with my elderly parents under very difficult conditions due to the war. With my brothers and my young child, whom I gave birth to during the war, we were displaced to the south and live in a narrow tent. My parents need medical care and medications that I cannot provide due to the current situation. My child needs nutrition and healthy food Please help

👇

Despite my efforts, I was unable to raise enough donations to meet our basic needs. We desperately need your support, and even small donations can make a big difference in our lives.

[art-of-manliness]

5 Fast-Food Meals That Are High in Protein and Less Than 600 Calories

If you’re trying to lose weight, one of the challenges you’ll face is what to do about those times when you find yourself at a fast-food restaurant. The offerings at these establishments are typically incredibly high in calories. A Big Mac meal at McDonald’s can set you back 1,300 calories. Damn! If your calorie goal for the day is 2,400 calories, that’s more than half your daily calories in a single meal. The typical advice for people losing weight is to just avoid fast-food restaurants altogether. And with some preparing, thinking ahead, and good decision-making, you can accomplish that most of the time. But not 100% of the time. Sometimes, life throws a wrench in your plans. Maybe you’re on a road trip, and your friends decide to stop at Carl’s Jr. for lunch. Maybe your kid’s soccer team decided to go out to dinner to Chick-fil-A after the game. Maybe you’re just really pressed for time and need to grab something fast at a drive-thru on the way from work to another engagement. What to do? Well, what if I told you you don’t have to choose between convenience and your fitness goals? You can have your fast-food burger and eat it too—all while staying on track with your weight loss. When you want to lose weight, you want to choose foods that are lower in calories and higher in satiating, muscle-building protein. Thankfully, most fast-food restaurants now offer options that meet this criteria. With a bit of creativity, you can easily select meals at pretty much all the major fast-food restaurants that will give you 30+ grams of protein (which is a good minimum goal for a meal) and only clock in at around 600 calories. Below, we provide some suggestions for meals that meet these metrics that you can get at five popular fast-food restaurants. One thing to keep in mind is that while you can reduce the calories in your fast-food orders, it’s hard to reduce the amount of sodium. These are going to be sodium bombs. So they’re not great for everyday dining, but they’ll do in a pinch. Whether you’re looking to shed a few pounds or maintain your hard-earned gains, this guide will show you how to navigate the pitfalls of fast-food menus and stay on track with your goals. General Guidelines to Keep Your Fast-Food Meals Lower in Calories Before we get into specific meals, here are some general guidelines to follow that will allow you to keep your meals lower in calories, regardless of the fast-food establishment you visit: * Food tracking apps like MyFtinessPal are your friends. I use the app all the time when I’m at fast-food restaurants. Quickly look up the calorie and macro count of foods and piece together your meal with that info. * Choose grilled over fried meats. * Choose lean proteins. While you can still enjoy a beef burger, protein sources like turkey or chicken breast generally have fewer calories. * Ask for extra protein. Adding extra protein, like extra meat, can help increase satiety while keeping calories low. * Skip the fries. If you’re looking for a side, get fruit or salad instead. Also, hot take: fries aren’t that good anyway! * Skip the high-fat sauces, dressings, and condiments. Ask for lower-calorie options instead. * Load up on veggies. Satiety is premised in part on volume; calorically dense foods won’t fill you up and will leave you feeling hungry. To increase volume and nutrition, add low-calorie veggies to your meals like extra lettuce, tomatoes, and onions. * Choose water or unsweetened drinks like diet sodas. Finally, don’t be afraid to enjoy yourself with a no-holds-barred high-calorie fast-food meal every now and then. I love getting a double cheeseburger on occasion. You can just adjust your macros and calories accordingly and eat less the rest of the day. Or just chalk it up to an anomalous indulgence, and get back to your diet the next day. You don’t have to eat perfectly 100% of the time to still lose weight and stay healthy. Fast-Food Meals That Are 600 Calories or Less With More than 30 Grams of Protein McDonald’s… http://dlvr.it/TBgWkR

[pettirosso1959]

In una frizzante mattina d'inverno in Svezia, una graziosa bambina di nome Greta si è svegliata in un mondo perfetto, dove non c'erano prodotti petroliferi che rovinavano la terra. Gettò da parte il lenzuolo di cotone e la coperta di lana e uscì su un pavimento di terra battuta ricoperto di corteccia di salice polverizzata con pietre. "Che cos'è questo?" lei chiese.

"Corteccia di salice polverizzata", rispose la sua fata madrina.

"Cos'è successo al tappeto?" lei chiese.

"Il tappeto era di nylon, che è fatto di butadiene e acido cianidrico, entrambi a base di petrolio", è stata la risposta.

Greta sorrise, riconoscendo che gli aggiustamenti sono necessari per salvare il pianeta, e si trasferì al lavandino per lavarsi i denti dove invece di uno spazzolino da denti, trovò un salice, maciullato su un'estremità per esporre le setole di fibra di legno.

"Il tuo vecchio spazzolino da denti?" ha osservato la sua madrina, "Anche nylon".

"Dov'è l'acqua?" chiese Greta.

"Lungo la strada nel canale", rispose la sua madrina, "Assicurati solo di evitare l'acqua contenente il colera"

"Perché non c'è acqua corrente?" Chiese Greta, diventando un po 'stizzosa.

"Bene", disse la sua madrina, che per caso insegnava ingegneria al MIT, "Da dove iniziamo?" È seguito un lungo monologo su come le valvole del lavandino necessitano di sedi in elastomero e su come i tubi di rame contengono rame, che deve essere estratto e su come è impossibile realizzare macchine movimento terra completamente elettriche senza lubrificazione degli ingranaggi o pneumatici e su come il minerale deve essere fuso. per fare un metallo, e questo è difficile da fare solo con l'elettricità come fonte di calore, e anche se usi solo elettricità, i fili hanno bisogno di isolamento, che è a base di petrolio, e sebbene la maggior parte dell'energia della Svezia sia prodotta in un ambiente rispettoso dell'ambiente a causa dell'idroelettrico e del nucleare, se fai un bilancio di massa ed energia attorno all'intero sistema, hai ancora bisogno di molti prodotti petroliferi come lubrificanti e nylon e gomma per pneumatici e asfalto per riempire buche e cera e plastica ed elastici per iPhone per sostenere la tua biancheria intima durante il funzionamento di un forno fusorio di rame e. . .

"Cosa c'è per colazione?" intervenne Greta, la cui testa faceva male.

"Uova di gallina fresche, nutrite in modo assortito", rispose la sua madrina. "Crudo."

"In che modo, crudo?" chiese Greta.

"Bene, . . . " E ancora una volta, a Greta è stato detto della necessità di prodotti petroliferi come l'olio per trasformatori e decine di prodotti petroliferi essenziali per la produzione di metalli per padelle e alla fine è stata educata su come non si può avere un mondo senza petrolio e poi cucinare le uova . A meno che tu non strappi il tuo recinto anteriore e accendi un fuoco e cuoci con cura il tuo uovo in una buccia d'arancia come fai nei Boy Scouts. Non che tu possa più trovare arance in Svezia.

"Ma io voglio uova in camicia come fa mia zia Tilda", si lamenta Greta.

"Tilda è morta questa mattina", ha spiegato la madrina. "Polmonite batterica."

"Che cosa?!" intervenne Greta. “Nessuno muore di polmonite batterica! Abbiamo la penicillina. "

"Non più", ha spiegato la madrina "La produzione di penicillina richiede l'estrazione chimica utilizzando acetato di isobutile, che, se conosci la tua chimica organica, è a base di petrolio. Molte persone stanno morendo, il che è problematico perché non esiste un modo semplice per smaltire i corpi poiché le terne hanno bisogno di olio idraulico e i crematori non possono davvero bruciare molti corpi usando come combustibile recinzioni e mobili svedesi, che stanno rapidamente scomparendo - utilizzati su il mercato nero per arrostire le uova e stare al caldo ".

Questa rappresenta solo una frazione della giornata di Greta, una giornata senza microfoni in cui esclamare e una giornata senza molto cibo, e una giornata senza barche in fibra di carbonio su cui navigare, ma una giornata che salverà il pianeta.

Sintonizzati domani quando Greta ha bisogno di un canale radicolare e impara come viene sintetizzata la novocaina.

[sognosacro]

L'essere femminile è fatto per ricevere, accogliere. Una volta stabile questo, esso si apre come una fontana e nutre in abbondanza. Altrimenti sarebbe malsano, sofferenza.

Perció uomini, esseri maschili, nutrite le vostre donne come regine. Donate voi stessi pienamente.

Non chiedete loro niente. Siete voi a dover dare i vostri frutti, che avete seminato e coltivato con amore.

Loro lo accoglieranno e con amore se ne prenderanno cura.

Sapranno versare il loro amore, nel momento in cui il vostro cuore sarà capace di darlo.

