elaine bird jill dickenson - sth stage... · nursing care turning the patient’s body gently onto...
TRANSCRIPT
Elaine Bird
Jill Dickenson
Communication is Critical Consider communication difficulties & differences
Understand individual behaviour
Know individuals- cultural & spiritual concerns
Reflect as a team to ensure a consistent approach – staff
skills/own values in recognising symptoms can vary.
Knowledge of families their understanding, how they
express themselves, previous bereavement issues.
Allow time for care planning meetings
Decision Making Discussions about decisions for care & treatment are
of critical importance because of the progressive &
inevitable decline
Plan & discuss potential moral and ethical dilemmas
early - for example nutrition and hydration
Best interest – consider who should attend –plan
early
Document & communicate clearly - ambiguous
documentation can lead to inappropriate intervention
and miscommunication
Recognise Dying
Its very difficult to assess when a
person stops living with dementia &
starts dying from it
Group Work
5 minutes to discuss when would
you consider a person with a
dementia diagnosis is potentially
‘dying’ from the complications?
Indicators of End Stage Dementia Care Requires all care for activities of daily living
Unable to walk without assistance/ requires a hoist
Urinary & faecal incontinence
No consistent meaningful conversation
Vision, memory & hearing problems
Reduced dietary & fluid intake - increased risk of
aspiration, dry mouth
Weight loss
Recurrent infections
Scratching or picking at skin
Restlessness
Rigidity, facial grimacing, teeth grinding
Holistic Assessment for
individuals & their families
What do we mean by
holistic assessment
Physical Hearing & Visual problems
Pain & general discomfort
Nausea & Vomiting
Poor appetite & swallowing
difficulties
Respiratory Problems
Skin problems
Tiredness, restless increased
agitation.
Constipation & infections
Psychological
Depression & low mood
Poor sleep pattern
Disorientation/confusion
Anxiety /fear
Frustration
Grief- sense of loss
Social Worries about the future for
family
Financial burden
What's going to happen to
them
Family conflicts
Spiritual & religious Hope & creativity
To be listened to
Receive respect, honesty &
truthfulness
Religious practices, values,
cultures & beliefs associated with
dying.
Case Study 1. What are the indications that there is a
symptom problem
2. What could be the causes of the symptoms
3. What steps are you going to take to alleviate this problem
4. How & when will you review
Pain Difficult to interpret
Concerns strong analgesia causes increased
sedation & premature death
Uncontrolled pain impacts on quality of life
Assessment can be challenging even through
using recognised assessment tools
Effective care plans that are updated and identify
current pain management, moving & handling
techniques, positioning.
Importance of communication, education & team
work
Recognised Pain Assessment Charts for people with dementia
It is crucial staff consider a holistic approach to pain assessment
Pain tool chosen needs to be effective for individuals – no two people are the same.
Communication & training is critical for care team & relatives in how to use the tool
Abbey Pain Scale
PAINAD (Pain Assessment in Advanced Dementia)
Communication, Education & Documentation
Pain –the facts ‘Pain is whatever the patient says it is
and exists whenever he says it does.’
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage
Pain is NOT a normal aspect of ageing
Pain assessment is essential in the management of pain.
Nurses/carers are in the best position to assess, treat and evaluate pain
‘Pain is whatever the patient says it is
and exists whenever they says it does’ …
BUT
Many patients may not be able to:-
Communicate pain
Identify location of pain
Describe type of pain
Severity of pain
Types of Pain (will influence
medication prescribed) Soft Tissue Throbbing/tender/ache
Oedema Heavy/tight
Nerve Throbbing/burning/toothache
Raised intracranial pressure Thumping restricting
Bone Gnawing/aching
Colic Cramping/exhausting/gripping
Communication/Assessment/Evaluation
Principles in Managing Pain
Right Drug by the Ladder
Right dose by mouth/patch/injection
Right Time by clock
Clear documented evidence of description of pain
Clear documented evidence of outcomes from intervention.
Restlessness/agitation Unable to get comfortable
Scratching or picking at skin
Varying degrees of restlessness -
shouting, moaning twitching, jerking,
fidgeting, irregular breathing, plucking
at clothes/ sheets
Hallucinations
Causes Uncontrolled Pain
Dyspnoea
Retained secretions
Constipation
Urinary retention
Drugs – many drugs can cause cognitive decline, agitation, hallucinations & abnormal behaviour. Rationalise drug treatment.
Renal or liver failure.
Causes Metabolic – uraemia, hypercalcaemia,
hypoglycaemia, hypoxia from anaemia.
Infections – UTI, respiratory infections – treating
in some circumstances may be helpful in
reducing terminal restlessness
Cerebral – primary or secondary tumours
Anxiety – unresolved family conflict, denial , fear,
spiritual distress.
Withdrawal – of alcohol, narcotics or nicotine if a
heavy smoker.
Treatment Reassurance
Re-positioning
Consider reversible options – treat infection,
constipation, dehydration, medication review
Medication maybe appropriate
Benzodiazepines
Anti psychotics
Communication, Education & Documentation
Nausea
Identify the cause as this will affect treatment
Metabolic Renal Failure, Chest & Urinary Tract
Infections, Dehydration
Organic Constipation, Bowel obstruction
Medication
Psychological anxiety
Causes often unknown in EoLC
Assess, communicate, document Evaluate
Correct the correctable
Infections, medications, constipation
Non –pharmacological treatment Environmental factors posture, fresh air,
appropriate food, carers sat in the right position to
feed.
Small appetising meals
Good oral hygiene
Good bowel care – are laxatives effective or
required??
Diversional treatment- gentle music
Communication, Education and Documentation
Pharmacological treatment
If cause is gastro-intestinal poor gastric
emptying /reflux try metoclopramide, Domperidone
If cause is metabolic try haloperidol, Levomepromazine
If hyperacidity consider antacid, omeprazole, lansoprazole
If cause is psychological try lorazepam Evaluate Regularly
Respiratory Secretions
Common symptom at end of life
Distressing for resident family and
carers
Are oral antibiotics appropriate
Nursing care Turning the patient’s body gently onto their side
or turning the head to the side.
Reassure family.
Stop any fluids if not already done so if the patient is not swallowing.
Keep the mouth moist and clean
Apply lip balm.
Suctioning not recommend since this can increase distress and loosen more secretions.
Consider medication diamorphine /midazolam/buscopan