

31. 30 • Communication Skills Effective communication skills are essential for nurses, who are critical in providing high-quality patient
care. Nurses must be able to communicate effectively with patients, families, and other healthcare providers to ensure that the best
possible care is delivered. Nurses need to acknowledge and understand the concerns of the patient and family and respond appropriately to
bring clarity to their current situation. Effective communication is crucial in palliative care, where nurses are vital in supporting patients
and families through the end-of-life journey. Here are some core communication skills for palliative care nurses: • Active listening: Nurses
should listen attentively to patients, family members, and other healthcare providers to understand their concerns, fears, and needs fully. •
Empathy: Nurses should be able to understand and relate to the emotions and feelings of their patients and their families, providing
comfort and support. • Clear and concise communication: Nurses should be able to communicate clearly and concisely with patients and
their families, using appropriate tone and language. They should also use plain language to explain complex medical information. • Non-
verbal communication: Nurses should be aware of their body language, facial expressions, and gestures, which can convey more
information than words alone. • Open and honest communication: Nurses should be open and honest with patients and their families,
discussing end-of-life issues, including pain management, palliative sedation,and withdrawal of treatment. • Culturally sensitive
communication: Nurses should be aware of cultural differences and be able to communicate effectively with patients and their families
from diverse backgrounds. • Conflict resolution: Nurses should be able to manage disagreements and conflicts between patients, families,
and healthcare providers in a respectful and constructive manner. Core Principles of Communication These principles can help nurses to
communicate effectively and achieve their goals, whether it is to build strong relationships, resolve conflicts, or achieve success in the
workplace. • Respect: Respect involves treating others with dignity and recognizing their worth. It involves valuing their opinions and
ideas, even if they differ from our own. Respecting others' boundaries, cultural backgrounds, and beliefs is critical in building positive
relationships and fostering open communication. • Empathy: Empathy is the ability to understand and relate to the feelings, thoughts, and
experiences of others. It involves putting ourselves in another's shoes and seeing things from their perspective. Empathy helps to build
trust and strengthen relationships by demonstrating our willingness to understand and support others. • Trust: Trust is the foundation of all
healthy relationships. It involves having confidence in others' integrity, reliability, and ability to meet our expectations. Trust is built over
time through consistent and transparent communication and by keeping our commitments. • Unconditional positive regard: Unconditional
positive regard involves accepting and valuing others for who they are, regardless of their thoughts, feelings, or behaviors. It involves
seeing the good in others and treating them with kindness and compassion. Unconditional positive regard helps to create a safe and
supportive environment where individuals feel accepted, valued, and respected. Every patient has different communication needs, which
may change throughout their illness.
 32. 31 Consequences of poor communication Poor communication in palliative care can have significant negative consequences for
patients, families, and healthcare providers. Some of the consequences of poor communication in palliative care may include: 1. Increased
anxiety and distress: Patients and families may feel anxious, confused, and uncertain about their medical condition, prognosis, and
treatment options if they do not receive clear and accurate information from healthcare providers. 2. Inadequate pain and symptom
management: Poor communication between healthcare providers may result in inadequate pain and symptom management, leading to
increased suffering and decreased quality of life for patients. 3. Reduced patient satisfaction: Poor communication can lead to reduced
patient satisfaction and trust in healthcare providers, potentially leading to patients and families seeking care elsewhere. 4. Conflict and
disagreements: Poor communication can result in misunderstandings and disagreements between patients, families, and healthcare
providers, potentially leading to conflict and ethical dilemmas. 5. Increased burden on family caregivers: Poor communication can result
in family members feeling unprepared and overwhelmed with the responsibilities of caregiving, leading to increased stress and burnout. 6.
Increased healthcare costs: Poor communication can lead to repeated hospitalizations, unnecessary medical interventions, and increased
healthcare costs. Barriers to effective communication Professional versus social dialogue: Unlike social interactions, any form of
professional dialogue would have an implicit contract between the professional and the patient. This differentiation brings forth a unique
set of barriers and problems for professionals during communication with the patient. Professional problems in communicating with
patients: • Fear of upsetting the patient • Fear of causing more harm than good • Unsure about answering difficult questions • Afraid of
saying, “I don’t know.” • Patient’s belief that health professionals are too busy • Unable to manage patient’s emotions • Unable to improve
the situation • Fear of the untaught • Fear of being blamed Patient’s problems in communicating with health professionals Patients - • think
that the health professionals are too busy. • think that they are more interested in their physical care. • they do not want to know about any
emotional problems. • are frightened to complain in case they stop treating them. • are frightened of going out of control. • may be terrified
of having the truth revealed.
 33. 32 The problems arising in communication • Pretending to be busy • Selective attention to safe physical aspects • Not exploring
beyond physical issues • Premature/false reassurance • Premature normalization • Jollying along • Inappropriately introducing humor •
Concentrating on physical tasks • Using euphemisms to mislead • Disappearing from the stressful situation • Patronizing and talking down
to patients • Using medical jargon • Distancing behaviors Examples of good and poor communication techniques 1. Ask for open
techniques! Nurse “Is your pain better today? This closed question gives either a yes or no answerand needs revision. Nurse: “How are
you feeling?” This allows the patient to open up and vent their feeling. 2. Be empathetic Patient: “I feel scared when I am breathless.”
Nurse: “Take these tablets to ease your breathing”. Here, the nurse has ignored the patient's emotions, which is wrong. The correct
approach would be. Patient: “I feel scared when I am breathless.” Nurse: “Breathlessness can be very frightening. It is very
understandable. I shall give you the prescribed medicines which should help you.” OR Nurse: “What scares you most when you get
breathlessness?” 3. Be sensitive while telling the truth Patient: “The doctor said my cancer is incurable.” Nurse: “Don't worry about such
things. Everything will be okay”. Here, the nurse is giving false reassurance, which is not the correct approach. A better statement would
be as follows.
 34. 33 Nurse: “It must have been tough to hear that cancer has spread, but we will do our best to help you however we can.” 4. Always
try to balance hope and truth Nurse: “There is nothing more we can do; your disease is incurable, so there is no point in staying in the
hospital.” Here the nurse is destroying hope, which is incorrect. The nurse should try to balance hope and truth. Nurse: “I am sorry that no
more treatments are available to cure your disease, but we can start other medicines to make you more comfortable. Then you can be at
home with your family. If you need any help in future, you must come to the clinic or contact me.” 5. Keep confidentiality and avoid
unhealthy curiosity Patient: I have not told anybody before, but I got this cancer because I had an abortion when I was seventeen.” Nurse:
“Were you not worried at that time.” Here the nurse is getting curious about the irrelevant matter. The right approach would be as Nurse:
“We need to discuss this more, as it is incredibly significant for you, but please know that everything we discuss will be kept
confidential.” The nurse here assures confidentiality, and at the same time, he would like to have more details which would be medically
significant. 6. Partnership between nurse and patient Nurse: “You must take this medicine for your pain. Unless you accept this, your
painwill remain as such. The nurse is imposing their agenda on the patient, which is wrong. Nurse: “Your pain is caused by the disease,
and you need pain medicine. How about trying it?” Here the nurse is trying to set up a bond with the patient by soliciting his opinion.
Nonverbal communication Nonverbal communication is an important aspect of communication in palliative care, as it can convey
emotions, empathy, and understanding. Non-verbal communication: Non-verbal communication is featured by mode and tone of voice
with which words are spoken; gestures going with the speech; looks and facial expressions; physical contact, touch, body posture, pitch
and pace of voice, and active listening. Here are some examples of nonverbal communication in palliative care: • Eye contact: Making eye
contact with the patient and their family members can convey empathy and understanding, and can help to establish a rapport. • Facial
expressions: Facial expressions, such as a smile or a nod, can convey empathy, understanding, and support. • Touch: Appropriate touch,
such as holding a patient's hand or giving a hug, can convey compassion and comfort. • Body language: Body language, such as leaning
forward or sitting at the same level as the patient, can convey attentiveness and interest.
 35. 34 • Silence: Silence can be a powerful tool in palliative care, allowing patients and their family members time to process their
emotions and thoughts. • Tone of voice: The tone of voice can help to convey empathy, understanding, and support. A gentle tone can help
convey a caring attitude, while a rushed or dismissive tone can convey impatience and lack of concern. • Environment: The environment
can also convey nonverbal communication. Creating a calming and welcoming environment can convey support and empathy. It's
important for nurses in palliative care to be aware of their nonverbal communication and to use it in a way that conveys empathy,
understanding, and support to patients and their family members. Learning to communicate with patients having advanced and progressive
diseases Communicating with patients who have advanced and progressive diseases in palliative care can be challenging, but it is essential
for providing compassionate care. Effective communication with patients facing progressive disease, with complex problems and an
uncertain future, is challengingand needs more skills andpractice. Patients with advanced and progressive diseases have issues other than
physical, and they require compassionate listening and empathetic responses. Here are some tips for effective communication: • Use
simple language: Use plain and straight forward language to ensure that patients can understand you easily. • • Respect the patient's
autonomy: Respect the patient's autonomy and allow them to make decisions about their care to the extent that it is possible. • Provide
support: Provide support to patients and their families to cope with the changes that come with the advanced and progressive stages of the
disease. • Collaborate with the healthcare team: Work collaboratively with other healthcare team members to ensure that the patient's
physical, emotional, and spiritual needs are met. • Use nonverbal communication: Use nonverbal communication, such as touch, eye
contact, and facial expressions, to convey empathy and understanding. Show empathy: Show empathy and understanding towards the
patient's emotional andphysical challenges. • Be honest: Be honest and transparent about the patient's condition, prognosis, and treatment
options. • Listen actively: Listen carefully to the patient's concerns and feelings, and encourage them to share their thoughts. Fig.2.2:
COMMUNICATING WITH PATIENTS HAVING ADVANCED DISEASE
 36. 35 • Avoid false hope: Avoid providing false hope or unrealistic expectations, and instead focus on providing comfort and symptom
management. • Consider cultural and spiritual beliefs: Consider the patient's cultural and spiritual beliefs when communicating and
providing care. By using these strategies, healthcare providers can communicate effectively with patients with advanced and progressive
diseases in palliative care and provide compassionate care that meets their physical, emotional, and spiritual needs. Basics steps of
communication i. Preparing for listening ii. Questioning iii. Listening effectively (facilitating) shows that you have heard iv. Responding i.
Preparing for listening It is essential to practice active listening as it is the key to effective communication. Active listening: involves fully
focusing on the speaker and attempting to understand their message. This includes paying attention to the speaker's verbal and nonverbal
communication, asking clarifying questions, and providing feedback. Active listening requires the listener to be fullyengaged in the
conversation, to concentrate on what is being said, and to be present in the moment.Active listening is important in palliative care, as it
can help healthcare providers to understand thepatient's needs and concerns and provide appropriate care. Passive listening: on the other
hand, involves listening without actively engaging in the conversation. The listener may appear to be listening but is not fully focused on
the speaker's message. Passive listening may involve nodding, making eye contact, or saying "mm-hmm" without really paying attention
to the content of the message. Passive listening can lead to misunderstandings, miscommunication, and missed opportunities for building
rapport with patients and their families. The following methods help to enhance listening skills. • Greeting and seating: Allow the patient
to take their comfortable position in the bed or chair. Provide privacy and sit beside the patient at a reachable distance without any barrier
between the patient and yourself. • Ask open questions: Open-ended questions give freedom to the patient to decide what andhow much
they should tell. • Encourage talking: To get more details and develop better rapport, it is good to encouragethe patient to talk about his
concerns. • Maintain eye contact: It gives confidence to the patient that they are being actively listenedto. • Tolerate brief silence: Silence
can have diverse meanings in communication. It can be understood as a time to think, consider a response, or express emotions. • Avoid
unnecessary interruptions: Interruptions should not be too frequent in a way that affects the flow of communication. • Show them that they
are listened to: The patients should feel that they are being heard by verbal and non-verbal means. This can be done by repetition,
 reiteration, and reflection. • Summarize and prioritize the agenda: We must summarize and explain the treatment planand help them with
shared decision-making. • Empathize and give realistic hope. Nurse have to approach the patients with empathy and to provide realistic
hope.
 37. 36 ii. Questioning Questioning is an important aspect of communication that involves asking questions to gather information, clarify
understanding, and encourage dialogue. There are several types of questions that can be used in communication, including: 1. Open-ended
questions: These are questions that require more than a simple yes or no answer. They encourage the speaker to provide more detailed
information and can help to facilitate conversation and encourage the exploration of thoughts and feelings. Example: "What brings you to
palliative care today?" 2. Closed-ended questions: These are questions that can be answered with a simple yes or no. They can be useful
for getting specific information but may not encourage further conversation. Example: "Have you experienced any pain today?" 3.
Leading questions: These are questions that are phrased in a way that suggests a particular answer. They should be avoided as they can
bias the response. Example: "You're not experiencing any pain today, are you?" 4. Clarifying questions: These are questions used to gain a
better understanding of the speaker's message. They can be useful for ensuring that the listener has understood the speaker's meaning.
Example: "Can you explain what you mean by 'feeling anxious'?" 5. Reflective questions: These are questions used to reflect back the
speaker's message to show that the listener has understood. They can be useful for building rapport and showing empathy. Example: "It
sounds like you're feeling overwhelmed by the situation. Is that correct?" 6. Hypothetical questions: These are questions used to explore
potential future scenarios or situations. They can be useful for decision-making and problem-solving. Example: "What would you like to
do if your pain becomes too difficult?" In palliative care, open-ended, clarifying, and reflective questions may be particularly useful for
building rapport with patients and their families, understanding their needs and concerns, and providing appropriate care. There are several
key principles of questioning in communication that can help to promote effective communication: 1. Use open-ended questions: Open-
ended questions allow the speaker to provide more detailed information and encourage further conversation. They are useful for building
rapport and understanding the speaker's perspective. 2. Avoid leading questions: Leading questions suggest a particular answer and can
bias the response. They should be avoided in communication. 3. Use clarifying questions: Clarifying questions help to ensure that the
listener has understood the speaker's message. They can be used to gain a better understanding of the speaker's perspective. 4. Use
reflective questions: Reflective questions reflect back the speaker's message to show that the listener has understood. They can be used to
build rapport and show empathy.
 38. 37 5. Avoid interrupting: Interrupting can be seen as disrespectful and can hinder effective communication. It is important to allow
the speaker to finish their thought before responding. 6. Be aware of nonverbal communication: Nonverbal cues such as tone of voice and
body language can impact the effectiveness of questioning. It is essential to be aware of these cues and use them to guide the questioning
process. Effective questioning can help nurses to understand the patient's needs and concerns, provide appropriate care, and build rapport
with the patient and their family. It is important to usequestioning techniques that are respectful, empathetic, and focused on understanding
the patient's perspective. iii. Listening effectively (facilitating) shows that you have heard Listening effectively and facilitating a
conversation involves more than simply hearing the speaker's words. It involves actively engaging in the conversation, demonstrating
empathy,and providing feedback to show that you have understood the speaker's message. The listening wheel can be followed to show
that you are listening. • Open Questions: How? What? Where? Who? Why? • Summarizing: A summary helps to show the individual that
you have listened to and understood their circumstances and feelings. • Reflecting: Repeating a word or phrase encourages the individual
to continue and expand. • Clarifying: Sometimes, an individual may gloss over a crucial point by exploring. These areas further, we can
help them clarify these points for themselves. • Short Words of Encouragement: The person may need help to go on with their story –use
words like ‘yes’ or ‘go on.’ • Reacting: We need to show that we have understood the situation by reacting to it – “That it sounds like it is
exceedingly difficult.” Effective listening and facilitating: Ten Commandments 1. Stop talking: The first commandment of good listening
is to stop talking and start listening 2. Put the speaker at ease: The patient can organize his thoughts and convey them meaningfully only
when put at ease. 3. Show them that you want to listen and maintain eye contact: The nurse should make it clear that they are attentive and
keen to receive the message. This may be done byappropriate body movement or proper posture. 4. Remove distractions: The nurse has to
remove distractions, if any, such as shutting the door, switching off the cell phone and removing objects between the patient and the nurse
so that body movements can be observed. 5. Empathize with them: An essential requirement for effective listening is that the nurse should
show empathy or proper understanding. 6. Be patient and tolerate short silences: wait for the speaker to complete the talk. The nurse
Fig.2.3: LISTENING WHEEL
 39. 38 should avoid frequent interruptions, derogatory remarks, negative comments, and distracting gestures. 7. Hold your temper: The
nurse may not appreciate the communicator’s message. That does not give the nurse the right to instant reaction. 8. Don’t argue or
criticize: The nurse should not challenge and blame the patient. Any such argument or criticism would be detrimental to the flow of
communication. 9. Ask questions: Positive interventions by the nurse are desirable. The nurse should ask appropriate questions at the right
opportunity to elicit more information. 10. Stop talking: For speaking to progress smoothly, talking should be stopped by the nurse and
keep listening. The benefits of effective listening • Build trust and strong relationships • Helps to resolve conflict • Prevents missing
valuable information • Enables us to find or expect problems • Helps to build more knowledge iv. Responding Effective responding in
palliative care communication is important to ensure that the message is received and understood. Here are some key principles of
responding in communication: • Acknowledge the message: Start by acknowledging the speaker's message to show that you have heard
and understood what they have said. • Provide feedback: Provide feedback to the speaker to show that you are engaged in the
conversation. This can be in the form of nodding, making eye contact, or providing verbal cues such as "I see" or "I understand." • Reflect
on the message: Reflect on the speaker's message to show that you have understood their perspective. This can be done summarizing what
has been said or paraphrasing the message in your own words. • Show empathy: Demonstrate empathy by acknowledging the speaker's
feelings and validating their perspective. This can help to build trust and rapport. • Respond appropriately: Respond appropriately to the
 speaker's message. This may involve providing information, offering support, or asking further questions to clarify understanding. • Avoid
interrupting: Avoid interrupting the speaker as it can be seen as disrespectful and can hinder effective communication. Fig.2.4:
LISTENING TO PATIENT
 40. 39 Tips for responding to create a supportive helping relationship • Respond in a way that focuses attention on the issues and
concerns: clarify inconsistencies and gather facts quickly and unobtrusively. • Probe with open–ended statements to gain more
information. Use Tell me more about …, Let us talk about that, or I'm wondering about … Responding in this manner is usually more
effective than using specific who, what, when, where, and why questions. • Ask for clarification, e.g., I am having trouble understanding
what you're saying. Is it that …? Or could you review that again, please? • Use understandable words. Listen to the vocabulary of the other
person to get a clue to their level of understanding. • Try not to preach, blame, or be demanding. • Try to avoid straying from the topic! •
Show understanding and sincerity in your responses, so the patient will feel comfortable discussing more information. • Try not to talk
excessively about yourself. Keep self–disclosure to a minimum! • Give responses proper for the age, sex, and emotional state of the
patient! • Be comfortable with silence. Do not feel that silence needs to be filled with talk! • Try to remain neutral and nonjudgmental in
responding to actions, comments, or conditions you find antagonizing, shocking, or hostile. • If you become tangential (straying from the
topic), try to refocus the discussion. • If people become emotional and cry, allow them to call. Show respect. Do not stop them but try to
make them feel comfortable while crying. • Use responsive body language: make eye contact, and lean forward. In palliative care,
effective responding is important to ensure that the patient's needs and concerns are addressed, and that appropriate care is provided. It is
important to use responding techniques that are respectful, empathetic, and focused on understanding the patient's perspective. By
demonstrating empathy, active listening, and appropriate responses, healthcare providers can promote effective communication and build
trust with patients and their families. What is not recommended during clinical communication? 1) Do not at once reply to the patient’s
words. It is helpful to enquire about feelings or real questions behind the patient words. E.g., When a patient asks… “Sister, how long do I
have?” the implicit question usually is “Sister…now that I have very little time left, what can I expect? How can you help me?” 2) Do not
use philosophies or moralize. They may hurt the patient’s feelings and stop the further conversation. E.g., “You should not say such
things. God gave your life. Trust in God.” 3) Avoid comparisons. It is insensitive to say that someone else’s grief is more significant;
therefore, the patient has no right to grieve. E.g., “Look at that man over there. He has no family; he is alone and in pain. At least be
thankful that you have a loving family.” 4) Avoid meaningless words. E.g., “There is nothing to be afraid of.” 5) Avoid medical words.