Il nostro amore infinito sgorga dall'interno, se le svuotate chiedendo, pretendendo non resterà piú niente. Soprattutto a loro.

Non si fideranno piú dell uomo, saranno infelici e voi approfitterete di questa debolezza e chiederete ancora di piú e se loro non ve lo possono piú dare perché non c'è, voi lo chiederete a qualcun altro.

Ma se tutti facessero cosí, morireste di fame.

Cari uomini, pensateci prima di voler qualcosa da qualcuno.

Pensate realmente a cosa state facendo.

Se solo siete abituati ad arrangiarvi e a dare piuttosto che a prendere vi accorgerete che molte cose si apriranno al meglio.

Loro non vi devono niente e questo moto innaturale è contro le leggi della vita.

Potreste mostrare un pó di rispetto e con dare non intendo rose e gioielli. Nessun umano si nutre con petali e metallo.

Dare è inteso come aprirsi alle proprie vulerbilità e accettarle come tali, saperle condividere e aprezzare con lei.

Ascoltare con amore e interesse sincero.

Trattare con degna nota il vostro sè, cosí anche la donna.

Perché sappiamo che l'idea media che si ha di una donna è quella che pulisce casa e cucina, fa la madre e si fa in 10 per tutti, ma è proprio questo che deve finire.

A nessuno piace distruggersi per amore degli altri.

Ovviamente sono daccordo che certe donne devono imparare l'amor proprio, ma chi ha mai detto che la donna è questo? La donna è molto di piú di una credenza abituale dettata dagli stereotipi.

Ritrovare il proprio lato femminile, creativo, empatico, accogliente, vi aiuterà ad avvicinarvi a loro e a comprendere quelle cose che disprezzate, temete, non capite, è uguale, sempre stato fa che siete distanti e le donne non sono solo dei gioielli o delle amanti dello shopping.

Potete capire quale potere inestimabile risiede in esse, appunto conoscendo prima in voi stessi quella parte rinnegata, sottomessa e maltrattata da ormai generazioni, millenni, fa parte della storia e della cultura, ma, concepiamo il fatto che, una donna felice nella storia io non l ho vista fin ora.

Quindi cari uomini fate i vostri conti e risarcite i vostri debiti.

Grazie.

Cordialmente

Una donna

[noneun]

Una codina di dietro

Gli eucarioti sono quel gruppo di esseri viventi dotati di cellule con all'interno un nucleo contenente il DNA. Noi animali ne facciamo parte, così come le piante, i funghi e molti altri organismi unicellulari. Esclusi i batteri e gli archea, che sono procarioti: organismi unicellulari privi di nucleo. Per cui, nei procarioti, il DNA gira libero nell'intera cellula.

Bene, moltissimi organismi, eucarioti e procarioti, possiedono, almeno in uno stadio della propria vita, cellule che hanno la capacità di muoversi utilizzando una specie di microscopica codina, il cosiddetto flagello.

In moltissimi di questi organismi il flagello, o più di un flagello, è posto anteriormente. Quindi il movimento di questa codina trascina in avanti la cellula.

In un particolare gruppo di eucarioti, invece, ad un certo punto della storia della vita sulla Terra, comparve un flagello che funzionava al contrario, spingendo la cellula anziché trascinarla.

Questo gruppo è stato chiamato Opisthokonta, dall'unione di due parole greche: "opísthios" cioè retro, posteriore, e "kontós" ovvero polo, cioè flagello. Ovvero quelli con una codina di dietro.

Chiaramente ci sono opistoconti unicellulari che possiedono il flagello per tutta la vita, altri che invece ce l'hanno solo in alcuni stadi, come noi e i funghi. Questi ultimi, che quindi sono molto più imparentati a noi che alle piante, possiedono questa codina di dietro quando producono le spore. Noi quando produciamo gli spermatozoi, che tecnicamente non sono altro che la primissima e incompleta fase della vita di un individuo adulto.

I vantaggi di questa innovazione, avvenuta sicuramente più di un miliardo di anni fa, sono stati notevoli. Essere una cellula spinta, anziché trascinata, fa risparmiare energia, aumenta l'agilità, permette un più semplice sviluppo di organi sensoriali e meccanismi di cattura del cibo. Mentre, sul retro, la codina reagisce agli stimoli sensoriali e avvicina la cellula alle sostanze nutritive.

Le innovazioni nell'evoluzione degli opostoconti da quel punto in poi sono state innumerevoli, è chiaro. Ma è bello pensare che, da un certo punto di vista, la storia della vita sulla Terra si può riassumere con la seguente timeline formata da poche fondamentali pietre miliari:

niente codina > codina davanti > codina dietro > scienza aerospaziale.

[susieporta]

DOVE VA A FINIRE L’ amore QUANDO FINISCE?

- Come faccio - mi chiese -

A lasciarlo andare ? Non vederlo piu’,non sapere piu’ niente di lui .

- perché devi figlia- rispose la curandera guardando verso l’antica quercia .

- vedi , nulla davvero ci appartiene ma chi abbiamo amato ha mescolato con noi il suo corpo astrale .

- che significa?

- che vi siete intrecciati come i rami dell’edera , ma non nel corpo , quello e’ momentaneo, nello spirito .

- ma a me non basta .

Sto male , voglio ancora vederlo e toccarlo e parlargli .

Non ce la faccio .

- non ce la devi fare - rispose sorridendo la donna di cui nessuno conosceva l’ eta’ .

- non ce la devi fare perché non sei tu a decidere : l’amore improvvisamente e senza merito arriva , come un canto di uccelli a mezzanotte .

E cosi’improvvisamente e senza motivo se ne va .

Ma non finisce mai.

Continua in quest’ altra dimensione .

- quale dimensione ?

Chiede la ragazza soffiandosi il naso avvolto dalle lacrime .

- la dimensione dell’invisibile. Dove vivono i maestri, i sacri spiriti, gli esseri di luce e le forze superiori .

I vostri spiriti congiunti e intrecciati salgono su fino a li , fino a diventare impercettibili e tuttavia continuano a vivere .

Vedi cara : l’umano non accetta che cio’ che può vedere e’ pari a un granello di sabbia a confronto dell’oceano.

- sto iniziando a capire ma fa ancora male .

- lo so bambina .

Non scacciare il demone del dolore : ogni volta che il cuore si spacca, si allarga un po’ di piu’ ma solo se lo lasci fare.

Se respingi, fingi , rigetti indietro, ti stordisci con le frivolezze , ritornera’ piu’ forte e ti chiudera’ il cuore .

E un cuore chiuso, e’ cio’ che di peggio puoi dare al mondo .

- gia’ in passato , Signora ho chiuso il mio cuore per non soffrire piu’ ed e’ stato sempre peggio !

- certo! Dimorare nelle tenebre e nella paura non e’ mai bene cara .

Non cercare di capire il dolore , lascia che ti travolga come un’onda, fatti lieve come piuma , lasciato attraversare come burro , ma se chiudi il cuore allora i demoni danzeranno sul tuo petto e ne’ gioia ne’ dolore toccheranno piu’ il tuo ventre .

E questo equivale a morire .

- si , ho capito .

Ho capito che essere forti significa stare 5 passi indietro.

Lo lascero’ andare ...

- domani sera , con la luna piena, da sola , vai in collina e pianta un ulivo .

Le sue foglie argentate saranno nutrite dalla tua leggerezza .

Qualcosa crescerà da questo strappo ma solo se lasci che la luce lo disinfetti .

E cosi sara’ per la pianta .

E la ragazza ando’ .

Con la luna calda di agosto a piantare il suo amore finito tra o cespugli di ginestra .

Scivolo’ dentro se’ per un po’

E la curendera non la perse mai di vista .

Da lontano, la vedeva con l’ occhio interiore e lei inviava ogni sera gli spiriti del bosco a vegliarle il sonno ...

Testo originale di

_ClaudiaCrispolti_

Proprietà letteraria riservata:

NOTA BENE Primo: non ho mai letto la profezia della curandera

Secondo questo racconto breve e’ un Mio pezzo originale scritto nel 2020

Vi prego di NON spargerlo in giro sotto falso nome

I miei post sono firmati e protetti da diritto di autore.

