Treatment provided to manage pain and alleviate suffering experienced by a person dying. Palliative care is a unique moment in life where emphasis is on the journey not the destiny. In adopting a holistic approach to care practice the nurse can support the essence of the individual by ensuring their comfort and needs are met within an environment conducive to stages of end of life living. (Harris, Nagy & Vardaxis 2006, p.1274).
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b) How does the practice of palliative care differ from acute care for the nursing staff?
Although death occurs in both practices, expectations of the client by the nursing staff would be significantly reduced in palliative care as the body is in a progressive degenerative state contrary to the acute setting where increases in body functions indicate recovery and expedite discharge (Harris, Nagy & Vardaxis 2006, p.28 p.1274).
c) What ethical issues may staff face while working in a palliative setting?
Contradictions of core values, defining and segregating personal assumptions and professional development of nursing staff would be continuously challenged in a palliative setting. Politics, global economics and organisational constraints would also impinge on ethical issues faced by staff (Johnstone 2006, pp. 130-134).
d) What personal care strategies may nurses need to employ to help them deal with the unique
stresses related to working in palliative care?
Strategies to reduce stress include regular physical exercise, maintenance of a nutritional eating plan, personal hygiene and routine sleep patterns-albeit shift work is disruptive. Acknowledge self-worth either by indulging in a regular luxury or personal time out. Participate in grieving, team de-briefing and grief counselling. Understanding human foibles and maintaining a sense of humour can improve coping skills required to deal with stress (McMurray 2005, p.101).
e) How can reflective practice be of benefit to nurses in the palliative care settings?
Observational skills are heightened when consciously aware of environment and subjectivity can increase the ability to improve outcomes by manipulation. Reflection allows for self and procedural evaluation and promotes resilience. Experience in the clinical care setting combines theory with practical knowledge which can increase coping mechanisms required by the nurse to evolve and adapt to perpetual change (Usher & Holmes 2006, pp. 100-105).
a) List three pathophysiological changes that you may observe while caring for a client in the last
few weeks or days of life care?
Three changes that may be observed in end life care include; Anorexia-loss of appetite, Akinesia-absence of movement and Atrophy-decrease in muscle and body mass (Porth 2005, p.1501).
b) How do palliative illnesses such as cancer affect a person’s ability to perform ADL’s?
The presence of disease, retention of chemical therapy, controlled medication all exacerbate chronic fatigue alienating mind from body increasing frustration borne from the inability to perform activities of daily living. At all stages of disease the body is fighting to compensate perpetuating fatigue encouraging systemic changes that cannot be regulated to resonate throughout the system. One example would be the inability to swallow caused by either obstruction or medication affecting respiration and appetite, creating chemical imbalances in the stomach and along the gastrointestinal tract with further complications resulting in the bowel (Tollefson 2005, pp. 908-911) (Mott 2005, pp. 1379-1380.)
c) What interventions and or equipment may be used to support palliative clients to perform
Equipment may include frames, walkers, lifters, trapeze bars, thickeners in fluids, pureed food, prompts with ablutions and routines. Enable continuity in care by providing succinct habits in documentation and communication with all staff members. Continuous assessment to identify pain, symptoms and recovery times following exertion will assist the nurse in educating and supporting client losses and create realistic alternatives to manage ADL’s while encouraging client autonomy. (Mott 2005, pp. 1385-1396).
d) How do palliative clients hydration and nutritional needs differ from acute clients particularly
during end of life care?
Nutrition and hydration needs of the palliative client fluctuate as the effects of anxiety, depression and futility of disease progress. Decline in the body’s need and tolerance for nutrition and hydration which eventuates to mouth swabs and ice chips is compounded by continual bed rest, medication and immobility, further disabling the body’s ability to secrete hormones required to regulate and balance homeostasis and avoid organ failure. Generally with acute care clients, the body is capable of compensating single organ failure by intervening with appropriate responses. Interventions by the body include mobilisation of body defences and an increase in metabolism which requires a balance of nutrition and hydration to promote healing (Tollefson 2005, pp. 1245-1252).
Q 3 Case Study – Mr Klamic
a) What would be the benefits of offering a grief counsellor to Mr. Klamic and his family?
Particular benefits of offering grief counselling is that it can allow all family members to address unresolved issues of disillusion and resentment associated with loss. A grief counsellor helps the family understand the processes involved by exploring coping mechanisms, strengthening communication skills, and forming allegiances (Griffiths & Crookes 2006, pp. 185-189).
b) What would be the benefits of discussing the spiritual and cultural aspects of Mr. Klamic’s care
with Mr. Klamic and his family.
Recognition and understanding of specific cultural needs by the nurse will encourage a therapeutic relationship with the client and his family which will facilitate in appropriate care for Mr. Klamic. Promoting inclusion can empower the family to actively participate in care. An example of benefits regarding discussing spiritual needs would be rituals associated with religion as in the administration of Holy Communion and Last Rites (Omeri 2006, pp. 277-280).
c) Discuss the grieving process and how it might differ for each of the parties involved, Mr. Klamic,
his wife and children.
Experience associated with the transition of dying and death is unique and the impact on the surviving family members needs to be acknowledged and addressed. Although Mr Klamics’ children no longer live at home, the family structure is fractured, dynamics within the family will shift, behavioural changes may occur as perceptions of role in life, become displaced (Mooney 2005, pp. 559-568).
d) What significant others or community services could the nurse access for support in the
grieving process for Mr. Klamic and his family.