They are jargon from the patient’s point of view. Technical language tends to overwhelm patients.
 41. 40 6) Avoid false reassurance. E.g., "When your general health improves, we shall try more chemotherapy. That will cure you.” It
does not provide comfort, and it destroys trust. Reassurance is essential to keephope after due interactions and explanations, but it must be
based on truth. 7) Do not make assumptions. Check the patient’s insight about the diagnosis and prognosis and what it means to her. E.g.,
“What made you ask that question?” 8) Avoid a condescending attitude. The patient will be open to you only if you deal with them
respectfully. 9) Do not force your beliefs or convictions on the patient. E.g., “You must regularly chant for strength to endure this” is
imposing your beliefs on a patient. 10) Avoid sympathy, which is hard to bear. E.g., “Oh, you unfortunate thing; it is so sad you must go
through this terrible disease.” Instead, convey empathy – an attempt to put us in the patient’s shoes and understand what he is going
through. E.g., “I can see that you are going through a lot….” 11) Avoid inappropriate humour. E.g., “You are waiting for your final Visa?
Ha, ha!”. The patient himself may use humour as a coping strategy, but coming from us, it may seem insensitive. 12) Avoid both lies and
thoughtless honesty. Lies may not be believed; even if accepted, they will destroy trust later. Also, the truth should not be disclosed like a
bombshell. Truth is a powerful therapeutic tool but must be applied in the right doses at the right time. COMMUNICATING BAD NEWS
Breaking bad news (BBN) refers to the process of delivering information to a patient, family member, or caregiver that may be distressing
or difficult to hear. This can include news about a serious illness,a poor prognosis, a treatment failure, or other negative developments
related to the patient's health.BBN is a challenging aspect of palliative care, as it can be emotionally difficult for both the patient and the
healthcare provider. BBN is essential to communication as it takes time for the patient to accept the truth. It needs to be discussed in detail
and clarified when more information is shared. It can significantly impact the patient's emotional well-being and abilityto make informed
decisions about their care. It requires empathy, sensitivity, and effective communication skills to ensure that the patient and family
members receive the information they need to make informed decisions and cope with the emotional impact of the news We need to
analyze ourselves beforehand • Should we tell the diagnosis to the patient or not? • If you were diagnosed with cancer, would you want to
be told? • How would you feel if your family hid the news from you? Why should patients be told about their disease? • The patients have
the right to know about their disease. • If it allows patients and families to plan their life.
 42. 41 • Knowing the truth allows the patients to cope with their disease. • Reduces uncertainty. • Avoids false hope. • Builds trust
between the patient and the physician. • Helps complaints with treatment. Breaking Bad News Breaking bad news is an essential part of
healthcare, but it can be a challenging and emotional experience for both patients and healthcare providers. Here are some steps to follow
when breaking bad news: 1. Prepare for the conversation: Before you start the conversation, prepare yourself mentally and emotionally.
Review the patient's medical history and any relevant test results, and anticipate their potential reactions and questions. 2. Choose an
appropriate location: Choose a quiet and private location where you can talk without interruption or distractions. Make sure the patient is
comfortable, and offer them a glass of water or tissues if necessary. 3. Set the tone: Begin the conversation with empathy and compassion.
Be direct but compassionate, and avoid medical jargon. Ask the patient if they would like a family member or friend present during the
conversation. 4. Deliver the news: Use clear and simple language to explain the diagnosis and the implications. Allow time for the patient
to process the information and ask questions. Provide information about treatment options, potential outcomes, and support resources. 5.
Address emotions: Acknowledge the patient's emotional reactions and offer reassurance and support. Allow them to express their feelings
and concerns, and validate their emotions.Offer resources for emotional support, such as counseling or support groups. 6. Develop a plan:
Work with the patient to develop a plan of care that aligns with their goals, preferences, and values. Involve the patient in decision-
 making, and offer choices whenever possible. Set realistic expectations, and provide ongoing support and communication. 7. Follow up:
Follow up with the patient and their family after the conversation to answer any remaining questions, offer additional support, and monitor
their physical and emotional well- being. COLLUSION The act of shielding information from the patient or family is called collusion.
Collusion in palliative care refers to the situation where healthcare providers and the patient or family members avoid
discussingdifficulttopicssuchasend-of-lifedecisions,prognosis, or treatment options. This collusion can occur for various reasons, including
the healthcare provider's fear of causing distress to the patient or family, a lack of communication skills or training, or the patient or
family's reluctance toface the realityofthesituation. Collusion in palliative care can have negative consequencesfor the patient and their
loved ones, and it's important for healthcare providers and caregivers to prioritize open and honest communication and respect the patient's
autonomy and wishes. Collusion = “PLEASE DON’T TELL” Collusion implies information (about diagnosis, prognosis, and medical
details about the patient) being held by some and kept from significant stakeholders. The type of professional care team treating the patient
and colluding with the family members is a frequent problem. In addition, withholding of information also occurs between the
professional team and the patient. There are several types of collusion that can occur in palliative care:
 43. 42 Family collusion: This occurs when family members or caregivers work together to withhold information from the patient or make
decisions without the patient's input. This can happen when family members feel that they know what is best for the patient, or when they
believe that the patient cannot handle bad news. Provider collusion: This occurs when healthcare providers withhold information from the
patient or make decisions without the patient's input. This can happen when providers feel that the patient is not capable of handling the
information or when they believe that the patient's family members or caregivers are better equipped to make decisions. Patient collusion:
This occurs when the patient withholds information from their healthcare providers or family members, or when they defer decision-
making to others. This can happen when the patient feels overwhelmed or powerless, or when they are unable to express their preferences
or needs. Collusion in palliative care can have negative consequences for the patient and their loved ones, and it's important for healthcare
providers, patients, and their families to work together to prioritize open and honest communication and respect the patient's autonomy
and wishes. Consequences of collusion • The patient lacks trust in everyone close to them, including the professional team • Unfinished
business for the patient or family members • Chronic anger • Depression and suicidal tendencies • Disturbed sleep patterns • Disturbed
eating patterns • Disturbed leisure patterns • Disturbed conversation patterns All these factors can result in the patient losing control and
entering a stage of chronic depression resulting in weakness, weight loss, and disability. Managing collusion • Acknowledge with family
members that a collision exists. • Speak reassuringly, for instance, by saying, “you know your brother much better than I do.” • Empathize
with the difficult position the family member is in. For instance, one could say, “It must be challenging for you to maintain secrecy with
the patient,” or “I guess you don’t normally keep important things from your brother.” • Empathize again and as often as possible to gain
the family member’s trust. • Empathizing and asking a dire question. One could say, “What effect does this have on you?’ Effect of
Collusion Collusion creates an atmosphere of suspicion, poor communication, and poor relation between the patient and his family
members. One is never able to remain honest. This situation gets worse as time goes by for both professional team members and family
members. Communication could get stifled and scary, leading to more emotional distress and increased isolation from family members
 44. 43 The effects of collusion in palliative care can be particularly harmful, as patients and families rely on healthcare providers to be
open and honest about their condition and treatment options. Here are some of the effects of collusion in palliative care: • Lack of
informed decision-making: When healthcare providers collude, patients and families are denied the information they need to make
informed decisions about their care. This can lead to decisions being made based on incomplete or inaccurate information, potentially
resulting in treatments that are ineffective, unnecessary, orharmful. • Loss of trust: Collusion can erode trust between patients, families,
and healthcare providers. When patients and families discover that healthcare providers are not being honest with them, they may become
suspicious of their motives and lose confidence in their ability to provide effective care. • Increased emotional distress: Collusion can
increase emotional distress for patients and families. When patients and families are not given the information they need to understand
their condition and treatment options, they may experience feelings of confusion, anxiety, and mistrust. • Worsened quality of life:
Collusion can negatively impact the quality of life for patients and families by limiting their ability to make informed decisions about their
care. Patients may receive treatments that are not aligned with their values, preferences, and goals, resulting in decreased quality of life
and increased suffering. • Legal and ethical implications: Collusion in palliative care can have legal and ethical implications, as patients
have the right to be fully informed about their condition and treatment options. Healthcare providers who collude may be subject to legal
action and disciplinary measures. Overall, collusion in palliative care can significantly negatively affect patients, families, and healthcare
providers. It is important for healthcare providers to be open, honest, and transparent about a patient's condition and treatment options, and
to work collaboratively with patients and families to develop a care plan that aligns with their goals, values, and preferences. Breaking
collusion can be a painful and challenging task. The family members will need your support, the patient needs your help, and we, as
professionals, may also need support. ANGER Anger is a common emotion experienced by patients in palliative care, as well as their
families and caregivers. Anger is a response to feelings of helplessness, distress, and fear. It may also be a negative result of ineffective
communication between healthcare professionals and the patient/carer/ family members. Anger is often unleashed on a person perceived
as close (like a spouse, close friends, or close family members) or non - threatening (usually security staff, reception staff, attenders, junior
nurses, and junior doctors). It's important to acknowledge and address anger in a compassionate and empathetic manner to ensure that
patients and their loved ones feel heard and supported. There are several reasons why patients and their families may experience anger in
palliative care, including: • Loss of control: Patients and their families may feel like they have lost control over their lives, as they may not
be able to make decisions about their care or may have to rely on othersfor assistance. • Fear and uncertainty: Palliative care often
involves uncertainty about the future, which can be frightening and overwhelming for patients and their families. • Unresolved issues:
Patients and their families may have unresolved issues related to their illness or past experiences, which can lead to anger or resentment. •
Pain and discomfort: Physical pain and discomfort can also contribute to anger and frustration.
 45. 44 Approach to Anger • The patient may direct anger at you irrespective of whether you are the source of distress. Acknowledge and
name the emotion. Then address the need of the patient to be understood. E.g., “I can see that you are angry; can we sit down and talk….
tell me what you thought went wrong… I may be able to help you.” • Be calm and empathetic and use positive non-verbal throughout the
conversation. • Give the patient time to express himself. • Allow the patient to express his emotions/feelings. • Observe the nonverbal cues
of the patient. • Acknowledge the reasons for anger. • Arrive at a consensus through ‘participatory decision-making.’ • Summarize the
conversation. • Ask if the patient wants to add something or needs any clarification. • Assure your continued support and follow-up after a
stipulated time. DENIAL Denial is the patient’s refusal to take on board the bad news. It is avoiding thoughts and feelings that are painful
or that you cannot deal with. It occurs to some degree in everyone who has a serious illness. It is a shock absorber that helps you bear an
overwhelming situation and cope with it. However, for some patients, denial of the illness or its severity can cause delayed diagnosis or
compromised compliance with treatment. In that event, patient and sustained efforts may be required to convey at least one part of the
truth to permit treatment. Denial can be a problem if the patient: • Does not accept the diagnosis and /or prognosis and avoids/delays
treatment. • Minimises the symptoms and implications of the illness. • Insists on continuing with curative treatments and other measures
which have been proven futile/ineffective. Denial is a common defence mechanism in most palliative care patients. It varies in severity
and pervasiveness. It has varying effects on the process of adaptation. In some cases, denial reduces anxiety, while, in others, it results in
excessive delay in seeking help and poor compliance to treatment. Questions that may give an idea about the nature of denial. • What do
you think about your illness? • What is your understanding of the seriousness of your illness? • What are your plans? • Do you have
another plan (Plan B) if the former is found to be not working? Assessment of denial • A cognitive evaluation is essential to rule out the
possibility of any psychiatricdisorders. • Check the patient’s insight – set up what they know. This should include their understanding of
the diagnosis, prognosis, and current treatment regime. • Listen to the words used and observe the non-verbal communication when the
patient narrates. This will tell you how much the patient knows or how he feels about the illness. Approach to Denial • Ensure that the
patient’s denial is not due to a lack of information, understanding, or agreement
 46. 45 with medical recommendations. • Distinguish between a fact being denied (e.g., diagnosis of cancer) and implications of the fact
denied (e.g., cancer will not return). • Assess how and when the patient uses denial. • Assess the benefits and risks of denial to the
patient’s psychological condition and compliance with treatment. • If the denial is expressed by minimization of illness or lack of
emotional response, it signals that the patient is frightened. Provide emotional support and discuss their issues/concerns. • Adopt a non-
confrontational approach. If the denial is causing significant problems, confrontation may only increase the use of denial. • Finally,
emphasize to patients that they will not be abandoned. They will be supported and cared for. Conclusion Good communication is a skill
that ensures improvement. Good communication is essential for ensuring the patient’s needs are under-allowed and can be met by the
healthcare team. Good communication allows the nurses to connect with the patients and those who are important to them, understand
their priorities and wishes, and support them to make informed decisions about their care. Reflect on your conversations and think about
what went well and what you could do better next time.
 47. 46 Activity for Unit 2 I. Multiple choice questions 1. Which of the following is most important in communication? a. Asking
questions b. Giving advice c. Listening actively d. Pacifying 2. All the following will help in setting up a good therapeutic relationship,
EXCEPT: a. Active listening b. Empathy c. Genuineness d. Judgment 3. Communication with a patient mostly happens through: a. Verbal
medium b. Nonverbal medium c. Written medium d. Electronic medium 4. What should be the correct approach in communicating bad
news? a. Should be said to all patients b. Should be told only to the family c. Should be said to the patient if they express the wish d. The
doctor should decide whether to tell or not 5. While you see a patient during consultation, the patient breaks down, and you tell him that
“don’t worry, it will be all right”. This response is: a. Empathic response b. Premature reassurance c. Active listening d. Validation 6. The
advantage of effective communication in the nurse-patient relationship is: a. Reduces certainty b. Prevent realistic hope c. Prevent
inappropriate adjustment d. Guide and give direction 7. When we communicate with the patient, this action means they are ready to
interact: a. Not responding b. Having eye contact c. Keeping silence d. Turning opposite side 8. This means reviewing the main points
covered in an interaction: a. Reflecting b. Paraphrasing c. Restating d. Summarizing
 48. 47 II. True or False 1. Collusion does not create an atmosphere of suspicion. 2. Breaking Bad news always causes distress to patients
and the person breaking the bad news. 3. Active listening is a crucial part of communication. 4. Sensitive truth-telling is harmful to
patients. III. Short Answers 1. List the basic steps of communication. 2. Enumerate the nonverbal communication techniques 3. State the
do’s and don’ts in communication 4. Enumerate communication skills 5. Explain the approach to anger IV.Group activity/Role Play
Objective: Reinforce practical communication skills! Activity instruction • Encourage the students to perform role play on breaking the
bad news in the classroom. • Divide the students into small groups and tell them to discuss how to communicate effectively with the
patient and the caregiver's scenarios, like when the patients are in different stages of illness denial, anger, bargaining, depression and
acceptance stages. Role Play 1 Role: Palliative Care Nurse Patient: Mrs Sujatha, a 40-year-old woman with terminal cancer Setting:
Hospital room Question: Mrs Sujatha has been admitted to the hospital for the third time in six months due to her worsening condition.
During her previous hospital stay, she was informed that her cancer had spread and it's no longer responding to treatment. The physician
has asked you to speak with Mrs Sujatha about her prognosis and end-of-life care options. Please role-play the conversation with Mrs
Sujatha, considering the principles of effective communication and breaking bad news. Discussion Points: • Steps of breaking bad news •
Do’s and don’ts in effective communication in all the stages of illness
 49. 48 Unit 3 NURSING MANAGEMENT OF SYMPTOMS Introduction Patient descriptions of physical symptoms and their severity
are the primary data for symptom assessment in palliative care. Exploring patients' reports of symptoms requires thoroughness,
persistence, and patience, a fundamental aspect of palliative care. Symptom assessment usually involves taking a detailed history from the
patient to understand the cause and severity of the symptom. Ideally, the management should be guided by a comprehensive assessment of
symptoms subjectively and objectively. This helps us evaluate the significance of symptoms on patients' distress, quality of life, and
 survival. Effective symptom management aims to provide comfort and can potentially increase the quality of life for patients and families.
Holistic approach in symptom assessment and management Holistic care focuses on the whole person, not just the condition. It looks at
how the individual is dealing with the situation, their physical, psychological, social and spiritual domains of health and any issues they
are experiencing. Integrating holistic/palliative care principles into routine nursing practice at the hospital and home care makes it possible
to provide patients and their families with high-qualitycare.Symptoms are inherentlysubjective; hence, self-report must be the
primarysource of information. Detailed history-taking is important. The assessment of symptoms is a vital aspect of nursing care to
provide comfort and enhance the quality of life. Principles of Symptom Assessment and Management • Anticipate needs: A proactive and
systematic approach to symptom assessment can help anticipate patients’ clinical needs and support care management. • Assess and
manage holistically: Consider which problems most affect the person’s quality of life (physical, emotional, social and spiritual). Many
symptoms are multifactorial, or occur in clusters, and some causes may be more or less reversible than others. • Manage pre-emptively:
Given the nature of this persons’ disease, consider what problems may need to be planned for, and ensure that essential medications can be
accessed when needed so that the symptoms continue to be managed. To avoid delays for example over a weekend, it is advisable to
indent and ensure that medication is available within the facility prior to its being needed. This pre-emptive action is referred to as
anticipatory prescribing. • Assess and reassess frequently: Consider using simple assessment tools like the Symptom Assessment Scale
(SAS) - to screen for and monitor symptoms. Check for adverse effects oftreatments, as well as benefits, regularly. o Assess whether
problems are likely to be due to reversible or irreversible causes. o Consider and discuss the likely burden of various treatment options
(cost, difficulty of undergoing investigations, realistic improvement that might be expected etc.). o Consider both pharmacological and
non-pharmacological management options.
