Assessment and Care Planning Of The Palliative Client

Anne Ediger R.N. BScN, C.H.P.C.N.(C)

Tammie-Lee Rogowski R.N., C.H.P.C.N.(C), C.C.H.N.(C)

The Home Care Nurse

Learning Objectives

Understand what is unique to a Palliative assessmentGather information in an organized mannerFamiliarize ourselves with assessment toolsIdentify potential problems and possible interventionsTo gain specialized knowledge and skill as set out by the core competencies

Assessing the Palliative Care Client

Assessment of the Palliative Patient

Includes all aspects of a basic health assessmentFocus is on philosophy of careGoals of care are identified Continual effort in consensus building

Some Reminders

Be organizedGive patient/family a brief outline of what to expectAllow the patient to choose the locationAllow the patient to decide who else should be presentMay start with medications that are current

Some Reminders

Acknowledge that some questions may be emotionally difficultShow respect, kindness, and compassion

Barriers To Assessment

Poor communicationFear of the word “Palliative”Fear of advancing diseasePatient/family trying to “protect” each otherFear of taking “strong medications”Fear of running out of medications, and dying in painConcerns of medication side effects

ESAS

ESASEdmonton Symptom Assessment System

PurposeQuantifies the experience and helps develop a care planTo assess the nine symptoms that are common to palliative patientsSeverity is rated at the time of assessmentThe patients opinionProvides a clinical profile over timeOnly one part of a holistic clinical assessmentA tool used across program/agencies

When to do ESAS

On a regular basisMore often if symptoms are not well controlledTo evaluate effectiveness of medication changes

Who Should Complete ESAS

Ideally the patientA caregiverIf completed by caregiver, can omit depression, anxiety, well beingThe person completing ESAS must be indicated

Symptoms Identified in ESAS

Pain

SeverityLocationDurationCharacteristicNew painAggravating/ relieving factorsMedications/treatments presently usingWhat meaning does it have to patient and family

Tired

It is subjectiveSeverityDurationAssess reversible causesWhat meaning does it have to patient/familyHow does it effect quality of life/safetyHelps us to assess for needed support services/equipment

Nausea

SeverityAssess for possible causesFrequencyOnset and durationAggravating/alleviating factorsWhat medications are already in placeDescription of emesisAssess bowels and bowel sounds

Depression

SeverityAsk “Are you depressed?”Differentiate between feeling sad and feeling depressedPast history of depression, how was it treatedAssess recent changes in antidepressant medicationsAssess for suicidal thoughts, and ask if they have a planAssess signs and symptoms of hypoactive delirium

Anxiety

SeverityAsk “Are you Anxious?”Assess for specific fears and causes of anxietyHelp patient and family to name fearsPatient/family may respond with crying. Do not try to stop itExplore past coping mechanisms

Explore what support systems they have in placeAssess for need of psycho/social support/spiritual careAssess for signs and symptoms of delirium or Opioid toxicity

Anxiety

Drowsy

Severity of “sleepiness”How many hours of sleep in 24 hoursIs it difficult to stay awakeAssess for possible causesAssess for changes in OpioidsPerform a medication reviewAssess respiratory rate and patternAssess patients safety in mobilizingUse or need of safety equipment

Appetite

Lack of appetiteDifferentiate between appetite and amount eaten (food and liquids)Assess for possible causesAssess present and past interventionsHow does the decrease in intake affect the caregiver/familyAssess the patients/families understanding of the causes of anorexia/cachexiaHelp patient/family to think of food as a comfort measure

Feeling of Wellbeing

Ask “How are you?” and mean itMay indicate general state of comfortIf all other scores on ESAS are low, but “wellbeing” is high, may indicate potential changes of declineGood days/bad days

Dyspnea

SeveritySubjective experienceAt rest/with activityAggravating/relieving factorsAssess for possible causes/complications of metastatic diseaseHow is dyspnea affecting the patient/familyAssess for recent changes in respiratory rate/chest sounds

“Other”

BowelsDate of last BMAmountConsistencyAbdominal distentionRectal fullnessUse of stool softeners/laxativesIncontinence of bowel/bladder

Oral DisordersDry mouth/hydrationOral Candidiasis/stomatitisLoose fitting denturesDysphagiaHiccups

Skin DisordersPressure ulcersTumor necrosis/odorPuritisJaundiceEdema

Fever and SweatsAssess for potential infectionFever can be tumor relatedSweats can also be caused by malignancies

