Holistic Palliative Care For Mrs Hong

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Question 1

Define the term ‘holistic care’

Provide examples of how you would provide holistic palliative care to Mrs Hong and her family in each of the following 10 aspects.  (word limit – 100 Words)

Response:

CATEGORY

EXAMPLES

Definition of Holistic care

Holistic care in nursing is the practice of providing treatment and care interventions by considering the person as a whole including their social, physical, cultural, emotional and religious dimensions.

Pain relief – pharmacological

The nurse can collaborate with the general practitioner to prescribe pain medications such as analgesics or fentanyl.

Pain relief – non- pharmacological

Interventions can include massaging, cold or warm compressions and physio or occupational therapy.

Physical care

Mrs Hong should be repositioned frequently to prevent any risks of pressure ulcers.

Nutritional support

The nurse must collaborate with the dietician to provide meal plans as per disease condition and her Asian traditions.

Elimination  support

The nurse should supervise and assist Mrs Hong in her elimination and assist her in practicing hygiene and self-care whilst respecting her privacy. If incontinent, support can be provided using catheter or incontinence pads

Social support

The nurse and the team must provide opportunities for Mrs Hong’s family to visit her and also arrange activities which are culturally appropriate to support her needs.

Cultural support

The nurse must ensure to respect Mrs Hong’s cultural traditions and beliefs and treat her in a non-discriminatory manner

Religious support

The nurse must respect Mrs Hong’s religious beliefs in a non-judgmental and non-discriminatory manner.

Emotional support

The nurse can engage in positive interpersonal communication and affirmations to provide emotional support to Mrs Hong.

Reference

Lukovsky, J., McGrath, E., Sun, C., Frankl, D., & Beauchesne, M. A. (2021). A survey of hospice and palliative care nurses’ and holistic nurses’ perceptions of spirituality and spiritual care. Journal of Hospice & Palliative Nursing, 23(1), 28-37.

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Question 2

What document would outline Mrs Hong’s wishes for her care if she was unable to tell you?

What details might this document include?

Response: An advanced care directive is the document which would provide an understanding about Mrs Hong’s wishes for her care in case she is unable to communicate the same. It will contain details of her values, goals, beliefs and preferred care interventions for the future during emergencies or if she is unable to communicate. It also contains details of the decision maker who will formally be a substitute to take decisions on her behalf if she loses the mental capacity to engage in personal decision making.

REFERENCE: Jones, T., Luth, E. A., Lin, S. Y., & Brody, A. A. (2021). Advance care planning, palliative care, and end-of-life care interventions for racial and ethnic underrepresented groups: a systematic review. Journal of Pain and Symptom Management, 62(3), e248-e260.

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Question 3

a) Reflect on and outline your values, beliefs and attitude towards death and dying – give an example.  

b) State how your beliefs and values may affect your provision of care to the client- give 2 examples.

Response:

PART A: Reflect on and outline your values, beliefs and attitude towards death and dying

My beliefs, attitudes and values towards death and dying are that of the Approach Acceptance (AA) practice. Individuals who are AA believe that death is an opportunity for happiness post life and thus, do not hold any depression or fear regarding it.

PART B: State how your beliefs and values may affect your provision of care to the client

1. EXAMPLE- My beliefs will thus enable me to remain positive in Mrs Hong’s care and also support her emotionally. For example, firstly, I myself will be able to view her condition with optimism and high self-esteem.

2. EXAMPLE- Secondly, I will also be able to support her emotionally and assist her to be optimistic in case she feels emotionally distressed.

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Question 4

What is the scope of practice for an Enrolled nurse when caring for a dying client?

(Refer to the NMBA Enrolled Nurse standards for practice –especially Code Conduct 3.6- End of Life Care).

Describe how these standards and codes dictate the care ENs provide – give 4 points from the STANDARDS FOR PRACTICE and Codes of Conduct. (Word limit – 30 Words per point)

References: review mapping

Standard 3

Code of Conduct

As per Statement 4, nurses must aim to respect the culture, dignity, values and ethnicity of the patient whom they are providing care to.

As per Statement 3, ENs must conduct themselves as per the laws and standards which are relevant to the nursing profession.

As per Statement, ENs must practice in a safe manner when providing care to the end of life patient.

As per Standard 2, ENs must practice based on best practice standards as per the health system.

