rosdahl and kowalski textbook of basic nursing
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Rosdahl and Kowalski TEXTBOOK OF BASIC NURSING. Ch. 100 Hospice Nursing. Evolution of the Hospice Movement. *Hospice : philosophy of care Hospice programs care for terminally ill persons, while treating them with dignity. - PowerPoint PPT PresentationTRANSCRIPT
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Rosdahl and KowalskiTEXTBOOK OF BASIC NURSING
Rosdahl and KowalskiTEXTBOOK OF BASIC NURSING
Ch. 100
Hospice Nursing
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Evolution of the Hospice Movement Evolution of the Hospice Movement
• *Hospice: philosophy of care
• Hospice programs care for terminally ill persons, while treating them with dignity.
• The goal of hospice care: to provide as much pain relief as possible, while helping the client to meet basic needs.
•
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Sample Criteria for Admission to a Hospice
Sample Criteria for Admission to a Hospice
• *Dx of progressive, terminal illness
• Control of symptoms is primary goal after determining no curative treatment is available*
• Life expectancy of no more than 6 months
• DNR/I order
• Many hospices admit people with cancer, as well as other diagnosis such as HIV/AIDS*
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Goals of Hospice Goals of Hospice
• Hospice care focuses on four areas of human needs
– Physical
– Psychological/emotional
– Social/cultural
– Spiritual
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Key ConceptKey Concept
• A hospice program may be located in a place other than the client’s home.
• For example, a number of hospices have been established in prisons.
• The National Prison Hospice Association (NPHA) has been instrumental in developing these programs for prison inmates. Locations include Texas, Connecticut, and Angola Prison in California.
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Characteristics of a HospiceCharacteristics of a Hospice
• Centrally administered, autonomous program
• **Goal is intensive palliative not curative care
• *Major unit of care is the client and his or her family
• Team members should practice interdisciplinary care.
• Support for hospice staff as well as client’s caregivers
• Services extended to the family during the time of bereavement (Medicare requires a 1-year follow-up.)
• Services based on client’s physical needs, not financial resources
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Key ConceptKey Concept
• The hospice concept incorporates control of physical and psychological symptoms, continuous access to medical and nursing services, trained caregivers, and bereavement support for survivors
• *Assessment and treatment of pain and other symptoms, assist with patient-centered communication and decision making and coordination of care.
• *pain management is a vital component
• Cure is not the goal—the focus is on relief and comfort. Hospice attempts to make the dying process an experience of coming together for clients and families.
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Service Coordination Service Coordination
• Hospice staff members coordinate a client’s care in the client’s home for as long as possible.
• Funding
– Private insurance, Medicare and Medicaid assistance
– Services usually covered on a per-diem (by the day) basis
• Equipment
– Durable medical equipment is also covered by third-party payors.
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Symptom Management Symptom Management
• The client, the family caregivers, and hospice team plan together to manage pain and other symptoms.
• Clients usually discontinue radiation therapy or chemotherapy before admission to a hospice.
• Hospice clients are often encouraged to designate
– Do Not Resuscitate (DNR)
– Do Not Intubate (DNI)
– Do Not Hospitalize (DNH)
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Client and Family as Care Unit Client and Family as Care Unit
• Initial home visit by an RN
• Other hospice team members make most of the home visits.
• Team members assist family members
– Funeral planning and plans for the future
– Refer clients for writing a will and financial planning
– Support groups
*Compassion Fatigue-natural stress reaction, may result in the inability to care for loved one
S/S-hoplessness, difficulty concentrating, suicide
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Respite CareRespite Care
• Respite: caregivers occasionally “take a break”
– Usually for a period less than 30 days*
• Several way to give family a break
– Admit client to inpatient hospice, hospital, or nursing home
– Arrange for supplemental home care for a few days
• Cost of respite care is often covered by third-party payors
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Interdisciplinary Care Interdisciplinary Care
• Interdisciplinary team (IDT) or group (IDG)
– Physicians, nurses, medical social workers, therapists (occupational, physical, speech, respiratory, massage), clergy, bereavement coordinators, dietitians, pharmacologists, home health aides, homemakers, and volunteers
– Nurse role-maintain a sense of humor *
• A plan of care (POC) is established for each client; input is obtained from the client, the primary caregivers, and members of the IDT.
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Interdisciplinary Care, cont.Interdisciplinary Care, cont.
• Role of primary caregivers
– Identify changes in the client’s condition that might not be noticeable to others
– Suggest approaches to care that meet with everyone’s approval
– *Provide a constant liaison between the client and the hospice team
– Perform some functions of daily care
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Interdisciplinary Care, cont.Interdisciplinary Care, cont.