Community support services could include, a senior member of the families’ religious affiliation which would offer pastoral care, Polish associations also offer support with members volunteering their time to friendship visits, respite for family members, Centrelink financial support, Family Services can advise on government assisted funeral schemes, Domicillary help with house, garden and shopping (SA Community Connecting Up Australia 2009, website).
e) Why is it important to consider language barriers when information needs to be discussed with
a client and their family?
Client confidentiality requires medically trained health care translators be appointed when there is a language barrier. Informed consent relies on the understanding of medical information received by the client and their family. Other obstacles that need to be considered with language barriers are loved ones protecting client or denial by client, cultural and religious beliefs, personal and or vested interests by other parties (Dowd, Eckermann & Jeffs 2005, pp. 131-137).
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f) How does pain management in the palliative setting differ from in the acute setting?
The goal in palliative care is to comfort and alleviate whereas the focus in acute care is on rehabilitation albeit pain management is ultimately directed by the opinion of the Doctors’ will.
Managing pain with the palliative client requires administration prior, to prevent increases in suffering. Timing of administration when moderated appropriately may reduce dosage required for continual pain control. Generally in acute care initial aggressive pain management is required to stimulate the body, inducing healing processes. Increased homeostasis enables mobility of the body which is beneficial in reducing pain management as the clients body avails to strategies implemented (Tollefson 2005, pp. 1188-1189).
g) Other than Opioid use what other strategies may be employed to manage Mr. Klamics pain?
All forms of diversional therapy warrant investigation and use of if client is agreeable. Simple strategies of holding a hand, giving a gentle hug, listening, participation in a chat or debate of interest to client, encourage journaling-written or taped, arouse interest in unexplored possibilities. Initiate changes to environment so the client can absorb and enjoy the seasons or an excursion outside in the elements. Massage, aroma, visualisation and music therapy, are alternatives that may be offered to Mr. Klamic to increase his comfort. Guidelines for implementing therapies will probably vary between organisations, prior reference to policies and procedure is recommended (Taylor 2005, pp. 896-900).
h) Other than patient statements, what are some of the observations and assessment nurses may
use to gauge a patients pain level?
Regular assessment of vital signs, deep sadness – watery eyes, pallor of the skin, grinding of teeth, flinching and clenching of extremities, irregularities in breathing , inability to find comfort or solace and foetal curling. Listening to and enquiring with family members of noticeable pain. Reduce external irritants and monitor signs on skin; pressure areas, pallor, cyanosis, jaundice, heat and beads of sweat. Reference to medication, pain (Wong & Baker) and behavioural charts and levels of participation in activities of daily living may help to gauge clients’ pain levels (Tollefson 2005, pp. 1183-1198).
i) What are the Enrolled nurses responsibilities when caring for a patient with a morphine
Responsibilities include ensuring machine is functioning and calibrated in accordance to pharmacy order and that pain is being controlled and frequently reassessed. Cannulation tube should be free of kinks and the area surrounding the site of insertion is devoid of redness, heat, swelling and pain. Co-signing record of use of a schedule 8 drug on register and reporting variants, adverse reactions and side effects to the Registered Nurse while implementing the five rights of medication are mandatory of the Enrolled nurse working within their scope of practice (Tollefson 2005, p.1210) (Davis, 2005, pp. 874-881) (ANMC, 2007 p.2).
a) How does Mr Klamic’s diagnosis affect his ability to be an organ donor?
Although Mr. Klamics’ diagnosis impedes his ability to donate organs and tissue to a living recipient,
it may be possible for him to donate himself in entirety to science. Criteria for scientific donation would be assessed on an individual basis by the receiving school of medicine and would require prior contact between Mr. Klamic and or his power of attorney and the particular institution. (The University of Adelaide School of Medical Sciences 2011, website) (Australasian Transplant Co-ordinator’s Association Incorporated 2006, website).
b) When may an autopsy be required in the palliative setting? Who carries out the autopsy, who
gives permission for the autopsy?
Several occasions when an autopsy is performed include times when death occurred within 24 hours of seeking emergency treatment and or discharge from a hospital, residents of licensed residential facilities and residential homes where cause of death was unable to be certified by a doctor or qualified paramedic. An autopsy is performed by a medical pathologist under the direction of the State Coroner to establish precise cause of death. The Coroners Act 2003 permits the autopsy, delays can occur when objections raised by next of kin warrant consideration by the State Coroner (Courts Administration Authority of South Australia-Coroner’s Court 2011, website).
c) What is an Advanced Health Directive?
An Advanced Care Directive or Living Will is a legal document notarised at a time when a person is sound of mind, eighteen years or over in age. In this document the bearer states in advance how their future personal needs are to be met, if and when an event fails them to do so. Advantage of the ACD is it allows the person to control preferences of medical treatment while releasing others of decision making responsibility (Attorney-General’s Department 2011, website).
d) Which legislation governs the provision of palliative care?
Legislation governing palliative care in South Australia is the Consent to Medical Treatment and Palliative Care Act 1995 and Schedules under the Act 1995. Guardianship and Administration Act 1993, Power of Attorney and Agency Act 1984, Coroner’s Act 2003, Controlled Substances Act 1984, and Drugs of Dependence Regulations (Australasian Legal Information Institute 2011, website).
e) Care delivery in the palliative care setting is governed by the policies and procedures of the
Hospital. What kind of situations may these policies deal with?
Situations that may be in Hospital policies include admissions, discharge and patient care documentation, client rights, dying with dignity, standards of care, clinical procedures, informed consent advanced health directives, death certification, code blue and met calls, do not resuscitate requests, bereavement, use of complimentary therapies, life prolonging intervention, organ donation, O.H.& Safety, equity and diversity, grievances, cultural safety, risk management, staffing, nursing informatics and hospital emergencies (Royal Adelaide Hospital 2010, website).
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