Nursing and Midwifery Board of Australia. (2022). Nursing and Midwifery Board of Australia – Professional standards. Nursingmidwiferyboard.gov.au. Retrieved 8 April 2022, from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx.

Standard 3

Standard 3.6 dictates ENs to consult with the RN and other team members to provide accurate health information and care to end of life patients

Standard 3.2 encourages ENs to practice accountability and responsibility for the nursing care which they are required to provide to the patient during end of life care.  

Standard 3.9 guides the EN to ensure the safety of themselves as well as others when addressing the needs of the end of life patient.

Standard 3.5 encourages the EN to clarify their responsibilities and roles to the RN while addressing the needs of the the end of life patient.

Nursing and Midwifery Board of Australia. (2022). Nursing and Midwifery Board of Australia – Enrolled nurse standards for practice. Nursingmidwiferyboard.gov.au. Retrieved 8 April 2022, from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/enrolled-nurse-standards-for-practice.aspx.

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Question 5

Identify physiological changes by body system that you may observe in a client who is dying- List two per system

Response:

REFERENCE:

Ranse, K., Ranse, J., & Pelkowitz, M. (2018). Third-year nursing students’ lived experience of caring for the dying: A hermeneutic phenomenological approach. Contemporary nurse, 54(2), 160-170.

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Question 6

Provide examples of 3 members of the Multidisciplinary Team (MDT) and how each one will assist in providing holistic care to Mrs Hong and her family

NB. If including nurses please include specialist nurses – state their specialty).

Response:

MDT member 1: Physiotherapist/Occupational Therapist

Role: Assist the patient in engaging in activities of daily living and provide them pain relief.

MDT member 2: Registered Nurse

Role: Assist the patient in their elimination, hygiene and nutritional needs as well as social support.

MDT member 3: General Practitioner/Oncologist

Role: Regulate medication dosages in the patient as per changing health needs.

REFERENCE:

Fernando, G. V. M. C., & Hughes, S. (2019). Team approaches in palliative care: a review of the literature. International journal of palliative nursing, 25(9), 444-451.

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Question 7

a) Identify signs of swallowing and breathing difficulties. Which nursing management strategies could you use in each case?

b) Why is oral care important to consider in a client who is unable to eat or drink?

Response:

a)  Swallowing difficulty

· Choking or coughing when drinking and eating

· Gurgling sound when drinking or eating

· Persistent sensation being stuck

Nursing management strategies x 2 (Word limit 15 words)

1. Assist patient in maintaining an upright position when drinking or eating

2. Using fluids or soft foods to enable swallowing

b) Breathing Difficulties

· Shortness of breath

· Laboured or forced breathing

· Pain in the chest when breathing

Nursing Management strategies x 2 (word limit 15 words)

1. Educate patients on breathing exercises

2. Assist patients in relaxation training and upright positioning.

c) Oral Care

· It is important to maintain the moisture levels and softness of the oral mucosa

· It is also important to ensure that the gums and teeth are kept free from plaque.

REFERENCE: 

Brady, G. C., Roe, J. W., O’Brien, M., Boaz, A., & Shaw, C. (2018). An investigation of the prevalence of swallowing difficulties and impact on quality of life in patients with advanced lung cancer. Supportive Care in Cancer, 26(2), 515-519.

Eisenmann, Y., Golla, H., Schmidt, H., Voltz, R., & Perrar, K. M. (2020). Palliative care in advanced dementia. Frontiers in Psychiatry, 11, 699.

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Question 8

Mrs Hong’s breast tumour has developed into a malignant wound.

Explain what malignant means and describe how you would care for the wound.

Response:

A malignant wound occurs cancerous cells infiltrate the skin as well as the lymph and blood vessels surrounding it resulting decreased vascularity and tissue death. For wound management, hydrocolloid dressings can be used to control the wound exudate followed by using saline solutions to cleanse and debride the wound as well as decrease odour.

REFERENCE:

Patel, B. C., Ostwal, S., Sanghavi, P. R., Joshi, G., & Singh, R. (2018). Management of malignant wound myiasis with ivermectin, albendazole, and clindamycin (triple therapy) in advanced head-and-neck cancer patients: a prospective observational study. Indian Journal of Palliative Care, 24(4), 459.

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Question 9

What signs/ changes may you observe in Mrs Hong that may indicate that she has deteriorated further?

Who would you report these changes to?

Explain how would you support Mrs Hong’s daughter as she witnesses her mother deteriorating?