[chalkrevelations]

Review guide under here, so I can cross things off as I go. Certification exam coming up soon. This is what I’m going to be doing for the next month or so. Meanwhile, queue is in charge.

disease progression and imminent death

assessment and staging scale

FAST

**FAST staging: 1. (normal adult) no difficulties; 2. (normal older adult - mild memory loss) word finding, location of objects; 3. (early dementia) decreased job function evident, decr. organizational capacity, difficult travel to new locations; 4. (mild dementia) decr. ability at complex tasks, handling finances; 5. (moderate dementia - diff with serial subtraction; date/year/home address) assistance in proper clothing choice; 6a. (moderately severe dementia - diff with names of family/friends, delusions/hallucinations/obsessions, increased anxiety, poss violent; daytime sleep/night wakefulness) assistance in dressing; 6b. assistance bathing more freq.; 6c. assistance toileting more freq.; 6d. urinary incont. more freq.; 6e. bowel incont. more freq.; 7a. (severe dementia - incontinent x2, lose speech & ability to walk; bedridden -> sepsis, pna) limited speaking ability (half dozen words in av. day/interview); 7b. single intelligible word in av. day/interview); 7c. lost amb. ability; 7d. needs assistance to sit up (i.e., arms on chairs); 7e. lost ability to smile

Karnofsky

PPS

local coverage determination

disease-specific guidelines

SSx of imminent death - usually in clusters rather than individual SSx

weeks to months

loss of appetite (early sign) -> weight loss, cachexia (family distress: signifies decline, inability to nourish as a sign of care. educate that force feeding -> vomiting and aspiration). artificial nutrition if consistent with GOC, but educate that it does little good and may increase distressing symptoms. consider decrease if patient has in place but vomiting, aspiration, edema, CHF, pulmonary edema, other SSx fluid overload

cachexia incl. muscle wasting, anorexia, fatigue, weakness, as well as weight loss

unintentional weight loss = or >5% body weight

BMI < 20 (pt <65yo) OR <22 (pt >65yo)

<10% total body fat

increased cytokine levels (-> muscle tissue breakdown/catabolism)

albumin level <35 g/L

enourage oral fluid intake for as long as possible; team to work with family to determine if supplemental hydration. NOT USUALLY NECESSARY in terminal phase, although in some cases hypodermoclysis may ease delirium, opioid toxicity, agitation, dehydration

days to weeks

possible psychological and spiritual distress - depression, anxiety, grief, isolation in final weeks (highest levels of anxiety - COPD likely d/t dyspnea). Hopelessness, general dissatisfaction with life, overall sense of suffering in advanced dz.

increasing weakenss and dependence on caregivers

dysphagia/aphagia - if unable to take PO, consult with prescriber to d/c unnecessary meds; to promote comfort, KEEP pain meds, anxiolytics, antiemetics, anticholinergics, antipyretics (alteranate routes)

asthenia -> bedbound + incontinence, malnutrition -> risk for skin breakdown. SKIN CARE, frequent repositioning. Kennedy ulcers in final days, despite skin care (sacral, pear- or butterfly-shaped)

focus care on SYMPTOM MGMT and comfort as pt declines.

hours to days

educate family on saying goodbye/resolving conflicts, creating mementos (recording pt’s voice, hand casts, photos, etc), finalizing funeral arrangements, gathering loved ones who want to be present at TOD, normal changes in pt condition (decr. appetite, incr. somnolence, cyanosis, etc.) and that they don’t cause pain/distress for pt

aggressive and prompt symptom mgmt to alleviate distress - determine if change in meds/routines is root cause.

Some SSx may not be distressing for pt (ex. some terminal agitation) but impacts safety - address via activity as tol., thx environmen, music thx, meds (haloperidol, chlorpromazine, risperidone, lorazepam)

some distressing for family but not pt - terminal secretions (death rattle). educate family, reposition pt., suction oropharynx (NOT deep suction). if dyspnea or pt distress, anticholinergics (hyoscamine SQ, atropine SL, glycopyrrolate SL, scopolamine SQ/topical

SSx: confusion and vision of loves ones who’ve passed away; terminal agitation -> incr somnolence -> unresponsiveness; respiration changes (aphea, Cheyne-Stokes, agonal breathing, terminal secretions); temporal wasting; dehydration; pain; cyanosis (lips, extremities), cooling of extremities; HTN -> hypotension; peripheral edema; mottling; incontinence -> oliguria -> anuria. increasing asthenia and somnolence -> coma OR mutliple symptoms w/ terminal agitation period prior to coma.

pts withdraw and lose verbal ability, but THOUGHT REMAINS INTACT - caregivers should continue to talk, provide soothing sounds (music) throughout dying process

educate caregivers on nonverbal signs of pain/discomfort (often r/t tumor pressure, GI distress, frailty, siffness, immobility, bladder distention (FLACC scale)

FINAL HOURS: profound weakness/fatigue, guant/pale, withdrawal from others/reduced awareness, glassy/cloudy eyes, unable to take PO, oliguria-anuria, agonal respirations/apnea, tachycardia, unresponsive

adhere to advance care plan, avoid unnecessary interventions incl. VSx monitoring, treat FEVER, d/c unneeded routine meds

educate family re: pre-death “rally” - sudden reawakening/awareness of surroundings, coherent conversation, increased appetite -> semicomatose within hours (family distress, false hope)

if esophageal varices - prep family for poss. terminal hemorrhage (not usually painful for pt but visually distressing), provide support, focused attn during. poss. pt sedation if awake and alert. hemostatic dressings in chronic bleeding. dark towels.

inteventions: agitation (benzos, music, massage, dim lights, cool env.); dehydration (freq. oral care, ice chips as tolerated, hypodermoclysis/protoclysis if GOC consistent); dry mouth (oral care, lip balm, ice chips and oral swab as tolerated, artificial saliva); dyspnea (trx cause if poss., opioids, reposition for comfort, fan for moving air/cool env.); edema (elevate extremities as tolerated, diuretics, decrease/discontinue artificial nutrition/hydration of fluid overload SSx); fever (acetominophen PR, fan, light clothing, cool compress to head); incontinence (change promptly, skin care after each incident, reposition freq to protect skin); pain (PO meds until not tolerated -> SQ, PR; adjuvant meds PRN, reposition, distraction, massaage, heat/cold); terminal secretions (reposition, anticholinergics, oral suction); decubitus ulcers (skin care, wound care, topical lidocaine)

afterdeath care

assessment/document: general appearance, absence of heart/lung sounds on auscultation (1 full minute), lack of pupillary response to light, absence of response to verbal/tactile stimuli, TOD, who was notified of death, what time family/caregiver notified hospice agency (for home care patients), to who body released (morgue, funeral director, etc.)

postmortem care with attention to cultural/religious preferences; invite family to participate if they desire; emotional support for family with assurance team will provide bereavement support up to 1yr

prep death certificate as req. by state law, notify primary care provider

FEDERAL LAW - if death in hospital, primary decision maker must be approached re: organ donation

DISEASE SPECIFIC

end-stage cancer

neuro disorders

           neurologic

           neurovascular (w/ cva, coma admission criteria)

cardiac disorders

pulmonary disorders

renal disorders

hepatic disorders

infx (esp. viral hepatitis), autoimmune dz, genetic predisposition to liver dz, cx, chroncia ETOH, fatty liver -> liver damage

risk factors: ETOH abuse, exposure to blood/body fluids (parenteral drug abuse, tattoos, blood transf. prior to 1982), hepatotoxic chemical exp., diabetes/obesity (Hep C #1, alc. cirrhosis #2)

irreversible dz processes -> chronic lliver failure (CLF) ->ESLD. erratic trajectory with increasingly frequent, severe exacerbations of symptoms. sudden death r/t complications.

ascites, hepatic encephalopathy, anorexia/cachexia, portal hypertension, poor immunity, n/v, lyte imbalance, pruritis, malaise, esoophageal varices, pain, muscle/extremities wasting d/t malnutrition

assessment: symptoms (pain, n/v, altered bowel, rectal bleeding, dysphagia, abd. distention, pruritis), jaundice of sclera and skin, rash, petichiae, open areas from scratching, nonhealing wounds, temporal wasting & sunken eyes d/t malnutrition; abd inspection/ausc/percussion/palpation (boardlike w/ generalized peritonitis; rebound tenderness with local inflamm)

Model of End-Stage Liver Dz (MELD) - INR, bilirubin, creatinine levels. (score 10-19 = 92% 6-month mortality)

Child-Turcotte-Pugh (CTP) - total bilirubin, albumin, INR, degrees of encephalopathy & ascites (Class A = 95% 12-month mortality)

ascites indicates 50% 2-year mortality (6-month median survival rate when refractory)

liver failure -> renal failure (hepatorenal syndrome); HRS type 1 -> 4-week survival rate; type 2 -> 6-month survival rate

DISCUSS PALLIATION EARLY

HOSPICE CRITERIA:

symptoms (ascites, hepatic encephalopathy, HRS, varices) are refractory to intervention

PT > 5 seconds over control OR INR > 1.5

serum albumin <2.5 gm/dL, plus one or more:

ascites, refractory or pt noncompliant

spont. bacterial peritonitis

HRS, elevated creatinine and BUN, oliguria (<400 mL/d), urine Na concentation <10mEq/L, chirrhosis and ascites

hepatic encephalopathy, refractory or pt noncompliant

recurrent variceal bleeding despite thx

SUPPORTING documentation: progressive malnutrition, muscle wasting, continued active alcoholism (>80g ETOH/d), hepatocellular carcinoma, Hep B (HBsAg) positive

dementia/neurocognitive disorders

NCDS - decline from previous function, distinct from congenital

risk factors - age (60yo, 85yo), genetic predisposition, female, poor diet/obesity/diabetes, depression, education level, multiple comorbidities

memory changes, poor recognition, word searching, decr. executive function, poor attention span, behavior/mood changes, altered perception, decreased function re: ADLs

