Rosdahl and Kowalski TEXTBOOK OF BASIC NURSING

1. Rosdahl and KowalskiTEXTBOOK OF BASIC NURSING Ch. 100 Hospice Nursing

2. 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.

3. 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*

4. Goals of Hospice • Hospice care focuses on four areas of human needs • Physical • Psychological/emotional • Social/cultural • Spiritual

5. Key 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.

6. Characteristics 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

7. Key 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.

8. 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.

9. 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)

10. 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

11. Respite 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

12. 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.

13. 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

14. 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

15. 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.

16. Emotional 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

17. Spiritual 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. N/V • Nauseated clients should lie on their right side • Relaxation techniques • Antiemetics • Dolasteron mesylate (Anzemet)* • Carbonated beverages • Dry food • Ice chips

24. Symptom Control in Hospice Care Refer to Important Medications 99-1.

25. 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.

26. 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.

27. 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

28. Key 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.

29. 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

30. Personal 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

31. Management of Odor • Disagreeable odor may embarrass clients • To control odor • Aerosolized sprays • Wintergreen oil • Charcoal filter dressing • Mechanical air filter

32. 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

33. 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.

34. 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**

35. Medications Used in Pain Management Refer to Important Medications 99-2. Corticosteroids-appetite stimulants*

36. Nursing Alert • Many non-opioids are mild anticoagulants and must be used with caution. • Evaluate respiratory function when taking opiates**

37. Pharmacologic 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

38. 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.

39. Pharmacologic Therapy, cont. • Management of side effects • Sedation • Respiratory depression • Dangerous lowering of blood pressure • Constipation • Somnolent

40. Key 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.

41. 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

42. 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

43. 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

44. 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.

45. When 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.