 50. 49 Fig 3.1: SYMPTOM ASSESSMENT SCALE (SAS) • Timely referral: If a problem does not respond to primary care
management, or is complex, refer to specialist palliative care for further advice. The key points in managing symptoms are as follows: 1.
Base the care components on the patient’s idea of the quality of life. 2. Follow the five “A” s of chronic care – “Assess, Advice, Agree,
Assist, Arrange.” 3. Correct the correctable contributory factors. 4. Involve the multidisciplinary team to address the care needs in all
dimensions – physiotherapist, psychologist, nutritionist, medical social worker, occupational therapist, yoga therapist etc. Use non-
pharmacological as well as pharmacological treatment. 5. For any continuous pain, analgesia is better achieved with round-the-clock
administration of analgesics rather than giving them SOS basis. 6. Keep the treatment regimen as simple as possible for the patient. 7. A
formatted prescription with names of drugs, the reason for the use, dose and timings is more advisable than verbal advice. 8. Seek expert’s
advice in intractable situations. 9. Avoid false re-assurances yet maintain realistic hope. 10. Prioritize concerns from the patient’s point of
view. 11. Review and fine-tune care inputs. General guidelines for all nurses. 1. Listen attentively. Be a good listener. 2. Do not consider
the patient's problems insignificant. 3. Do not force your opinions/beliefs upon the patient. 4. Do not ignore the patient's queries. 5. Try
not to give any false hopes. 6. Ensure confidentiality. PAIN Pain is an unpleasant feeling, such as a prick, tingle, sting, burn or ache. Pain
is what the person says,"it hurts". Definition: “An unpleasant sensory and emotional experience associated with, or resembling that
associated with actual or potential tissue damage”- International Association for the Study of Pain (IASP) Concept of pain: Pain is always
a personal experience that is influenced to varying degrees by biological, psychological, and social factors. Through their life experiences,
individuals learn the concept of pain. Pain cannot be inferred solely from activity in sensory neurons.
 51. 50 Assessment and Documentation of Pain Assessment and documentation of pain are essential for evaluating therapy efficacy, for a
better understanding of the pain, for encouraging and supporting the patient and for future reference. A comprehensive pain assessment
will allow for determining the causes related to psychosocial factors, quality of pain, quality of life and functional status. Such an
assessment should include the location of pain, intensity, characteristics, mechanisms, expressions and functions, assessment of the
psychosocial factors and the current analgesic treatment, and the response to the same. Assessment of a patient's pain requires a structured
approach, good listening, and observation skills with constant re-evaluation. The assessment could get challenging if the patient
experiences more than one type of pain. There are many approaches to assessing pain, and each professional will develop his/her approach
to the history of pain. It is important to keep in mind an outline scheme for assessment with which you are confident. Assessing pain •
Seek to establish a relationship with the patient. • Encourage the patient to do most of the talking. • Begin with a wide - angle open
question before on focusing and clarifying specifics. • Watch the patient for clues regarding the pain. • Avoid jumping to conclusions. Pain
assessment tools need to be valid, reliable and relevant. PQRST of pain A good understanding of the patient's pain forms the keystone of
the development of a treatment plan. If not well controlled, pain can interfere with every aspect of the patient’s daily life from their ability
to carry out simple activities of daily living, such as washing and dressing, to their tolerance of other treatments. Inadequate pain
assessment is an important contributing factor to the under-treatment of pain. Assessment of pain is complex because pain is always
subjective. The patient’s self-report of pain is the single, most reliable indicator of pain. The basic principle in the assessment of pain is
that the clinician must accept the patient’s self-report of pain. Using pain diagrams to document the pain ateach visit is a good practice.
Fig.3.2: PAIN DIAGRAM
 52. 51 Table 3.1: PQRST of Pain P = Provokes/Precipitating/Palliating • What causes pain? • What makes it better? • What makes it
Worse? • What previous treatment have youtried to relieve your pain? • Were they effective? Q = Quality • What does your pain feel like?
• What words would you use todescribe your pain? • Is it sharp? • Dull? • Stabbing? • Burning? • Crushing? (Try to let the patient describe
the pain) R = Radiates • Where does the pain radiate? • Is it in one place? • Does it go anywhere else? • Did it start elsewhere and now
localized to one spot? S = Severity • On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine, how much
does it hurt right now? • How much does it hurt at its worst? • How much does it hurt at its best? (This is a difficult one as the ratingwill
differ from patient to patient.) T = Time • When did your pain start? • How often does it occur? • Has its intensity changed? • How long
does it last? Pain Scales for Measurement of Intensity of Pain Two types of Pain Scales are available. i. Multidimensional:
Multidimensional scales explore all dimensions of pain. Since they take time to administer, multidimensional pain scales are not suitable
 for use in busy outpatient settings. ii. Unidimensional: Unidimensional scales assess the overall intensityof pain.These take little time to
administer and hence are suitable for busy clinical settings. Any one of the following scales can be used. a) Numeric Rating Scale (NRS):
This is the most commonly used pain scale. The patient needs to rate the intensity of their pain on a scale of 0 to 10. Zero means no pain,
while 10 stands for severe pain. This scale is commonly used for persons above the age of 10 years. Fig.3.3: NUMERIC RATING SCALE
 53. 52 b) Visual Analog Scale: Visual Analog for Pain consists of a horizontal (or vertical) line. The left end of the line signifies no pain,
which is depicted by a smiling face, while the right end signifies the worst possible pain with a frowning face. This visual depiction of
pain levels helps patients communicate their pain intensity. As the intensity of pain in VAS is majorly depicted with images of facial
expression, it can be used on a wide range of patients, including little children and elderly people who might not be accustomed to using
other pain scales such as the Numerical Rating Pain Scale. It is much easier for any patient to express their perception of the intensity of
their pain on VAS rather than converting it to a number as required in the Numerical Pain Scale. The patient can simply mark a spot on the
scale that they feel represents their current state of pain. c) Wong-Baker Faces Pain Scale (Observation scale for kids): The rating in
Wong-Baker pain scale is similar to the numerical rating but it combines pictures with the number for the rating of the pain. This scale can
be used even for children as they can point to the face that depicts their intensity of pain. Chronic pain Chronic pain refers to pain that
persists for more than three to six months, beyond the expected healing time. Various underlying conditions, such as arthritis,
fibromyalgia, nerve damage, or a pastinjury can cause it. Chronic pain can significantly impact an individual's physical, emotional, and
social well-being, affecting their quality of life, sleep, mood, and ability to work and engage in activities. Pathways of Chronic Pain Pain
pathways comprise a complex sensory system, which is activated to provide protective responses to noxious stimuli. • Nociceptors: Pain is
caused by stimulation of free nerve endings called ‘nociceptors’. • Peripheral sensitization: Tissue injury as in trauma or disease like
cancer, causes stimulation of free nerve endings in the skin and connective tissues like bone (somatic nociceptors) and viscera (visceral
nociceptors). This results in the release of pain-producing substances like bradykinin, serotonin, histamine and prostaglandins. They
sensitize the nociceptors to the effect of these substances, enhancing the pain. Fig.3.4: VISUAL ANALOG SCALE Fig.3.5: WONG-
BAKER FACES PAIN SCALE
 54. 53 • Central sensitization (spinal cord and brain levels): In the dorsal horn of the spinal cord, only a few specific interneurons take
part in normal pain transmission. When these cells constantly are stimulated by long-standing continuous pain, the surrounding ‘sleepy’
receptors also get sensitized and increase the pain sensation. This is called central sensitization • Recruitment: When pain is present for a
prolonged period, the adjacent segments of the spinal cord also get stimulated, which is why patients complain of a wider area of pain than
the actual anatomical area of the disease. Example: a patient with a cancer pancreas complains of chest and lower abdomen pain (although
initially restricted to the T10/T11 dermatomes). • Descending inhibitory pathway: This refers to inhibitory neurons (a built-in mechanism
inour nervous system) present in the dorsal horn cells, which block the transmission of pain impulses and are the major endogenous
mechanism of pain inhibition. The descending pathways from the brain and thalamus stimulate these neurons. This helps modulate the
degree of transmission at different levels of the pain pathway, and the final pain perception is a balance of these inputs. • Connections
within the brain: Pain impulses transmitted to the thalamus are relayed to several areas of the cerebral cortex: the sensory areas of the
parietal lobe, which allow localization and interpretation of the pain. The limbic system is involved in both the emotional and autonomic
response to pain; the temporal lobe is involved in pain memory. The frontal lobe assesses the cognitive function, the significance of the
pain based on emotional response and leads to pain behavior, which differs from person to person. Pathophysiology of Chronic Pain
Chronic pain is a complex condition influenced by various physiological, psychological, and social factors. It is defined as pain that
persists for longer than three months and can be caused by various underlying conditions, including nerve damage, injury, inflammation,
and disease. The four main mechanisms involved in the physiology of pain are transduction, transmission, perception and modulation.
These are the key processes involved in generating and perceiving painsignals in the body. Transduction: Transduction is the process by
which physical stimuli, such as heat, pressure, or injury, are converted into electrical signals by specialized nerve cells callednociceptors.
Nociceptors are located throughout the body and are responsible for detecting potentially harmful stimuli. Transmission: After a
nociceptor is activated, it sends an electrical signal along nerve fibers to the spinal cord and the brain. The signal is transmitted through a
series of synapses, or connections between nerve cells,which can amplify or dampen the signal. This process is known as transmission.
Fig.3.6:PHYSIOLOGY OF PAIN
 55. 54 Perception: Perception is the conscious awareness of pain. It occurs when the pain signal reaches the brain and is interpreted as
painful. The perception of pain is influenced by a variety of factors, includingthe intensity and duration of the pain signal, as well as the
individual's emotional and cognitive state. Modulation: Modulation is the process by which the intensity of pain signals is either amplified
ordampened. Modulation can occur at several levels of the nervous system, including the spinal cord and brain. It involves the release of
neurotransmitters, such as endorphins, which can inhibit the transmission of pain signals and reduce the perception of pain. In summary,
transduction is the conversion of physical stimuli into electrical signals by nociceptors, transmission is the process by which the pain
signal is transmitted to the brain, perception is the conscious awareness of pain, and modulation is the process by which the intensity of
pain signals iseither amplified or dampened Classification of Pain Pain may be classified as 1) Nociceptive and 2) Neuropathic
Nociceptive Pain This refers to pain resulting from the stimulation of peripheral nerves. Pain impulses enter the spinal cord through the
dorsal horn and ascend to higher centers in the brain. Inhibitory impulses block transmission at the spinal cord- dorsal horn, preventing
transmission of theimpulses. Neuropathic Pain Neuropathic pain is pain arising from damage to the peripheral or central nervous system.
Clinical presentations include sensations such as burning or stabbing in areas of sensory loss. Central pain refers to neuropathic pain
caused by damage within the central nervous system. There is usually an area of altered sensation incorporating the area of pain. A
cerebrovascular accident or spinal cord damage may be associated with central pain. Neuropathic pain could be of different forms, such
as: • Sympathetic-mediated pain is a relatively uncommon form of neuropathic pain due to sympathetic nerve injury. Essential features are
pain (often with burning sensation) and sensory disorder related to a vascular as opposed to a neural distribution. Such a problem is also
 associated with reduced sweating and dry shiny skin. • Hyperalgesia – An increased response to painful stimuli. • Allodynia – A painful
response to stimuli such as light touch that does not usually cause pain • Phantom limb pain - Phantom limb pain is a condition in which a
person experiences pain or other sensations in a limb that is no longer present. This phenomenon is most commonly experienced by
amputees, as it occur after a nerve injury or other trauma that results in the loss of a limb. Fig3.7: DIAGRAMMATIC
REPRESENTATION OF TYPES OF PAIN
 56. 55 Pain Management Introduction Severe chronic pain, including cancer pain, can be managed well through a systematic approach.
For example, adequate pain relief can be achieved in 70 to 90 percent of patients if proper treatment guidelines for cancer pain are
followed. WHO analgesic ladder is a simple protocol for treating chronic pain. Management Principles: By the clock: Prescribe round-
the- clock doses in contrast to SOS doses for effective pain relief. By the mouth: Start with oral immediate-release opioids, titrate to an
effective dose before switching to sustained-release opioids. By the ladder: Medications should be provided according to the severity of
the pain. WHO LADDER FOR PAIN MANAGEMENT The WHO Pain Ladder is a set of guidelines for the management of pain,
developed by the World Health Organization (WHO) in 1986. It is a widely accepted approach for the treatment of pain in patients,
particularly those with cancer. The WHO Pain Ladder consists of three steps, each of which corresponds to a different level of pain
severity: Step 1: Non-opioid analgesics, such as Paracetamol and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), are used for the
management of mild to moderate pain. Step 2: If the pain is not adequately controlled with non-opioid analgesics, weak opioids such as
Codeine or Tramadol can be added to the treatment regimen. Step 3: If the pain is still not adequately controlled with weak opioids, strong
opioids such as Morphine are added to the treatment regimen. Strong opioids are used for the management of severe pain. The WHO Pain
Ladder is designed to be flexible and can be adapted to the patient's individual needs. For example, a patient with moderate to severe pain
may begin treatment with a weak opioid instead of a non-opioid analgesic, depending on their level of pain and individual circumstances.
Overall, the WHO Pain Ladder provides a framework for the management of pain that is widely used and has been shown to be effective
in improving the quality of life for patients with pain. Fig.3.8: WHO PAIN LADDER
 57. 56 WHO Analgesic Ladder Once the patient is started on the analgesic ladder, they must be reviewed regularly to titrate the exact
dose requirements and to assess for side effects, change in pain quality etc. • STEP I: (MILD PAIN) Non-opioid (Paracetamol), NSAID
(Diclofenac or Ibuprofen) • STEP II: (MODERATE PAIN) Weak opioids like Codeine, Tramadol • STEP III: (SEVERE PAIN) Strong
Opioids like Morphine, Fentanyl, Buprenorphine NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) • NSAIDs exert an anti-
inflammatory action by inhibiting prostaglandin synthesis. Commonly recommended NSAIDS are Ibuprofen, Diclofenac etc. Elderly
patients or those with a history of peptic ulcers may be more at risk of getting side effects. A proton pump inhibitor such as Omeprazole
has been shown to reduce this risk. Different NSAIDs have different reported relative risks. Ibuprofen has the safest side effect profile
among traditional NSAIDs. • Headache due to raised intracranial pressure may be semi-resistant to opioids. It is, therefore, better to try
paracetamol. If necessary, these can be given rectally (paracetamol, naproxen or diclofenac) or subcutaneously (diclofenac or ketorolac). •
List of certain NSAIDs that can be used for pain relief: Drug Typical starting dose Acetaminophen 650mg x 4hrly Ibuprofen 200-800mg x
6hrly Diclofenac Sodium 50-75mg x 8-12hrly Naproxen 250-750mg x 12hrly Piroxicam 10-20mg daily Ketorolac 10 mg qid Table 3.2:
NSAIDS Adverse effects of NSAIDs Continued use of NSAIDs may cause damage to the gastrointestinal, hepatic, renal system and
interfere with platelet function. The symptoms may include nausea, heartburn, dyspepsia, gastrointestinal (GI) bleeding, and ulcers. The
risk of GI events with NSAIDs increases with  Increasing dose of NSAIDs  Increasing age  NSAIDs used in combination with
Aspirin • NSAIDs /Aspirin taken with alcohol
 58. 57 OPOIDS These drugs are best given by the oral route and the dose is tailored to suit each individual’s needs instead of trying to
give the standard dose. The dose of Morphine varies from patient to patient. There is no set maximum dose or ceiling effect for morphine.
An expert will administer high doses after appropriate titration against pain.Alternate routes of administration when oral administration is
not possible for some reason are rectal, subcutaneous, intramuscular and intravenous. The risk of addiction with the use of opioids is small
and has been traditionally exaggerated. Morphine and other opioids should not be withheld for fear of addiction when the patient requires
a stronger analgesic. Commonly used opioids for pain relief: Step II Weak Opioids (Oral) Usual starting dose Codeine phosphate 10 – 15
mg x 4hrly Tramadol hydrochloride 50mg x 6hrly Step III Strong Opioids (Oral) Morphine Sulphate (oral) 5 – 10 mg x 4hrly 30 – 60 mg
x 12hrly (sustained release) Table 3.3: OPIOIDS Oral Morphine Morphine administered by mouth or oral route is the choice for cancer
pain. It is administered as tablets (i.e., 10 mg, 20 mg) or as aqueous solutions. Basics of Morphine use: • There is no standard dose or
upper limit for chronic cancer pain. The correct dose is that which controls pain with minimal side effects. • The dose is to be titrated for
each patient. • A laxative and anti-emetic for constipation and nausea/vomiting must always be given with morphine. Myths about
Morphine • Used only for patients with cancer • Use only when the end of life is near • Can cause addiction/dependence • Can cause
respiratory depression • Can’t be used for children Guidelines for starting a patient on Oral Morphine 1. Oral Morphine is indicated in
patients with pain who do not respond to the optimizedcombined use of a non-opioid and a weak opioid. 2. If the patient takes two or more
PRN doses in 24 hours, the regular dose should be increasedby 30-50% every 2-3 days. 3. Prescribe stimulant laxatives. Adjust the dose as
necessary. Constipation may be moredifficult to manage than pain. 4. Warn patients about the possibility of initial drowsiness. 5. For
outpatients, write out the drug regimen in detail with time, name of drug and amount
 59. 58 tobe taken and arrange for follow-up. 6. Ordinary (normal/ immediate release) Morphine tablets or solution • Morphine is given
q4h regularly ‘by the clock’ doses of an equal amount. • After 1-2 days, adjust the dose upwards if the patient still has pain or uses two
ormore SOS doses per day. • Continue q4h regularly. 7. A double dose at bedtime obviates the need to wake the patient up for a 4 hourly
dose in theearly morning. Morphine - what to be careful about? The following details should be kept in mind before starting a Morphine
treatment regimen: o Painkillers such as Morphine may be taken regularly if the cause of the pain has not been treated and cured. The
effect of Morphine wanes in about four hours. Hence it has to be taken every four hours. o A double dose may be taken at night in order to
avoid waking up from sleep to take the medicine. o Morphine does not cause acidity or heartburn, so it can be taken before or after food. o
 Morphine induces constipation. Therefore, the medicine for constipation has to be taken along with Morphine on the doctor's direction. o
Morphine may induce vomiting initially in some patients. However, vomiting may not lastwith the normal Morphine course of a week or
more. It is advisable to take medicine to control vomiting while starting a Morphine regimen. o If the patient is drowsy or delirious after
taking Morphine, it could be due to an overdose. Stop the next dose and inform the doctor. The same is to be adopted if the vomiting is
severe or if there is a urinary blockage. o At no cost should the dosage recommended for one patient be followed for another patient.