APA diagnostic criteria (dementia): significant decline from previous level in multiple domains (complex attention, executive function, learning and memory, language, perceptual/motor, social cognition) based on concern from knowledgeable informant or clinician or documented by testing/assessment + interferes with ADL independence + not just delirium + not better explained by another mental disorder

Alzheimer’s - slow progression (6-8 years) with exacerbations of underlying illnesses; short term memory loss, decreased attn, word searching

vascular - stepwise decline; onset gen. corresponding to TIA/CVA/cerebral infarct; variability of symptoms: aphasia, motor deficits, impaired executive function/recall/problem solving

Lewy body - progressive symptoms: neurocognitive changes, movement disorders, hallucinations, parkinsonian movements, falls, delusions, sleep disturbance

frontotemporal - (umbrella - nerve cell damage) variable progression; aphasia, obstinacy, apathy, motor disturbances, disinhibition, decr. facial recognition, emotional distancing

PT/OT/ST to maintain function & speech/swallow ALAP; advance care planning, GOC, long-term management (LTC facility?) EARLY

cholinesterase inhibitors (donepazil) to impr. cholinergic transmission in early stages; NMDA receptor agonists (memantine) later stages (impr. memory, enhance reasoning, maintain physical function - can be used together

late stage - interdisciplinary team - serious motor impairment ->safety issues, dysphagia/incontinence/immobility -> skin integrity infection -> agitation, delirium/depression/lethargy, pain, SOB, limb contractures

terminal phase - per advance directive and GOC, d/c interventions if questionable benefit

CRITERIA FOR HOSPICE ADMISSION

FAST** Stage 7 or beyond PLUS one or more of

aspiration pna

septicemia

pyelonephritis

multiple S3/S4 pressure injuries

recurrent fever

other significant condition suggesting limited prognosis

hx shows inability to maintain sufficient fluid/calorie intake in past 6 months (10% weight loss, albumin <2.5gm/dL)

**FAST staging: 1. (normal adult) no difficulties; 2. (normal older adult - mild memory loss) word finding, location of objects; 3. (early dementia) decreased job function evident, decr. organizational capacity, difficult travel to new locations; 4. (mild dementia) decr. ability at complex tasks, handling finances; 5. (moderate dementia - diff with serial subtraction; date/year/home address) assistance in proper clothing choice; 6a. (moderately severe dementia - diff with names of family/friends, delusions/hallucinations/obsessions, increased anxiety, poss violent; daytime sleep/night wakefulness) assistance in dressing; 6b. assistance bathing more freq.; 6c. assistance toileting more freq.; 6d. urinary incont. more freq.; 6e. bowel incont. more freq.; 7a. (severe dementia - incontinent x2, lose speech & ability to walk; bedridden -> sepsis, pna) limited speaking ability (half dozen words in av. day/interview); 7b. single intelligible word in av. day/interview); 7c. lost amb. ability; 7d. needs assistance to sit up (i.e., arms on chairs); 7e. lost ability to smile

endocrine disorders (most common)

thyroid dz

hypo (high TSH) - weight gain, jaundice, hoarsenes, decreased sbp/increased dbp, pericardial effusion, bradycardia, edema, fatigue, myalgia/arthralgia, blurred vision, impaired hearing, increased perspiration, fever/sore throat, depression/emotional lability, cold intolerance, paresthesia, constipation; myxedema crisis/coma - LEVOTHYROXINE 1-2 mg/kg/d.

hyper  (low TSH, high T4/T3) - Grave’s disease comorbid 60-80%. nervousness, irritability, tremor, muscle weakness, bruit over thyroid, hyperactivity, heat intolerance, hair loss, palmer erythema; thyroid toxicosis/thyroid storm (antithyroid meds, inorganic iodine, bile acid sequestrants, beta-blockers, glucocorticoids) - antithyroid meds (methimazole, propylthiouracil), beta-blockers for andrenergic symptoms. radioactive idodine thx/thyroidectomy.

diabetes

DM2 risk factors: age, htn, hypercholesterolemia, weight/obesity, smoking, inactivity, hyperglycemia;

increased risk of stroke, cardiac events; retinopathy, neuropathy

maintain AIC <5.7% or fasting plasma glucose <100 mg/dL

prioritize comfort/quality of life (when to d/c BG monitoring; EDUCATION of pt, family re: d/c)

immunologic disorders (w/ hiv admission criteria)

PAIN MANAGEMENT

assessment

chronic pain/chronic pain syndromes

low back pain - recurrent, refractory, impaired mobility, debilitation

myofascial pain syndrome (MPS) r/t muscle, fascia, tendon injury - myositis, fibrositis, myofibrositis, myalgia,

neuropathic

peripheral - diabetic neuropathy, nutritional deficiency, HIV, carcinoma - activity, allodynia

central - spinal cord trauma, tumors, vascular lesions, MS, Parkinson’s, postherpetic neuralgia, phantom limb, reflex sympathetic dystropy (CRPS)

CRPS - neuropathic, allodynia (diaphoresis, vascular changes, asthenia, disuse (PT, nerve blocks)

chronic postoperative pain (CRPS) - phantom limb, chronic donor site, postthoracotomy pain syndrome, joint arthroplasty (acute + chronic -> multimodal trx)

reticular - compression of neck/spine nerve roots (sciatica, injury, herniated disk, foraminal stenosis, inflammation) - sharp, stabbing, radiating

cancer - neuropathy, parasthesia, r/t tumor growth, trx, comorbidities - frequent assessment for rapid changes, short- + long-acting

PQRST

palliative & precipitating factors (what makes it better or worse)

quality (what does it feel like)

radiation (is it in one area or does it travel) (somatic gen. well-localized, visceral gen. poorly localized, neuropathic gen. radiates)

severity (can you rate it for me)

timing (better or worse at certain times, when did it start, how long does it last)

nonverbal: FLACC, Wong-Baker FACES, Faces Pian Scale Revised (FPS-R) (children 1-7), PAINAD

impacts

physical - quality, severity + related symptoms (nausea, sleep disturbance, depression, anxiety, immobility,

psychological - anxiety, depression, hopelessness; quality of life, incl. planning activities around pain/meds (Patient Health Questionnaire (PHQ-9, depression); GAD (GAD-10) screenings)

social - isolation, social consequences of reporting pain

spiritual - FICA Spiritual History (spiritual distress)

SUD - gen. more severe pain experience, poss. require higher med dose

40% comorbid mental/emotional/behavioral disorder

serious illness as trigger for substance abuse

AUDIT-C, Opioid Risk Tool

interventions

nociceptive pain (somatic or visceral) (sharp and localized)

visceral (gnawing, ache) - multimodal mgmt; metasteses, pancreatic tumors/pancreatitis, biliary or SBO/colon obstruction

neuropathic - multimodal mgmt, incl. nonopioids, gabapentinoids, antidepressants, SNRIs, anticonvulsants, Na-channel blocking antiarrhytmics. (opiods as second/third-line; methadone; high doses for effective trx)

WHO pain ladder

Step 1 - nonopioids with or without adjuvants

Step 2 - opioids with or without adjuvants, nonopioids

Step 3 - opioids for mod-severe pain (long-acting + short-acting) + adjuvants

non-opioids

acetaminophen (PO, PR, IV)

NSAIDS (selective vs. nonselective COX-2 inhibitors)

opiods

SEs

constipation (gastric motility) - bowel regimen (laxative + stool softener)

n/v (gastric motility, CTZ & opioid receptor stimulation)

entiemetics to antagonize specific receptors:

haloperidol - D(2)

promethazine - H(1)

naloxone - DOR

ondansetron, tropisetron, dolasetron, granisetron - 5-HT(3)

scopalamine - ACh

aprepitant - NK-1

dronabinol - DCB(1)

pruritis (partic. MORPHINE) (histimine release; effects on mu-opioid, dopamine, serotonin receptors) - rotation, reduction, antihistimines (xerostoma, confusion, blurred vision in geriatric pt - TOPICALS instead)

sedation (difficulty clearing incl. geriatric, renal dysfunction) ->

respiratory depression (opioid naive, sleep apnea, geriatric, drug-drug interactions, obesity, cardiac/respiratory disorders, functional/psych status, comorbidities) - naloxone, education

opioid-induced neurotoxicity (accumulated opioid metabolites)

partic MORPHINE then HYDROMORPHONE (kidney excretion, i.e., risks in geriatric and renal dysfunction)

fentanyl, sufentanil

do not use meperidine in palliative/hospice d/t seizure risk

myoclonus - first, most common sign

reverse mechanism, therefore -> reduce/rotate

clonazepam, midazolam, benzos, baclofen, dantrolene

overdose - often drug-drug interaction (opoids + benzos)

confusion/delirium, n/v, pinpoint, lethargy, cyanosis, respiratory distress/failure

naloxone (IN, SL, IV, IM)