Response:

A. Deterioration signs and changes: These will include increased restlessness, confusion and distress in the patient. There may a sudden decrease in urine production as well as a lack of responsiveness in the patient resulting lack of breathing and heart rate.

B.  Reporting: As an enrolled nurse, the responsibility would be to report to the RN the changes so as to proceed further with clinical decision making.

Explain how you would support Mrs Hong’s daughter: –

The nursing team must ensure to comfort Mrs Hong’s daughter by explaining her that they are trying their best to address her concerns as per the advanced care directive prepared by her. The nurse must also try their best to provide Mrs Hong the opportunity to take part in the clinical decision making of her mother as she is deteriorating for her emotional wellbeing.

REFERENCE: 

Detailleur, S., Vos, R., & Goeminne, P. (2021, August). The Deteriorating Patient: Therapies Including Lung Transplantation. In Seminars in respiratory and critical care medicine (Vol. 42, No. 04, pp. 623-638). Thieme Medical Publishers, Inc..

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Question 10

Mrs Hong is no longer conscious but is demonstrating signs of distress by groaning in pain. (Include also nonverbal cues of pain and distress).

What is the most appropriate Nursing tool to use and what else can you observe to assess Mrs Hong’s pain?

Response:

Nonverbal cues of distress and pain include moaning, restlessness, emotional distress, reluctance in moving and also demonstrating of gestures by the patient to indicate the area of pain. The most appropriate nursing tool which can be used to assess pain is the PQRST pain assessment. This is because this assessment provides an understand of the factors triggering the pain, the quality or nature of the pain, the area of the pain, the level of severity of discomfort of the pain and existing treatment of the pain. Additionally, the nurse can also observe non-verbal cues such as the patient’s hand movements, gestures and even any subjective expressions and facial expressions to assess the pain.

REFERENCE:

Munkombwe, W. M., Petersson, K., & Elgán, C. (2020). Nurses’ experiences of providing nonpharmacological pain management in palliative care: A qualitative study. Journal of clinical nursing, 29(9-10), 1643-1652.

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Question 11

Split into two boxes

Mrs Hong is no longer conscious but is demonstrating signs of distress by groaning in pain- you have assessed Mrs Hong and decided to  assist in decreasing Mrs Hong’s distress.

a) What options for pain relief would you consider if Mrs Hong cannot take oral medications? (non-pharmacological treatment options)

b) Outline 4 methods used to administer pharmaceutical pain relief to Mrs Hong now she is unconscious and no longer able to swallow

Response: Reference:

a) Non -Pharmaceutical Pain relief: These can include providing the patient with cold and hot compressions, massages and repositioning techniques as a means of relieving her pain.

Sholjakova, M., Durnev, V., Kartalov, A., & Kuzmanovska, B. (2018). Pain relief as an integral part of the palliative care. Open access Macedonian journal of medical sciences, 6(4), 739.

B) Outline methods of pharmaceutical pain relief administration

· Neuropathic pain relief can be administered using anticonvulsant medications such as pregabalin and gabapentin

· Pain caused due to nerve damage or irritation can be relieved using Tricyclic antidepressants

· Intravenous forms of opioids can be used for pain relief such as morphine and fentanyl.

· Intravenous injections of tramadol can also be used for pain relief.

Sholjakova, M., Durnev, V., Kartalov, A., & Kuzmanovska, B. (2018). Pain relief as an integral part of the palliative care. Open access Macedonian journal of medical sciences, 6(4), 739.

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Question 12

Discuss and recommend 3 nursing daily living activities which will be required for Mrs Hong now that she is unconscious and no longer able to provide for her own self care needs. (consider activities of daily living that Mrs Hong can no longer do for herself)

Response:

1. The nurse will need to assist Mrs Hong in repositioning herself so that she is decreased risk of pressure ulcers.

2. The nurse will also need to assist Mrs Hong in her elimination needs with the help of catheters.

3.  The nurse will also need to assist Mrs Hong in cleaning and grooming herself and also addressing her dietary requirements using tube feeding

REFERENCE:

Franchini, L., Ercolani, G., Ostan, R., Raccichini, M., Samolsky-Dekel, A., Malerba, M. B., … & Pannuti, R. (2020). Caregivers in home palliative care: gender, psychological aspects, and patient’s functional status as main predictors for their quality of life. Supportive Care in Cancer, 28(7), 3227-3235.

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Question 13

You assess Mrs Hong and believe she has died.

