In the last post we recommended that nurses use a standardized tool to assess patients receiving end-of-life care. Regular assessment identifies changes in the patient’s condition more reliably and effectively than using an ad hoc approach. The patient’s input as well as the inmate’s caregiver or hospice volunteer should be sought. A nursing assessment includes observation and evaluation of the patient’s cognition and functional ability. The nurse should note any new or worsening symptoms and communicate these to the treatment team.
The treatment plan should anticipate symptoms and side effects expected in the patient’s near future and include order sets or treatment algorithms that nurses can use to responsively manage symptoms. Patients will experience these symptoms long before they require inpatient care and nurses can provide advice that will help inmates manage these symptoms while they are still able to live in general population. The following paragraphs describe what nurses can do to relieve common symptoms that patients with terminal illnesses will experience.
Pain is one of the symptoms that the treatment plan for any patient receiving end-of-life care should anticipate. It is the most common symptom and will increase with time. An incremental yet aggressive approach to control pain with use of analgesics and other medications is recommended. Nurses have a key role in educating patients about pain control, what to expect, and how it can be managed with the patient’s active engagement. This discussion should also elicit the patient attitudes and expectations about pain because these will influence the experience as well. The nurse should also identify the patient’s preferences and experience with non-pharmacologic measures that can be employed to manage pain and include these in the plan of care as well. More information about pain management in the correctional setting can be found in Chapter 13 of the Essentials of Correctional Nursing.
Fatigue is another common symptom and will increase with time. Nursing care to address fatigue includes ensuring the patient has assistance to carry out activities of daily living. Activities should take place according to the patient’s preference, if at all possible, so that as fatigue sets in less important activities can be eliminated. Helping the patient to schedule the day to ensure that there is time to rest between periods of activity, encouraging mild exercise and improving the sleep environment also can address symptoms of fatigue.
Insomnia is often the cause of a related symptom, drowsiness. Nurses can assist by counseling the patient to maintain a regular sleep and wake schedule, to engage in exercise as tolerated and how to improve the sleep environment. Teaching the patient relaxation techniques such as the use of imagery or deep breathing also can assist the patient with insomnia. Finally explore with the patient possible underlying causes (spiritual crisis, fear of incontinence or nightmares) which may suggest additional avenues to deal with the symptom. Patients who exhibit daytime drowsiness should be assessed for risk of falling and protective measures put in place to prevent falls. Some drowsiness may be an early side effect of medication rather than insomnia, if so monitor the patient closely to see if symptoms resolve or seek a change in prescription.
Nausea may be caused by the disease itself or it may be the result of treatment. An episode of nausea may be resolved initially by a day of clear liquid nourishment and then a bland, low fat diet. Nursing measures that will comfort the patient with ongoing nausea include: elevating the head of the bed, having the patient wear loose clothing, avoiding orders that trigger nausea, avoiding food that is difficult to digest, providing frequent small meals and mouth care, keeping the room temperature comfortable and increasing the air circulation. Finally teaching relaxation techniques can assist the patient to manage the symptom. These include breathing, use of imagery and music.
Loss of appetite can be addressed by providing food and beverages that the patient prefers, providing frequent small meals and mouth care, minimizing odors that suppress appetite and providing pleasant or diversionary activity while eating. Nurses can help patients to rest before and after eating. Loss of appetite is a sign of impending death and important to report to the treatment team so that the patient can be supported without undue pressure to take nourishment.
Shortness of breath can be addressed by positioning the patient in a sitting position with arms resting on a table, cooling the room temperature, using a humidifier, increasing air circulation in the room and counseling the patient to breathe through pursed lips. If the patient is on oxygen and complains of dyspnea mechanical problems with the oxygen delivery system should be investigated. Teaching relaxation techniques can assist the patient to manage is symptom also. These include use of imagery, massage and music.
Anxiety and restlessness can result from the patient’s experience of these symptoms, the disease itself or from treatment of the disease. The first nursing actions are to reassure the patient, have someone stay with the patient if possible and to make sure that the patient has the things that help them manage their ADLs such as eyeglasses, dentures hearing aids etc. Other nursing actions that can reduce anxiety include reducing sensory stimulation, re-orienting the patient to their environment, restoring the patient’s daily routine if necessary, providing a distracting activity such as reading, card playing, or television. Nurses should also explore whether the patient is experiencing a spiritual crisis or concern that I causing anxiety and make a referral for pastoral or other counseling.
For more on nursing and end-of-life care in the correctional setting see Chapters 8 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.
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