CONVERSIONS

oral to parenteral - 3:1

long-acting dose - (actual TDD incl. PRNs / 2) Q12H

oral rescue dose (breakthrough pain) - 10-20% TDD Q1-2H PRN

parenteral rescue dose - 50-100% hourly rate Q15 min PRN

drug-to-drug*

adjuvants (NSAIDs, COX-2 inhibitors, muscle relaxants, psychotropics, antidepressants, antiepileptics, anxiolytics, sedatives, amphetamines, antiarrhythmics, Ca-channel blockers, ketamine, lidocaine, capsaicin, tramadol, etc.)

non-pharmacologial

evaluation

SYMPTOM MANAGEMENT

neuro

cardiovascular

terminal cardiac diagnosis -> deteriorating status; multiorgan system failure

coagulation problems inabilty to clot or regulate clot formation d/t tumor invasion, trx SE, thrombocytpenia, nutritional deficiency, anticoag use, coag abnormalities -> bleeding disorders/internal bleeding SSx epistaxis, hemoptysis, hematemesis, melena, hematochezia, hematuria, vaginal bleeding, sings of incr ICP

bleeding/hemorrhage - if nonacute, stop bleeding (packing, compression dressing, topical hemostatic, position to decr bloodflow, astringints) and alleviate pt’s anxiety. educte pt and family for risks for bleeding (partic in liver dz). Catastrophic hemorrhage - stem further bleed IF CONSISTENT WITH GOC. Radiation thx, palliative TACE, endoscopy, vitamin K, vasopressin, antifibrinolytics, otreotide (for varices), platelet transfusion, FFP. possibly palliative sedation. Dark-colored towels to reduce visual impact for pt and caregivers.

thrombi/dvt - risk d/t immobility, orthopedic trauma, circulatory problems - use TED hose/SCDs prophylatically. DVT SSx: edema, pain, localized warmth, venous distention, localized tenderness to palpation. Dx via venogram (”gold standard” but invasive), venous doppler to detect blood flow (evaluate/compare both extremities). Trx: hepairin, low molecular weight heparin (LMWH), unfractioned heparin, fondaparinux. NO enoxoparin (Lovenox) (a LMWH) in acute renal failure.

pulmonary embolism - d/t thrombus formation, often DVT migrattion to pulmonary artery. Risks: genetic predisp., recent surgery, hx DVT/PE, immobility, hospitalization, cx, age, HF, stroke, acute respiratory failure, IBD. may be initially asymptomatic/vague symptoms. Unexplained chest pain in 97% of confirmed PE. other SSx: anxiety, diaphoresis, cought, syncope, hemoptysis, hypoxemia, hypotension, pleuritic rub.  -> pressure increase in R ventricle -> tacycardia, crackles, fever, prounounced S2 (with closure of pulmonic and aortic valves), S3 (d/t fluid overload), possible S4 gallop (d/t thickned ventricular walls 2ndry to HTN or aortic stenosis).

lab testing is not definitive. rule out differential dx w/ d-dimer, ESR, leukocyte level, dehydrogenase, BNP, troponin. rule out differential dx with chest XR. spiral CT with contrast can more accurately confirm - if non-contrast d/t allergy, renal impairment then ventilaion/perfusion (V/Q) scanning. Gold standard dx - confirmation via pulmonary angiogram (expensive and invasive)

trx: stabilize. invasive measures only if consistent with GOC (mechanical vent, intubation) - improve ventilation. BIPAP noninvasive may also improve.

pharm (IV resuscitation, vascular stabilization) - vasopressors (norepinephrine, dopamine, epinephrine), anticoags (LMWH, unfractioned heparin, fondaparinux, warfarin, rivaroxaban). in initial phase, intiate parenteral heparin, LMWH, rivaroxaban, fondaparinux - > transitioned to oral or other agent. IF NOT CONSISTENT WITH GOC: alleviate dyspnea and anxiety, incl. sedation if sever distress and symptomatic. Family education, d/t suddenness, poor prognosis

DIC - thrombi -> infarction in multiple vessels/organs -> organ damage + internal bleeding d/t platelet depletion; risks: sepsis, inflamm dz, cx, liver dz, trauma, aneurysms, vascular disorder. ssx initially subtle; bruising purpura, petechiae, hematemesis, hematuria, hematochezia, hemothorax. trx: replace blood and blood products, correct metabolic shifts. anticoags (may need cautery, cryoablation to control bleeding), synthetic protease inhibitors (block serine proteases, incl. thrombin), antifibrinolytics, IF ORGAN FAIULRE, natural protease inhibitors, but avoid antifibrinolytics

angina d/t increased cardiac O2 demand d/t activity, cardiac vessel onbstruction, MI. stable vs. unstable. ssx: sudden chest pain, tightness, heaviness, squeezing, pain radiating to jaw/arms/back, SOB, fatigue, nausea (2-3 symptoms together - atypical angina). trx: rule out MI or occlusion, treat symptomatically - discontinue precipitating activities, nitroglyc SL/PO/TD/IV/lingual spray. Possible invasive (angioplasty, stent, CABG) if benefits outweigh risks

edema

lower extremities d/t ES organ failure (partic (R) heart/liver/kidney), med SE, superior vena cava syndrome (SVCS), vascular insufficiency, hypoalbuminemia, fluid overload. pitting vs. non-pitting. incr weight -> discomfort, decr mobility. trx: elevation, compression. diuretics may NOT be useful, particularly if refractory. interventions implemented slowly to prevent incr. cardiac symptoms.

lymphedema d/t obstruction/removal of lymph nodes (r/t cx surgeries, other trx) -> lymph accumulation -> fibrosis, sclerosis -> permanent edema. pre-fibrosis, trx with elevation, compression. diuretics generally NOT useful. SKIN CARE. manual lymphatic drainage by trained massage or PT (promoting mobility, ROM, QOL)

syncope temp. loss of consciousness d/t low blood flow to brain (hypotension, r/t (ES) cardiac dz/afib, dehydration, fluid shifts, postural changes (orthostatic)). SAFETY - educate pt and family on changing position slowly, assistance for transfers, sit/lie down at warning SSx: nausea, diaphoresis, lightheaded. Recurrent -> anxiety, somatization, panic -> fluoxetine. Testing (EKG, lab studies for lyte imbalance/dehydration, tilt table to test) for cause if GOC consistent. Pacemaker may relieve fatigue, dyspnea, syncope.

SVCS obstruction of SVS/nearby lymph nodes/vessels (usually d/tprimary tumor or mets from lung cx/breast cx/lymphoma) -> SSx obstructed drainage from hed/neck/UEs (facial swelling, JVD, distention of chest veins, UE edema, ruddy complexion; over 2-week period - cough, dyspnea, hoarseness, blurred vision, syncope, HA, confusion, obtundation). Confirm dx via chest XR, CT, MRA. trx via chemo/radiation, steriods, diuretic, thrombolytics, stent/bypass. RAISE HOB 45-90 degrees to promote drainage. prognosis (age over 50, extent of malignancy, hx smoking, steroid use) fair to poor, <6mo to 2yr -> team discussion GOC re: interventions

respiratory

gi

constipation (abd distention, nasea/indigestion, <3BM/wk, difficult to pass/straining, feeling of incomplete emptying)

d/t slowed gi mobility, increased intestinal water absorption, obstruction, meds (incl. antidiarrheals, opioids), immobility, low fiber, dehydration

ausculate, palpate, skin turgor, hx (diet, mobiliyt, usual patter, associated issues, typical consistency)

high fiber diet, 2-3L fluids/day, exercise as tolerated, laxatives (increase if opiod increases)

bulk forming (absorb water, increase mass, stimulate peristalsis - psyllium (Metamucil), 5-7g daily start OR methylcellulose (Citrucel) 4-7g daily startt; 12-72H to onset. Use prophylactically, DO NOT use with ileus or impaction; req. 300-500ml fluid each dose (prevent impact.)

