palliative care nursing

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ROLE OF A NURSE INPALLIATIVE CARE

Jhessie L. Abella RN RM MAN


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Symptoms at the Endof Life

Pain 84% 67%

Trouble breathing 47% 49%

Nausea and vomiting 51% 27%Sleeplessness 51% 36%

Confusion 33% 38%

Depression 38% 36%

Loss of appetite 71% 38%

Constipation 47% 32%Bedsores 28% 14%

Incontinence 37% 33%

Seale and Cartwright, 1994


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FLORENCE THE FIRSTPALLIATIVE CARE NURSEFlorence Nightingale

herself stated:

I use the word nursing for

want of a better. She went

on to say:' The very

elements of nursing are allbut unknown

(Nightingale, 1860).


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DEFINING PALLIATIVE CAREPalliative care is an approach that

improves the quality of life of patients and

their families facing the problem associatedwith life-threatening illness, through the

prevention and relief of suffering by means

of early identification and impeccable

assessment and treatment of pain and otherproblems, physical, psychosocial and

spiritual.

WHO


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WHO Definition ofPalliative Care Provides relief from pain

Affirms life and regards dying as a normal process

Intends to neither hasten nor postpone death

Integrates the psychological and spiritual aspects of

patient care

Offers supports system to help patient live as actively as

possible until death

Offers supports system to help the family

Will enhance quality of life


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PALLIATIVE CARE


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PALLIATIVE CARE GOALIts goal is much more than comfort

in dying; palliative care is about living,

through meticulous attention to controlof pain and other symptoms,supporting emotional, spiritual, andcultural needs, and maximizing

functional status


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PALLIATIVE CARESETTINGS

anywhere


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VIRGINIAS DEFINITION OFNURSINGThe most succinct and relevant to palliative

care is Virginia's definition of nursing;

Nursing is primarily assisting the

individual in the performance of those

activities contributing to health andits recovery, or to a peaceful death.


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Dying Persons Bill of Rights

I have the right to be treated as a living human being until Idie.

I have the right to maintain a sense of hopefulness however

changing its focus may be.

I have the right to be cared for by those who can maintain asense of hopefulness, however changing this might be.

I have the right to express my feelings and emotions about

my approaching death in my own way.

I have the right to participate in decisions concerning mycare.


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I have the right to expectcontinuing medical and nursing attentioneven though cure goals must be

changed to comfort goals.I have the right not to die alone.

I have the right to be free from pain.

I have the right to have my questionanswered honestly.

I have the right not to be deceived.


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I have the right to have help from and for my family inaccepting my death.

I have the right to die in peace and dignity.

I have the right to retain my individuality and not be judged

for my decisions which may be contrary to beliefs of others.

I have the right to discuss and enagage my religious and/or

spiritual experiences, whatever these may mean to others.

I have the right to expect that the sanctity of the human

body will be respected after death.

I have the right to be cared for by caring, sensitive,

knowledgeable people who will attempt to understand my

needs and will be able to gain some satisfaction in helping

me face my death.


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Most Common Condition inChildren Birth defects

Heart defects

Certain cancers, such as leukemia, brain and

neurological cancers, bone cancers and lymphoma Cystic fibrosis

Muscular dystrophy

Cerebral palsy

Sickle Cell Anemia

Spina bifida

Liver disease

Kidney disease


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Domains of Palliative Care

Advance care planning

Physical and emotional comfort

Social, bereavement, and spiritualsupport

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Advance Care Planning

Understand Values of the Person

What makes life worth living

Quality vs. prolongation of life

Concerns over illness, suffering, control,alertness, family, death

Religious or spiritual concerns

Understand Legal Requirements

Statutes and requirements vary by state

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Advance Directives are a way for you to make

decisions regarding health carein advance. This document

allows people to plan their health

care before they becomeincapacitated, or unable to make

sound decisions for themselves.


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Process of Advance CarePlanning

Step 1: Introduce the Topic

Define ACP process and philosophy, determinecomfort level with discussion, determine

competence and desire to name an agent

Step 2: Structure Discussions

Discuss preferences and wishes and explore anyinconsistencies

Step 3: Document Preferences

Document thoroughly and review frequently

Update as needed7


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Assessment & Management

of Symptoms

Physical symptoms may include pain,nausea/vomiting, diarrhea, constipation, itching,shortness of breath, lack of appetite, and others

Attend to self reports and behavioral cues

Manage symptoms

Assess frequently and communicate with appropriateprofessionals

Develop an ongoing plan of care focused on maximizingcomfort

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ain Pain defines it as an unpleasant sensory

and emotional experience associated withactual or potential tissue damage.

