Question

Location: Oncology

Unit History/Information:

The patient is a 56 year old female with a history of ovarian cancer diagnosed 4 years ago and treated with surgery and chemotherapy. The patient was found to be BRCA1 positive at the time of her surgery – her tumor was graded as IIIB. Eighteen months ago, the patient found a lump in her right breast which was biopsied and found to be malignant. She underwent a lumpectomy, followed by chemotherapy and radiation. Two months ago the patient started to experience pain in her hips, back and shoulders, a feeling of loosing her balance at times and RUQ abdominal discomfort. A medical workup revealed extensive metastatic disease in her bones, brain and liver. The medical team determined that further treatment would be futile. The patient is married with two children who live out of state. Her daughter is single and frequently travels for business. Her son is married with two small children. The daughter and son have visited three times since the patient’s symptoms began two months ago – the daughter is currently at the bedside. Advance directives have been signed by the patient who has chosen to be a DNR and who has named her spouse as her healthcare surrogate decision maker. It has been fi ve days since the patient was admitted to the Oncology Unit – on admission she presented with signifi cant dyspnea and malignant ascites. An abdominal paracentesis was performed with 3000 mL of fl uid removed. Over the past fi ve days, the patient’s abdomen has again become distended and tight and a fl uid wave is evident on assessment. Because of the patient’s dyspnea and general discomfort, she has decided to stay in the acute care setting and is refusing admission to Hospice. She is using oxygen at 2 LPM per nasal cannula and has a Foley catheter and an IV in place. She has been on a regular diet since admission but is unable to eat due to nausea and vomiting. Healthcare Provider’s Orders: Foley catheter as needed for urinary retention or patient comfort Oxygen at 2 LPM per cannula then titrated as needed for dyspnea IV D5/0.45% NaCl at 50 mL/hour Morphine Sulfate 10 mg IV every 4 hours around the clock Morphine Sulfate 1 to 6 mg IV every 1 hour as needed for break through pain/dyspnea Lorazepam 0.5 to 1 mg IV every 4 hours as needed for anxiety/nausea/seizures Haloperadol 0.5 to 1 mg SC every 4 hours as needed for agitation/nausea Acetaminophen 650 mg rectal suppository every 4 hours for pain/fever Hyoscyamine tablet 0.125 to 0.25 mg sublingual every 4 hours as needed to control excess secretions Docusate 50 mg/Senna 8.6 mg (Senokot-S®) one capsule orally twice a day. Hold if diarrhea Laxative, suppository or enema of choice as needed for constipation Activity as tolerated with assistance Mouth care every 2 hours when awake – soft foam, lemon or glycerin swabs

Discuss the nursing management of the patient-family unit at end of life.

Answer 1

Staffs have numerous obligations in end of life care which will go from having a touchy discussion with a person about their consideration and inclinations, perceiving any adjustments in condition and offering empathy and backing to the patient and those critical to them. This will require a wide assortment of abilities and a familiarity with the qualities which support this conduct. Merciful care must be at the bleeding edge of all nursing consideration however is significantly progressively basic in the arrangement of thinking about kicking the bucket individuals and those near them.

You will have numerous duties in end of life care, which will run from talking with and tuning in to people and those near them about their consideration and inclinations, watching, examining and recording any adjustments in conditions and offering sympathy and backing. This will require an expansive scope of aptitudes and a familiarity with the qualities which support this conduct.

When giving finish of life care, guarantee you:

•           treat individuals sympathetically

•           listen to individuals

•           communicate plainly and delicately

•           identify and meet the correspondence needs of every person

•           acknowledge agony and misery and make a move

•           recognise when somebody might be entering the most recent couple of days and long periods of life

•           involve individuals in choices about their mind and regard their desires

•           keep the individual who is arriving at a mind-blowing finish and those critical to them in the know regarding any adjustments in condition

•           document a rundown of discussions and choices

•           seek further exhortation if necessary

•           look after yourself and your associates and look for help in the event that you need it

Nursing care

"Palliative Care is tied in with placing life into a patient's days not days into their lives" – Nairobi Hospice

Albeit testing and sincerely requesting, when you are bolstered to have the correct aptitudes, information and frame of mind, end of life care can be fulfilling.

End of life care is given in a scope of settings which incorporate consideration in the network, an emergency clinic, care home, hospice and so on. Notwithstanding care setting, the nature of care ought to be of the best quality.

At the point when it is perceived by attendants and specialists that an individual might be biting the dust, this should be conveyed in a delicate and sympathetic manner to the withering individual (as fitting) and those near them.

How we speak with the individual who is biting the dust will rely upon every individual case. This is a very delicate zone and ought to show restraint drove, with delicate, legit answers utilizing language the individual gets it. At no time should the discussion proceed, if there is any sign that the patient wouldn't like to proceed. Staff should consistently be careful that a few patients won't need this discussion and consequently it ought not happen. In any case, it is significant that discussions should happen with families to set them up for looming passing.

Care of the individual

At the point when you give great nursing care to those toward a mind-blowing finish, you will give all encompassing consideration including giving physical, passionate, mental and profound help. The individual might be a patient, however recollect that they are additionally another person that might be feeling lost, befuddled and have inquiries regarding their nourishing and hydration needs. Similarly, the individual may not come to you with questions, wanting to keep them to oneself, or examine with someone else based on their personal preference. It's imperative to give the individual a chance to stay responsible for who they wish to impart these issues to. Remember that those near the individual may likewise be searching for help and data.

It is essential to be delicate to individuals' needs in connection to nourishment and hydration. In the event that somebody has an inquiry, attempt your best to answer it on the off chance that you are capable, or ensure you look for guidance from a progressively senior individual from staff on the off chance that you aren't sure.

Understanding the withering procedure

Thinking about an individual during the most recent couple of weeks and long stretches of life can be upsetting and requesting. A wide range of sentiments and feelings may surface from every one of those included.

Acknowledgment of kicking the bucket is very intricate. This is recognized in the writing and in reports in regards to end of life care, for example, More care, less pathway (Neuberger 2013) and Dying without poise (Parliamentary and Health Service Ombudsman, 2015).

It is valuable for staff to utilize prognostic marker instruments in the most recent year of life. For instance, the Gold Standards Framework (GSF) and the Palliative Performance Scale 2 (PPS).

At the point when it is perceived by medical caretakers and specialists that an individual might be passing on, you at that point need to impart this in a touchy and humane manner to the individual and those near them. It is likewise essential to impart why it is just important to give negligible hydration.

A key some portion of the medical caretaker's job is having the option to come nearby the individual who is biting the dust and those near them and to help them all through what is a characteristic procedure.

The time before death is commonly quiet for patients, and there is a delicate unwinding that may take a few days. Numerous individuals are worried that demise will be an agonizing encounter for the individual, however the body just begins to 'let go' of life. Now and again an individual can get anxious, however this can be dealt with.

There are physical indications of the regular procedure of the individual's body bit by bit backing off. Once in a while these signs seem a couple of hours before death, and now and again it tends to be a couple of days.