lubricant (also prevents reabsorption of water) - glycerin suppository 1PR qd OR mineral oil 30-60mL PO qd; 6-8H to onset (suppository 15-30 min)

opioid antagonists (block opioid receptors in bowel) methylnaltrexone (Relistor) for chroninc NON-cx pain 450mg PO qAM or 12mg SQ qAM (dose weight-based for adv. illness), OR naloxegol (Movantik) 12.5-15mg PO qd; 30-60min onset; d/c all maintenance laxatives prior to use, ensure close proximity to br

osmotic (pull water in and increase peristalsis) - lactulose (10g/15mL) @ 15-30mL qd to MAX 60mL/d in devided doses (24-48H onset), OR polyethylene glycol (Miralax) (48-96H onset) 17-34 g/d (dissolve 1cap in 8oz liquid /day up to 8 doses per day; poss bloating, flatulence

surfectant/detergent (draw water into colon) - docusate sodium (Colace) (whatever - this is useless) 100mg qd-BID (1-3 d onset) OR mineral oil 14-15mL qd (onset PO 6-8H, PR 2-15min); BITTER liquid, mix with juice or milk

bowel stimulants (stimulate submucosal nerve plexus -> incr. peristalsis) bisacodyl (Dulcolax PO) - 5mg qd start up to 30mg qd (6-10H onset), Dulcolax suppository (10mg PR qd) (,1H onset), OR senna (senokot) 15mg qd start to max 70-100mg qd (6-12H onset) - AVOID with ileus, obstruction, monitor for lyte/fluid imbalance, may develop tolerance. SE cramping, n/v with senna.

fecal impaction - bisacodyl or glycerin suppository, 2% lidocaine gel with disimpaction (avoid if possible perf or bleeding)

diarrhea (passed too quickly for water absorption) - abd pain, cramp, lethargy/weakness, n/v, distention, anorexia, incr thirst - dehydration, nutrient/lyte imbalance

d/c laxatives, assess for impaction, ID any ssx infx, replace fluids/lytes, provide skin care for incontinence. antidiarrheals cautiously with fever

opiods/opiod derivatives (ex. diphenoxylate/atropine (Lomotil)) 1-2 tabs PO BID-QID PRN

nonopiod (ex loperamide (Immodium)) 4mg PO 1x at ssx onset, then 2mg after each loose stool. (GERI SE - anticholinergic effects - prefer Lomotil)

antacids, adsorbents (bismuth salicylate - also antiinflamm and antibx) for n/d/indigestion; 2 262mg tabs QH PRN up to 16 tabs/24H

bulk-forming/fiber agents (absorb excess water) - ex. psyllium 1-2 tsp mixed with liquid up to TID

incontinence (muscle weakness/atrophy, neuro dz, severe diarr) - ID and remove (if poss) the cause; track associated ssx (weight loss, fever, R bleeding, steatorrhea)

env changes - BSC, clear path and proper lighting, remove physical restraints

skin care, with barrier cream/ointment

ascites (portal hypertension, hypoalbuminemia; malignancy, HF -> abd fluid collection) - indicate ES dz

discomfort, altered body image, decr mobility, dyspnea (diaphr. pressure), umbilical hernia, cellulitis, bacterial peritonitis

restrict NA 2g/d, fluid restriction, spironolactone (50-400mg qd), furosemide (20-130mg qd), paracentesis (if >4L, IV albumin), TIPS (potential hepatic encephalopathy)

repeated paracentesis -> indwelling abd cath

maintain trx consistent with GOC

hiccups (benign minutes to 2 d, persistent 2 d to 1mo, intractable longer than 1mo) -> indigestion, bloating, pain, abd distention, insomnia, fatigue. Quality of life

nonpharm - hold breath, breath into paper bag, compress diaphr., ice in mouth, induce cough/sneeze, pressure on nose, swallow sugar, eat lemon wedge with bitters, eat soft bread, touch palate with cotton swab, ocular compression, carotid massage, CBT (???), repositin, faseting, NG tube, acupuncture, induce emesis, disrupt phrenic nerve action (ablation last resort d/t pulmonary function risk)

pharm - simethicone 15-30mL PO q4H for distention; baclofen 5-10mg PO q6-12H up to 15-37mg qd OR midazolam 5-10mg PO q4H for muscle spasms; gabapentin 300-600mg PO TID for anticonvulsant; amitryptyline 10-50 mg PO OR sertraline 50-150mg PO QIS for CNS effects; haloperidol 2-10mg PO/IV/SQ q4-12H to block dopamine and alpha-andrenergic receptors

n/v (increased salivation, loss of appetite, diaphoresis) ASSESS N/V SEPARATELY

 cerebral cortex (fear, anxiety, stress, memories, sensory stimulation)

pressure receptors (increased ICP)

chemoreceptor trigger zone (central neural pathway) (opioids, serotonin, dopamine, histamine, acetylcholine, antibx, NSAIDS, electrolyte disturbance, inhln agents)

glossopharyngeal/trigeminal (stimulate GP nerve - surgery, tumor growth, etc.)

vestibular (middle ear surgery, motion, vertigo)

 GI (infx, cytotoxic meds, GI irritants, constipation, obstr., decr. motility)

-> stim vom center in medulla oblongata ->emesis

ANTICHOLINERGICS (hycoscine (scop) 1.5mg patch, 0.5-3 patch TD Q72H OR 0.6-1mg SQ/IV Q6-8H - spec. if d/t motion or obstruction. geri - anticholinergic SEs) (atropine opthm 1%, 1-2 drops SL Q8H PRN) (hyoscyamine 0.4-0.6mg SQ Q4H PRN)

ANTIHISTIMINES  (diphenhydramine 25-50 PO/SC/IV Q6H PRN (blocks H1 receptors in vom center, CTZ, vestibular nuclei). GERI - risk for extrapyramidal SEs) (cyclizine 50mg PO Q4-6H PRN to max 200mg/day - rec. for incr. ICP, motion sickness pharyngeal stimulation, mechanical BO)

BENZOS (lorazepam 0.5-2mg PO/SQ/IV Q8-12H - use with another agent unless caused by anxiety)

CANNABINOIDS (dronabinol 5-10mg PO Q3-6H, nabilone 1-2mg PO BID - CHEMO, if other trx ineffective)

CORTICOSTEROIDS (dexamethasone 4mg PO Q6H WITH FOOD - prophylactically during chemo/radiation; may help reduce BO)

DOPAMINE RECEPTOR AGONISTS 0-20mg PO/SQ/IV Q6H OR 25mg PR (partic for opoiod-induced nausea) - blocks dopamine in CTZ. sedating effect - may be beneficial for imminent patients)

OCTREOTID (100-400mcg SQ Q8H) - BO

PROKINETICS (metoclopromide 10-20mg PO/SQ/IV Q4-6H up to 40mg - CHEMO n/v) - for gastric stasis, admin prior to meals; reduce dose geri, renal dz. NOT in BO, perf, or immediately postoperative

SELECTIVE 5-HT3 RECEPTOR AGONISTS (ondansetron 4-8mg PO/SQ/IV Q8H on Day 1 chemo; 16-24mg PO 1x OR 8-16mg IV 1x (max dose 16mg)) - specif. prophyl. chemo/radiation n/v (PREMED)

SUBSTANCE P AGONISTS (NKI receptor agonists) (aprepitant 125mg PO 1x Day 1 chemo, then 80mg PO Qmorning on Day 2-3. PREMED 1H prior on Day 1, with a corticosteroid (dex) and a 5-HT3 agonist (Zofran)) - used with ondansetron prophyl. chemo/radiation n/v

nonpharm: hydration, small meals/fulll liquid, withhold routine meds if poss, complementary thx (aromatherapy, meditation, relaxation), reposition, CBT, intervention for tumor growth (surgery, stent, NGT, decompression)

(malignent) bowel obstruction (d/t intraabdominal cx) (-> sepsis, perf, necrosis) (n/v undigested food, poss fecal matter in advanced MBO; hyperactive bowel sounds/borborygmi; pain/distention with large intestince) - prognosis 30-90 days

palliative mgmt for n/v, pain, colic, possible parenteral fluid fo comfort, NGT for distention. FREQ oral care, ice chips for dry mouth

palliative pharm: opioids, anticholinergics, corticosteroids (metoclopramide 10mg Q 6-8H nausea 1st line; octreotide 50-100mcg SQ/IV Q8-12H antisecretory, but high cost, SE (n/d, pain, constipation))

gu

infx, cx, ES dz, iatrogenic

bladder spasms - stabbing/cramping, colicky suprapubicpain d/t detrusor muscle acting agaisnt partial/fully blocked bladder outlet (by tumor, blood clot, stent, cath (too large, kinked, blocked)). urgency or leakage poss. smaller cath, balloon inflated to appropriate size, drink sufficient fluids, avoid caffeine/alcohol/other irritants, anticholinergics (with care in geri pt); botulinum toxin A injection into detrusor to decr. urgency sensation

incontinence - transient in delirium, UTI, immobility, sever constipation; med SE; diminished contraction of detrusor. review meds for SE incontinence, sedation (reduced sensitivity to fullness); timing (only at night, stress (sneeze, etc.), continual?. Skin care; review incontinence aids with caregiver for bedbound patient. SSX of UTI - > sample and UA. Poss indwelling cath (UTI risk))

