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Geriatrics
Palliative pains and care
Courses of Geriatrics
 


 

The palliative care:

A- HISTORY:

1) AT THE WORLD LEVEL:

1842: Jeanne Garnier

1879: Dublin, Ladies Irish

1905: London, St Joseph Old people's home

1967: St Christopher Old people's home (first modern old people's home)

1969: accompaniment in residence

1975: E. Kubler Ross

1975: creation of a unit of palliative care in Montreal

1976: first international congress of palliative care

2) IN FRANCE:

1983: creation of JALMAV (until death to accompany the life)

1984: creation of the ASP (association of palliative care)

1984: reflexion on the euthanasia

1986: circular of August 26 and first European congress of palliative care

1987: creation of the first unit of palliative care in the University City

1988: creation of the first teaching (CREFAV)

1989: creation of the first mobile unit to the Hotel God

1990: creation of a university diploma

1993: Delbeque report/ratio on the evolution of the palliative care in France

B - GENERAL INFORMATION:

1) DEFINITION:

Charter of the ASP:

The palliative care is active care in a global solution.

Their objective is to relieve the physical pains, as well as the other symptoms.

They take into account the psychological, social and spiritual suffering.

They are interdisciplinary.

They are addressed to the patient as anybody, to his family and her close relations.

They intervene in residence or in institution.

The formation and the support of looking after and voluntary belong to the step.

The palliative care and the accompaniment regard the patient as a being living and death like a natural process.

Those which exempt them seek to avoid the unreasonable investigations and treatments.

They refuse to cause death intentionally.

They endeavour to preserve the best quality of possible life until the death.

They propose a support for the close relations in mourning.

They get busy, by their clinical practice, their teaching and their research tasks, so that these principles can be applied.

2) COMPOSITION Of a TEAM:

All the members of the team must voluntary, be motivated, trained.

a) Doctor:

• Control of the pain

• Dealt with of the other symptoms

• Dealt with of the side effects of the therapeutic ones

b) Tally male nurse:

• Coordination of the action of looking after

• Startup of protocols of care

• Relations with the coordonator of the voluntary ones

• Regulation of the admissions after opinion of the doctor

• Reception of the families before and at the time of the hospitalization

c) IDE:

• Clean Care male nurses

• Administration of the drugs and the poisons

• Bandage of the wounds

• Appreciation of the comfort of the patient

d) Nurse's aide (E):

• Toilet, changes

• Posturation of the patient

e) Kinesitherapist:

• Massages, active and passive mobilization

• Demonstration of postures and techniques of mobilization

• Research of the comfort of the patient

f) Psychologist:

• Listening of the patient

• Taken in dependent

g) Welfare officer:

• Material aid with the patient and his family

• Adjustment of a return to residence or worms of other medicalized structures

• Administrative Formalities

• Support for mourning

h) Secretary:

i) People of the worship:

k) The voluntary ones:

3) NEED FOR FORMAL TIMES OF MEETINGS:

• Daily Meetings of synthesis

• Meetings of mourning

• Groups of word

C - KEY WORDS:

• Interdisciplinarité

• Dealt with total of the patient

• Organization of the care around the patient and his rate/rhythm

• Integration of the family

The pain in geriatrics:

Often underestimated, badly studied and badly dealt with.

Frequency of the chronic pains: 20 to 63%, even 71% according to authors'.

A - DEFINITION:

Definition of the IASP (International association for the study of the pain):

The pain is a sensory and emotional experiment unpleasant, associated a tissue lesion real or potential, or described in terms implying such a lesion.

The pain is always subjective.

Each individual learns to what applies the term because of experiments related to wounds of the beginning of the life.

B - CHARACTERISTICS:

a) Socially:

The pain is often lived like normality, a practice “related to the age”.

It is often standardized.

b) Physiopathologiquement:

It does not seem to exist of reduction in the threshold of the pain.

On the other hand, one observes a reduction in the pains known as “useful”: pain of the infarction…

Also with an increase in potentially painful pathologies.

To these defects of expression, the obstacles are added to the expression of the painful feeling: handicaps not allowing more to express it.

c) the repercussion of the pain is also specific:

One observes:

• Reduction in the threshold of the pain at the old patient

• Deceleration idéatoire and intellectual

• Modification of the psychomotor and social activities

• Behavioral problems: prostration, confusion, regression, agitation

One can also observe direct signs of the pain at rest, but especially to the mobilization.