McCaffery, a nurse and leader in the painmanagement field, has a more usefuldefinition for nurses. She says,

:Pain is whatever the person experiencingit says it is and exists whenever he says

it does.


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Autonomic NervousSystem Responses to Pain Sympathetic Nervous System Responses

Blood pressure

Pulse rate

Respiratory rate

Dilated pupils

Perspiration

Pallor

Parasympathetic Nervous System Responses Constipation

Urinary retention


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CH R CTERISTIC CUTE CHRONICTime Limited, short duration

Lasts 3-6 months, longer

duration

Purpose Sign of tissue injury No purpose

Verbal Reports pain, focuses on painNo report of pain unless

questioned

Behavioral

Restless, thrashing, rubbing

body part, pacing, grimacing,

and other facial expressions ofpain

Tired-looking, minimal

facial expression,

quiet, sleeps, rests,

attention on other

things

PhysiologicIncreased heart rate, blood

pressure, respiratory rate

Normal heart rate, blood

pressure, respiratory

rate

Interventions

Responds to analgesicsLess responsive to

analgesics

Standard doses effectiveHigher doses needed for

pain relief

Parenteral or oral route used Oral route preferred

Additional drugs (adjuvant) Additional drugs often


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INTERVENTION COMMENTSPHYSICAL

Heat, cold, massage, transcutaneous electrical

nerve stimulation (TENS)

Increase pain threshold, reduce muscle spasm, and

decrease congestion in injured area. Effective in

reducing pain and improving physical function.

Techniques require skilled personnel and special

equipment. May be useful as adjuncts to drug

therapy.PSYCHOLOGICAL

Relaxation

Jaw relaxation Effective in reducing mild to moderate pain and asan adjunct to analgesic drugs for severe pain.Progressive muscle relaxation

Simple imagery Use when patients express an interest in relaxation.Requires 3-5 minutes of staff time for instructions.

Music Both patient-preferred and easy listening music

are effective in reducing mild to moderate pain.Imagery Effective for reduction of mild to moderate pain.

Requires skilled personnel.

Educational Instruction

Effective for reduction of pain. Should include

sensory and procedural information and be aimed

at reducing activity-related pain. Requires 5-15minutes of staff time.


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Relation Techniques1. Breathe in slowly and deeply.2. As you breathe out slowly, feel yourself beginning to relax; feel the tension

leaving your body.

3. Now breathe in and out slowly and regularly at whatever rate is comfortable for

you. You may wish to try abdominal breathing. If you do not know how to do

abdominal breathing, ask your nurse for help.

4. To help you focus on your breathing and to breathe slowly and rhythmically, do

the following:

a.Breathe in as you say silently to yourself, in, two, three.

b.Breathe out as you say silently to yourself, out, two, three.

c.Each time you breathe out, say silently to yourself a word such as peace

or relax.

5. You may imagine that you are doing this in a position and a place you have

found very calming and relaxing, such as lying on a beach in the sun.

6. Do steps 1 through 4 only once, or repeat steps 3 and 4 for up to 20 minutes.

7. End with a slow, deep breath. As you breathe out, say to yourself, I feel alert

and relaxed.


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Nausea and Vomiting There are several causes of nausea and

vomiting. Noxious odors, tastes, or sights cansometimes trigger this response. Certainmedications such as opioid analgesics (narcoticpain medications),NSAIDs, antibiotics, andchemotherapeutic agents can cause nausea aswell. Physical changes in the gastrointestinaltract such as constipation or a bowel

obstruction are yet other examples of causes.Because treatment of nausea and vomiting canlargely depend what's causing it, your healthcare provider will do a thorough assessment to

try to determine the cause.


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Social, Bereavement, and

Spiritual SupportMeeting the needs of the dying person

Offering hope

Providing comfort

Assuring community

Maintaining meaning

Sustaining dignity Limiting fears of abandonment

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Social & Spiritual Support

Nursing

Assist with hygiene, dignity, and privacy;maintain open communication with individual andfamily; encourage family involvement in care

Social Services

Coordinate family support; engage communityservices; assure wishes are congruent with

advance directives and resolve any conflictsDietary

Arrange meals for family; provide comfort foods;liberalize diet; provide extra fluids for person

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Social & Spiritual Support

Activities Offer pet therapy, reminiscence, aromatherapy,

music therapy, gardening, and visits fromchildren as desired

PT/OT Assist in maintenance of independence and

comfort; consult on positioning, safety issues,and pressure ulcer care

Community

Involve hospice, local clergy, and volunteers

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Moment of Death

Develop approaches to ensure that death doesnot occur alone

Maintain on call system-- family, staff, and

volunteers to spend time with those activelydying

Support family members at time of death

Assume care of and show reverence for the body

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Bereavement Support forSurvivors