A. What action should you take within your scope of an Enrolled Nurse?

B. Identify one legislation for the notification of a death in a healthcare facility in your state?

             In what circumstances should a death be referred to the coroner?

Response: REFERENCE

A. My action as an EN would be to first report the situation to the RN so as to obtain supervision on the decision to be taken after the death of a patient.

B. There is no specific law for the notification of death. The nurse and practitioners are to notify the next of kin of the decreased person. If the death was unexpected, then the death needs to be reported to the coroner who will examine the nature and circumstances of death.

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Question 14

a) What care activities are undertaken once a person dies? Please list.

b) How would you maintain respect and dignity for a client when preparing their body after death (include one cultural or religious practice)?

Response:

a) The family members of the person have to be first informed of the death. The body and the room needs to be cleaned and washed and prepared for death so as to preserve the dignity and appearance. Opportunities must also be provided to the person’s family to take part in the preparations. The body then has to be transferred to the mortuary or to the location preferred by their family.

b) In order to preserve the respect and dignity of the patient, the personal care activities need to be prepared two to four hours after the person has died. This will retain their appearance. To address their dignity and cultural traditions, their family members or members of the same sex must be allowed the opportunity to prepare the body.

REFERENCE:

KHUT, Q. Y. (2020). Infection Prevention and Control for the Safe Management of a Dead Body in the Context of COVID-19.

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Question 15

How does the care requirement change for a patient after death who:

· Requires an autopsy

· Wants to be an organ donor

(consider the legislative requirements for the care of a person after death who requires an autopsy or chooses organ donation)

Please complete the table

Response:

REFERENCE:

Bacon, E. R., Ihle, K., Lee, P. P., & Waisman, J. R. (2020). Building a rapid autopsy program–a step-by-step logistics guide. Translational Medicine Communications, 5(1), 1-14.

Deshmukh, C. D., & Baheti, A. M. (2020). Need, process and importance of organ transplantation. Asian Journal of Pharmacy and Pharmacology, 6(2), 126-131.

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Question 16

List three ethical and legal considerations for organ donation?

Response:

1. Consent should be obtained from the family and the patient for organ donation.

2. The patient should be provided education on the process of organ donation.

3. The complications of organ donation must be educated and the patient should not be coerced in the plan.

REFERENCE:

Smith, M., Dominguez-Gil, B., Greer, D. M., Manara, A. R., & Souter, M. J. (2019). Organ donation after circulatory death: current status and future potential. Intensive care medicine, 45(3), 310-321.

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Question 17

How would you provide support to Mrs Hong’s daughter (Mrs McFarlane) after her death?

Outline 3 community services you could refer Mrs McFarlane to, to support her with grief and loss? One service from your local/home area.

Response: REFERENCE:

Support for Mrs Mc Farlane

Mrs Farlane can be supported by the nurses by being educated on grief services and counselling organizations in the community whom she can refer to for overcoming her bereavement.

Community services

1. Griefline is a telephone counselling services offering grief counselling and loss services

2. The Australian Centre of Grief and Bereavement offers community counselling, bereavement, and support services for people who are grieving.

3. The Compassionate Friends Victoria offer support services to family members who have lost their kin or siblings.

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Question 18

How would you support your own self-care after caring for a long term client who has died?

Provide 3 examples of ways you could take care of your own wellbeing

Response:

Supporting self- Care

I can support my self-care by speaking to a colleague or a supervisor or attend counselling services to take care of my wellbeing

Personal Wellbeing

1. Maintain a journal or diary of positive affirmations

2. Consult local or community counselling services

3. Consult  a friend or a supervisor.

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Question 19

What services are available which can assist you and your healthcare colleagues to debrief after a death in your workplace? (Provide  3 examples of general services available and how they can assist with debriefing and supporting healthcare professionals).

Please provide one example of a service in your local area.

Response:

General services

1. Nurses can speak to their immediate supervisors for support

2. Nurses can speak to the manager or the administration for a day or specific time allocated for debriefing

3. Nurses can inform their supervisors on the need to allocate a separate time during shift hours for debriefing and support.

Local Area resource:

NURSE-ON-CALL is a helpline service which nurses can use to obtain grief, counselling and bereavement support

REFERENCE:

McCallum, K. J., Walthall, H., Aveyard, H., & Jackson, D. (2021). Grief and nursing: Life and death in the pandemic. Journal of advanced nursing.