Palliative Care Order Set - Stratis Health

Palliative Care
Annotations Committee on Evidence-Based Practice/May 6, 2008
19. Seizure Management
The goal of the acute management of seizures is to stop the seizure activity. Diazepam and lorazepam
are drugs that are utilized for the acute control of seizures. Once the acute seizures are under control, then
evaluation and further anticonvulsants may be initiated based on the seizure type.
Orders
Lorazepam 2 to 4 mg IV. Repeat in 15 minutes if necessary
Diazepam 5-10 mg IV or IM every 10-15 minutes up to total of 30 mg
Diazepam 0.2 mg/kg rectally. May repeat in 4 to 12 hours if necessary
(Cereghino, 2002 [B]; Collins, 2001 [R]; Pellock, 2004 [R])
20. Skin and Wound Care Management
Pressure Ulcers
Pressure ulcers may occur despite optimal care in a patient whose immunological and nutritional status is
compromised. Overall goals of care will influence specific treatment approaches. In some patients, complete
healing of pressure ulcers is an achievable outcome. Control of pain, drainage and odor are essential in all
patients.
Emphasize prevention, when possible. Assess risk with a validated tool such as the Braden Scale. Address
nutrition within the overall goals of care. Evaluate beds, chairs and other furniture the patient will use
regularly, and provide appropriate pressure-relieving surfaces where needed (Nixon, 2006 [A]). Frequently
changing the patient's position will relieve pressure on the skin, but must be balanced against possible
discomfort such movement may cause. Good perineal care to manage incontinence of urine and stool is
critical. Indwelling urethral catheters and rectal tubes may reduce skin irritation from moisture and fecal
material, particularly if open areas are already present. Because skin integrity can be compromised within
hours, caregivers must monitor the patient frequently (McDonald, 2006 [M]).
The use of doughnut-shaped cushions or devices is contraindicated for both pressure reduction and
relief.
Do not massage pressure points; this further compromises circulation to the ischemic area.
In all cases, the clinician must accurately describe the wound, using accepted staging criteria, as these
characteristics will define the best wound care regimen. The wound stage is not revised as a wound heals,
although a worsening wound is reclassified.
Pressure ulcer staging
Stage 1: non-blanchable erythema, epidermis intact
Stage 2: partial thickness loss of epidermis or dermis
Stage 3: full thickness skin loss, into subcutaneous tissue, but not involving fascia
Stage 4: full thickness skin loss, involving fascia, muscle, bone, other supporting structures
(Oxford Textbook of Palliative Care Medicine, 2004 [R])
A wound whose base is completely covered by exudate or necrotic tissue is unstageable until the material
is removed.
Pressure sores on the heels that are covered with dry eschar are unstageable.
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