Sympathy cards

Pamphlets on grief and loss, referral tocommunity services

Memorial services Bedside services

Flowers and cards in reception area

Angel tree, memorial garden, or otherremembrance area

Follow-up call or letter to family

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Communication skills

Physical care skills

Psychosocial skills Teamwork skills

Intrapersonal skills

Life closure skills

(BECKER 2009)

PALLIATIVE CARE COMPETENCIES


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COMMUNICATION SKILLSThe ability

to field and respond to sometimes profound or rhetoricalquestions about life and death

to know when to say nothing, because that is the mostappropriate response;

to use therapeutic comforting touch with confidence;

to challenge colleagues who may wish to deny patientsinformation; and, perhaps

to discuss the imminent death of a relative with families.


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TEAM WORK SKILLSThe growth of the

nursing role within

these teams has

been dramatic and

continues to

represent a much-

admired model of

working (Cox andJames, 2004).


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PHYSICAL CARE SKILLS the knowledge and skills necessary to deliver

active, hands-on care in whatever settingthroughout a long period of illness.

observational skills and the intuitive ability torecognize signs

advising doctors of the appropriateprescription and dosage to manage pain

the advocacy role nurses have towardspatients at a time of extreme vulnerability.


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PSYCHOSOCIAL SKILLS

An ability

to work with families, anticipating their

needs,

putting them in touch

with services and

supporting them

when appropriate


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INTRAPERSONAL SKILLSNurses need to recognize and attempt to

understand personal reactions that occur as a

natural consequence of working with dying and

bereaved people, and to be able to reflect on

how this affects care given in sensitive

situations.

It is the most challenging of all competencyareas and plays a significant part in the

professional growth of those who choose to

work in this field

Becker and Gamlin


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LIFE CLOSURE SKILLS This area is concerned with nursing behaviours

and skills that are crucial to patients and

familiesdignity, as they perceive it, when life is

close to an end and thereafter.

Such care has been described as sacred work,

in which the nurse enters into the patients

intimate space and touches parts of the body

that are usually private


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PALLIATIVE CARE PLANPalliative care plan includes

-care goals

-symptom management-advance care planning

-financial planning

-family support

-spiritual care

-functional status support andrehabilitation

-co morbid disease management


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SUFFERING

EMOTIONALPSYCHOSOCIAL

PHYSICAL

SPIRITUAL

MULTIDIMENSIONALITYOFSUFFERINGS


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COMMON SYMPTOMS Fatigue

Pain

Nausea Vomiting

Insomnia

Dyspnea

pyrexia

Anorexia; cachexia

Impaired mental

status

Dry mouth

Constipation

Diarrhoea

Fever


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MANAGING PAIN Assess the multi dimensions of pain & determine the

type of pain

Employ a assessment scale

Use WHO ladder

Administer around the clock doses and break throughdoses

Seek the help of appropriate alternative therapies

Continue evaluating pain control and pain status


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DYSPNEA Address the anxiety with assurance and

relaxation techniques

Maintain saturation above 90% withsupplemental oxygen

Suctioning is generally not indicated

Administer 5-10mg of morphine q4h if thepatient is not on opioids


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P t ti l P lli ti C


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Potential Palliative Care

Interventions

Control of

Pain

Dyspnea

NauseaVomiting

Support

Emotional

Spiritual

Psychosocial

CPR

Ventilation

Highly

burdensome

Interventions

InfectionsTransfusions

Hypercalcemia

Dialysis

Tube Feeding

PalliativeGenerally

Not Palliative

Variable


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PALLIATIVE SEDATIONIntermittent sedation for relief of intractable

symptoms when they are not controlled even with

aggressive measures.

- it is different from assisted death as it is not

intended for death yet often foreseen

- sedative dose is not a killing dose


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SPIRITUAL CARE Assess the desire for spiritual counseling and

support

Obtain information regarding significantreligious rituals, beliefs and practices

Encourage their practice to the extent possible

Foster the insights

Spiritual coping strategies enhance self

empowerment


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SUPPORTING FAMILY Assess family structure, functioning, strengths and

weaknesses, knowledge deficits.

Encourage communication among family members

Respect their privacy and accept the coping styles

Conduct meetings to review the goals and decisions

Teach care giving skills to the primary caregiver

Assist throughout grieving process and in bereavement


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ADVANCED CARE PLANNING

Living wills

Health power of attorney A completed patient values history


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palliative care nursing

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