Nursing actions to relieve common symptoms associated with the end of life

man feeling painIn 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.

Photo Credit: © djtaylor – Fotolia.com

Nursing practice and use of non-pharmacologic measures to address chronic pain

Recently I attended a meeting of the local chapter of the American Correctional Health Services Association and heard a presentation about a program to manage chronic pain in the correctional setting.  Even though nurses deliver the majority of care in the correctional setting no nurses were involved in this program; it was a completely physician- driven model of care. It made me wonder why nurses are not collaboratively managing clinical care of patients with chronic pain. What role do correctional nurses have in addressing patient’s chronic pain?

 

The Institute of Medicine (IOM) identified pain management as an essential responsibility for nurses (Relieving Pain in America, 2011).  This responsibility is more than simply carrying out the provider’s treatment orders; it includes implementation of nursing interventions to manage and reduce a patient’s experience of pain. Interventions that are within the independent scope of nursing practice include non-pharmacologic measures to manage symptoms and assist the patient with coping.

 

The National Commission on Correctional Health Care (NCCHC) adopted a position statement October 2011 recognizing that chronic pain requires more than just determining which medications are appropriate.  The position statement emphasizes a multifaceted approach to chronic pain using a biopsychosocial model that includes evidenced based therapeutic options. The NCCHC’s position statement can be obtained at http://ncchc.org/resources/statements/chronic_pain.html. The Institute for Clinical Systems Improvement (ICSI) recommends that treatment plans for chronic pain include:

  • The patient’s personal goals regarding quality of life
  • Sleep improvement
  • Increased physical activity
  • Stress management
  • Decreased levels but not elimination of pain (2011).

 

There are a number of non-pharmacologic approaches to improve sleep, increase activity and manage stress but which ones have the best evidence to support their use?  The ICSI and the Registered Nurse Association of Canada (RNAO) are two organizations that evaluate the research and publish recommendations regarding chronic pain on a periodic basis. There is strong evidence to incorporate the following interventions into the plan of care for patients who have chronic pain. Each is within the nursing professions’ scope of practice.

 

Exercise: Exercise provides physical reconditioning, elevates mood, increases functionality and helps maintain mobility. No one type of exercise is more effective than another. Nurses can recommend, teach, coach and supervise patient exercise. No referral to a physical therapist or recreation specialist is needed. No special equipment or facility is needed.

 

Relaxation: Helpingpatients incorporate relaxation techniques into their daily life has been found to improve treatment adherence, reduce anxiety, and enhance pain tolerance. Relaxation techniques include massage, use of heat or cold, meditation, imagery, diaphragmatic breathing, autogenic training, progressive muscle relaxation and music. Relaxation decreases physical tension, increases oxygenation and circulation, lengthens and relaxes muscle fibers.

 

Cognitive behavioral change: This intervention is considered by the ICSI to be the most effective non-pharmacologic tool in managing chronic pain. Cognitive change involves restructuring the patient’s view of pain and increases the patient’s coping strategies. It involves finding ways to change habits or beliefs by experimenting with different ways to solve problems. The nurse assists the patient to develop goals for change, a plan to accomplish the goal incrementally and periodic coaching and follow up on progress.

 

The recommendations and evidence for these interventions can be found at these sites:

 

 

  • Registered Nurses Association of Ontario. (2002, Supplement 2007). Assessment and Management of Pain. International Affairs and Nursing Best Practice Guidelines Program. Toronto: Registered Nurses Association of Ontario. Retrieved 4/14/2012 at http://rnao.ca/bpg/guidelines/assessment-and-management-pain

 

Here are some great resources about non-pharmacologic approaches to pain:

 

http://www.youtube.com/watch?v=aUaInS6HIGo&noredirect=1

 

http://im4us.org/Chronic+Pain+Patient+Resources

 

http://healingchronicdisease.org/en/chronic_pain/self_care/index.html

 

http://www.mayoclinic.com/health/yoga/MM00650

 

http://www.fammed.wisc.edu/sites/default/files//webfm-uploads/documents/outreach/im/module_meditation_patient.pdf

 

Chapter 13 of the Essentials of Correctional Nursing has more discussion about the nurses’ role in managing pain and the challenges of doing so in the correctional setting.  If you would like to share your successes incorporating non-pharmacologic approaches into the treatment of patients with chronic pain please use the comments section of this post?  You may also want to attend the session on this subject at the National Conference on Correctional Health Care in Las Vegas on October 22, 2012 (registration information is at http://ncchc.org/education/national.html). If so, see you there!

Photo credit: © littleny – Fotolia.com