Management of opioid overdose and side-effects Patients should be warned of the possible side effects of Morphine, such as nausea and
drowsiness that is usually temporary and often not a problem. If sleepiness continues for a few days, other possible causes, such as uremia,
hypercalcemia or toxicity from other medications, should be excluded. Constipation is predictable, and most patients need prophylactic
laxatives. If toxicity occurs, reduce the Morphine dose. The patient may need to miss several doses. Restart at a lower dose. Side effects of
opioids • Constipation: Stepwise escalation of oral stimulant (Tablet Bisacodyl 10 mg HS increased to TDS) or if needed, an osmotic
laxative (Syrup Lactulose) on opioid initiation. • Nausea and vomiting: Usually self-limiting within 1 week. Prescribe Tablet
Metoclopramide 10 mg TDS or Tablet Haloperidol 1.5-2.5 mg HS. • Drowsiness: Initial drowsiness may be a sign of effective pain relief
in a sleep-deprived patient. Stimulants such as Dextroamphetamine or Modafinil may be helpful if sedation Fig.3.9: PAIN RELIEF BY
ORAL MORPHINE
 60. 59 persists. • Delirium: Assess for reversible causes like hypercalcemia and UTI. If no other cause is apparent, consider Haloperidol
2.5-5 mg HS/PO. • Myoclonus: May respond to Benzodiazepines but may be a sign of opioid toxicity requiring hydration, opioid dose
reduction or switching. • Pruritus and Sweating: Try opioid rotation or 5HT3 antagonists (e.g. Ondansetron, Granisetron). Morphine
toxicity Common symptoms of Morphine toxicity are myoclonic jerks, over-drowsiness (difficult to arise), hallucinations and confusion.
Patients with renal impairment are at high risk of developing Morphine toxicity as the metabolites are excreted in the urine. If toxicity is
observed, the drugs should be discontinued immediately. The patient may have to miss several doses for the toxic symptoms to disappear
and should be started with the much lower dose and may require spacing 6th hourly, 8th hourly etc. Signs of Overdose • Drowsiness •
Delirium • Myoclonus • Respiratory depression (Very rare) Use of Naloxone: Respiratory depression due to oral Morphine is rare,
although the incidence can increase whenMorphine is given intravenously. Indications: • Respiratory rate < 8 breaths/minute, difficult to
arouse the patient and clinical evidence ofcyanosis. OR • Respiratory rate 10-12 breaths/ minute, difficult to arouse and oxygen saturation
<90% Dilute 0.4mg of Naloxone in 10 mL NS and administer 0.5 mL every 2 minutes until the normal respiratory rate is achieved. Once
the normal respiratory rate is achieved, the patient should be constantly observed. This is because the half-life of naloxone is about 20
minutes, whereas the half- life of Morphine is about 4 hours. So the patient should be observed for more than 4 hours after the
administration of naloxone. Once the effects of naloxone wear off, respiratory depression can again set in. Management of Neuropathic
Pain The drugs used for Neuropathic Pain are considered as Adjuvant analgesics (Co-analgesics). It is a drug, which is not an analgesic in
its prime function but can enhance pain control in combination with an analgesic. E.g., anti-emetics, anti-depressants, anti-convulsant,
muscle relaxant, antispasmodic, antibiotics, anxiolytics and antacids. 1. Adjuvant drugs Adjuvant drugs are used in addition to analgesics
in pain relief. Adjuvants may belong to one of two categories – • Drugs used to limit the side effects of analgesics • Co-analgesics useful
in certain types of pain Along with drug therapy, it must be ensured that the patient’s activities are analyzed, and those precipitating pain
are avoided or reduced. Non-pharmacological measures like hot pads, relaxation, and music therapy may also be tried.
 61. 60 2. Tricyclic Antidepressants The mechanism of analgesic action occurs principally by the facilitation of descending inhibitory
pathways. E.g., Amitriptyline, Imipramine. Lower doses than the dose commonly required for depression will be effective in neuropathic
pain. Other less sedating tricyclic antidepressants may be more useful for certain patients. 3. Anticonvulsants Carbamazepine tends to
result in more side effects, mainly when combined with other drugs. Build up doses slowly to minimize adverse effects. Gabapentin is the
only anticonvulsant licensed for treating neuropathic pain. Reported results with Gabapentin show that it is as effective as other
anticonvulsants but may have fewer associated side effects and it is more expensive. 4. Anesthetic Agents Ketamine: An anesthetic agent
causes dissociative anaesthesia and has shown to be analgesic at sub anaesthetic doses. 5. Other Drugs Topical Lignocaine / Bupivacaine:
It may be useful for superficial localized areas of pain such as fungating wounds for short periods. Prolonged use may lead to skin
sensitization. Although the systemically absorbed dose will be small, care should be exercised with patients susceptible to cardiac
problems. Capsaicin: Capsaicin cream (0.75%) may be used for the pain from post herpetic neuralgia. Capsaicin is a derivative of chilli
pepper and must be applied 4-5 times a day after wearing gloves. Nursing interventions for the management of pain. • Assess pain
characteristics using PQRST of Pain • Assess for signs and symptoms associated with chronic pain such as fatigue, decreased appetite,
weight loss, changes in body posture, sleep pattern disturbance, anxiety, irritability, restlessness, or depression. • Assess the patient's
perception of the effectiveness of methods used for pain relief in the past. • Evaluate gender, cultural, societal and religious factors that
may influence the patient's pain experience and response to pain relief. • Assess the patient's expectations of pain relief. • Assess the
patient's attitudes toward pharmacological and non-pharmacological methods of pain management. • For patients taking opioid analgesics,
assess for side effects, dependency, and tolerance. • Assess the patient's ability to accomplish activities of daily living, instrumental
activities ofdaily living, and demands of daily living. • Encourage the patient to keep a pain diary to help in identifying aggravating and
relievingfactors of chronic pain. • Acknowledge and convey acceptance of the patient's pain experience. • Provide the patient and family
with information about chronic pain and options available forpain management. • Assist the patient in making decisions about selecting a
particular pain management strategy. • Teach the patient and family about using non-pharmacological pain management strategies. • Cold
applications: Cold reduces pain, inflammation, and muscle spasticity by decreasing
 62. 61 the release of pain-inducing chemicals and slowing the conduction of pain impulses. This intervention requires no special
equipment and can be cost-effective. Cold applications should last about 20 to 30 minutes. • Heat applications: Heat reduces pain through
improved blood flow to the area and reduction of pain reflexes. This is a cost-effective intervention that requires no special equipment.
Heat applications should last no more than 20 minutes. Special attention needs to be given to prevent burns with this intervention. •
 Massage of the painful area: Massage interrupts pain transmission, increases endorphin levels, and decreases tissue oedema.This
intervention may require another person to provide the massage. • Progressive relaxation, imagery and music: These centrally acting
techniques for pain management work by reducing muscle tension and stress. The patient may feel an increased sense of control over his
or her pain. Guided imagery can help the patient explore images about pain, pain relief, and healing. • Distraction: Distraction is a
temporary pain management strategy that works by increasing the pain threshold. It should be used for a short duration, usually less than 2
hours at a time. Prolonged use can add to fatigue and increased pain when the distraction is nolonger present. • Acupressure: Acupressure
involves finger pressure applied to acupressure points on the body. Using the gate control theory, this technique works to interrupt pain
transmission by "closing the gate". This approach requires training and practice. • Transcutaneous Electrical Nerve Stimulation (TENS):
TENS requires the application oftwo to four skin electrodes. Pain reduction occurs through a mild electrical current. The patient can
regulate the intensity and frequency of the electrical stimulation. Home care teaching • Teach the patient and family how to give pain
medications. • Explain to the patient and caregiver about each analgesic's time of intake, duration, route,expected side effects and
importance of PRN dose. • Write out the instructions clearly on the medicine envelope. • Encourage the patient to use complementary
therapies like distraction, music and imagininga peaceful scene, as much as possible. • Explain the importance of drug compliance in pain
management and discourage taking anyself-prescribed medications. Teach the family how to give oral Morphine. • Teach the patient and
family about the rectal route for Morphine administration in patients whocan’t take it orally. • Advise family on additional methods for
pain control - emotional support, physical method(touch, hot and cold application). • Give adequate information on managing side effects
of analgesics at home (e.g., constipation- T. Dulcolax 5mg; dry mouth— ice chips, lemon pieces). • Non-pharmacological interventions: A
range of techniques exists to complement pharmacological approaches. Not all approaches will be appropriate for every patient.
Positioning, reassurance, good communication, psychological support, joint mobility (passive & active), spiritual counselling, diversion
therapy, art or music therapy, etc., are also useful.
 63. 62 DYSPNEA Dyspnea occurs in almost half of the patients referred for palliative care. It can be very frightening. It restricts
activities. There is a loss of independence, frustration, anger and depression. Breathlessness at rest can cause anxiety and panic attacks.
Patients often fear suffocating to death. Explanation and support are important. Causes of Dyspnea 1. Some causes are reversible. e.g.,
wheezing due to tightening of airways. It can be made better with medicines given by the doctor. Check if the patient has been given any
drugs or nebulizer earlier 2. Morphine is very helpful in decreasing breathlessness by acting on various centers in the brain. 3. Oxygen: It
may help in a few cases where there is less oxygen in the blood, but in cases where the disease destroys the lungs, it may not help.
Pharmacological Management • Positioning – Make the patient to sit in Fowler’s position; avoid abdominal or chest compression and
restrictive clothing • Airflow - encourage cool air flow over the face - open window, electric fan, ceiling fan, handheld fan • Distraction -
reading, relaxation, company, music, TV or radio • Energy conservation / Functional pacing • Encourage pacing and planning of exertion
to tolerance. • Controlled Breathing: Aim to reduce the rate of breathing (breath in, blow out) • Encourage diaphragmatic (“use lower chest
muscles”) and pursed-lip breathing. • Encourage relaxation of shoulders (e.g., take the weight off the shoulders by resting arms on
support) and upper chest muscles on breathing • Loose, comfortable clothes • Wiping the face with a wet towel • Massage of the shoulders
may further assist relaxation and encourage diaphragmatic Related to Cancer • Cancer of the lungs, trachea or throat • Cancer has spread
to other parts of the body • Distension of the stomach due to either cancer or fluid • Anemia related to cancer Unrelated to cancer • Asthma
• Infections:Tuberculosis, Pneumonia etc. • Cardiac- related issues • Tobacco induced - lung diseases • Plural effusion or Pneumothorax
Table 3.4: CAUSES OF DYSPNEA Management: Possible cause Management Asthma Bronchodilators, Corticosteroids, Physiotherapy
Pulmonary oedema Diuretics, Morphine Pneumonia Antibiotics, Physiotherapy Pneumothorax Chest drainage, Oxygen Table 3.5:
PHARMACOLOGICAL MANAGEMENT OF DYSPNEA Non-Pharmacological Management
 64. 63 breathing. • Assess psychological factors: Listen to, understand, and address the patient's fears. • Relaxation techniques used
regularly can reduce long-term levels of anxiety and can be taught. • Dyspnea is frightening to patients, families and staff. Reassurance
and explanation are vital parts of the treatment, whatever the cause. • Modifying lifestyle, breathing retraining and relaxation may be
beneficial if instituted early. • Consider referral to a physiotherapist or occupational therapist. • A portable/table fan directed onto the face
often eases dyspnea. • Good oral care is important if there is persistent mouth breathing. • Humidified oxygen may help acute dyspnea but
should be used alongside other measures, and its use should be reviewed regularly. Respiratory physicians only should instigate long- term
oxygen therapy for chronic respiratory illness. NAUSEA AND VOMITING Nausea and vomiting can cause patients and their relatives
great distress. Of the two, nausea causes the most prolonged misery. Many patients can tolerate one or two episodes of vomiting a day,
while persistent nausea can beprofoundlydebilitating. Nausea is an unpleasant wave-like sensation in the back of the throat epigastrium or
throughout the abdomen that may or may not lead to vomiting. Vomiting occurs when the contents of the stomach are forcibly and
involuntarily expelled. It is generally preceded by nausea. In illnesses like cancer, problems in the food pipe and stomach/ bowel often
result in severe vomiting and nausea. Chemotherapy medicines used in cancer also cause vomiting. Vomiting is found in bedridden
patients due to certain other reasons too. Retching is the movement of the diaphragm and abdominal muscles in a spasmodic, rhythmic
manner. Usually, nausea is present, and the action results in vomiting. Retching is an attempt to vomit without expelling the contents.
Common Causes of Nausea and Vomiting • Obstruction in the movement of food and water through the oesophagus,stomach and intestine
due to cancer • Medication-induced vomiting (chemotherapy, radiation) • Some forms of cancer • Brain tumor • Certain medications like
morphine etc. • Infections • Ascites • Constipation • Gastroparesis or slow stomach emptying • A reaction to certain smells or odours •
Ulcers
 65. 64 Assessment - Nausea and Vomiting Onset When did the vomiting start? Is it related to food intake? What is the time interval
between food intake and vomiting? Amount Number of episodes of vomiting What is the quantity of the vomitus? (Overall/ Each episode)
Colour What is the colour of the vomitus? Is there any bloodstain in the vomitus? Smell Is there a foul smell to the vomitus? Frequency
How many times in a day do you vomit? Precipitating factor Smell, food and other activities Associated symptom Headache, abdominal
 pain, fever, heartburn, abdominal distention, hiccups, constipation, loose stools, signs of dehydration Sensorium Conscious/semi-
conscious/unconscious oriented/disoriented/calm/agitated/restless Vestibular disturbances Do you feel dizzy? Drugs What medications are
you currently on?Recent chemotherapy or radiotherapy If on NG tube Amount, type and frequency of feeding Examination a) Per-Rectal
digital examination if constipated b) Blood pressure and Heart rate recording Table 3.6: ASSESSMENT OF VOMITING Consider the
route of administration of medication as • Persistent vomiting may reduce gastric emptying, resulting in decreased drug absorption. • The
parenteral route may reduce tablet burden, which may be a contributing factor to Nausea and Vomiting. • For persistent nausea/vomiting,
it is preferable to give subcutaneous infusion rather than bolus injections which are more apt for a single episode. • Anti-emetics in
suppository or tablet form can also be administered rectally. Management of Nausea and Vomiting 1. Try to provide care to the patient in
a well-ventilated room. Put on the fan if needed. 2. Avoid smells that cause nausea, e.g., the smell of cooking, phenol, Dettol, etc. 3. Keep
a bowl for vomiting close by. 4. Give small portions of food at frequent intervals instead of big meals at one time. 5. Give liquid in small
quantities (1/4 to ½ cup) at intervals of half an hour. Salted rice water (water drained out after cooking) or ORT (oral rehydration therapy)
liquid or tender coconut water can be given. 6. Try to make the patient sit up while eating and let him not lie down immediately after food.
7. Give the patient the food that they prefer. 8. Make sure that the patient takes plenty of fluids. 9. Make sure that the medication
prescribed for vomiting is taken in the proper dose at the appropriate time. 10. When the patient is feeling better, begin eating clear soups,
mild foods, and liquids until all symptoms are gone for 12 to 48 hours.
 66. 65 11. Don't force the patient to eat too much at once. Stretching the stomach may worsen nausea and cause vomiting 12. Avoid milk,
alcohol, caffeine, carbonated beverages, and most fruit juices. Milk may increase feelings of nausea. 13. Odour: avoid strong smells (e.g.
food, infected/necrotic tumours, etc.), use deodorizers. 14. Dietary interventions: • small amounts of food more frequently • cold rather
than hot food • avoid spicy, rich, fatty and very sweet food • salty food tends to be tolerated better, e.g. dry biscuits • small frequent drinks
or sips of fluid • crushed ice cubes / frozen drinks such as Coke and fruit juice • Ginger is a useful antiemetic, in ginger tea or crystalline
form 15. Good oral hygiene (especially after vomits) 16. Relaxation/distraction techniques 17. Position: sitting upright, head of the bed to
relieve pressure on the abdomen 18. Relaxation therapy Signs of Dehydration • Encourage small and frequent feeds. • Encourage the
patient to choose the menu. • Explain to the patient and family about the signs and symptoms of dehydration and hyponatremia. • Avoid
taking high protein diet when the patient has nausea and vomiting. • Make sure the patient is taking adequate salt –Normal salt intake 1.0-
1.2 gm/day. • Avoid sitting near the kitchen while cooking. This smell may aggravate nausea. • Environmental modification – eliminates
strong smells and sights. • Maintain good oral hygiene, especially after episodes of vomiting. • Use complementary therapy to manage
nausea and vomiting, e.g. Distraction. • Rule out the cause- if it is constipation, consider laxatives or enemas as necessary. • Educate the
patient and family about taking the medication at the correct time. (e.g.,T.Omeprazole on an empty stomach; T. Metoclopramide
[Perinorm] 10mg half an hour before food). • Increased thirst • Dry mouth • Swollen tongue • Sunken eyes • Too little urine • Dark colour
urine • Confusion • Skin that withdraws too slowly after being punched • Weakness • Dizziness • Palpitations (feeling that the heart is
jumping or pounding) • Sluggishness • Fainting Table 3.7: SIGNS OF DEHYDRATION Home Care Education
 67. 66 CONSTIPATION Constipation occurs when bowel movements become difficult or less frequent. Constipation is a common
problem in palliative care, affecting up to 90% of patients receiving palliative care. It can be caused by various factors, including
decreased physical activity, decreased intake of fluids, dietary fiber, medications, and other underlying medical conditions. Key Principles
o “Prevention is better than cure”. o ALWAYS prescribe a laxative when commencing an opioid analgesic. o Careful assessment of bowel
patterns is crucial, e.g., the report of a bowel movement does notexclude constipation. o In palliative care patients, constipation treatment
differs from that in healthy active people. o Even with inadequate oral intake, the bowel produces its own ‘bulk’, which can cause
constipation. o Remember, ‘diarrhea’ (spurious diarrhea) can overflow due to faecal paction (a detailed history can be helpful). Causes of
Constipation General • Lack of exercise • Lack of physical activity • Confusion, sedation • Sense of guilt as the patient must depend on
help for his basic needs. • Lack of privacy • Fatigue • Stress Disease-related • Pain • Certain health problems like Parkinson's disease,
hypothyroidism • Fatigue • Intestinal obstruction (Problems in the GI tract that compress or narrow your colon and rectum can cause
constipation.) • Spinal cord compression • Dehydration Nutritional • Changes in the type of food. • Decreased intake of food and water •
Lack of adequate fibre in food • Low residue diet Drug-induced • Opioids (Morphine, Tramadol, Codeineetc.) • Antidiarrheal • Anti-
depressants Table 3.8: CAUSES OF CONSTIPATION Table 3.9: SYMPTOMS OF CONSTIPATION Symptoms of Constipation Assess
for the following • Few bowel movements • Trouble having a bowel movement (straining) • Hard or small stools • A sense that everything
didn’t come out • Swollen abdomen or abdominal pain • Vomiting • How often does the patient have a bowelmovement? • How long has
the patient had symptoms? • What does the stools look like and Whetherthe patient has blood in the stool? • Eating habits • Level of
physical activity • Type of medicines taken
 68. 67 Assessment of Constipation Table 3.10: ASSESSMENT OF CONSTIPATION Examination • General examination: evidence of
dehydration • Abdominal examination: for prominent faucal masses/other masses • Auscultate for bowel sounds • Inspection of the anal
area: look for haemorrhoids and anal fissure • Rectal examination: soft or hard faeces, empty rectum • If a stoma is present, then gently
examine the stoma Management 1. Correct any correctable causes. 2. With multiple ongoing risk factors, as they are in most cancer
patients, suggest laxatives regularly versus SOS. 3. Titrate the dose of laxatives according to the response (stool frequency and
consistency). 4. Stimulant laxatives are the first choice of laxatives for prevention and treatment. 5. Patients with irritable bowel syndrome
may experience painful cramps with stimulant laxatives and often prefer osmotic laxatives such as lactulose or polyethylene glycol (PEG).
