Question:
A 7 year-old Islamic boy with all (Acute Lymphoblastic Lymphomaemia)
He is now home and has been transferred to Palliative Care for End-of-Life Disease.
He has been informed by his family that he now only has a short life expectancy.
He lives in the home of his mother and father as well 2 siblings, a 5 and a 9 year old.
The patient is suffering with constipation. He is embarrassed and has difficulty talking to his care team about it.
How can we help him with his current care plan?
What are your priorities as a patient?
Discuss with the client and his family the support they will need at the end of their lives and after death.
Give a short description of each stage of grief.
Students might want to use Kubler Ross for a foundation, but can also explore other research on this subject.
Consider one of these scenarios.
Describe the condition for which you have chosen
What tests can be performed to detect the condition you have chosen?
What symptoms can your patient show with your specific condition?
What is the treatment?
What is the chance of survival for someone with this condition?
Answer to Question: NURS6711 Palliative Care Practice
Meeting the Priorities of The Patient and Their Needs
By ensuring the patient is able to use the toilet when he requires it, the current care plan can be used to meet his needs.
He must not get constipated. This is why two things are necessary. First, the patient will need more activity to discourage constipation. Second, fluids will need to be sufficient and he should eat plenty of fibre-rich foods.
The patient’s primary goal is to reduce discomfort from difficulty defecating, and to keep him hydrated.
Care Plan for the Constipated Patient
Assessment
Subjective: The patient says that he’s not experienced a bowel movement in the past for longer than usual.
Objective: Diffused abdomen, dry and cracked mucus membrane.
There are no cups in the patient’s sink, or on the table.
Diagnosis
Actual diagnosis Balloon Expulsion Test
The balloon expulsion testing is a quick and easy way to determine if a patient can remove artificial stool.
As there is no single method, several techniques can be used.
A 50ml balloon with warm water will be filled and then placed in the patient’s rectum.
The patient will be asked if they want to expel the balloon in private, and to do so in a sitting posture (Gladman Aziz & Scott et.al., 2009).Potential diagnosis
Constipation is possible even without any tests because of the patient’s sedentary lifestyle.
Constipation is caused when there is inactivity, a lack of exercise or prolonged bed rest.
Patients can become constipated if they feel isolated.Planning/Objectives/Outcomes
Starting on April 25, 2017, the patient should be able to pass a formed, soft stool daily.
Patient will provide details of the preventative measures to ensure constipation does not recur by April 25, 2017
Interventions
Encourage the patient and give them fluids, 2-3 liters each day.
Argument: When the patient is adequately hydrated, he will have soft stool. In addition, the intestines will be able to absorb enough moisture.
Education about inactivity and constipation.
Patient will be encouraged and supported to walk on a daily basis.
Rationale
Through the intestines.
This causes the stool to dry out, making it more difficult for you to pass.
Evaluation
Patient has passed stool that was softened and formed on 25/04/2017.
Patient verbally recognizes the importance to stay hydrated on 25/4/2017
Support and services that the family and client will require at the end-of-life and after death
End-oflife goals for care include: maintaining comfort, quality life and choices of a patient who is in terminal phase; giving support to the patient; and taking care of the spiritual, psychosocial and psychological needs of the patient as well as their family.
Mohammed and his loved ones will be allowed to have an Islamic Imam visit to pray and visit.
The Imam can assist the family with accepting God’s will with respect to Mohammed’s death. He might also be able to help with planning the rituals needed to prepare Mohammed for his transit to the afterlife.
A hospital will offer support for the families. It will have a grief counselor that will be there to help them before and after their brother/sister’s death.
Cultural differences will need attention (National EOL Framework Forum 2010, 2010). Therefore, counselors selected to walk with families will be from both sexes.
Mohammed will also have a male staff to care for him after he passes.
Further, the practice of shared decision making will be used where all parties are made aware about the patient’s imminent death.
This increases the chance of Mohammed dying peacefully. Mohammed’s wishes, preferences and needs will also be taken into consideration (Frank, 2009).
Lorenz, Lynn, & Dy (2008).
Most patients have the same care goals: Living longer; getting cured; maintaining or increasing quality of life, functionality and independence; reaching goals in life; becoming comfy; supporting caregivers (Kaldjian Curtis, Shinkunas et. al., 2009).