Vital SignsWhen to take Blood PressurePulseRespiratory rateWhen not to take vital signs

Palliative Performance Scale

death0%

drowsy or comamin to sipstotal careunable to do any activitytotal bed10%

full/drowsy/confmin to sipstotal careunable to do any activitytotal bed20%

full/drowsy/confNormal/Reducedtotal careunable to do any activitytotal bed30%

full/drowsy/confNormal/Reducedmainly asstunable to do most activitybed40%

full/drowsy/confNormal/Reduced

much assistanceunable to do any work;ext diseasesit/lie50%

full or confusionNormal/Reduced

occ assistanceunable hobby, houseworkreduced60%

full or confusionNormal/Reducedfullunable normal work, significant reduced70%

fullNormal/ReducedfullNormal act with effortfull80%

fullNormalfullnormal, some evidence of diseasefull90%

fullNormalfullnormal, no evidence of diseasefull100%

ConsciousIntakeSelf careActivity & Evidence of DiseaseAmbulationPPS Level

PPSPalliative Performance Scale

Excellent communication tool for health care providersIt may have prognostic valueHelps assess patient safety, level of care/resources neededHelps identify/prioritize assessment and care planning

Summary of Assessment

What are the presenting problemsWhat interventions are presently in placeWhat options are available

Establish goals of care

Care planning

Care Planning For The Palliative Care Client

Learning Objectives

Components of a care planNursing diagnosisManagement of a Palliative client outside of a care facility Management of common symptoms experienced by Palliative care clientsFollow the “Hospice Palliative Care Nursing Standards of Practice”

Care Planning

The development and maintenance of a individualized plan of careNANDA approved Involve the clientInvolve the familyInvolve the Palliative Care Team

Purpose of the Care Plan

To communicate the clients specific care needs to staff who caring for the clientA plan of nursing care that changes as the clients care needs and condition changeIt is based on identifiable health concerns that the client is experiencingClient specific!!! With a holistic focusPain and symptom management

How Are Care Plans Formed?

Use the nursing process: the process by which nurses deliver care to their clientsCollect subjective and objective dataIdentify actual problems the client is experiencingThink about potential problems that may ariseIdentify the areas that the client needs nursing care

AssessmentMake a Nursing DiagnosisInclude relating factors (R/T)Include evidence that supports the diagnosis (your objective data that supports the diagnosis)State the expected outcomes, or GoalsShould include a Evaluation Date (not in Palliative Care)Establish specific nursing Interventions

How Are Care Plans Formed?

NANDA Nursing Diagnosis

Health Function/MaintenanceAlteration in Health MaintenanceAlteration in Home MaintenanceImpaired/Ineffective CopingImpaired /Ineffective Family CopingCaregiver Role StrainRisk for Powerlessness/HopelessnessInsufficient Support SystemAlteration/Disturbed Body Image

NutritionImpaired SwallowingAlteration in AppetiteAlteration in NutritionKnowledge Deficit

NANDA Nursing Diagnosis

NutritionImpaired SwallowingAlteration in AppetiteAlteration in NutritionKnowledge Deficit

Knowledge Deficit R/T Changes In Nutritional Requirements

NANDA Nursing Diagnosis

EliminationAlteration in Urinary EliminationAlteration in Bowel EliminationUrinary IncontinenceRisk for ConstipationPerceived DiarrheaBowel Incontinence

NANDA Nursing Diagnosis

Activity/RestDisturbed Sleep PatternImpaired Physical MobilitySelf Care Deficit: Dressing, Bathing, Feeding, ToiletingFatigueActivity Intolerance

NANDA Nursing Diagnosis

Goals for Palliative Clients

Client will be supported by the entire Palliative Care teamClient will receive optimal palliative careClients pain will be managedClients symptoms will be controlledClients quality of life will be maintainedCare giver stress will be minimized

Nursing Interventions

Based on our assessmentBased on actual or potential health concerns that we have identifiedGroup interventions by:

Home ManagementHealth StatusSymptoms

Management of the Palliative Client at Home

Identify the primary physician willing to care for client at homeIdentify the Home Care Case Coordinator Teach client and family after hours/ on-call accessibilityAlways re-assess care plan, clients care needs, and medication managementAlways include client and family in decision making

As the clients PPS declines, their needs changeMonitor changes in your clientIncrease visits Reassess the appropriateness and route of medications