However, lactulose can taste unpleasant and also cause bloating. 6. For patients with opioid-induced constipation, Methyl naltrexone may
be helpful after a trial of first-line recommended stimulant laxatives and osmotic laxatives. 7. The rectal interventions are both undignified
and unpleasant; however, their short onset of action can be extremely satisfying. Rectal interventions should be avoided when there is
potential for severe infection (neutropenia), bleeding (thrombocytopenia), or rectal/analdisease. 8. If rectal measures are required (when
bowels have not moved for more than three days). Generally, a stimulant suppository is tried first, then an enema as the next option.
 Bowel pattern How regular are your bowel patterns? (Before the onset of illness and now) Dietary pattern Amount of water consumed per
day Inclusion of food rich in fibers Consistency Hard stools or soft stools Duration How long have you been having difficulty in bowel
movements?When was the last time you passed stool to your satisfaction? Associated symptoms Vomiting, abdominal pain, Abdominal
distention/abdominal fullness, Hiccups,Loose stools, visible peristalsis Increased bowel sounds Drugs What medications are you currently
on? How frequently are you taking laxatives? Perineal problems Perianal ulcers/fissures, tumours,Haemorrhoids
 69. 68 Prevention of constipation Simple measures should be incorporated as part of the routine palliative care plan for all patients. •
Eating regular meals and making use of gastro colic reflex. • Check the patients’ perception of their bowel functions. • Establish what is
normal; Be mindful of bowel routine and comfort. Assess the patient's level of discomfort relating to constipation and its management.
The aim of treatment is comfortable defecation and not increased stool frequency. • Prophylaxis is better than treatment. Therapy should
be regular and not intermittent, similar to the treatment of chronic pain. Always add a stimulant laxative with an opioid prescription. •
Mobility: Activity is the key stimulus to colonic peristalsis and defecation. Mobility should be encouraged as much as physical limitations
permit. • Regular toileting: keep a record of stool frequency. • Maintain adequate oral fluid and fibre intake. Fibres must be avoided in
severe constipation as they can precipitate colic pain. • Provide privacy for going to the toilet, and maintain the same even if a bedpan is
used. • If the patient develops loose stool once or twice a day after starting the laxative, continue laxative at a lower dose than prescribed.
If the patient passes a large volume of watery stool more than 4 times a day (always rule out spurious diarrhea), stop the laxative till stool
normalizes, and give ORS in the interim period. • Even after regular laxative use, 40 to 60% of terminally ill patients need additional
rectal evacuation measures on a continuing basis. Role of Nurses in Caring for a Patient with Constipation • Assess the usual pattern of
elimination; compare it with the present pattern. Include quantity, frequency, colour and quality of stool. • Ensure privacy for the patient
and provide bedside commode or bedpan, if required. • Ensure the patient is taking medicines as per the prescription. • Daily exercise may
help to prevent and relieve constipation. Even bedridden patients shouldbe given some light exercises according to their ability. • Evaluate
usual dietary habits, eating habits and liquid intake. • Assess activity level. • Evaluate current medication usage that may contribute to
constipation. • Maintenance of an adequate bowel protocol usually requires a prophylactic stool softener and stimulant. • Encourage
patients to drink plenty of fluids as tolerated while increasing their activity as appropriate. • High fibre diet (e.g., raw fruits, fresh
vegetables, whole grains) to be taken with adequate fluids. • Consider enema and suppositories, if the patient can no longer tolerate oral
medications. • Digitally remove impacted stool if present, before giving suppositories and enema Overflow Diarrhea or Spurious Diarrhea
Overflow diarrhea, also known as fecal impaction diarrhea, is a type of diarrhea that occurs when a hard mass of stool becomes impacted
in the rectum and colon, preventing the normal passage of stool. As a result, liquid stool leaks around the impacted mass and causes
diarrhea. Overflow diarrhea can be caused by a various factors, including chronic constipation, dehydration, poor bowel habits, and certain
medications. It is more commonly seen in elderly
 70. 69 patients, those with neurological disorders, and those who are bedridden or have limited mobility. Treatment for overflow diarrhea
involves removing the impacted stool, which can be done using laxatives, enemas, or manual evacuation. Once the impaction is removed,
a bowel management plan should be established to prevent further constipation and the development ofoverflow diarrhea. This may
include dietary changes, the use of stool softeners or laxatives, and establishing a regular toileting routine. Instructions for home care
patients: 1. Explain about laxative protocol necessary for the patient. 2. Explain to the patient that even though the patient is on a liquid
diet, they are expected topass stools (at least a small volume). 3. Seek medical help when the patient has more than 2 to 3 days of
constipation 4. Explain about spurious diarrhea. DIARRHOEA Diarrhea is a common condition characterized by frequent (more than
three times a day) loose,watery bowel movements. Causes Symptoms • Unusual dietary habits • Imbalance in laxative therapy • Drugs:
Antibiotics, Chemotherapy etc. • Partial obstruction/ Fecal impaction • Radiotherapy • Rectal tumour/ RVF • Faecal incontinence, loss of
sphincter control • Urgent need to go to the toilet • Watery stool • Abdominal pain and cramping • Change in colour of stool • Mucus, pus,
blood or fat in the stool • Fatigue • Nausea and vomiting • Bloating and cramps Table 3.11: CAUSES AND SYMPTOMS OF
DIARRHEA ASSESSMENT OF DIARRHEA Bowel pattern • How regular are your bowel pattern? Dietary pattern • Any recent change
in food consumed? Consistency • Watery stool or mucoid stools Duration • When did the diarrhea start? • How long have you been having
diarrhea? Frequency • Number of episodes per day Associated symptom • Vomiting • Abdominal pain or cramps Abdominal distention,
Fever • Signs of dehydration Drugs • What medications are you currently on? • How frequently are you taking laxatives? General
Examination • Per-Rectal digital examination • Perianal skin condition • Blood pressure and Heart rate Table 3.12: ASSESSMENT OF
DIARRHEA
 71. 70 Role of nurses in caring for patients with Diarrhea (in palliative care setting) • Assess the patient's normal bowel elimination
pattern. • Determine the cause of incontinence. • Perform per rectal examination to rule out faecal impaction. • Provide privacy for the
patient. • Ensure close proximity for the toilets/bedpan/commode. • Ensure the patient has supportive clothing or pads. • Assess the use of
diapers and underpads. • Assess perineal skin integrity. • Correct any obvious factors related to the assessment. • Notify the physician in a
suspected case of bacterial infection. • Educate the patient and family about cleaning the perineum carefully and gently after defecation. •
Instruct patient and family on any untoward signs and symptoms, including dizziness, excessive thirst, fever, etc. • Provide support to the
patient and family. • Advice to eat small frequent bland meals. Low residue diet –potassium-rich. • Avoid intake of hyperosmotic
supplements. • Increase fluids in the diet by at least 3 litres/day, which includes electrolyte drinks. • After each evacuation, wash the
perineal area with soap and water and dry them thoroughly. • Treat any perineal irritation with moisture barrier ointment. • Dispose pads,
diapers, or collection devices as soon as possible. • Administer drugs as per the prescription: Loperamide, Opioids, Codeine. • Gradually
reintroduce proteins and then fats to the diet as diarrhea resolves. Instructions for home care patients 1. While cooking and storing food,
the following rules can prevent diarrhea: • Wash hands before and after taking food • Always keep food that could spoil in the fridge • Use
only boiled and cooled water. • Ensure that meat is cooked thoroughly 2. Always eat freshly prepared food (meat, fish, and shellfish). 3.
Explain to the patient the signs and symptoms of dehydration. 4. Explain ORS preparation 5. Acknowledge the carer’s burden and educate
 that sharing the work will reduce the burden 6. Explain the importance of maintaining skin integrity NUTRITION AND HYDRATION
Maintaining and correcting nutrition is a significant problem in terminally ill patients, particularly when suffering from advanced
malignant disease. Previous surgery, radiotherapy and chemotherapy worsen the problems. Hence intake of a balanced diet is necessary
for mental and physical health. The patient and family must be educated about the importance of nutrition. General instructions • Diet
must be planned according to the needs of the patient. • Procedures to be done at least one hour before the meals. • Serve the food in a
good environment. • In a bed-ridden patient, assemble everything near the patient and assist if needed.
 72. 71 • Give easily digestible food. • Give time to the patient to eat the food. • Talking to the patient while he/she is eating will make the
patient feel good. • Before and after food, give water for hand washing and oral care. • Ensure adequate intake of fluids and dietary fibre. •
Eat as much as the patient wants and as frequently as he/she wants. • Give nutritious food and dietary supplements as needed. • Change
food consistency as needed. • Give nasogastric feeding when the patient is unable to accept oral feeding. • Prevention and management of
oral thrush, nausea, and constipation. Causes of deficient Nutrients • Anorexia • Nausea and vomiting • Obstruction in the alimentary tract
and poor absorption • Excessive loss of nutrients • Cancer cachexia • Adverse effects of the treatment • Low socioeconomic status In
palliative patients: • Assess the degree of nutritional deficiency. • Decide the type, quality, route and administration of nutrients. • Assess
effects and side effects for further continuation. • Consider the physical, psychological, social cultural and financial aspects of the patients
and family. Routes of administration of Nutrients • Oral route • Parenteral route or Central / Peripheral vein • Oral route is the best,
simplest, cheapest and most acceptable method. Psychological factors like anxiety, depression and attitude of relatives are also
contributing factorsthat affect the appetite of the patients which can be improved by • Attractive presentation of food • Pleasant
environment • Correct temperature and aroma of food • Small frequent feeds • Taste tolerance • Effective communication • Psychological
support for both patient and family Points to be kept in mind when patient is on naso-gastric feeding: • Give the patient a Fowlers position
or raise the chest with extra pillows. • Prevent air entry inside the tube by pinching or folding the tube, opening the cap, and fixing
thesyringe (20ml or 50ml). • Aspirate the stomach contents and see whether the tube is in position. • If the aspiration fluid is more than
50ml, skip the feed. • Before and after the feed, give about 15- 20 ml of plain water.
 73. 72 • Give a total of 200 ml of prepared feed. (Total feed plus water not to exceed 250ml, accordingto the condition of the patient) •
Give the feed slowly without air entry. • Ensure oral care every 4 hourly. • Keep the patient in the same position for half an hour. • Put the
patient in side-lying position (to prevent aspiration) FATIGUE Fatigue is a common symptom in palliative care patients and can
significantly affect their quality of life. There are various reasons why fatigue can occur in palliative care patients, includingthe underlying
disease, medication side effects and emotional distress. Therefore, managing fatiguerequires a multidisciplinary approach that includes
medical, psychological, and social interventions. It is the self-recognized state in which an individual experiences an overwhelming
sustained sense of exhaustion and decreased capacity for physical and mental work that is not relieved by rest. Fatigue is associated with a
various physical and psychological conditions and not the same as tiredness which is temporary. Assessment • Evaluate the patient’s
description of fatigue: severity, changes in severity over time, aggravating or alleviating factors. • Using an appropriate quantitative
scoring scale, 1 to 10, for example, can aid the patient informulating the amount of fatigue experienced. Causes of fatigue • Previous
physical illness • Pain • Psychological factors • Side effects of medication • Anaemia • Disease progression • Sleep disorders • Imbalanced
nutrition • Extended responsibilities and demands at home or work Assessment • Identifying the related factors to fatigue can benefit in
recognizing potential causes andbuilding a collaborative plan of care. • Assess the patient’s ability to perform ADLs. • Assess the patient’s
nutritional ingestion for adequate energy sources and metabolic demands. • Evaluate the patient’s outlook for fatigue relief, eagerness to
participate in strategies toreduce fatigue, and level of family and social support. • Review results of laboratory or diagnostic test: • Blood
glucose • Hemoglobin/hematocrit • BUN • Oxygen saturation, resting and activity • Changes in these physiological measures may be
associated with other measurement data torecognize possible sources of the patient’s fatigue.
 74. 73 • Observe physiological reaction to activities, such as any alterations in BP, respiratory rate,or heart rate. • Assess the patient’s
ability for exercise and physical movement. • Assess the patient’s sleep patterns for quality, quantity, time taken to fall asleep and feeling
upon waking up. • Observe any alteration in thought processes or behavior after awakening. • Assess the patient’s routine medications and
self - medications. • Assess the patient’s emotional reaction to fatigue. Management of Fatigue Managing fatigue requires a
multidisciplinary approach that includes medical, psychological, and social interventions. Medical interventions may include the
management of the underlying disease,adjusting medications, and managing symptoms that contribute to fatigue, such as pain, nausea, and
breathlessness. In some cases, complementary therapies, such as massage or acupuncture, may alsobe used. Psychological interventions,
such as counselling or cognitive- behavioral therapy, may help patients to manage emotional distress and improve their coping strategies.
Social interventionsmay involve providing practical support, such as home care or transportation services, to reduce the physical and
emotional burden on patients and their caregivers. Care of the patient with fatigue • Restrict environmental stimuli, especially during
planned times for rest and sleep. • Encourage the patient to maintain a 24-hour fatigue or activity log for at least 1 week. • Aid the patient
with developing a schedule for daily activity and rest. Emphasize theimportance of frequent rest periods. • Teach energy conservation
methods. Collaborate with an occupational therapist as needed. • Assist the patient with setting priorities for preferred activities and role
responsibilities. • Promote sufficient nutritional intake. • Provide comforts such as judicious touch or massage and cool showers. •
Encourage verbalization of feelings about the impact of fatigue. • Offer diversional activities that are soothing. • Identify energy
conservation methods such as sitting and dividing ADLs into convenientsegments. • Set practical activity goals with the patient. • Stay
away from topics that annoy or disturb the patient. • Aid the patient in developing habits to promote effective rest/sleep patterns.
POWERLESSNESS Powerlessness is a common experience for many patients receiving palliative care, as they may feel they have little
control over their illness and the care they receive. This can be particularlychallenging for patients who are used to being independent and
making their own decisions. Powerlessness means that the person does not have the strength or resources to change a situation. People
with chronic conditions often have a long‐term experience of powerlessness because they feel unable to change outcomes. Managing real
 and perceived powerlessness is significant. Lack of control and the incapacity to act and change may dominate everyday life for persons
with chronic illnesses. Accepting and acknowledging one’s limitations due to chronic illness may result in a sense of helplessness.
 75. 74 Despite the limiting effects of chronic illness and feelings of powerlessness, individuals continue to exert power and control in
areas of their lives through adaptation and accommodation to their evolving abilities. When power resources are significantly altered and
affected, an individual with chronic illness may experience feelings of powerlessness. To deal with this powerlessness, persons with
chronic illness should direct their energy toward their intact power resources. The patient may experience Powerlessness as: • A disruption
of identity • Loss of familiarity with bodily responses • Loss of familiarity with emotional responses • Loss of familiarity with social
standing • Loss of familiarity with one’s environment Assessment • Assess for feelings of apathy, hopelessness, and depression. These are
the element ofpowerlessness. • Determine the patient’s power needs or need for control. • Evaluate the patient’s decision-making
competence. • Know situations/interactions that may add to the patient’s sense of powerlessness. • Appraise the impact of powerlessness
on the patient’s physical condition (e.g., appearance,oral intake, hygiene, sleep habits). • Assess the role of illness plays in the patient’s
sense of powerlessness. • Note if the patient needs information about illness, treatment plan, and procedures. • Evaluate the results of the
information given on the patient’s feelings and behavior. Care of patients experiencing powerlessness • Therapeutic communication -
encourage verbalization of feelings, thoughts, and concernsabout making decisions. • Encourage the patient to identify strengths. • Discuss
with the patient concerning their care (e.g., treatment options, the convenience ofvisits, or time of ADLs). • Encourage an increased
responsibility for self-care. • Help the patient re-examine negative perceptions of the situation. • Eliminate the unpredictability of events
by allowing adequate preparation for tests orprocedures. • Give the patient control over their environment. • Aid the patient in recognizing
the importance of culture, religion, race, gender, and age ontheir sense of powerlessness. • Support in planning and creating a timetable to
manage increased responsibility in the future. • Use of realistic short-term goals for resuming aspects of self-care and foster confidence
inone’s abilities. • Avoid using coercive power when approaching the patient. • Render positive feedback for making decisions and
engaging in self-care. ANXIETY Anxiety is a common issue for patients receiving palliative care. It can severely impair their qualityof
life and limit their mobility, social interaction, enjoyment, and sense of well-being. Anxiety can be caused by a various factors, including
the patient's physical symptoms, the emotional impact ofthe illness, and uncertainty about the future. Anxiety disorders often co-exist
 76. 75 with depression in palliative care patients. To help manage anxiety in palliative care, healthcare providers may use a combination
of pharmacological and non-pharmacological interventions. Medications such as benzodiazepines or antidepressants may be used to
reduce anxiety symptoms, while non-pharmacological interventionssuch as relaxation techniques, mindfulness meditation, and counselling
may also be helpful. It's important to note that anxiety is a normal response to the stress and uncertainty of serious illness. Itis important
for healthcare providers to provide emotional support to these patients. They can alsowork with the patient and their family to develop a
care plan that addresses the patient's anxiety andsupports their overall well-being. Anxiety assessment • Assess the signs and symptoms of
anxiety like excessive worrying, increased motor tension,autonomic hyperactivity, and vigilance/ scanning. • Assessment of the nature of
anxiety, acute or chronic and whether part of another psychiatricsyndrome such as a depressive disorder. • Assessment for any reversible
factors such as pain or inappropriate medications. Stimulant drugs or excessive alcohol intake or withdrawal may exacerbate anxiety. •
Understand the unexplored worries. It is necessary to provide time and opportunity for patients to express their worries and concerns and
for these concerns to be addressed honestly and clearly. Management of Anxiety A non-pharmacological approach is recommended before
initiating pharmacological therapy in managing palliative care patients. Lifestyle modifications: A) Exercise: Moderate exercise that is
appropriate for an individual’s functional ability is helpful. Walking outside or in the park at a pace that an individual can tolerate will be
sufficient. Bedridden and wheelchair-bound individuals can do simple stretching, flexion and extension exercises. Patients who are too
frail can try walking within the home with support and supervision. B) Diet: • The deficiency of vitamins B1, B6, B12, and folic acid can
be mistaken for anxiety disorder. • Similarly, alterations in the serum electrolytes can cause anxiety symptoms. • Discussing the
importance of balanced diet may be the only intervention required in somepatients with anxiety. C) Sleep: • Sleep and anxiety are strongly
linked. Anxiety can cause insomnia. • Sleep hygiene education can promote good sleep, which includes avoiding frequent daytimenaps,
late evening exercises, late heavy dinners, reducing intake of stimulants, reducing ambient noise and controlling other environmental
factors that disturb sleep. • Some drugs may also disturb sleep pattern (diuretics, steroids etc.,) • Guided imagery is useful in preventing
anxious thoughts that prevent sleep onset.
