ASSESSMENT OF THE PATIENT RECEIVING HOSPICE PALLIATIVE CARE
Common symptoms experienced by the dying patient are: Pain Dyspnea Nausea Vomiting Constipation Loss of appetite Urinary urgency and incontinence Insomnia, confusion, delirium Anxiety and depression
Pain
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A subjective sensation that is influenced physical, emotional, and social circumstances. May result from a number of conditions such as tumor progression, toxicities of chemotherapy, and radiation, infection, and muscle ache. Pain assessment includes the quality of pain, onset, location, and description of the discomfort.
Visual Analogue for Pain Scale
ABCDE Guide to Pain Assessment
ABCDEask about the pain regularly. Assess pain systematically Believe the patient and family in their reports of pain and what relieves it. Choose pain control options appropriate for the patient, family, and setting. Deliver interventions in a timely, logical, and coordinated fashion empower patients and their families. Enable them to control their course to the greatest extent possible.
COMPONENTS OF A COMPREHENSIVE PAIN ASSESSMENT
1. 2. 3. 4. 5. 6.
Characterize the pain by location, quality, intensity, and duration. Describe aggravating and relieving factors Describe how the pain interferes with activities of daily living Describe the impact of the pain on your state of mind Describe responses to previous pharmacological and non pharmacological interventions Keep a diary that includes all of the above issues.
Dyspnea
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Refers to an unpleasant awareness of an increased need to ventilate, such as breathlessness or difficulty of breathing. May result from extreme fatigue, anemia, hypoxia, respiratory muscle fatigue, heart failure, anxiety, or pain.
Loss of Appetite
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A diminished or nearly lack of interest in food with early satiety. May occur from numerous underlying problems, e.g. side effects of medications, constipation, taste abnormalities, oral infection, and disease progression.
Constipation
- Often the result of the using opioid medications for pain relief. - Symptoms include hard stools, abdominal distention and pain, and increased bowel sounds.
Assessment: - note the date of the last bowel movement - stool characteristics - quality of bowel sounds - checking the rectum for fecal impaction
Nausea and Vomiting
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May occur as a result of constipation, poor gastric emptying, oral and esophageal lesions, uremia, liver failure, anxiety, or as a side effect of chemotherapy. Assessment: Note the abdominal tenderness Auscultate bowel sounds Date and consistency of last bowel movement Contents and color of vomitus
Urinary Urgency and Incontinence
Assessment: Subjective report of: -urinary urgency -nocturia -incomplete bladder emptying -dysuria Localized abdominal pain Fullness or tenderness of suprapubic areA Fecal impaction
Insomnia, Confusion and Delirium
Insomnia difficulty falling asleep at night, wake up without intention during the night, wake up prematurely from sleep. Confusion and Delirium Assessment: - Note the patients reality orientation - Interaction with others in environment - Complaints of insomnia - Delusions or hallucinations
Anxiety and Depression
Assessing anxiety: - Insomnia - Tremors - Palpitations - Irritability - Restlessness - Appetite change - Decreased ability to concentrate Decreased appetite, fatigue, and insomnia are physical indicators of depression.
NURSING DIAGNOSES
Pain Ineffective airway clearance Constipation Nausea Disturbed Sleep Pattern Acute Confusion Anxiety Ineffective Coping Disturbed Thought Processes
Nursing Diagnoses related to patients caregiver:
1.) Caregiver Role Strain the caregivers felt difficulty in in performing the family caregiver role. Level of readiness of a caregiver: -willingness to assume the role -knowledge about the role -knowledge of the disease process -knowledge of the treatment regimen -confidence in the ability to manage care at home -knowledge of equipment operation
2.)Anticipatory Grieving
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The intellectual and emotional responses and behaviors by which individuals work through the process of modifying self-concept based on the perception of potential loss. Expected outcome is grief resolution -ability to express feelings about loss -verbalize acceptance of the loss -describe the meaning of the death -participate in planning the funeral -share the loss w/ significant others
IMPLEMENTATION
Complementary and Alternative Medicine (CAM) - Involves those therapies that have a focus beyond specific symptom management. MANAGING PAIN Principles of Pain Management: 1. Using the simplest dosing schedules and least invasive routes. 2. Using the right drug for the specific type of pain experienced 3. Anticipating, preventing, and treating side effects 4. Giving medications for persistent pain around the clock 5. Respecting individual differences in the treatment plan
Severe Pain
Strong opioids + adjuvant agents
Mild to Moderate
Opioid-acetaminophen Combination +adjuvant agents
Mild Pain
Nonopioids around the Clock + adjuvant agents
Tolerance a physiological state characterized by a decrease in the effects of a drug that results in the patient requiring a higher dose. Physical Dependence the body becomes dependent on the opioid. It can be expected within two to three days of initiating an opioid. Addiction is a psychological dependence on medication exhibited by a craving for the mood altering effects of medication.
Withdrawal Symptoms:
Anxiety Irritability Chills Joint pain Lacrimation Rhinorrhea Diaphoresis Nausea Vomiting Diarrhea Abdominal cramps
Barriers to Pain Management
Problems Related to health Care Professionals Poor assessment Concern about regulation of controlled substances Fear of patient addiction Concern about side effects of analgesics Concern about patients becoming tolerant to analgesics
Problem Related to Patients and Family Caregivers
Reluctance to report pain Concern about distracting the health care provider from treatment of underlying disease Fear that pain means the disease is worse Concern about not being a good patient Reluctance to take pain medication Fear of addiction or of being thought as an addict Worries about unmanageable side effects Inadequate knowledge of pain management Concern about becoming tolerant to pain medications
Nonpharmacological options:
Physical therapy Use of heat or cold treatment Distraction humor
Managing Dyspnea
Place the patient in a semi-fowlers position Allaying anxiety Providing a cool mist vaporizer Keeping the room temperature cool Administer medications to control dyspnea
Managing Loss of Appetite, Constipation, Nausea and Vomiting
NI for GI symptoms: Eliminating odors Minimizing movement by the patient Supplying an emesis container within reach Providing oral hygiene Circulating room air Administering pharmacological agents Providing small frequent feedings Elevating the head of bed Note the color and consistency of foods most appealing to the patient or best tolerated by patient
- Give medications that can be given prior to meals that improve the appetite. - give yogurt or nystatin for cases of oral thrush -
Constipation
Administer stool softeners and stimulants Increase the fluid intake Increase bulk or fiber in the diet
Nausea Administer medications - drugs that act on chemoreceptive trigger zone - gastrokinetics - antihistamines - anxiolytics
Managing Urinary Urgency and Incontinence
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Placing an indwelling urinary catheter Administer medications Changing the diuretic regimen
Managing Insomnia, Confusion, And Delirium
Reverse the day-night sleep patterns by allowing the patient to be as active as possible during daytime hours. Hypnotic drugs Provide a quiet environment and eliminate unnecessary stimuli. Speak clearly in simple short sentences, and focus on the present Well lit surroundings during daytime hours Place familiar objects in the environment and safety measures. Medications: Haloperidol, diphenhydramine, chlorpromazine
Managing Anxiety and Depression
Explore the patients concerns and encourage them to express those concerns. Help patient use coping strategies that have been helpful in the past, non-pharmacological interventions. Drug therapy- beta adrenergic blockers id patient has somatic symptoms.