Management of the Palliative Client at Home

Interventions

Psycho SocialSpiritualPhysical Care/Symptom management

• Pain• Dyspnea• Elimination• Nutrition• Nausea/Vomiting• Delirium• General/other concerns• End of life• Palliative Care Emergencies

Psycho Social

Important to gain an understanding of the meaning and preparedness of the client and familyIdentify quality of life issues for clientIdentify the care givers, support systems, coping mechanismsEnsure proper documents are in order:

POAHCDACPLAD

Always ensure a calm peaceful environmentEquipment needsEnsure the clients primary location in the home is comfortable for client and familyAnticipatory Grief

Psycho Social

Anticipatory Grief

Roles are being re-definedPersonal affairs must be put into order Life reviewFearFuneral

Spiritual

Spirituality as opposed to religionEncourage client to find meaning and purpose in remaining lifeAwareness and understanding of illness, of death and dying:beliefs, hopes, strengths, fears Ask client or family if they would like to be referred to a spiritual care provider, social worker, counselingAlways hope

Physical Care/Symptom Management

PainDyspneaEliminationNutritionNausea/VomitingDelirium

Pain

Pain assessment is done each visit (tools)Each persons pain experience is uniqueHave client rate pain ?/10, type, location, radiation, relieving/aggravating factorsTeach client/family use of long acting, short acting and breakthrough analgesicTeach what Breakthrough Pain isIf client increasingly requires more BTA, liaise

with MD to increase LA opioidsIncident Pain

Pain

Assess need for adjuvant therapies-Drugs (NSAID, steroids, antidepressants)-Medical (radiation, nerve blocks, acupuncture) -Psychological (relaxation, imagery, touch,

…music)-Physiotherapy (heat, cool, massage)-Spiritual (prayer, meditation, scripture)

If medication adjustment was made, follow up! Increase visits, change your care plan

Pain

Answer questions/teach re: side effects of opioids and their management (nausea, tiredness, constipation)Dispel myths related to opioid use Monitor need for opioid rotation Monitor need to change route of administration (severe nausea, dysphagia)

Dyspnea

Dyspnea is a subjective experience that requires an objective assessment and proper interventionsAuscultation, use of accessory muscles, pursed lips, cyanosis, cough, oral mucosa, agitationPositioningMinimize energy expenditureIncrease ventilationProvide reassuranceMedications to relieve SOBOxygen

Elimination/Bowel

Constipation #1 issueMonitor BM’s: frequency, amount, consistencyEncourage client to record BM’s on a calendarMonitor use of laxatives and softenersIncrease water intakeAuscultation of bowel soundsPerform rectal checks

Elimination/Bowel

Opioids/Laxatives go hand in handTeach:

Body still produces stool despite oral intakeWatery stool does not mean diarrheaIf obstructed=hospital admission

Nutrition

DehydrationAssess oral mucosa every visitLook for signs and symptoms of infectionAssess swallowing every visitChanges in taste contribute to decreased appetite

Nutrition

Teach client and family normal processes and loss of appetiteAnorexia/cachexiaTeach family: weight loss, smells, change in tasteFluids over solidsTeach mouth care

Nausea/Vomiting

Severity of the symptomThink of the underlying causeThink of the target receptor zonesAdd a second agent before switching agentsMedication reviewAlternate route

Nausea/Vomiting

Eat/drink small amounts often Ensure adequate hydrationEat in a pleasant environmentRelax after meals, sitting upAvoid food odorsAvoid greasy, spicy foodsRelaxation, imagery

Delirium

Distinguish delirium from dementiaDelirium when not at end of life is reversibleDelirium at end of life is manageable

Delirium

Ask the client about hallucinationsThink of the underlying causeTreat the underlying causeTeach the family signs and symptoms of delirium/confusion/agitationComfort and safety measuresMinimize family distress

General

Fatigue/sleep disturbances, general malaiseWoundsSkin breakdownBraden scaleBladder spasms/urinary retention

Care Planning at End Of Life

Mouth care every hour or moreAnxiety of client and familyTerminal respiratory secretionsLots of teaching required, provide family with “When Death Is Near”Skin break down/ mottling

Care planning for Palliative Care Emergencies

Spinal Cord Compressionsigns and symptoms

Superior Vena Cava Obstructionsigns and symptoms

Hypercalcemiasigns and symptoms

Teach family/client Review how to access after hours on call nurse

Conclusion

Assess the clientMonitor careTeach the familySupport family and clientPrepare them for death