 77. 76 D) Relaxation techniques: • Jacobson muscle relaxation technique or progressive muscle relaxation technique can be taught to
patients with anxiety. This technique involves sequentially tightening (5 seconds) and relaxing (10 seconds) the specific muscle groups. •
This technique can be combined with mental imagery and breathing exercises. E) Mindfulness: Mindfulness involves focusing on the
present. The idea is to notice the details like smell, texture, colour, patterns, taste and emotions. There are several ways of practicing
mindfulness: walking outside, looking through a window, doodling, brewing tea, staying away from the phone, journaling,etc. F) Social
activities and networking: Social interactions and networking maintain connectedness. It is not only an essential social stimulusbut also
improves synaptic connections. Purposeful social connections directed towards common goals offer engagement, focus and direction- e.g.,
Prayer gatherings, book clubs, social tasks,etc. Pharmacological management Consider the following principles in the pharmacological
management of anxiety disorders. • SSRIs (Selective Serotonin Reuptake Inhibitors) are the first line of choice. • When SSRIs fail, then
move to other groups like Serotonin-Norepinephrine Reuptake Inhibitor (SNRIs), Tricyclic antidepressants (TCAs) • Always monitor for
hyponatremia and bleeding manifestations when SSRIs and SNRIs are used. • Benzodiazepines have neuro-cognitive effects, can cause
confusion, and dissociative phenomena, and increase the risk of falls. Avoid using benzodiazepines as much as possible.When used, limit
use to 2 to 4 weeks. Nursing Interventions for Anxiety Nursing interventions for Anxiety can apply to any individual with anxiety,
regardless of etiologic and contributing factors. • Recognize awareness of the patient’s anxiety. • Acknowledgement of the patient’s
feelings validates and communicates acceptance of thosefeelings. • Use presence, touch (with permission), verbalization, and demeanor to
remind patients that they are not alone and to encourage expression or clarification of needs, concerns, unknowns, and questions. •
 Familiarize the patient with the environment and new experiences or people as needed. • Interact with patients peacefully. • Accept the
patient’s defenses; do not dare, argue, or debate. • Communicate in simple language and brief statements. • Reinforce the patient’s reaction
to or expression of pain, discomfort, or threats to well- being(e.g., talking, crying, walking, and other physical or nonverbal expressions). •
Lessen sensory stimuli by keeping a quiet and peaceful environment; keep “threatening” equipment out of sight. • Allow the patient to talk
about anxious feelings and examine anxiety-provoking situations if they are identifiable. • If the situational response is rational, use
empathy to encourage the patient to interpret the anxiety symptoms as normal. • Recommend patients to keep a log of episodes of anxiety.
Instruct the patient to describe
 78. 77 whatis experienced and the events leading up to and surrounding the event. • Recognition and exploration of factors leading to or
reducing anxious feelings are importantsteps in developing alternative responses. The patient may be unaware of the relationship between
emotional concerns and anxiety. • Encourage the patient to consider positive self-talk like “Anxiety won’t kill me,” “I can do this one step
at a time,” “Right now I need to breathe and stretch,” “I don’t have to be perfect.” Cognitive therapies focus on changing behaviors and
feelings by changing thoughts. Replacing negative self-statements with positive self-statements aids in reducing anxiety. • Consider the
patient’s use of coping strategies that the patient has found effective in the past. • Avoid unnecessary reassurance; this may increase undue
worry. • Reassurance is not helpful for the anxious individual. • Assist the patient in developing new anxiety-reducing skills (e.g.,
relaxation, deep breathing,positive visualization, and reassuring self-statements). • Intervene when possible to eliminate sources of
anxiety. SOCIAL ISOLATION Lack of social contacts and interaction with very few people can lead to social isolation. People usually
face some loss at the end of life, whether that is their self-image, sense of control, relationships, or independence. This can mean that
people are isolated from the things they love the most, including hobbies, interests, friends and what ultimately makes them feel like
themselves. This is particularly relevant if someone has to change their living accommodation to allow for care. Loneliness is a sad feeling
of isolation from others, usually accompanied by mental fatigue, bitterness, or despair. Loneliness is bad for physical and psychological
health, while membership insocial groups acts as an umbrella in its appearance. Causes of social isolation: • Loss of spouse • Migration of
children • Empty nest Syndrome • Financial insecurity • Disability • Social status • Underlying psychiatric illnesses • Depression
Approach to Social Isolation To address social isolation in palliative care, providers can take several approaches. One approach is to
provide social support through hospice or palliative care services. These services mayinclude support groups, counseling, and spiritual
care, all of which can help patients feel less isolatedand more connected to others. Another approach is to involve family and friends in the
patient's care. This can help to maintain important relationships and provide emotional support to the patient. Palliative care providers can
work with patients and their families to identify ways to involve loved ones in the care process, such as attending medical appointments,
helping with daily activities, or simply spending time together. Technology can also be valuable in addressing social isolation in palliative
care. Telemedicine and other communication tools can help patients stay connected with their care providers and loved ones, even if they
cannot be together physically.
 79. 78 SPIRITUAL DISTRESS Spirituality is “a dynamic and intrinsic aspect of humanity through which persons seek
ultimatemeaning, purpose and transcendence and experience relationship to self, family, community, society and nature. Spirituality is
expressed through beliefs, values,traditions andpractices.” Spirituality is a very fluid concept. People tend to define it in very different
ways. Some associate it with their concept of God, some do not. Spiritual distress is an impaired ability to experience and integrate
meaning and purpose through connectedness with self, others, art, music, literature, nature, and/or power greater than oneself. When
people get sicker and approach the end of their life’s journey, there is often a great deal of spiritual distress and suffering. Each person
needs to come in to terms with their losses in their ownway. We are there to walk with them on that journey, not to tell them what to think,
feel or believe.Therefore, we must not try to take the suffering away by trying to impose our own spiritual solutionsonto their spiritual
struggles. Assessment of Spiritual Distress • Assess history of religious affiliation. • Assess spiritual beliefs. • Assess the spiritual meaning
of illness and death. o “Do you wonder regarding the meaning of your illness?” o “How does the current situation affect your relationship
with God, your beliefs, orother sources of strength?” o “Do your illness and grief interfere with expressing your spiritual beliefs?” •
Assess whether patients need help with unfinished business. Approach to spiritual Distress • Provide understanding and acceptance. •
Support crying by offering caring touch. • Encourage verbalization of feelings of anger or loneliness. • When the patient requests, arrange
for priests, rituals, music, prayers, scriptures or images. • If requested, sit with the patient who wishes to pray and arrange for a priest at
the time ofdeath as per their request. • Do not provide intellectual solutions for spiritual problems. To address spiritual distress in palliative
care, providers can take several approaches. One approachis to provide spiritual care, including counselling, prayer, and other forms of
spiritual support. Palliative care providers can work with patients to identify their spiritual needs and preferences and develop a care plan
that addresses them. Another approach involves chaplains or other spiritualleaders in the care team. These individuals can provide
additional spiritual support and guidance and help patients connect with their faith communities and religious traditions. IMPAIRED
PHYSICAL MOBILITY Mobility is the ability to move the entire body freely and normally. It encompasses muscle strength, range of
motion, and endurance capacity. Mobility is associated with physical movement, including both simple gross motor movements and more
complex fine motor movements, along with associated coordination of those movements. With mobility, one can move functionally and
efficiently with little to no restrictions or difficulty.
 80. 79 Physical mobility requires sufficient muscle strength and energy, adequate skeletal stability,joint function, and neuromuscular
synchronization. Anything that disrupts this integrated process can lead to impaired mobility or immobility. Impaired physical mobility is
a common issue for palliative care patients, as their illness or condition may limit their ability to move and perform daily activities. This
can lead to decreased independence, increased dependence on others, and reducedquality of life. Immobility and its complications have
been shown to have the potential to cause physical disability and emotional suffering for patients, as well as to increase healthcare costs
for facilities and communities. A comprehensive understanding of the concept of mobility is critical to providingoptimal patient care. By
incorporating appropriate assessment skills, early mobilization efforts, andproper prevention strategies, the nurse can help patients recover
 their former degree of mobility andflexibility in support of an optimal quality of life. Causes of impaired mobility or inability to move
freely • Muscle imbalance • Muscle weakness • Tightness • Improper alignment and posture • An injury that is currently in rehabilitation
or was not fully or properly rehabilitated. Signs and Symptoms • Inability to move purposefully within the physical environment,
including bed. mobility,transfers, and ambulation. • Inability to perform the action as instructed. • Limited ROM. • Reluctance to attempt
movement. Some diseases which may cause impaired physical mobility are • Alzheimer’s Disease and Dementia • Amputation • Burn
Injury • Cerebral Palsy • Cerebrovascular Accident • Congenital Hip Dysplasia • Fracture • Guillain-Barre Syndrome • Hemophilia •
Kawasaki Disease • Laminectomy • Osteoporosis • Parkinson’s Disease • Rheumatoid Arthritis • Scoliosis • Spinal Cord Injury
Assessment Impaired physical mobility represents a complex healthcare problem involving many differenthealthcare team members. •
Assess for impediments to mobility. • Assess the strength to perform ROM to all joints.
 81. 80 • Assess input and output records and nutritional patterns. • Monitor nutritional needs as they relate to immobility. • Evaluate the
need for assistive devices. • Assess the presence or degree of exercise-related pain and changes in joint mobility. • Assess the safety of the
environment. • Assess the emotional response to the disability or limitation. • Consider the need for home assistance (e.g., visiting home
care team). • Assess the patient’s or caregiver’s understanding of immobility and its implications. • Note for progressing thrombophlebitis
(e.g., calf pain, Homan’s sign, redness, localizedswelling, a rise in temperature). • Check for skin integrity for signs of redness and tissue
ischemia (especially over ears,shoulders, elbows, sacrum, hips, heels, ankles, and toes). Nursing Interventions for impaired physical
mobility • Assist patient for muscle exercises as able or when allowed out of bed; execute abdominal exercises and knee bends; hop on
foot; stand on toes. • Present a safe environment: bed rails up, bed in a down position, and essential items closeby. • Establish measures to
prevent skin breakdown and thrombophlebitis from prolonged immobility. • Clean, dry, and moisturize the skin as necessary. • Use anti-
embolic stockings or sequential compression devices if appropriate. • Use pressure-relieving devices as indicated (air/water/gel mattress).
This is to prevent skin breakdown, and the compression devices promote an increased venous return to prevent venous stasis and possible
thrombophlebitis in the legs. It may also decrease pressure on skin or tissues that can damage circulation, potentiating tissue ischemia or
breakdown and decubitus formation risk. • Turn and position the patient every 2 hours or as needed. Position changes optimize circulation
to all tissues and relieve pressure. • Execute passive or active assistive ROM exercises to all extremities to enhance increased venous
return, prevent stiffness, and maintain muscle strength and stamina. It also avoids contracture deformation, which can build up quickly and
could hinder prosthesis usage. • Promote and facilitate early ambulation when possible. Aid with each initial change:dangling legs, sitting
in the chair, ambulation. • Show the use of mobility devices, such as trapeze, crutches, or walkers. These devices can compensate for
impaired function and enhance the level of activity. Such aids are to promote safety, enhance mobility, avoid falls, and conserve energy. •
Help with transfer methods by using reasonable assistance of persons or devices when transferring patients to bed, chair, or stretcher. • Let
the patient accomplish tasks at their own pace. Do not hurry the patient. Encourage independent activity as able and safe. • Give positive
reinforcement during the activity. Patients may be unwilling to move or initiate new activities because of fear of falling. • Consider
energy-saving techniques. Rest periods are essential to conserving energy. Provide the patient with rest periods in between activities. •
Give medications as appropriate. Antispasmodic medications may reduce muscle spasms or spasticity that interfere with mobility,
analgesics may reduce the pain that impedes movement. • Help the patient in accepting limitations. Let the patient understand and accept
theirlimitations and abilities. On the other hand, assistance must be balanced to prevent the patient from being unnecessarily dependent. •
Encourage resistance-training exercises using light weights when suitable. Strength training
 82. 81 and other forms of exercise are believed to be effective in maintaining independentliving status and reducing the risk of falling in
older adults. • Help the patient develop sitting balance and standing balance. This helps out in retraining neuronal pathways and motor
responses. • Keep limbs in functional alignment with one or more of the following: pillows, sandbags, wedges, or prefabricated splints.
Maintain feet in a dorsiflexed position. This avoidsfoot drop and too much plantar flexion or tightness. • Encourage coughing and deep-
breathing exercises. Use suction as necessary. Make use of an incentive spirometer. • Present suggestions for nutritional intake for
adequate energy resources and metabolic requirements. Correct nutrition is necessary to keep a sufficient energy level. • Encourage a diet
high in fibre and a liquid intake of 2000 to 3000 ml per day unless contraindicated. Liquids maximize hydration status and avoid
hardening of stool. It also decreases the risk of skin irritation or breakdown. • A sedentary lifestyle contributes to constipation. Set up a
bowel program (e.g., adequate fluid, food high in bulk, physical activity, stool softeners, laxatives) as needed. Note bowelactivity levels. •
Offer diversional activities. Observe emotional or behavioral reactions to immobility. Forced immobility may heighten restlessness and
irritability. Diversional activity helps in refocusing attention and promotes coping with limitations. • Explain to the patient the need to call
for help, such as a call bell and special sensitive call light. • Set goals with the patient or significant other for cooperation in activities or
exercise and position changes. • Reinforce principles of progressive exercise, emphasizing that joints are to be exercised to the point of
pain, not beyond. “No pain, no gain” is not always true! Pain occurs because ofjoint or muscle injury. • Teach the patient or family to
maintain a home atmosphere hazard-free and safe to prevent injury related to falls and help the patient maintain a desired level of
functional independenceand reduce fatigue with activity. • Explain the progressive activity to the patient. This may help to increase self-
confidence and reduce frustration. Patient teaching • Adherence to recommended prevention and treatment strategies can significantly
affect whether the patient will regain mobility or develop immobility-related complications. • Educate patients and their families regarding
the risks of impaired mobility and the importance of maintaining the highest level of physical activity possible. • Discuss the importance
of turning and repositioning to maintain skin integrity. Explain that passive and active range-of-motion exercises will help the patient
maintain joint flexibility, muscle strength, and muscle mass. • Discuss fall prevention techniques. For example, teach patients to change
positions slowly to avoid orthostatic hypotension. • Stress the importance of optimal nutrition in healing; the patient and family should
understand that meals high in protein and nutrients benefit healing. Also, inform patients about the importance of adequate fluid intake to
help prevent both urinary tract infections and constipation. • The psychological impact due to impaired mobility and immobility can be
 devastating. Provide the patient and family with information about support groups and community resources as appropriate for any
identified physiological, psychosocial, spiritual, and financial needs.
 83. 82 SELF CARE DEFICIT Self-care refers to those activities an individual performs independently throughout life to promote and
maintain personal well-being. Activities of daily living or ADLs are defined as the task we regularly do such as feeding ourselves, bathing,
dressing, grooming, work, homemaking and leisure. However, there are some that might have difficulties in performing self-care. Self-
care deficit is the inability of an individual to perform self-care. The deficit may be the effectof temporary limitations, such as those one
might experience while recovering from surgery, or theresult of gradual deterioration that erodes the individual’s ability or willingness to
perform the activities required to care for themselves. Assisting in activities of daily living is the skill required in nursing. The nurse
coordinates servicesto maximize the patient's independence and ensure that the environment the patient lives in is safe and supportive of
their special needs. Assessment • Assess the patient’s strength to accomplish ADLs efficiently and cautiously on a daily basis. The patient
may need help with some self-care measures related to eating, bathing, grooming, dressing, toileting, bladder and bowel management,
transfer, ambulation, and/orstair climbing. • Determine the specific cause of each deficit (e.g., visual problems, weakness, cognitive
impairment). • Consider the patient’s need for assistive devices. • Recognize choice for food, personal care items, and other things. •
Evaluate gag reflex prior to initial oral feeding. • Verify the need for home health care after discharge. • Monitor impulsive behavior or
actions indicative of altered judgment. Nursing Interventions • Establish short-term goals with the patient to help them set realistic goals to
reduce frustration. • Guide the patient in accepting the needed amount of dependence. • Present positive reinforcement for all activities
attempted, note partial achievements. • Render supervision for each activity until the patient exhibits the skill effectively and is secured in
independent care. Regularly re-evaluate to ensure that the patient is keeping the skill level and remains safe in the environment. •
Implement measures to promote independence but intervene when the patient cannot function. • Boost maximum independence. • Apply
regular routines and allow adequate time for the patient to complete the task. Feeding • Allow the patients to feed themselves as soon as
possible (using the unaffected hand, if appropriate). Assist with the set up as needed. The dominant hand may also be affected if there is
upper extremity involvement. • Ensure the patient wears dentures, hearing aid and eyeglasses if required. • Place the patient in a
comfortable position for feeding. • Provide the patient with proper utensils (e.g., wide-grip utensils, rocking knife, plate guard, drinking
straw) to aid in self-feeding.
