Palliative Care Nursing
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Transcript of 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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Dying Persons Bill of Rights
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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Dying Persons Bill of Rights
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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