NURS6711 Palliative Care Practice

Introduction:

Meeting the needs of the patient and Priorities

The needs of the patient can be met using the current care plan by ensuring that he is assisted to use the bathroom whenever he needs to. The main aim is to ensure that he does not get constipated and to achieve that two things need to be addressed: the first is that the patient will need to be more active to discourage constipation, and the second will be to ensure he has taken sufficient fluids and fibre-rich foods. The key priority in the patient’s care is to minimize discomfort that is brought by difficulty in defecating and to ensure that he is not dehydrated.

Care plan for constipated patient

Assessment

Subjective: the patient states that he has not had a bowel movement in a longer period than he is accustomed to.

Objective: Distended abdomen, dry and cracking mucus membrane. There are no cups on the patient’s sink or table.

Diagnosis

Actual diagnosis. Balloon expulsion test

The balloon expulsion test is a simple assessment of a patient’s ability to remove artificial stool. Several techniques are used as there is no one specific approach. A 50ml balloon will be filled with warm water which will then be placed in the patient’s rectum. The patient will be asked to expel the balloon in privacy, in a sitting position; the normal time to expel is usually one minute, anything longer is indicative of constipation (Gladman, Aziz & Scott et al., 2009)

Potential diagnosis

Because of the sedentary life that the patient is currently living, constipation is highly likely even in the absence of any tests being done. A lack of exercise, inactivity and prolonged bed rest causes constipation. In addition, a sense of lacking privacy can result in the patient becoming constipated.

Planning/Objectives/Outcomes

1. Patient should pass formed, soft stool everyday commencing on 25/04/2017.
2. Patient will spell out the measures that will ensure non-recurrence of constipation by 25/04/2017.

Interventions

1. Encourage the patient to take fluids everyday: 2-3 liters per day.

Rationale: when the patient is hydrated adequately, he will have softer stool and the intestines will have sufficient provision of moisture.

2. Provide education on inactivity and constipation. Patient will e encouraged to take short walks on a daily basis

Rationale: Inactivity slows the passage of stool which makes the stool to dry and harder to pass. through the intestines. This dries stool, making it harder to pass.

Evaluation

1. Patient has passed stool that is formed and soft since 25/04/2017.
2. Patient verbally acknowledges the importance of being adequately hydrated on 25/4/2017.

Support and services that the client and the family will need at end-of- life and after death

The end-of-life goals of care are: maintaining comfort, quality of life, and choices that a patient has and who is in the terminal phase of his/her illness; to give support to their individual self; and to take care of the spiritual and psychosocial needs of the patient and family. That said, Mohammed and his family will be allowed to have an Imam come over to visit and pray with him and the family. The Imam will assist the family in accepting the will of God with regard to the passing away of Mohammed; he may also plan with the family on the necessary rituals that will need to be performed in preparing Mohammed to transit into the afterlife.

Families’ support will also be accorded by the hospital where the institution will provide a grief counselor to walk with them and counsel them prior to and after the death of their son/sibling. Cultural differences will need to be addressed appropriately (National EOL Framework Forum, 2010) and hence, the counselors chosen to walk with the family will be from both genders. In addition a male staff will take care of Mohammed once he passes on.

Further, shared decision-making will be practiced where all parties will be made aware of the patient’s imminent death. By doing so, the probability of a good death is increased where Mohammed’s preferences, wishes, and needs will be addressed (Frank, 2009).  The changing care goals will be discussed as part of the process (Lorenz, Lynn, & Dy, 2008).  Most patients identify similar care goals which include: living longer; getting cured; maintaining or improving quality of life, functionality, and independence; achieving goals in life; becoming comfortable; supporting caregiver and family (Kaldjian, Curtis, & Shinkunas et al., 2009).  As Mohammed becomes more aware of his imminent predicament, the goals will tend to shift too.

The 7 stages of Grief

Shock & Denial- this is the first stage of grief where a person who learns of the passing-on of a loved one is numbed by disbelief.  The family on receiving the news may deny the reality to a certain extent in an attempt to avoid the pain. The shock that the family members will experience will offer them emotional protection that will guard them against becoming overwhelmed by the demise of their loved one. The shock may last for a number of weeks. There may be those in the family who may be well prepared for the demise of the patient and may not be shocked but be in denial.

