Fundamentals of Nursing Care Concepts Connections Skills Second
- Slides: 48
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Chapter 10 Loss, Grief, and Dying Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Key Terms Associated with Loss, Death, and Grief § Comorbidity : Multiple, simultaneous diseases § Circumoral cyanosis: Cyanosis around the mouth § Euthanasia: Assisting with patient suicide Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Key Terms Associated with Loss, Death, and Grief (cont. ) § Grief: Response to loss § Respite: Arranging care for a patient to allow caregivers time away from strain and worry § Role reversal: Occurs when children become caregivers for their parents Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nurse’s Role § Know your own feelings about death, loss, and euthanasia. § Respect for human dignity should guide ethical decisions. § Your responsibility is to prevent needless suffering. § Know that addiction is not an issue in terminally ill patients. § Medicate the patient before pain is severe. Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Curative Care § Tests to make diagnosis § Tests to assess improvement or deterioration § Administration of medications, treatments, and various therapies § All provided with the intent of healing or curing the patient’s illness Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Multiple Choice Question A patient with end-stage cancer is not expected to live more than 3 months. What type of care would be offered to this patient? A. Curative care B. Palliative care C. Hospice care D. All of the above Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Answer C. Hospice care Rationale: Hospice services do not commonly include measures meant to cure or to stop the natural process of a terminal disease and the patient is thought to be in the final 6 months of life. As the team member at the bedside, the nurse fills the role of coordinator, teacher, advocate, and manager. Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Palliative Care § Physician-directed care § Patient prognosis may be more than 6 months § Incorporates comfort measures and otherapies meant to decrease symptoms § May even include aggressive interventions § Chemotherapy, surgery, radiation § These are not for curative purposes, but rather to relieve unpleasant symptoms Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Hospice Care § Focus: Patient comfort and dignity; prevention of needless suffering; assistance to live life to the fullest extent possible; relieving fear and anxiety as death nears § Does not cure or stop the terminal disease § Patient is likely in the final 6 months of life § Provides support for both patient and family § Patient and family have a voice in directing care § Includes respite care for family Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Ethics Related to Death and Dying § Unacceptable to assist a patient with ending life (euthanasia) § Responsibility to relieve fear, anxiety, pain § With a DNR order: your first concern should be to relieve patient’s pain and dyspnea, even if it could hasten respiratory or cardiac arrest Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition If You Want to Be Effective § Deliver compassionate care to all patients § Treat the patient with respect § Honor the patient’s beliefs, feelings, and cultural and spiritual values § Relieve the patient’s fear and anxiety as death approaches § Support the patient, family, and significant others as each one truly deserves Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition How Do You Feel About Dying? § You must reflect on: § Your own beliefs, feelings, values, fears, and anxieties § How you feel about death and what comes after death § What you believe constitutes dignity and respect in life, in dying, and in death § Being honest with your answers will help you help others Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Living Until They Die § Preparing for one’s own death is not an easy task for many in our society § But most people know that they § Do not want to die in pain § Do not want to die alone § Do not want to be a burden to their loved ones Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Living Until They Die (cont. ) § Many decisions have to be made § May include an advance directive in the form of a living will or a durable power of attorney § May involve decisions about children left behind § May involve financial decisions § Decision must be made about a do not resuscitate (DNR) order § Dealing with the process of grieving, individually and as a member of other groups Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition You Have Opportunities § Improve the patient’s dying experience or journey toward death by minimizing his fears and anxiety. § Provide adequate information regarding disease process, how it may progress, and that relief of pain and most symptoms is possible. § Reassure the patient that he will have full control over plan of care and degree of pain and symptom control. § Reassure the patient that he has the right to refuse any aspect of treatment or care that may be offered. Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition You Have Opportunities (cont. ) § Reassure the patient that he owns the right to control whether he dies at home or in a health facility, and who may be allowed to be present as death approaches. § Provide for spiritual needs and any religious rituals that may offer comfort to him. § Encourage him to make reconciliation whenever possible and with whomever there is discord. § Give him and loved ones space, privacy, and time to explore their experiences and feelings. Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition You Have Opportunities (cont. ) § You may need to gently let them know these are tasks that they might want to address § Do not attempt to define these tasks or experiences for them, because they are different for each person; let patient find his or her own way; be there if needed for support § Your own faith and confidence, but especially your presence (especially if there is no family or friend who is prepared to be there) , are a gift to your patient Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Durable Power of Attorney § Legal document, does not require an attorney, can be completed anywhere, with aid of a Notary Public § Grants the authority to make health-care decisions § Acts as proxy for the patient should the patient become disabled Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition The Legal Hierarchy of Family Relationships § Legal guardian with health-care decisionmaking authority § Spouse § Adult children of patient § Parents of patient § Adult siblings of patient Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Living Will § Written document prepared by a mentally competent patient § Indicates which procedures and measures the patient does or does not want, should an endof-life condition or disability occur Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Do Not Resuscitate (DNR) Order § Order written by the patient’s physician § Nurse’s responsibility to know that should the patient’s heart and respirations cease, no cardiopulmonary resuscitation or other efforts to restart the heart and breathing should be performed Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Guidelines for DNR Order § 1960 guidelines: CPR should not be used in cases of terminal, irreversible illness § Today: CPR is the standard of care for all patients in hospitals and nursing homes unless there is a DNR order Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Documenting a DNR • The patient may sign a do not resuscitate form. • The patient’s health-care proxy can sign the form. • After consulting with the family, the physician can write a DNR order on the patient’s chart if he or she feels the clinical situation warrants. Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Losses § § § Loss of individual Loss of family roles Loss of lover, companion, best friend Loss of bread-winner Role reversal, even before death Loss of parental comforter, mentor Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Kübler-Ross’s Five Stages of Grief § § § Stage I: Denial Stage II: Anger Stage III: Bargaining Stage IV: Depression Stage V: Acceptance Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Multiple Choice Question A patient diagnosed with terminal lung cancer asks his nurse, “Why did God let this happen to me? ” This patient is in what stage of Kübler-Ross’s five stages of grief? A. Denial B. Anger C. Bargaining D. Depression E. Acceptance Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Answer B. Anger Rationale: In the anger stage the patient questions why this is happening to him or her. Key phases the nurse might hear include the following : Why is this happening to ME? Why me? It’s not fair! Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Think Back. . . § To a time when you or your family experienced a loss (related to death, illness, employment, body image, and so on). § What was your reaction to the loss? § What methods did you employ to help yourself overcome the grief? § Were other people instrumental in helping you compensate for your loss? Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition End of Life Conversations, Ira Byock, MD § § § “Forgive me” “I forgive you” “Thank you” “I love you” “Good-bye” (permission to go) Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Your Presence Can Be a Gift § Your own faith, confidence, and especially your presence, just being there if there is no family or friend prepared to do this, are a gift to your patient. Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Signs and Symptoms of End-Stage Disease § § § Anorexia Anxiety and fear Cachexia Confusion and delirium Constipation Diarrhea Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Signs and Symptoms of End-Stage Disease (cont. ) § § § Dyspnea Fatigue Nausea and vomiting Pain Sadness/depression Weakness Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Psychological, Emotional and Mental Changes Prior to Death § § § Life review Introspection and reflection Need to communicate with family and friends Confusion Conversing with dead loved ones Loss of interest in food Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Physical Changes Prior to Death § Diaphoresis and clamminess § BP↓ and P↑ and later ↓ § Circumoral cyanosis and cyanotic nailbeds § Respiratory changes: apnea or Cheyne-Stokes; “death rattle” § Restlessness § Pallor or mottling of the skin § Unresponsiveness toward the end § Incontinence Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Caring for the Dying § Is not about cures § Is less about diagnostics, vital signs, lab values § More about caring, ensuring comfort, symptom relief § More about touching and simply being there for the patient and family § More about educating and supporting the family Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Caring for the Dying: Listening Skills • • • It is more about listening and less about diagnostics Note what they say and do not say Anticipate needs and fears Ask about life work and interests Give your attention • Do not allow being busy with other patients to keep you from giving your time Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Caring for the Dying: Teaching Skills § Use little medical jargon; make conversation warm, compassionate, and human § Teach what to expect during the process § Care for nonhealing wounds § Deal with poor appetite § Find non-food ways of caring Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Caring for the Dying: Teaching Skills (cont. ) § Teach the family ways to comfort the patient Reading to the patient Giving a gentle manicure or pedicure Giving a gentle massage of the feet, hands, or head Gently brushing or stroking the patient’s hair Singing softly to the patient, especially a song that might hold sweet memories § Viewing old family photos that bring joy to the patient § § § Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Beneficial Effects of Dehydration: Teach the Family These Things § Decreased pain perception § Decreased urine output, resulting in less incontinence and less need for toileting § Decreased production of gastric fluids, resulting in less nausea and vomiting § Decreased pulmonary secretions, resulting in less need for suctioning and less respiratory distress § Diminished edema and ascites Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition What to Observe and Then Provide Comfort For § § § Pain and nausea Impaired gas exchange; air hunger Dry mucous membranes Emotional or spiritual distress Uncomfortable positioning Problems with elimination Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nonpharmacological Treatments for Pain § § § Effleurage Distraction Heat/cold applications Massage Meditation/prayer Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nonpharmacological Treatments for Pain (cont. ) § Movement and range-of-motion exercises § Music therapy § Comfort positioning, pillow support, memory -foam mattress topper § Relaxation and breathing techniques Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nonpharmacological Treatments for Nausea § § § Cool compresses to the face and forehead Deep breathing Meditation/prayer Music therapy Relaxation techniques Small sips of clear liquids at the patient’s temperature preference Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Nonpharmacological Treatments for Dyspnea § § § Fan to move the air Meditation/prayer Positioning Pursed-lip breathing Relaxation techniques Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Discussing a Terminal Condition with a Patient § Your patient is not likely to just open up and say, “I’m dying and I want to talk to you about it. ” LISTEN CAREFULLY. It may be more like: § § “I don’t think I’m going to make it. ” “I am just so tired. ” “I don’t know why God doesn’t just take me. ” “I don’t know what is happening. ” So, be empathetic and be there for the patient. Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Connection Features § § § Clinical Connection Real World Knowledge Patient Teaching Laboratory and Diagnostic Post Conference Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Safety Features § Why are the particular safety features so important that they are highlighted as safety issues? § What could happen if those safety guidelines are not followed? Copyright F. A. Davis © 2015
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition Information in the Skills Procedures § Review the steps of each of the skills procedures. § Make sure you understand why the steps are important. § What could happen if each of the steps are not followed or are followed out of order? Copyright F. A. Davis © 2015
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