• Role of volunteers
– Provide emotional support, run errands, assist with physical care, provide short periods of respite, and help with child care and household tasks
– Assist families to share their feelings
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Interdisciplinary Care, cont.Interdisciplinary Care, cont.
• Role of on-call services
– Services of hospice staff are available 24 hours a day
– Staff members answer questions or concerns with reassurance and assistance.
– Staff members may make home visits at any time to help families deal with physical or emotional problems, and they come when the client dies.
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Emotional SupportEmotional Support
• Fears of the client
– Being alone when dying
– Having uncontrolled pain
• Family needs to let client know
– That they care
– That they are sad about the situation
• Family members also need emotional support
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Spiritual SupportSpiritual Support
• Most hospice teams have chaplains available for consultation.
• Various religious groups have different rituals and procedures related to illness, death, and care of the body after death.
• Hospice team
– Determine the desires of the client and family early in the process and follow these requests
– Consult with the client’s religious advisor
– Respect each client’s cultural and religious customs
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Bereavement Care Bereavement Care • *Bereavement (grieving) is part of the process of
dealing with a loved one’s death.
• Hospice members
– Attend funeral services
– Urge family members to talk about their loved one, reminisce about the person, share their feelings, and to work through their grief
– Make home visits*
– Encourage families to attend grief support groups, both before and after the client dies
– *Follow-up for a full year after a client’s death
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Support for Hospice Staff Support for Hospice Staff
• Hospice staff members need emotional support
– Support groups or other outlets must be available.
– Grieving when clients die is normal and acceptable.
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Assisting the Client to Meet Basic Needs Assisting the Client to Meet Basic Needs
• The hospice nurse
– Helps clients to meet basic needs
– Does not provide a great deal of direct physical care
– Focuses on identifying the needs of the client and family
– Case manager coordinates the client’s care with other members of the team and with the family
– Major role in symptom control
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Oxygen and Airway Oxygen and Airway
• Assisting in respiratory distress
– Maintain a patent airway**
– Stress reduction and position change
– Arrange for air to circulate or cool the room
– Elevate the head of the bed
– Assess vital signs, level of consciousness frequently
– Thoracentesis, medications
– Postural drainage, nebulizer treatments
• Assisting in seizures
– Anti-seizure medications
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Nutrition and Hydration Nutrition and Hydration
• Anorexia
– Encourage clients to eat or take fluids
• Most studies show people benefit from low oral intake**
– Appetite-stimulant medications may help
– Provide frequent, small meals and snacks
– Ensure the client receives good mouth care before and after meals
– Vitamins, tranquilizers, antidepressants, antiemetics
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N/VN/V
• Nauseated clients should lie on their right side
• Relaxation techniques
• Antiemetics
– Dolasteron mesylate (Anzemet)*
• Carbonated beverages
• Dry food
• Ice chips
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Symptom Control in Hospice Care Symptom Control in Hospice Care
Refer to Important Medications 99-1.
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Nutrition and Hydration, cont. Nutrition and Hydration, cont.
• Dehydration
– Assess for and report dehydration and complications
– The physician, together with the client and family, can determine appropriate treatment (if any) for dehydration or electrolyte imbalance.
– Alleviate dryness of the mouth by using ice pops, ice chips, drops of water, or allowing client to suck on a wet washcloth or a piece of hard candy.
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Elimination Elimination
• Diarrhea
– Follow the primary healthcare provider’s order for specific treatment.
– Low-residue diet lessens stimulation
– Eliminate specific foods causing gas or cramps.
– Encourage clients to drink a variety of fluids.
– Ensure good skin care around the rectum
– Remind caregivers to wear gloves.
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Elimination, cont. Elimination, cont.
• Constipation
– Determine if a bowel obstruction exists
– Encourage a high-residue diet if tolerated
– Provide mild laxatives or suppositories if necessary.
– Bowel regimen
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Key ConceptKey Concept
• Sometimes, clients think they are constipated because they are not having daily bowel movements.
• Teach them that a bowel movement every 2 to 3 days is common because of physical inactivity and low oral intake.
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Sleep and Rest Sleep and Rest
• Insomnia and hypersomnia
– Assist the client to sleep by providing comfort measures.
– *Soft music, relaxation tapes, self-hypnosis and guided imagery
– Depressed clients often sleep too much (hypersomnia).
• Goal of hospice care
– Adequate sleep at night
– Maintain normal activity, as much mobility as possible during the day
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Personal Care and ComfortPersonal Care and Comfort
• Skin breakdown
– Non-intact skin can be a source of infection and pain.