 84. 83 • Ensure that the consistency of diet is suitable based on the patient’s ability to chew and swallow. Thickened semisolid foods
such as pudding and hot cereal are most easily swallowed and less likely to be aspirated. • If vision is affected, guide the patient about the
placement of food on the plate. After Cerebro vascular accident (CVA), patients may have unilateral neglect and may ignore half of the
plate. • Provide an appropriate setting for feeding where the patient has supportive assistance. Dressing/Grooming • Provide privacy
during dressing. • Use appropriate assistive devices for dressing as assessed by the nurse and occupational therapist. • Suggest elastic
shoelaces or Velcro closures on shoes. • Give frequent encouragement and aid while dressing as needed. Assistance can reduce energy
expenditure and frustration. • Dressing requires energy. Utilise a wheelchair or stationary chair. A chair that provides more support for the
body than sitting on the side of the bed saves energy when dressing. • Establish regular activities so the patient is rested before any
activity. • Consider the use of clothing one size larger. • Recommend a front-opening brassiere and half-slips in females.
Transferring/Ambulation • For moderate assistance, the caregiver places arms beneath both patient’s armpits with the caregiver’s hands on
the patient’s back. • For patients needing maximal assistance, use a gait belt. • Raise the bed to a height that allows the patient’s feet to be
flat on the floor. • Grasp the gait belt with both arms and pull the patient forward. • Place a knee against the patient’s weak knee (if
applicable) and encourage the patient to put weight on the strong side during the transfer. • Encourage the patient to use their arms to
assist, as able, and to place them on the caregiver’s forearms. • This method maximizes patient support while protecting the care provider
from injury. • Aid with ambulation, direct use ambulation devices such as canes, walkers, and crutches. • Stand on the patient’s weak side.
• If using a cane, place the cane in the patient’s strong hand and ensure proper foot-cane sequence. • These methods promote patient safety
and aid with balance and support. Toileting • Assess previous and present patterns for toileting, introduce a toileting routine. The
efficacyof the bowel or bladder program will be improved if the patient's natural and personal patterns are considered. • Assess patient’s
ability to verbalize necessitate to void and/or capacity to use the urinal and bedpan. If suitable, bring the patient to the bathroom regularly
or intermittently for voiding. • Provide privacy while the patient is toileting. Lack of privacy may reduce the patient’s ability to empty the
bowel and bladder. • Give a bedpan or put the patient on the toilet every 1 to 1½ hours throughout the day and three times throughout the
night. Time intervals can be prolonged as the patient starts to verbalize the need to toilet on demand. This eradicates incontinence. • Give
suppositories and stool softeners.
 85. 84 • Observe the patient closely for loss of balance or fall. Maintain commode and toilet tissue close to the bedside for night time
utilization. Patients may hurry to the toilet or commode throughout the night due to fear of soiling themselves and may fall. • Keep the call
light within reach and teach the patient to call promptly. This allows staff members ample time to help transfer to the commode or toilet. •
Aid patients in eliminating or changing unnecessary clothing. Clothing that is not easy to getin and out may compromise a patient’s
capability to be continent. • Consider utilization of commode or toilet as early as possible. Patients are more successful in emptying their
bowel and bladder when sitting on commode. Several patients find it unfeasible using a bedpan. • Recognize prior bowel habits and
restore normal regimen. Increase bulk in diet, fluid intake,and activity. It supports the progression of retraining program and helps avoid
constipationand impaction. • Educate family and significant others to promote autonomy and intervene if the patient becomes tired,
incapable of carrying out tasks. This displays caring and concern but does nothinder with patient’s efforts to attain autonomy. • Inform
family members to allow the patient to perform self-care measures as much as possible. • Note: This may be very hard and discouraging
for the significant other or caregiver, depending on the extent of the disability and the time needed for the patient to accomplish the
activity. • Promote independence but intervene when the patient cannot carry out self-care activities. A suitable level of assistive care can
avoid harm with activities without causing disappointment. • Entertain patient input in the planning schedule. Patient’s worth of life is
 improved when wishes or likes are taken into consideration in daily activities. • Consider or use energy-conservation techniques. This
saves energy, decreases fatigue, and improves the patient’s capability to execute tasks. DELIRIUM Delirium is a disturbance in
consciousness and cognition that can result in confusion, disorientation, and difficulty with memory, attention, and thinking. Delirium is a
state of mental confusion that develops quickly, usually fluctuates in intensity, and results in reduced awareness of and responsiveness to
the environment. It may manifest as disorientation, incoherence and memory disturbance. Delirium is a common issue for patients
receiving palliative care, especiallyin the advanced stages of their illness. Causes • Infection: Pneumonia, sepsis • Metabolic
encephalopathy: organ failure, paraneoplastic syndromes • Endocrine: Hyper/hypothyroidism, Cushing syndrome • Drug withdrawal:
Alcohol, narcotics, hallucinogens • Immunologic: Systemic lupus erythematosus (SLE), vasculitis • Nutritional deficiencies • Drugs
Approach to Delirium • Monitor and record consciousness level, temperature, pain scores, pressure sores, and neurological and rectal
examination findings. • Administer drugs as per the prescription.
 86. 85 • Stop any offending treatment. • Correct metabolic abnormalities. • Quiet room, dim lights, calendar, clock. • Family support. •
Treat reversible causes (dehydration, hypercalcemia etc.) Nursing Management • Identify the cause, including the precipitating,
aggravating, and palliating factors. • Provide pharmacological and non-pharmacological management. • Providing a safe environment and
reassuring the patient that we keep them safe. • Communicate with the patient and family calmly, with a non-judgmental attitude, and use
simple terms. • Give only one choice or one decision to prevent agitation. • Pay active listening when they express their feelings during
delirium and support the patientand family. • Get the complete history of the recent changes after the health team visit and investigationor
medication. • Keep the patient hydrated and maintain the nutritional status. • Maintain and encourage the family members to maintain
normal urinary and bowel patterns (constipation and urine retention can cause delirium). • To avoid anxiety and fear, minimize
unnecessary stimuli. Encourage the use of assistive devices. • Maintaining proper position technique encourages active and passive
exercise. • Effectively manage the pain because it can exacerbate delirium. • Administer medications, such as antipsychotics, sedatives,
and analgesics, as prescribed, following safe medication administration practices. • Monitor for adverse reactions, including increased
confusion. • Reorient the patient continuously about the time, place, and person. Keep the clock, calendar, orientation board on the wall
facing the patient. • Call the patient by name and give them a mirror to help him get oriented by himself. • Maintain a consistent schedule
and stable environment. • Keep the patient’s belongings in the same location to decrease confusion. • Provide music, magazines, and
games with which he was familiar earlier. • Encourage the family to talk about the past event step by step. • Suggest to the family the
importance of following sleep hygiene for these patients. • Try to care for the patient with the same team members and avoid unnecessary
equipment inside the patient room. • Managing a patient with delirium in the home is extremely stressful for the family. Assessthe family
members' coping abilities and provide the necessary support. • An interdisciplinary team approach is needed to manage these patients. •
Palliative sedation is preferred at the end of life in reducing or eliminating symptoms as a primary goal and supporting the family or other
caregivers during this critical period. CARE GIVER ROLE STRAIN Palliative care patients are said to be the most vulnerable group in
society. The life-limiting illness affects not only the patient but also their entire family. Providing palliative care is often an exerciseof
treating the part, if not the whole, family of the patient. In addition to causing distress to the patient, it puts financial, personal, social, and
health stress on family members. Family members close to the patient may play the role of caregiver.
 87. 86 Caregiver strain is a common issue in palliative care, as caregivers often experience physical, emotional, and social stress
associated with caring for a loved one who is terminally ill. The excessive stress and demands on caregivers can lead to care giver role
strain which is experienced when a caregiver feels overwhelmed and cannot perform their role to the best of their ability. Caregiver role
strain symptoms are very similar to everyday stress and include feeling overwhelmed, being pessimistic, displaying an inability to relax,
and having widespread aches and pains (among many other things). Feeling of • Utilize in-home care services: Respite care to take a
personal break, adult day care, counselling and rehabilitation services on a routine basis to assist with the family member’s care. • Seek
financial help: If finances are an issue, approach an ASHA worker, who may advise you on available resources to help bridge the gap. She
may also refer to Village Health, Sanitation and Nutrition Committee/Jan Arogya Samiti/ Mahila Arogya Samiti/ Resident Welfare
Association who will ensure the availability of benefits from various governments and non-governmental programs/ schemes to the
eligible patients/ caregivers. • Ask for and accept help. Many family caregivers feel obligated to provide all the care and support their
loved one needs. It is challenging to do and can put both at risk for illness or injury. Make a list of the task others could help with and ask
other family members to help with those specific chores. • Set reasonable expectations for self and others. Care rendered may differ from
person to person and should not be criticized. Let the care given be good enough to keep the patient from risk for injury. • Talk with the
physician/nurse and make sure they know about the family caregiver. They may want to take extra steps to protect the caregiver’s health,
such as monitoring the blood pressure at home or prescribing a vitamin supplement. • Encourage self-care. This may be the most difficult
one for family caregivers to accept, but making time to take a brisk walk five days a week and eat a good diet can help them to stay
healthy. • Education and support: Providing caregivers with education about the patient's illness, trajectory, and symptom management can
help them better understand and cope with the situation. Caregivers may also benefit from support groups, counselling, and respite care to
help them manage their emotional and physical needs. • Care planning: Developing a care plan that outlines the patient's needs, the roles
and responsibilities of the caregiver and other healthcare team members can help to reduce the stress and anxiety accompany it. FIG.3.10:
CARE GIVER Caregiver strain often goes unrecognized. In the hustle and bustle of a busy life, it may not be detected until the family
caregiver suffers a health crisis of their own. Interventions There are steps you can advise a family caregiver to decrease the caregiver
strain. Advise them to
 88. 87 caregiver's burden and promote effective communication. • Providing support to the caregiver: Recognizing and addressing the
caregiver's symptoms and needs, such as pain, anxiety, and depression, can help to promote their well-being and improve their ability to
provide care. Overall, addressing caregiver strain in palliative care requires a multi-disciplinary approach that considers the needs of both
the patient and the caregiver. By providing education, support, and practical assistance, healthcare professionals can help to reduce
 caregiver burden and promote the well-being of both the patient and their caregiver. Conclusion Palliative care focuses on preventing and
relieving suffering and providing palliative care patients with the best possible quality of life. These patients typically experience multiple
symptoms, the most common of which are pain, depression, anxiety, fatigue, breathlessness, insomnia, nausea, constipation, diarrhea, and
anorexia. Symptom management helps the person feel more comfortable, improving physical well-being, functionality, and quality of life.
 89. 88 Activity for Unit 3 1. Multiple-choice questions 1. Pain associated with nerve damage is known as: a. Nociceptive pain b.
Neuropathic pain c. Psychopathic pain d. Referred pain 2. The best intervention to prevent opioid-induced constipation is: a. Give Fibre-
rich diet b. Give Laxative along with opioids c. Reduced dosage of the opioid if a patient develops constipation d. Give more than 2-3
litters of fluids 3. Non-pharmacological interventions for breathlessness include the following, EXCEPT: a. Try controlled breathing
techniques. b. Turn the fan on towards the patient. c. Be with the patient and reassure him that you are with him. d. Give nebulization. 2.
Group Activity/ Case Discussion Objective: To reinforce the symptom assessment and appropriate intervention. Activity instruction:
Students will be divided into groups and given case scenarios. Encourage themto discuss assessment and management; the group leader
will be asked to present to the class. a) Case 1. A 60-year-old man with a history of metastatic colonic carcinoma has been admitted tothe
hospital. He has intolerable pain and has been complaining of constipation for two days. Discussion Points: 1. How to assess his pain? 2.
Discuss the other concerns this patient will be facing. 3. How can we manage this patient's constipation? b) Case II: A 48-year-old woman
presents with nausea and vomiting. She has a history of breast cancer with widespread bone metastases. She is vomiting large amounts
(mostly undigested food) several times. She is intermittently nauseated and feels better for some time after vomiting. She was started on
Tab. Morphine q4h for pain three days back. Discussion Points: 1. What are the common causes of nausea and vomiting in palliative care
patients? 2. Discuss the likely cause of nausea and vomiting in this patient. 3. What is the standard drug given before giving Morphine to
prevent vomiting? c) Case III: A 54-year-old man was diagnosed with advanced cancer left lung 18 months back. He has been
experiencing a rapid deterioration in his health. He is currently unable to leave the house
 90. 89 due to breathlessness; he struggles with self-care and generally feels very low due to hisincapacity. Discussion Points 1. What
assessment will you carry out on this patient? 2. Discuss the non-pharmacological management of breathlessness. 3. Explain the nursing
care to be provided for this patient. d) Case IV: Mr. Suresh is a 65-year-old male diagnosed with advanced pancreatic cancer. He was
admitted to a hospice for palliative care due to the progression of the disease and the inability to tolerate chemotherapy. Mr. Suresh had a
history of hypertension, diabetes, and chronic kidney disease, for which he was receiving medications. He had a poor appetite and weight
loss and was experiencing severe pain in the abdomen, affecting his quality of life. Discussion Points 1. Discuss some issues that may
affect his Quality of Life. 2. As a palliative care nurse, explain how you manage Mr. Suresh. 3. Discuss health education to be given to
Mr. Suresh during his discharge. Essays 1. Enumerate the common symptoms experienced by patients receiving palliative care. Discuss
the nursing management of any one symptom. 2. Describe the recommended approach to managing pain in palliative care patients 3. What
are the common causes of constipation in palliative care patients, and how can they be managed effectively? 4. Discuss nursing care for a
patient with delirium. 5. Discuss the problems of Caregiver and Role of a nurse in addressing these issues. Written Assignments 1. Write a
care plan for any patient with chronic pain, cancer pain, or cancer-related breathlessness. 2. Write a care plan for a patient with delirium/
chronic constipation. 3. Prepare AV Aids on home teaching for a patient with breathlessness/vomiting.
 91. 90 Unit 4 NURSING PROCEDURES Introduction Palliative care nursing involves many procedures to comfort and support
patients with serious illnesses or conditions. The role of palliative care nurses is to provide compassionate, patient- centered care that
meets the unique needs of each patient and family. In this module, we will discuss some of the common nursing issues and their care in
palliative care. Wound Care Effective wound management and symptom control are essential in promoting comfort and quality of life for
patients in the palliative care setting. In palliative care, wound care can be challenging due to the complex nature of the wounds and the
patient’s underlying medical conditions. The goal of wound care in palliative care is to provide comfort and symptom management, rather
than cure or complete healing. Here are some considerations for managing healing and non-healing wounds: • Healing wounds: In
palliative care, some wounds may have the potential to heal, and efforts should be made to facilitate healing as much as possible. This
involves identifying the underlying cause of the wound, such as pressure or friction, and addressing it. This may include repositioning the
patient regularly, using appropriate support surfaces, and treating any infections that may be present. Wound dressings are used to promote
healing and reduce the risk of infection. • Non-healing wounds: Some wounds may not heal completely due to the nature of the wound or
the patient's underlying medical condition. In these cases, the goal of wound care is to manage symptoms and prevent complications such
as infection or further tissue damage. This may involve using dressings to manage exudate and odour, controlling pain, and maintaining
skin integrity. Sufferings of a patient with a chronic, non-healing malignant ulcer: It is important to keep in mind that a person with a
chronic, non-healing malignant ulcer suffers physically, psychologically, socially and spiritually. It affects all domains of life.
Understanding this helps us focus our interventions addressing each domain. Only this holistic approach improves patients' quality of life
with a chronic, non-healing malignant ulcer. Physical problems • Pain: Chronic ulcers produce chronic pain and problems associated with
chronic pain. Malignant ulcers especially have the tendency to infiltrate the adjacent tissues, and when a nerve is infiltrated, the patient
suffers from excruciating neuropathic pain. • Bleeding: It is a problem with malignant ulcers. Because of the neovascularisation of a
malignant tumour, these ulcers tend to bleed and are often difficult to manage. • Exudate: Malignant wounds produce excessive exudates
due to the vascular permeability of the tumour. Not all exudates are of infective origin—the presence of purulent exudate points to
infection. • Malodour: The cause of malodour is multifactorial. Infections, necrotic tissue and heavy exudates also produce malodour. The
presence of dead, necrotic tissues in the wounds makes it suitable for bacteria to colonise, resulting in further tissue destruction and the
production foul smelling exudates. Malodour causes severe distress to patients and their families. It affects the appetite, interferes with
sexual function, restricts social interaction, and leads to isolation.
 92. 91 • Pruritis: Pruritis in malignant fungating wounds is caused by stretching of the skin. This excessive stretching causes nerve
irritation. The dryness of the skin adds to the problem. • Maggots: It is the most devastating and frustrating problem seen in chronic non-
 malignant and malignant wounds. It is caused by poor wound care. When the wound is left open, flies lay their eggs producing maggots.
Maggots, though eat only the dead tissue, their movement causes pain, and the site of worms in the wound is very distressing for the
patients and the family. Psychological problems • Frustration: The non-healing and delayed healing nature of chronic ulcers in itself
causes frustration to the patient and families. Daily dressing is painful, cost and the time lost in the dressing adds to this frustration. In
patients with malignant wounds when the patients notice that the wound is only increasing in size even after repeated dressing, they get
more frustrated and disheartened. • Anger: Frustration leads to anger and resentment. Treatment failure, physical problems associated with
the wound, and family and social isolation results in anger. • Anxiety: Anticipating pain is one of the important causes of anxiety. Families
choosing not to reveal the diagnosis to the patient is a very common problem in our settings. This often results in collusion. For a patient
not knowing the diagnosis and having an ulcer that is taking a long time to heal is distressing. This is another important source of anxiety.
• Depression: Patients with chronic wounds suffer from depression. Hopelessness, family and social isolation play an important role in
leading the patient into depression. • Body-image issues: When the ulcer is in a place that is visible to others (Face and oral cavity) sense
of shame usually isolates the patients. Some even isolate themselves from seeking medical treatment. • Sexual problem: Chronic pain due
to chronic ulcers decreases the libido. Foul smell, discharge, family conflicts and spousal dissatisfaction exponentially worsen this. Social
problems • Isolation within the family: A patient with a malignant fungating wound is usually confined to a dark corner of the house.