As Mohammed becomes aware of his predicament, the goals may shift.
The 7 Stages In Grief
Shock and denial are the first stages of grief. This is when the person who has just learned of the death of a family member is overcome by disbelief.
Family members who receive the news may initially deny it to some extent to try to escape the pain.
The shock experienced by family members will provide them with emotional protection, helping them to avoid being overwhelmed by the death of their loved ones.
The shock could last for several weeks.
Some family members might be prepared for the death and not be shocked.
This stage, which is also known as guilt and pain, begins to develop after the shock has worn off.
This stage can cause immense suffering and inexplicable pain.
The patient’s family may experience unbearable and sometimes even painful pain.
It is important that every member of the family goes through this phase. They must feel the pain completely and not try to hide it by resorting to drugs and other substances.
The grief therapist will encourage their family to face the pain.
Anger, bargaining and anger- this is the third stage. In this stage frustration will turn to anger and resentment.
The family may feel the need to blame others or lash out at their loved one.
They may even blame God for failing to heal their loved ones.
The family should let out any unresolved emotions at this time. However, it shouldn’t be at the expense or permanent destruction of relationships with other people.
Family members might question why the pain is happening and blame their fate.
Some family members may start to bargain with God and promise to do certain things or not to do others in exchange for the loved one’s return.
The fourth stage of grief is loneliness, refection and depression. It is where everyone around assumes it is safe to continue with their daily lives. A long period introspection takes over the family.
This stage of grief is normal. However, outsiders who wish to help should not encourage the family members.
Encouragement from outsiders will not work as the family is coping with the grief and loss that comes with depression.
Family members will become isolated and begin to think about all the things they did for their loved one, while feeling emptiness and despair.
The fifth stage is the upward turn. This is where family members experience a sense calmness and are more organized.
The symptoms of the previous states, such as anger, depression and loneliness, bargaining or denial, start to disappear.
The family will begin to feel less pain and more anger as they return to their old normal lives.
As pain decreases, family members will focus more on the positive aspects of their lives.
As the family becomes more functional, the sixth stage of the process is to work through and reconstruct.
The brain starts to function normally again. They can look for real solutions to problems and issues that they face without the support of their loved ones who have passed away.
The family will not find it difficult to fulfill the obligations and roles of the loved one.
The family will begin to take realistic decisions like giving away, if possible, all the possessions that the loved-one left behind.
Hope and acceptance are the final stages in the process of family members learning to accept and deal with reality.
This stage is not necessarily a time of instant happiness for the family. However, it will allow them to move on to a more normal and peaceful life.
But, with time, the family can chart a course to continue living a normal life and be hopeful without their loved one.
Once the family recognizes that there are no other things they could do than what has been done, they will be able to move forward with hope.
Why Some People Do Not Complete Each Stage
There isn’t any evidence that suggests that there are stages to cope with the loss.
Kubler–Ross’s stages are not replicated in real life.
Anybody can experience these stages in a different order, or have feelings that are not part of the grief model.
Dysfunctional Grieving
Dysfunctional grieving describes a way of grieving that is emotional and behaviorally dysfunctional. It is different from adaptive, where there is progress toward resolution and healing.
Dysfunctional grief is when there is excessive grief. This can lead to psychological, behavioral and physical problems (Ruddock (2014)).
Health condition: Constipation
Description
Constipation is defined as a prolonged and difficult bowel movement.
There are many variations in the length of bowel movements.
Some have it three days a year, while others do it every other day (WebMD, 2016).
The side effects of chemotherapy ALL treatment are constipation (Leukemia in 2016).
The Tests to Diagnose Constipation
A physical examination includes careful examinations of the abdomen for stool presence, and more specifically in the left quadrant.
A standard physical examination is performed to rule out gastrointestinal mass.
Constipation: What Are The Signs?
The symptoms of constipation are: less bowel movement; trouble bowel movements; smaller hard stool; stomach pain or swelling; and throwing it up (WebMD 2016).
Treatment for Constipation
Patients should drink more fluids like water and juice.
A patient should consume more fruits and vegetables, including whole or dried fruits; cereals; bran, pasteurized, and cooked or raw foods to increase their dietary fiber.
A patient suffering from constipation should drink warm or cold beverages, such as lemonwater, 30 minutes before the normal time for their bowel movements.