Pain & guilt- this is the second stage that starts to manifest even as the shock and guilt wear off. It is characterized by suffering in immeasurable pain. The family of the patient may experience almost unbearable and excruciating pain. It will be critical that each member going through this phase to experience the pain in totality and avoid hiding it through using mechanisms of escape such as drug and substance abuse. The family will be encouraged by the grief therapist to face the pain that they will experience as it is the only way to alleviate it and that escapism will only postpone the pain but not eliminate it.
Anger and bargaining- this forms the third stage of grief where frustration will give way to feelings of resentment and anger. The family members may be tempted to lash out and blame others for the demise of the patient. The family may also put the blame on God for not healing their loved one. Bottled up emotions need to be released during this time but not at the expense of permanently damaging existing relationships with others. The family may blame fate and ask questions as to why it had to be them going through the pain. In addition, some of the family members may begin to negotiate with God and promise to do or not do some things in exchange of having their loved one back.

Loneliness, refection, and depression- this is the fourth stage of grief where when everyone else around assumes it is time for the family to get on with their daily lives, a sad and long period of reflection overtakes the family. This stage is normal and the family members going through it should not be talked out of it by outsiders who mean well. At this time, encouragement by others will prove futile as the family comes to terms with the magnitude of their loss which comes with depression. Family members will find themselves isolated and reflecting on all the things that they did with their loved one even as they experience a sense of despair and emptiness.
The upward turn is the fifth stage and here the family members will start experiencing a sense of calmness and be more organized. The physical symptoms associated with previous states such as isolation, reflection, anger, depression, loneliness, bargaining, denial and shock start to fade away. The family will start to go back to their previous life of normality and will spend lesser time feeling pain and anger than they did at the onset of the grief cycle. The family will start focusing on the other areas of their lives as attention to pain diminishes.

Working through and reconstruction is the sixth stage even as the family members become more functional. The mind begins to work again and they will start looking for realistic solutions to problems or issues without the help of their loved one who has passed on. The duties and roles that the loved one filled will at this point not seem painful to fulfill by the family. The family will also start to make realistic decisions such as giving away some, if not all, of the things that the loved one left behind and creating room for new occupancy  in whatever form, for the vacuum left by the loved one.

Hope and acceptance is the final stage where the family members learn to accept and handle the situation’s reality. Although the family may not experience instant happiness during this stage, they will not be able to return to the untroubled and carefree life that they had prior to the demise of their love one. However, with time the family will be able to chart a way forward to living a hopeful and normal life without their loved one. Once the family accepts that there is nothing any one of them could have done in addition to what had already been done, then will they enter a place of hope.

Why people may not go through each stage

There is no substantial evidence that supports the fact that there are stages for coping with the loss of a loved one.  No evidence has shown that people  go through the exact stages as outlined by Kubler-Ross. Anyone can experience the stages in different order or may experience feelings not encompassed in the grief model.  

Dysfunctional Grieving

Dysfunctional grieving is a response to loss that is behavioral and emotionally maladaptive and contrasts with adaptive where the latter moves progressively toward resolution and healing. In dysfunctional grieving, prolonged or excessive grief dysfunction can result in physical, psychosocial, and behavioral problems (Ruddock, 2014)

Health condition: Constipation

Description

Being constipated refers to tough and less frequent bowel movement. The length of time varies widely among people with regard to bowel movements. There are those that have three times a day while yet others have it once a week or bi-monthly (WebMD, 2016). Constipation is one of the side effects of chemotherapy ALL treatment (Leukemia, 2016)

Tests to diagnose constipation

A physical examination is done with careful examination of the abdomen for stool presence and more so in the left quadrant.  It is also important that gastrointestinal mass be excluded although, patients often go through a standard physical examination (Rao &Meduri, 2011).

Symptoms of Constipation

Some of the symptoms of constipation include: lesser bowel movement; trouble with bowel movement; smaller hard stool; belly pain or swollen belly; and throwing up (WebMD, 2016)

Treatment for constipation

A patient should consume more fluids such as juices and water. Dietary fiber should also be increased by consuming foods such as dried or fresh fruit; whole wheat products; cereals, bran, pasteurized fruit, and cooked or raw vegetables. A patient with constipation should be given hot or warm drinks such as lemon water 30 minutes prior to the time of their normal bowel movement. The patient should also be given a private and quiet bathroom (Economou, 2008)

Survival rate of persons with constipation

Constipation is not fatal and most people will be treated successfully after eating high fiber foods, exercise daily, and drink plenty of fluids. However, there are complications that arise from chronic constipation and these include rectal prolapse, fecal impaction, and hemorrhoids. Alternative Pain Management