retention - d/t UTI, mechanical obstruction (partic in BPH, colon/pelvice cx), neuro issues, meds (anticholinergics, antihisitmines, antidepressents, antihypertensives, anit-Parkinsons, antipsychotics, sympathomimetics, opoids (partic. with anticholinergics). REVIEW MEDS and d/c if possible. Indwelling cath if bladder firmness on palpation, bladder scan >300mL or PVR 200-300mL (including after straight cath)

msk

immobiility, pain, debility, mestatses, ESdz

impaired mobility + complications - incr. risk of skin breakdown, physical deconditioning, activity intolerance, pathological frx. assess skin condition and ulceration risk factors with reliable tool (Braden Scale***). combined with sensory loss, incontinence, poor nutrition -> incr risk of pressure ulcers. Risk of skin shear of friction abrasion when pt repositioned by others. PRIORITY PREVENTION - encourage active participatoin in repositioning using rails/trapeze bar; freq reposition for immobile pt; pillow, cushions, antipressure devices/mattresses. Nutritional assessment for deficiencies, weight loss, cachexia (direct correlation b/t pressure ulcer risk and nutritional deficiency (low protein, albumin); consider supplements if appropriate

deconditioning/activity intolerance - d/t prolonged immobility, med SE, anemia, dz progression -> fatigue, weakness, decr. stamina -> incr falls risk, decr ADLs and QOL. weakness, dyspnea with exertion, fatigue with activity. preserve stamina in nonambulatory pt through passive/active ROM as tolerated. prevent falls - proper lighting, assistance with transfers and ambulation, necessary objects (glasses, telephone, call bell) within reach

pathological fractures d/t dz (most common osteoporosis; bone mets). femur most common site, 75% of which at proximal end. Also tibia, humerus, ribs, spine. SSx - localized pain/swelling, numbness; if femur, affected leg uually shorter and externally rotated. -> surgical stabilization (w/ or w/out joint replacement) common; contraindicated if widespread meets or life expectancy <6mo. Determine risks and educated on proper positioning, safety. pain mgmt and joint stabilization. team should collab with pt/famlly for plan of care to promote QOL, consistent with GOC.

integumentary and mucous membrane

meds, dz progression, poor nutrition/hydration,

xerostomia (radiothx head/neck, Sjogren’s, depression/anxiety/stress, malnutrition) dry mouth + hyposalivation. assoc: thrush, poor dentition, dry mucous membranes -> ability to eat/talk/wear dentures, incr. risk halitosis/caries/thrush/taste change. remove reversible causes (incl. meds if poss.), proper hydration, freq oral hydration, sugar-free gum/candy

pharm: pilocarpine 5mg TID, cevimeline 30mg TID (SE: d/n/v, sweating); sialagogue - oral topical

pruritis chronic in renal/liver dz, hypo/hyperthyroidism, anemia, malginancies, HIV; med SE (partic. opioids) -> disrupt ADL/sleep patterns. assess using Woods lamp if poss; parasites, bacterial/fungal infx, lesions. trx any underlying cause; also topical ointments, barrier creams, soakes (calamine, menthol, oatmeal bath, antihist. cream, steroids, capsaicin). Geri use of systemic thx (antihist) with caution (anticholinergic SE)

wounds (pressure ulcers, tumor extrusions, nonhealing wounds) - pressure and anoxia -> tissue damage in as little as 20-40 minutes.

frequent reposition - if bedbound, every 2-4H on pressure-reducing surface away from ulcer site; premed 20-30 min if pain; flexibility if actively dying or comfortable in only one position

adequate nutrition/hydration incl PO, SQ, IV dydration if appropriate, nutritional supplements. Provide as appropriate with GOC and prognosis

wound care based on staging, GOC, prognosis. NPWT to remove excess drainage/necrotic tissue/infx if large. Debridement of necrotic tissue: mechnical (wound irrigation/hydrotherapy, enzymatic via topical agents with dressing change Qday); biosurgical (medical maggots); autolytic (moisture-retaining dressing changed Q3-5 days, causing self-destruction of necrotic tissue)

S1 nonblanchable erythema, localized, usually over bony prominence. skin intact, red/purple/blue

S2 partial thickness loss of epidermis, some dermis. shallow open ulcer/superficial erosion, pink-red wound bed, no slough

S3 full thickness loss of skin, necrosis of SQ tissue, SQ fat poss. visible, but tendon/muscle/bone NOT exposed. Poss. undermining/tunneling, slough, necrotic tissue

S4 full thickness loss of skin including epidermis, dermis, SQ tissue; poss. muscle/bone/tendon exposure, slough, undermining/tunneling

(suspect) deep tissue injury - localized discoloration (purple/maroon), non-blanching, epidermis intact, feels boggy

unstageable - full thickness tissue loss covered by eschar or extensive necrotic tissue (tan, yellow-green, brown) (must be cleared before true depth can be determined)

OTHER DATA: length/width/depth (mm), description of edges, presence/description/amount of undermining/necrotic tissue/exudate/granulation tissue and epithelialization, condition of surrounding tissue

increased infx risk - debridement and wound care. high-risk wounds: silver-release topical dressings, medical-grade honey dressings, thin film dressings, hydrocolloid for S2-3, faom for exudative S2 pressure ulcers, hydrogel for nonexudative/necrotic, calcium alginates to absorb exudate

control odors - QOL. metronidazole gel (0.77-1.0%) Qday x 1wk to reduce microbe growth. dessings with activated charcoal. if not expected to heal, povidone iodine.

manage pain with systemic analgeisic, low-dose morphine

psychosocial/emotional/spiritual

anger/hostility r/t illness, lack of control, dependency, family/caregiver response to illness - interdisciplinary team (partic. social workier, chaplain) to help pt/family proces and express in safe manner. provide reassurance feeling is common AND usually related to abother emotion (fear, depression, grief)

depression (persistent low mood, anhedonia >2wks + accompanied by at least four of: sleep disruption, weight loss/appetite change, psychomotor retardation/agitation, fatigue/energy loss, worthlessness/excessive guilt, decr. ability to think/concentrate, recurrent thoughts of death/suicidal ideation). uncertainty of dz trajectory, possibility of death. FREQ with anxiety, so assess for both. Therapeutic listening, team collaboration with pt to develop plan: relaxation techniques, meditation, CBT.

SSRI (citalopram 20-60mg/day, escitalopram 10-20mg/day, paroxetine 20-50mg/day, fluoxetine 20-60mg/day, fluvoxamine 50-100mg BID, sertraline 50-200mg/day) - may take sveral weeks for effect.

methylphenidate (Ritalin) if life expectency <2weeks

denial shields pt from consequences of illness until psychologically ready to cope - challenging may increase distress. Active listening, therapeutic silence, reflection, calm reassurance team is available for support as needed.

fear -> tachycardia, tachypnea, shaking, insomnia, diaphoresis, stomach upset, nightmares (response to real threat vs. anxiety response to perceived as well as real threat). Distraction, deep breathing, meditation, massage, CBT, focused support by team social worker/chaplain

grief -> intrusive thoughts, regrent, inability to think clearly, dulled/heightened emotions, nausea, fatigue, myalgia. Therapeutic listening, empathetic support, reassurance experience is normal. team social worker/chaplain factilitate life review, teach CBT techniques, provide spiritual support/guidance

loss of hope/meaning as hope for recovery fails. GOC convo with team to help pt focus shift from hope of recovery to comfort, preserved function, preserved dignity, other comforts. team facilitates life review, which may ID source of meaning.

guilt r/t regret for actions taken or failed to take. personal responsibility for illness, leaving family. -> existential suffering. Encourage pt to explore and express, also to work with team.

nearing death awareness (NDA) about 50% of terminal pts experience, usually coherent, comforting. Generally brings preace, may involved communicating with deceased loved ones, preparing for change, seeing the afterlife, knowing death is near. Culturally bound and varies by pt. Center on differentiating from negative delirium/hallucinations, validate perceptions.

sleep disturbances (insomnia, unusual patterns, daytime fatuge) - review and address dz progression, socioec factors, pain, meds, psych issues; promote restful sleep via sleep hygiene, allowing undisturbed rest, avoiding stimulants. nonpharm: relaxation techniques, massage, aromatherapy, music

suicidal ideation - warning signs: bebavior changes, withdrawing from friends/activities, giving away possessions, talking about suicide, incr. use of drugs/alcohol