Economou, 2008 states that patients should have access to a private, quiet restroom.
Survival Rate for Persons with Constipation
Constipation can be managed with good nutrition, regular exercise, and plenty of fluids.
Rectal prolapse, fecal opacity and hemorhoids are all possible complications of chronic constipation. Alternative Pain ManagementMassage
This is manual manipulation and application of pressure to soft tissue.
It involves stimulation of peripheral receptors. These receptors can be accessed through the CNS.
It reduces anxiety levels and stress levels, while increasing patient’s well-being and contributing to pain control (Falkensteiner. Mantovan.& Muller. 2011, 2011).
Reflexology
Manual pressure is used on specific areas such as the feet or ears.
These pressure points correspond both to organs and other areas of the body.
Reflexology is used frequently to reduce side effects and pain from the end stages of cancer chemotherapy. It also helps improve the quality and quantity of your life (Wilkinson, Lochart, & Gambles, (2008)).
Aromatherapy
This involves the application and massaging of plant essences onto the skin.
The oils reach your lymph systems through your circulatory system. They provide healing and support through intercellular fluids.
Short-term effects of aromatherapy on cancer patients have been documented (Boehm & Bussing & Ostermann (2012)).EFT
Emotional Freedom Treatment (EFT), which is an easy-to-learn method, involves tapping the patient’s middle and index finger tips onto acu-points that correspond to the energy meridians.
This will stimulate any disruption in energy flow and ease your pain (Healing Cancer Easily, 2007).
Magnet Therapy
Research shows that placing magnets on the skin results in relaxation of the capillaries which, in turn, increases blood circulation.
This will also increase blood oxygenation as well as the removal of prostaglandins.
This will, theoretically, relieve muscle spasms. Eventually, the pain will subside (Kuipers Sauder, Ray, 2007).References:Boehm, K., Bussing, A., & Ostermann, T. (2012).
Aromatherapy as an adjuvant treatment for cancer — A systematic review.
African Journal of Traditional, Complementary, and Alternative Medicines, 9.(4), 503-518.
Economou D (2008).
Constipation for cancer patients. (Retrieved on 24th April, 2017) https://www.cancernetwork.com/oncology-nursing/constipation-cancer-patient
Frank RK.
(2009). Shared decisions and their 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 mechanism. Neurogastroenterol Motil. 21:508-16.
Healing Cancer Naturally (2007).
Introduction to EFT. EFT stands for Emotional Freedom Technique. It is a way to heal your mind and body, and reestablish healthy energy flow.
Retrieved on April 25, 2017. https://www.healingcancernaturally.com/eft-emotional-freedomtechnique.htmlKaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. (2009).
Structured literature review on goals of end-of life care.
Am J Hosp Palliat Care. 25(6):501-11.Kubler-Ross, Elisabeth; Kessler, David (June 5, 2007).
“On Grief, Grieving: Finding Meaning Through the Five Stages. Scribner.
Retrieved April 24th 2017, via Amazon.Kuipers NT, Sauder CL, Ray CA. (2007).
Effect of static magnetic field on pain perception and activity of the sympathetic nerves in humans J Appl Physiol:102:1410-1415. Available at jap.physiology.org/content/102/4/1410.long. ?Leukemia.org (2016).
Acute Lymphoblastic Leukaemia. https://www.leukaemia.org.au/blood-cancers/leukaemias/acute-lymphoblastic-leukaemia-allLorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, et al (2008).
A systematic review of the evidence supporting palliative end-of life care: Ann Intern Med.15;148(2):147-59.
Maciejewski Paul K. Zhang, Baohui Block, Susan D. Block and Holly G. Prigerson (2007).
“An Empirical Examination of 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).
The guidance document Health system reform: Care at the End of Life.
Canberra: Palliative Care Australia.Rao, S. S. C., & Meduri, K. (2011).
What is required 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 mourning?
(Retrieved 24 April 2014). https://dying.lovetoknow.com/coping-grief/what-is-dysfunctional-grieving.
WebMd (2016).
What is constipation?
(Received on April 24, 2017, at 11:59 PM). https://www.webmd.com/digestive-disorders/digestive-diseases-constipation#1Wilkinson, S., Lockhart, K., Gambles, M., & Storey, L. (2008).
Reflexology to help patients with cancer.
Cancer Nursing 31(5), 354-356.