Hospice Palliative Care-Assessment

8/4/2019 Hospice Palliative Care-Assessment

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ASSESSMENT OF THE PATIENTASSESSMENT OF THE PATIENT

RECEIVING HOSPICE PALLIATIVE CARERECEIVING HOSPICE PALLIATIVE CARE

Common symptoms experienced by the dying patientare:

� Pain

�

Dyspnea� Nausea

� Vomiting

� Constipation

�

Loss of appetite� Urinary urgency and incontinence

� Insomnia, confusion, delirium

� Anxiety and depression



PainPain

- A subjective sensation that is influenced

physical, emotional, and social

circumstances.

- May result from a number of conditionssuch 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.



VisualVisual AnalogueAnalogue for Pain Scalefor Pain Scale



ABCDE Guide to Pain AssessmentABCDE Guide to Pain Assessment

A - ask about the pain regularly. Assess pain

systematically

B - Believe the patient and family in their reports

of pain and what relieves it.

C- Choose pain control options appropriate for

the patient, family, and setting.

D - Deliver interventions in a timely, logical, and

coordinated fashion

E- empower patients and their families. Enable

them to control their course to the greatest

extent possible.



COMPONENTS OF A COMPREHENSIVECOMPONENTS OF A COMPREHENSIVE

PAIN ASSESSMENTPAIN ASSESSMENT

1. Characterize the pain by location, quality,

intensity, and duration.

2. Describe aggravating and relieving factors

3. Describe how the pain interferes with activitiesof daily living

4. Describe the impact of the pain on your state of

mind

5. Describe responses to previous pharmacologicaland non pharmacological interventions

6. Keep a diary that includes all of the above issues.



- 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.

DyspneaDyspnea



Loss of AppetiteLoss of Appetite

- 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:Assessment:

-- note the date of the last bowel movementnote the date of the last bowel movement

-- stool characteristicsstool characteristics-- quality of bowel soundsquality of bowel sounds

-- checking the rectum forchecking the rectum for fecalfecal impactionimpaction



Nausea and VomitingNausea and Vomiting

- May occur as a result of constipation, poor gastricemptying, 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 IncontinenceUrinary 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 DeliriumInsomnia, Confusion and Delirium

Insomnia ² difficulty falling asleep at night, wake up

without intention during the night, wake up

prematurely from sleep.

Confusion and DeliriumAssessment:

- Note the patient·s reality orientation

- Interaction with others in environment

- Complaints of insomnia

- Delusions or hallucinations



Anxiety and DepressionAnxiety 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 DIAGNOSESNURSING DIAGNOSES

� Pain

� Ineffective airway clearance

� Constipation

�

Nausea� Disturbed Sleep Pattern

� Acute Confusion

� Anxiety

� Ineffective Coping

� Disturbed Thought Processes



Nursing Diagnoses related to patient·s caregiver:Nursing Diagnoses related to patient·s caregiver:

1.) Caregiver Role Strain ² the caregiver·s feltdifficulty 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 Grieving2.)Anticipatory Grieving

- 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



IMPLEMENTATIONIMPLEMENTATIONComplementary and Alternative Medicine (CAM)

- Involves those therapies that have a focus beyond specificsymptom 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



ToleranceTolerance ² ² a physiological state characterized bya physiological state characterized by

a decrease in the effects of a drug thata decrease in the effects of a drug that

results in the patient requiring a higherresults in the patient requiring a higher

dose.dose.

Physical DependencePhysical Dependence ² ² the body becomesthe body becomes

dependent on the opioid. It can bedependent on the opioid. It can be

expected within two to three days of expected within two to three days of

initiating an opioid.initiating an opioid.

AddictionAddiction ² ² is a psychological dependence onis a psychological dependence on

medication exhibited by a craving for themedication exhibited by a craving for the

mood altering effects of medication.mood altering effects of medication.



Withdrawal Symptoms:Withdrawal Symptoms:

�

Anxiety� Irritability

� Chills

� Joint pain

� Lacrimation

� Rhinorrhea

� Diaphoresis

� Nausea

� Vomiting

� Diarrhea

� Abdominal cramps



Barriers to Pain ManagementBarriers 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 FamilyProblem Related to Patients and Family

CaregiversCaregivers

� 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



NonpharmacologicalNonpharmacological options:options:

� Physical therapy

� Use of heat or cold treatment

� Distraction

� humor



ManagingManaging DyspneaDyspnea

� 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, NauseaManaging Loss of Appetite, Constipation, Nausea

and Vomitingand 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 mostappealing to the patient or best tolerated bypatient



-- Give medications that can be given prior toGive medications that can be given prior to

meals that improve the appetite.meals that improve the appetite.

-- give yogurt orgive yogurt or nystatinnystatin for cases of oral thrushfor cases of oral thrush

--



ConstipationConstipation

� 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 andManaging Urinary Urgency andIncontinenceIncontinence

- Placing an indwelling urinary catheter

- Administer medications

- Changing the diuretic regimen



Managing Insomnia, Confusion, And DeliriumManaging Insomnia, Confusion, And Delirium

� Reverse the day-night sleep patterns by allowingthe patient to be as active as possible duringdaytime 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 andsafety measures.

� Medications: Haloperidol, diphenhydramine,chlorpromazine



Managing Anxiety and DepressionManaging Anxiety and Depression

Explore the patient·s 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.

Hospice Palliative Care-Assessment

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