Massage

This is the manual manipulation of soft tissue in the body using various techniques and traction, and also pressure application. Stimulation of peripheral receptors is done and these access the brain through the CNS. It reduces anxiety and stress levels while increasing the patient’s well being thus contributing to control of pain (Falkensteiner, Mantovan, & Muller et al., 2011) 

Reflexology

This involves the use of manual pressure which is applied on specific zones or areas of the feet, ears, or hands. These pressure points correspond to the organs in the body as well as other parts of the body. Reflexology is used often in relieving chemotherapy side effects and cancer pain during the end stages, and also increases the quality of living (Wilkinson, Lochart, & Gambles et al., 2008)

Aromatherapy

This is the massaging of plant essences on the skin and may be inhaled or added to bathing water. The oils reach the lymph systems via the circulatory system and provide recovery through intercellular fluids. Aromatherapy has been shown to have short term benefits in cancer patient’s well being (Boehm, Büssing, & Ostermann, 2012). 

EFT

Emotional Freedom Technique (EFT) is a do-it-yourself method where the patient will tap with his  middle and index finger tips on acu-points which are the energy meridians. This will stimulate and re-align any interrupted flow of energy, facilitate or effect ease of pain (Healing Cancer Naturally, 2007)

Magnet Therapy

Research shows that magnet when placed on the skin causes the relaxation of capillaries which in turn increases blood circulation. This also increases blood oxygenation and removal of prostaglandins. In theory, this will relive muscle spasms and eventually pain will recede (Kuipers, Sauder, & Ray, 2007)

References:

Boehm, K., Büssing, A., & Ostermann, T. (2012). Aromatherapy as an Adjuvant Treatment in Cancer Care — A Descriptive Systematic Review. African Journal of Traditional, Complementary, and Alternative Medicines, 9(4), 503–518.

Economou, D (2008). Constipation in the cancer patient. (Retrieved on 24th April, 2017) https://www.cancernetwork.com/oncology-nursing/constipation-cancer-patient

Frank RK. (2009).Shared decision making and its role in end of life care. Br J Nurs. 18(10):612-8.

Gladman MA, Aziz Q, Scott SM, et al. (2009). Rectal hyposensitivity: pathophysiological mechanisms. Neurogastroenterol Motil. 21:508–16. 

Healing Cancer Naturally (2007). Introduction to EFT (Emotional Freedom Technique): Healing Mind and Body By Reestablishing Healthy Energetic Flow. (Retrieved on 25th April, 2017.) https://www.healingcancernaturally.com/eft-emotional-freedomtechnique.html

Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. (2009). Goals of care toward the end of life: a structured literature review. Am J Hosp Palliat Care. 25(6):501-11.

Kübler-Ross, Elisabeth; Kessler, David (June 5, 2007). “On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss”. Scribner. Retrieved April 24th 2017 – via Amazon.

Kuipers NT, Sauder CL, Ray CA. (2007). Influence of static magnetic fields on pain perception and sympathetic nerve activity in humans. J Appl Physiol:102:1410-1415. Available at jap.physiology.org/content/102/4/1410.long.?

Leukemia.org (2016). Acute lymphoblastic leukaemia (ALL). https://www.leukaemia.org.au/blood-cancers/leukaemias/acute-lymphoblastic-leukaemia-all

Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, et al (2008). Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med.15;148(2):147-59.

Maciejewski, Paul K.; Zhang, Baohui; Block, Susan D.; Prigerson, Holly G. (2007). “An Empirical Examination of the Stage Theory of Grief”. Journal of the American Medical Association. 297 (7): 716–23. doi:10.1001/jama.297.7.716. PMID 17312291.

National EOL Framework Forum. (2010). Health system reform and care at the end of life: a guidance document. Canberra: Palliative Care Australia.

Rao, S. S. C., & Meduri, K. (2011). What is necessary to Diagnose Constipation? Best Practice & Research. Clinical Gastroenterology, 25(1), 127–140. https://doi.org/10.1016/j.bpg.2010.11.001

Ruddock, V (2014). What is dysfunctional grieving? (Retrieved onn 24th April, 2014).  https://dying.lovetoknow.com/coping-grief/what-is-dysfunctional-grieving.

WebMd (2016). What is constipation? (Rerieved on 24th April, 2017). https://www.webmd.com/digestive-disorders/digestive-diseases-constipation#1

Wilkinson, S., Lockhart, K., Gambles, M., & Storey, L. (2008). Reflexology for symptom relief in patients with cancer. Cancer Nursing, 31(5), 354-360.