From where interest of a total assumption of responsibility of these patients by a team working in interdisciplinarity.

d) Etiology:

• Ostéo-articular Pains: 50 to 80% (osteoarthritis, osteoporosis, traumatisms

• Neurological Pains: 10 to 25%

• Arterial Pains: 6 to 20%

• Visceral Pains: 4 to 20%

C - CLASSIFICATION:

Three types of pains:

• By excess of nociception: localization, standard irradiation, without neurological disorders

• Neurogènes (old pains by desafferentation): tinglings, swarmings…

• Psychogenic: phantom limb

D - EVALUATION OF THE PAIN:

1) AUTO-EVALUATION:

Unidimensional scale:

• Verbal Scale simple, nominal, with several adjectives

• Relative verbal Scale

• Numerical Scale

• Analogical visual Scale (EVA): strip Disadvantages:

• Measurement intensity only

• One needs that the patient is lucid and communicate

Instruments:

• Questionnaire of Mac Gill: validate, reliable and sensitive (64 adjectives)

• Questionnaire pain of St Antoine (QDSA)

2) HETERO-EVALUATION:

Scale of hétéro-evaluation or behavioral:

Dr. Bourreau: “The repercussion of a pain on the behavior is indisputably the most objective indicator of the degree of handicap, disability and thus of severity of the pain”.

a) Scale pain child of Gustave Roussy:

• Validation in the child

• Direct Signs of the pain

• Voluntary Expression of the pain

• Psychomotor Lifelessness

• Repercussion on the sleep and the food

b) Roast evaluation of the pain of the USP of the Valley of Azergue:

3 moments of the day.

3) AT THE OLD SUBJECT:

a) Doloplus scale:

• Somatic Repercussion

• Psychomotor Repercussion

• Psychosocial Repercussion

b) ECPA:

Three groups of signs:

• Effect on the activity

• Observation apart from the care

• Observation during the care

4) CONCLUSION:

a) Limits:

• Absence of validation

• Heaviness of the scales

b) Advantages:

• Merit to exist

• Sensitizing of the doctors and the looking after teams

E - TREATMENT OF THE PAIN:

1) GENERAL RULES OF REGULATION:

• To identify the type of pain

• To prevent the pain on all the nycthémère

• To use the simplest routes of administration

• To choose the drug adapted best

• To prevent the side effects

• To adapt posology to the age and the state of the patient

• To evaluate the treatment and to readjust it

• To know the medicamentous interactions and the precautions for use

• To ensure an assumption of responsibility of good quality

2) THERAPEUTIC STRATEGY ACCORDING TO WHO:

a) Analgesics not opioïdes ± auxiliary: stage I

• Paracetamol: every 4 hours

• Aspirine

b) Weak analgesics opioïdes ± auxiliary: stage II

• DI-ANTALVIC

c) strong Analgesics opioïdes ± auxiliary: stage III

• Morphine: MOSCONTIN

3) AUXILIARY TREATMENTS:

• Corticoids

• AINS

• Antidepressants

• Antibiotic

• Myorelaxants

4) NIGHT CATCH:

Double dose the evening to cover the night.

5) PAINS OF DESAFFERENTATION:

a) Association with morphine:

Certain schools say that that is not used for nothing.

b) Antidepressants type ANAFRANYL:

Go for the fulgurating pains.

c) Antiépileptiques:

• RIVOTRIL

• TÉGRÉTOL

For the continuous pains.

D) Nerve sedatives:

• NOZINAN

Pains post-shingles Taken of load +++

F - MORPHINE DOES NOT KILL:

Prescribed well:

• It relieves the patient

• It keeps it conscious and lucid

It does not cause, at the patient who suffers:

• Nor dependence

• Nor habituation

• Nor respiratory depression

a) Presentation:

Potion.

Phials to be taken orally.

Forms with prolonged release: gélules.

b) Two manners of starting:

- > Potion: 2,5 to 5 Mg Revaluation at the end of 8 h.

Increase by stages of 1/2 amounts.

- > LP: 20 Mg 2 times per day

c) Characteristics:

Paroxysm: interdose of 10% of the daily amount.

Before the potentially painful gestures.

d) Equivalence:

In under-cut: 1/2 of posology per bone uninterrupted or discontinuous.

IV: 1/3 per bone uninterrupted.

e) Side effects:

• Constipation: dependent amount.

Systematic prevention (risk of fécalome)

• Sedation

• Nauseas: less than at the young subjects

• Respiratory Depression

• Confusion, hallucinations: rare. Nothing to make

• Retention of urine

• Oral Dryness: care of mouth if the patient cannot drink any more

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