Key assessment questions: Are you considering harming yourself? Do you have a plan to harm yourself? if either, considered at risk, take steps to ensure safety

intimacy/relationship issues incl. caregiver stress vs. dependency issues, loss of sexual relationship d/t illness. Discuss openly, normalize experience, reassure, encourage counseling

nutritional/metabolic

d/t dz progression, organ failure, med SE

anorexia/cachexia (anorexia/cachexia syndrome (ACS)) - cx, HF, COPD, HIV, renal dz - sign of advanced dz (POOR prognosis, even with intervention) - metabolic & neurohormonal changes, systemic inflamm, catabolism

oral nutritional suppl., ease diet restrictions, small/freq meals; enteral/parenteral supplementation NOT generally beneficial end-stage, before trial consider potential benefit, life expectencey, functional status (Karnofsky >50, medical issues manageable, caregiver available and pt able to have follow-up lab monitoriing

pharm - megestrol acetate, glucocorticoids, cannabinoids increase appetite/weight but uncertain effect on QoL. with depression, mirtazapine (Remeron) 15mg QHS, methylphenidate 2.5-10mg PO at 0800 and 1200

mid-arm circumference to assess malnutrition over time - weight loss and muscle wasting

dehydration r/t anorexia, med SE, n/v, BO, dysphagia, cognitive impairment (mucous membranes, skin turgor, bowel function - diarr; constip., impact.). may exacerbate delirium, confusion, agit,, myoclonus - NOT usually responsive to fluid replacement. SE artificial hydration - nausea, fluid overload, dyspnea, ascites, edema. is patient acutely ill/expected to recover some function or actively dying? PT AND FAMILY DISTRESS - educate.

oral or enteral fluid replacement; parenteral nutrtion through CVC or other long-term access. SQ fluids (hypodermoclysis) -absorption rate comparable to IV admin. (rarely use protoclysis, PR admin fluids to GI tract).

fatigue (subjective, some objective effects) r/t cx, HF, COPD, renal dz, HIV/AIDS, MS, etc.; poss. secondary to insomnia, distressing SSx, dz process, med SE, psych/spiritual distress

nonpharm - exercise as tolerated, pain and sx mgmt, counseling, medication, relaxation, music thx, sleep hygiene, avoid sleep disruption

pharm - benzo or antidepressent to enhance sleep. if not related to sleep quantity/quality, psychostimulants (methylphenidate, modafinil); corticosteroids; megestrol

hypercalcemia (serum Ca >14mg/dL -> urgent intervention) (metastatic cx as bone deteriorates and released Ca; hyperparathyroidism, lithium thx, Addison’s, Paget’s, vitminan A or aluminum toxicity) -> n/v, anorexia, wekness, constipation, thirst, AMS.

intervention for comfort even in advanced dz

bisphosphanates (pamidronate, zoledronate), calcitonin admin, IV hydration, bone reabsorption agents (gallium nitrate, plicamycin), dialysis

hypo/hyperglcemia d/t uncontrolled DM, sepsis, organ failure, cortisol imbalance, altered intake

monitoroing and mgmt may not be feasible in terminal illness d/t PO inability; ASSESS necessity of fingersticks, dietary control at EoL, EDUCATE pt and family on change to normal routine, REVIEW GoC

hypo <70mg/dL -> diaphoresis, dizziness, pallor, tachycardia, weakness, anxiety, tremors, nausea, hunger. <50mg/dl -> irritability, blurry/double vision, confusion, HA, slurred speech. <40mg/dL -> severe reactions incl. coma, seazure, death

15g carb, 15 minutes BG check, repeat PRN until >70mg/dL

glucagon 1mg IV/SQ (5i minutes to effect)

D50 IV/SQ (immediate)

corticosteriods for dual effect if dyspnea, pain, inflamm

hyper = fasting >116mg/dL OR postprandial >200mg/dL - overtreatment or non-compliance with treatment plan, DM, acute ilness, stroke, sepsis, MI, pancreatitis, meds (glucocorticoids, high-dose thiazides, dobutamine, atypical antipsychotics, cocaine) -> polyuria, polydipsia, polyphagia, glucosuria, weakness, fatigue, weight loss, blurred vision, poor wound healing, incr. infx risk, diabetic ketoacidosis (usually in DM1)

lifestyle modification

pharm: metformin up to 2250mg/day; sulfonylureas (glipizide, glyburide, glimepiride); metglitinides (matelinide, repaglinide); glucosidase inhibitors (acarbose, miglitol); thiazolidinediones (pioglitazone, rosiglitazone); dipeptidyl peptidase 4 (DPP-4) inhibitors (sitagliptin phosphate); amylin agonists (pramlintide); insulin

immune/lymphatic

d/t dz progression, organ failure, med SE

fever (T 101.3F/38.5C x1 OR 100.4F/38C x3 1H apart); d/t infx, immunological disorders, metabolic imbalance; antipyretics PO, PR + poss. antibx for symptom control. possible central fever (high T, skin cool) near death - antipyretics for comfort.

myelosuppression (anemia, neutropenia, thrombocytopenia) - dt decr. bone marrow activity (cx trx, end-stage dz)

anemia (Hgb <8.0 g/dL) - heart dz, pulmonary dz, kidney dz, inflammatory processes r/t chronic dz (age/weight-> higher risk). RBC transfusion (threshold 9.0 g/d/L in advanced dz), erythropoiesis-stimulating agents (epoitin-alpha, darbepoetin) although NOT wiht advanced cx (stimulation of tumor growth)

neutropenia (ANC <1,000/mm3) - bone marrow suppression, cx trx, infx med SE, autoimmune disorder; risk for febrile neutropenia (T 100.4F/38.3C longer than 1H + ANC < 500/mm3 with expectation to decrease). ASSUME with fever while on chemo until proven otherwise. if confirmed: broad-spectrum antibx, possible hospitalization for IV thx.

thromobocytopenia (<20,000/mm3 OR clinically significant active bleeding) - cx, aplastic anemia, med SE, autoimmune disorder, chronic ETOH; purpura + petichiae. if hemorrhage - rad thx, endoscopy, vitamin K, vasopressin, octreotride (for varices), antifibrinolytics, platelets or FFP, palliative TACE. (dark towels to reduce visual impact for pt and caregivers)

lymphedema - lymph accumulation -> fibrosis or sclerosis -> permanent edema. skin care, elevation and compression if no fibrosis yet, manual drainage (PT, MT). (diuretics not usually effective)

mental status changes

altered LOC (CNS dysfunction, med SEs, metabolic imbalance, infx, anxiety, psych issues)

confusion - Confusion Assessment Method (CAM) to detect delirium

delirium - inpt geriatric, postop, advanced illness (infx (UTI), renal failure, hepatic failure, CNS disorders, vascular disorders, pain) - acute onset, fluctuating symptoms, perceptual changes, sleep-wake cycle altered, delusions, hallucinations, paranoia, hyperactivity/lethargy; haloperidol (1mg), risperidone (1mg)

terminal delirium/terminal agitation - symptoms not reversible in >50% of patients - haloperidol 2-4mg PO/SC/IV Q30minutes up to 20mg/24hr, olanzapine 2.5-5mg SL HS-BID plus PRN Q4hr

patient/family care/education/advocacy

goals of care

psychosocial/spiritual/cultural

grief & loss

caregiver ed/support/advocacy

practice issues

coordination and collaboration

scope and standards of practice

* opioid drug-to-drug conversions (equianalgesic - PO and TD)

morphine  30mg

hydocodone   30mg

codeine   200mg

tramadol 100mg

oxycodone   20mg

oxymorphone, methadone 10mg

fentanyl TD   12.5mcg/H ##

hydromorphone   7.5mg

levorphanol 4mg

calculate current 24H dose (TDD including PRNs)

convert using equianalgesic

calculate new dose

reduce by 50% to account for cross-tolerance (can be titrated PRN) (DO NOT REDUCE FOR TD FENTANYL)

## morphine to fentanyl patch - each 2 mg PO morphine approximately equivalent to 1 mcg/hr fentanyl patch (e.g., morphine 100 mg/day → 50 mcg/hr patch applied q3days) (approx 2mg : 1mcg/H) Note: using this formula, 25 mcg/hr of transdermal fentanyl is roughly equivalent to 50 mg oral morphine/24 hours. This dose may be excessive when used in the opioid naïve or the elderly.

MORE CONSERVATIVELY: FDA prescribing information for transdermal fentanyl: 135-224 mg of morphine per 24 hours = 50 mcg/hr patch. Note: this range of morphine is very broad which may result in significant under-dosing.

IV morphine : IV hydromorphone = 5:1

IV morphine : fentanyl patch = 4mg/hr : 100 McG patch (approx.)

[moussezi]

Notice of Funding Opportunity

The U.S. Department of Agriculture’s Foreign Agricultural Service (FAS) is accepting fiscal year 2023 applications for the McGovern-Dole International Food for Education and Child Nutrition Program, which helps support education, child development and food security in low-income, food-deficit countries around the globe. The FY 2023 Notice of Funding Opportunity (NOFO) for the Program is now available on Grants.gov at FY 2023 McGovern-Dole NOFO. Priority countries for FY 2023 are Cameroon, Haiti, Mozambique, Nepal, Nicaragua, Sri Lanka, and Togo.  The application deadline is April 28, 2023.

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