– Encourage and assist client to change position often.
– Wear gloves when treating skin that is not intact.
– Keep the client’s skin clean and dry.
– Special mattresses may help prevent skin breakdown.
– Regular pain medications help client move more comfortably
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Management of Odor Management of Odor
• Disagreeable odor may embarrass clients
• To control odor
– Aerosolized sprays
– Wintergreen oil
– Charcoal filter dressing
– Mechanical air filter
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Emotional Concerns Emotional Concerns
• Depression
– Clients or family members may need treatment for depression.
– Listen with empathy and validate feelings.
– Provide antidepressant medication for clinical depression if ordered.
– Refer to a psychologist or psychiatrist if necessary
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Emotional Concerns, cont.Emotional Concerns, cont.
• Anxiety
– *Major causes
• Fear of severe pain
• Fear of being alone
• Fear of dying ALONE
• Concern about the future for their loved ones
– Clients become agitated or paranoid
• Listen and offer reassurance.
• Provide anti-anxiety medications as ordered.
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Pain Management Pain Management • Evaluation of pain
– Evaluate client’s pain and its level of interference with activities, rest, and general comfort.
– Ask client what makes pain worse or better.
– Classify pain as to its location, intensity, and severity.
– 5th v/s!!**
– *Medications are increased as pain intensity increases
– Narcotic dose may be aggressively increased if necessary-titrate up**
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Medications Used in Pain ManagementMedications Used in Pain Management
Refer to Important Medications 99-2.
Corticosteroids-appetite stimulants*
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Nursing AlertNursing Alert
• Many non-opioids are mild anticoagulants and must be used with caution.
– Evaluate respiratory function when taking opiates**
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Pharmacologic TherapyPharmacologic Therapy
• Administration routes
– *Oral medications are the first choice
• Sublingual
• Buccal
– Rectal
– Skin patch
– Subcutaneous or IV
• Saline lock/heparin lock* to avoid venipuncture
– Patient-controlled analgesia (PCA) pumps
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Pharmacologic Therapy, cont.Pharmacologic Therapy, cont.
• Around-the-clock medication administration
– Twelve-hour pain medication taken regularly
– PCA pumps
– Continuous-administration pumps
• Titration**
• Caregivers should give clients medications before pain occurs or before it increases.
• Allay fears of the caregivers about the client’s addiction to narcotics or other medications.
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Pharmacologic Therapy, cont.Pharmacologic Therapy, cont.
• Management of side effects
– Sedation
– Respiratory depression
– Dangerous lowering of blood pressure
– Constipation
– Somnolent
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Key ConceptKey Concept
• It is important to remember that hospice clients have lowered intake and activity and often have a bowel movement only every 2 to 3 days. This is normal. It is important to reassure the client and the caregivers in this case.
• People who smoke, abuse drugs and other substances, or who have been very athletic often require more medication to achieve comfort.
• People with severe liver or kidney damage may require higher dosages of pain-relieving medication.
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Psychosocial Modalities for Pain Management
Psychosocial Modalities for Pain Management
• Clients may benefit from psychotherapy, support groups, or pastoral counseling.
– Client education
– Encourage activities that distract clients from pain.
– Encourage exercise, if possible.
– Use guided imagery, self-hypnosis, guided relaxation, and visualization.
– Biofeedback technique
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Physical Modalities for Pain Management Physical Modalities for Pain Management
• Encourage clients to maintain physical activity.
• Encourage cutaneous stimulation modalities.
• Apply ice on the contralateral side
• Acupuncture and acupressure
• Transcutaneous electrical nerve stimulation
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Palliative Radiation, Medications, and Surgery
Palliative Radiation, Medications, and Surgery
• Palliative radiation
– IV injection of radioactive materials
• Medications
– Hormones
• Surgical interventions
– Temporary nerve block
– Permanent nerve block
– Ablative surgery
• debulking
– Palliative surgery
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Children in Hospice Programs Children in Hospice Programs
• Evaluate each child individually.
• Be specific in explaining death.
• Help children to understand that they have contributed to the world and family.
• Let them know they will be greatly missed.
• **Encourage family to explain death to the child in terms of their religious beliefs.
• Refer the family to a support group.
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When the Client DiesWhen the Client Dies
• Assist the client’s loved ones with end-of-life work.
• Ensure that caregivers know what to expect and what to do when death occurs.
• Instruct caregivers to call the hospice nurse when a client dies.
• Support the
• *Refer to bereavement support group
– Let family know they will continue to be involved in hospice for the next year
• Family’s wishes and assist with technical details.