Children don't visit that room, someone from the family enters the room with food and water and do dressing. Families often do this to
protect the patient without any malicious intent. But this completely isolates the patient from the family and patient feel alienated. •
Isolation from society: A patient with an ulcer is usually afraid of going out of the house. Fears like "What if someone accidentally hits me
when I am travelling on the bus?", "what if the dressing comes off?", "Will others be uncomfortable because of the foul smell?". These
fears are genuine and result in poor social interaction. They stop attending family functions, avoid social gatherings, and isolate
themselves. • Reduced mobility: Wounds that affect mobility can limit a person's ability to participate in activities they enjoy or are
necessary for daily life, such as work or caring for children. • Stigma and discrimination: Wounds that are visible or associated with
certain conditions, such as HIV or substance abuse, can lead to stigma and discrimination from others. • Caregiver burden: Wounds that
require routine care can cause caregiver burden, especially if the caregiver is a family member who must balance caregiving
responsibilities with other obligations. • Financial problems: The financial burden of caring for a chronic wound can offset the family
equilibrium, especially when the person suffering from the chronic wound is the breadwinner
 93. 92 or is required to visit the hospital every time for dressing. Loss of wages, loss of time and other healthcare expenditures push the
family into poverty. Spiritual problems • Loss of meaning and purpose: Wounds can lead to loss of meaning and purpose, particularly if
the patient is unable to engage in activities that give meaning to his/her life. • Questioning faith and beliefs: Wounds can cause patients to
question their faith or spiritual beliefs, particularly if they struggle to find meaning in their suffering or feel that their faith has failed to
provide comfort or healing. • Anger and resentment: Wounds can cause anger and resentment towards a higher power, particularly if the
patients feels that they have been unfairly afflicted or feel abandoned by their spiritual beliefs. • Guilt and shame: Wounds can cause
feelings of guilt and shame, particularly if the person feels that their wound is a punishment for past actions or if they feel that their wound
has made them unworthy of spiritual grace. • Loss of community: Wounds can lead to a loss of community, particularly if the patients are
unable to participate in religious or spiritual practices that were previously important to them. • The spiritual distress in a person with
chronic wounds can manifest as guilt, loss of faith, questions like "Where is God?", "Why me?" and "Have I been forsaken?". The
inability to perform some religious rituals causes fear and frustration among patients. In some proportion of patients, the suffering makes
them more spiritually active and engaging. Common Wounds in Palliative Care Several common types of wounds may occur in the
palliative care setting, including: 1. Pressure ulcers: Pressure ulcers, also known as bedsores, are a common type of wound that can
develop when a person is immobile or spends a lot of time in one position. They typically occur over bony areas and can be difficult to
heal. 2. Malignant wounds: Malignant wounds are a complication of advanced cancer and can be difficult to manage. They may be
painful, have a foul odor, and require specialised wound care. 3. Venous ulcers: Venous ulcers are a type of wound that occurs when there
is damage to the veins in the legs, which can lead to swelling, inflammation, and open sores. They are often slow to heal and may require
compression therapy. 4. Arterial ulcers: Arterial ulcers are a type of wound that occurs when there is damage to the arteries in the legs,
which can lead to reduced blood flow and tissue damage. They are often painful and slow to heal. 5. Diabetic ulcers are a common type of
wound that can occur in people with diabetes. They typically develop on the feet or lower legs and are caused by a combination of factors,
including poor circulation, nerve damage, and high blood sugar levels. Care of Wounds in Palliative Care In palliative care, wound care is
an important aspect of patient comfort and quality of life. The care of wounds in palliative care focuses on promoting healing and
preventing infection while providing pain relief and symptom management. Here are some key aspects of wound care in palliative care:
 94. 93 • Cleaning the wound: The wound should be cleaned with a gentle solution, such as sterile saline, to remove debris and bacteria.
This should be done using sterile gloves and a sterile technique. • Dressing the wound: The wound should be covered with an appropriate
dressing, which may depend on the type and severity of the wound. The dressing should be changed regularly to prevent infection and
promote healing. • Managing pain: Wound care can be painful, so pain management is important to palliative care. This may include
medications, such as opioids or nonsteroidal anti-inflammatory drugs (NSAIDs), as well as non-pharmacologic pain management
techniques, such as massage or heat therapy. • Preventing infection: Infection can be a serious complication of wounds, especially in
palliative care, where the immune system may be compromised. Measures to prevent infection may include hand hygiene, wearing gloves
and other personal protective equipment, and using sterile techniques when cleaning and dressing the wound. • Addressing psychosocial
concerns: Wound care can be emotionally and psychologically challenging for patients and their families. Palliative care providers should
address any concerns or fears related to the wound care process and provide emotional support as needed. PRESSURE ULCER Pressure
ulcers are a common problem in palliative care. Patients nearing the end of life may be bedridden or unable to move around, increasing
their risk of developing pressure ulcers. In palliative care, the focus is on providing comfort and relieving suffering, so preventing and
 managing pressure ulcers is an important part of patient care. Causes of pressure Ulcer Extrinsic Factors • Pressure: Prolonged pressure on
the skin and underlying tissues is the primary cause of pressure ulcers. This can occur when a person remains in one position for an
extended period, such as when they are bedridden or in a wheelchair. • Friction: Friction occurs when the skin rubs against a surface, such
as bedding or clothing, causing skin damage. Friction can also occur when the skin is dragged across a surface, such as during transfers or
repositioning. • Shear: Shear occurs when the skin is pulled in one direction while the underlying tissues are pulled in another. This can
occur when a person slides down in bed or when the head of the bed is elevated too high. Intrinsic Factors • Age: Older adults have thinner
skin, less natural cushioning over bones and poor nutrition • Lack of pain perception: e.g., Spinal cord injuries • Malnutrition: Both obese
and thin patients are at risk of developing pressure sores. But in thin patients, the progression stages of pressure sore are faster due to the
lack of subcutaneous fat. • Urinary or faecal incontinence: Moist skin can break down easily. Bacteria from faecal matter can cause
infections • Co-morbidities: Diseases conditions affecting circulation (diabetes mellitus, vascular diseases) / Smoking (Nicotine impairs
circulation and reduces the amount of oxygen in the blood) • Decreased mental awareness by disease (CVA), trauma or medications.
 95. 94 Potential sites of pressure injury Some potential sites for pressure ulcers include: 1. Bony prominences: Areas where bones are
close to the skin, such as the hips, tailbone, heels, and ankles, are common sites for pressure ulcers 2. Skin folds: Skin folds, such as those
around the groin or under the breasts, can be vulnerable to pressure ulcers due to friction and moisture. 3. Back of the head: Patients who
spend a lot of time lying on their backs may develop pressure ulcers on the back of their heads. 4. Shoulders and shoulder blades: Patients
who spend a lot of time lying on their sides may develop pressure ulcers on their shoulders and shoulder blades. 5. Elbows, knees, and
other joints: Joints subjected to prolonged pressure or friction, such as the elbows and knees, can be vulnerable to pressure ulcers. 6. Ears
and nose: Patients who spend a lot of time lying on their side may develop pressure ulcers on their ears or nose. 7. Feet and toes: Patients
who are unable to move or change position may develop pressure ulcers on their feet and toes. Stages of Pressure Ulcer Pressure ulcers,
also known as bedsores, are classified into four stages, according to the depth and severity of the wound: • Stage 1: This is the earliest
stage of pressure ulcer, where the skin is intact but is discolored, usually appearing as a reddened or darker area. The area may be painful
or tender to the touch, and the skin may feel warm or cool compared to the surrounding tissue. • Stage 2: At this stage, the skin is no
longer intact and may have a shallow open wound or blister. The ulcer appears as a partial-thickness skin loss that may be red, pink, or a
blister, with a shiny or dry wound bed. The area may be painful, and there may be some swelling. • Stage 3: In this stage, the ulcer extends
deeper into the skin and subcutaneous tissue, forming a full- thickness wound. The ulcer appears as a deep crater-like wound, with visible
fat and may have a foul odor. There may be significant tissue damage, including necrosis or slough, and the patient may experience
significant pain. • Stage 4: This is the most severe stage of pressure ulcer, where the wound extends even deeper into the muscle and bone.
The ulcer appears as a full-thickness wound, with extensive tissue damage and loss, exposing bone, tendons, or muscles. The patient may
experience significant pain, and there may be a risk of infection. Fig. 4.1: POTENTIAL SITES OF PRESSURE ULCER
 96. 95 Fig.4.2: STAGES OF PRESSURE ULCER Management of Pressure Ulcer Here are some key nursing considerations for
managing pressure ulcers in palliative care: • Prevention: The first key principle is preventing pressure ulcer from developing. This
involves regularly repositioning patients, ensuring proper support surfaces (such as pressure-reducing mattresses), and keeping their skin
clean and dry. • Assessment: Regular skin assessments can help identify pressure ulcers early and manage them appropriately. The
assessment should include identifying the stage of the ulcer, measuring its size, and determining the level of pain or discomfort the patient
is experiencing. • Pain management: Pressure ulcers can be painful, especially as they progress. Appropriate pain management, including
using analgesics and other pain-relieving interventions, is important to ensure that the patient is comfortable. • Wound care: Wound care
should be tailored to the individual patient and their specific needs. This may involve debridement, cleaning the wound, applying
dressings, and managing exudate. • Psychosocial support: Patients with pressure ulcers may experience embarrassment, shame, or social
isolation. Providing psychosocial support can help address these feelings and improve the patient's quality of life. It's important to
remember that pressure ulcers can significantly impact a patient's quality of life, and effective management requires a holistic, patient-
centred approach. Working closely with a multidisciplinary team, including wound care specialists, nurses, and other healthcare providers,
can help ensure that the patient receives comprehensive and effective care.
 97. 96 MALIGNANT WOUNDS Malignant Wounds/ Fungating wounds are very distressing for patients with advanced cancer. The
term 'fungating' refers to a malignant process of both ulcerating and proliferative nature. Lesions with a predominantly proliferative
growth pattern may develop into a nodular 'fungus' or 'cauliflower shaped lesion, whereas a lesion that is ulcerating will produce a wound
with a crater- like appearance. These fungating wounds may develop during the last few months of life. Malignant wounds are a common
complication of some advanced cancer and can be challenging to manage in palliative care. They are caused by infiltration of the skin by a
local tumour and recurrent or metastatic spread from a primary tumour. Sometimes a chronic wound may undergo malignant
transformation to produce a fungating wound. The goal of wound care in palliative care is to optimise patient comfort and quality of life
rather than to achieve complete wound healing. Assessment of Wound Assessing a chronic wound involves a comprehensive evaluation of
the wound and the surrounding skin to determine its size, location, depth, and any underlying causes. Here are some common steps
involved in the assessment of a chronic wound: • Wound history: A detailed history of the wound is important, including when the wound
first appeared, its location, size, and duration. The history should also include any previous treatments or interventions. • Wound
characteristics: It's important to document the appearance of the wound, including its color, depth, shape, and presence of drainage or
odor. Photographs and wound measurements can also be helpful in tracking changes over time. • Wound bed: The type and condition of
the wound-bed can provide important information about wound healing potential. The wound-bed should be assessed for tissue type (e.g.,
granulation, slough, eschar), moisture level, and presence of infection. • Peri wound area: The skin around the wound should be assessed
for signs of inflammation, infection, or damage. The peri-wound area should also be assessed for the presence of edema, hyperkeratosis,
or other skin conditions that may affect wound healing. • Pain assessment: The patient's pain level should be assessed using a validated
pain scale. The location, duration, and intensity of pain should be documented, as well as any factors that exacerbate or alleviate the pain.
 • Health status: A comprehensive health assessment should be conducted, including a review of medical history, current medications, and
any comorbid conditions that may affect wound healing. • Nutritional status: Nutritional status can impact wound healing. It's important to
assess for malnutrition, including low serum albumin levels, and other factors that may impact nutrition status such as dietary intake and
food insecurity. Fig.4.3: MALIGNANT BREAST CANCER WOUND
 98. 97 • Psychosocial, social and spiritual factors: Chronic wounds can significantly impact a patient's quality of life. Management of
Wound Here are some key principles to keep in mind when managing malignant wounds in palliative care: 1. Pain management: Pain
control is a crucial aspect of palliative wound care. Pain can be managed with various medications, including opioids and non-opioids, and
non-pharmacological interventions, such as positioning, relaxation techniques, and distraction. • Give an extra dose of pain medication
half an hour before dressing. • • • Irrigation of the wound with saline rather than cleaning with a gauze swab will reduce pain. •
Complementary therapies, such as relaxation, distraction or visualisation, can play an important part in pain management. 2. Wound Care:
The goals of wound management in palliative care are to minimise pain, odor, and exudate, and to promote healing. Wound dressings can
be used to cover and protect the wound, and topical agents such as hydrogels, antimicrobials, and odor-absorbing agents can be used to
manage symptoms. Consider anticancer treatment- RT, CT, debriding surgery in the case of cancers A) Maggots Prevention of maggot
infection is better than cure. The following steps should be used for infection, if present. • Wound should be covered with dressing all the
time and changed daily. • If maggots are present, apply or flush plain turpentine oil in the wound with a syringe. Protect the eye, nose and
ear with a pad and instruct the patient not to swallow if turpentine is spilled accidentally in the oral cavity, as there will be irritation. Wait
for 10 minutes after the application of turpentine. Remove maggots with the help of forceps. Previous dressing materials should be soaked
and removed to minimise pain during dressing. Another method is the use of non-sticky dressings. Maintaining the wound in a moist
environment will Fig.4.4: MALIGNANT WOUND reduce dressing adherence and protect exposed nerve endings. Pain can be kept in
check using a dressing material requiring less frequent changes. Fig.4.5: MAGGOTS IN WOUND
 99. 98 • Maggots come out from the hidden pockets of tissue when there is a lack of oxygen supply and irritation from turpentine vapour.
Therefore, turpentine flushing must be repeated for 3-4 days to remove all maggots. When completely removed, teach the carer the correct
way of wound cleaning and dressing. B) Malodour Usually caused as a result of anaerobic bacterial growth in dead tissues. This can be
controlled as follows: • Daily bath before dressing • Cleaning with normal saline • Mop the wound gently with gauze. Apply Metrogyl •
Application of Metrogyl powder to the wound. • If the wound is dry and painful, apply Metrogyl powder (crushed Metrogyl tablets) mixed
with Lignocaine jelly. • Change wound dressing at least twice a day until malodour settles. C) Discharge • Cancer wounds often produce
excessive amounts of discharge, which can be difficult to manage. Keep changing the dressings once soaked. D) Bleeding: • Wound
bleeding is common in cancer wounds. • Always mask the bleeding with dark-colored clothes. • If dressings are not soaked while
changing, bleeding may occur. • Bleeding occurs when cleaning roughly. • Using non-adherent dressings that maintain a moist
environment • Clean the wound by irrigation rather than swabbing will reduce trauma and bleeding. • Gentle removal of dressing after
soaking with saline or water is a good practice. E) Infection: • Thorough bath before dressing reduce malodour, infection and washes off
exudates. • The wound should be cleaned with normal saline or preferably under running water. • Antibiotics may be used to manage
infections, and regular wound assessments should be performed to monitor for signs of infection. 3. Patient's comfort • Use dressings that
will be most comfortable to the patient and cost-effective. • Used cotton saris or soft cloth can be made into gauze pieces and gamgee
pads. • Coloured pads have the advantage of masking the colour of blood or exudate from wounds. 4. Nutrition Good nutrition is essential
for wound healing, and patients with malignant wounds may require additional nutritional support. Dietary counselling and supplements
may be recommended to help ensure that patients are receiving adequate nutrients. 5. Psychosocial support Malignant wounds can
significantly impact a patient's quality of life, and psychosocial support can be beneficial in managing the emotional and psychological
aspects of wound care. Counselling,
 100. 99 support groups, and other forms of psychosocial support may be helpful for patients and their families. In summary, managing
malignant wounds in palliative care requires a comprehensive approach that addresses wound care's physical, emotional, and psychosocial
aspects. The focus should be maximising patient comfort and quality of life rather than achieving complete wound healing. Health
Education and Home Care Management We can help the patient and the carers by teaching them the proper procedure to be used while
caring for their loved ones. Explain to the carer that fungating wound is non-healing and, although it will be present lifelong, the
symptoms can be controlled. Provide the carer with support, counselling and practical demonstration of preparing dressing material at
home. Carers can use the following protocol for home-based sterilisation technique: Preparation of saline for cleaning and dressing: Add
one pinch of salt in one glass of water or two teaspoons of salt in 1 litre of water. Boil the solution for half an hour. Keep this water in a
clean closed container, and it can be used as per need Preparation of Dressing Material: Simple dressing material can be prepared at home.
Family members can be advised to preserve dark-coloured clothes to be used to clean bleeding wounds. An old cotton cloth that has been
washed well with soap and water and dried in sunlight can be used. The clean cotton cloth should be cut into small pieces, steamed for
half an hour, and stored in a clean airtight container. The following advice also should be given: • Hand should be washed before and after
dressing. • Waste materials should be properly disposed. • Regular follow up with healthcare worker is critical. COLOSTOMY CARE
Though the words ‘ostomy’ and ‘stoma’ are used interchangeably, they have different meanings. Ostomy is a surgery to create an opening
(Stoma) from inside to outside. A stoma is an opening that connects a body cavity to the outside environment. Ostomies, based on their
purpose, are classified into two types. • Input ostomies: Tracheostomy, Gastrostomy, Jejunostomy • Output ostomies: Ileostomy,
Colostomy, Urostomy Colostomy: A colostomy involves creating an opening in the abdomen and pulling through a portion of the colon.
This allows stool to pass directly from the colon, bypassing the diseased or damaged part. The consistency and frequency of the stoma
discharge depend on the colostomy type performed. Depending on the site, there are four main types of colostomies: ascending,
transverse, descending, and sigmoid. 1. Ascending colostomy: This procedure is performed on the ascending colon, on the right side of the
abdomen. This discharge is often irritating to the skin around the Fig.4.6: TYPES OF COLOSTOMY
 101. 100 stoma (peristomal skin). The stool that passes from this type is liquid and is rich in digestive enzymes. 2. Transverse colostomy:
This procedure is performed on the transverse colon across the abdomen. Discharge from this type is usually liquid to semi-formed in
consistency and is less irritating to peristomal skin. 3. Descending colostomy: This is performed on the descending colon, on the left side
of the abdomen. The stool is semi formed to formed in consistency because most of the water has been absorbed as it moves through the
ascending and transverse sections of the colon. 4. Sigmoid colostomy: This procedure is performed in the sigmoid colon, on the lower left
side of the abdomen. The stool has a normal, formed consistency. Stoma management The management of stoma patients in palliative care
nursing involves three principles: i. Assessment of patient's general condition, application of knowledge of the different types of stoma in
planning and evaluating the outcome ii. Management of the stoma and stomal appliances iii. Providing physical and psychological care
Common Issues • Stoma colour: Normal colour is deep pink to deep red and should be checked regularly. If the stoma appears blue or
purple, it could be a sign of inadequate blood flow to the stoma, known as ischemia. If the stoma appears black or brown, it may be a sign
of necrosis or tissue death. Necrosis can be caused by a variety of factors, including ischemia, trauma to the stoma, or infection. This is a
serious condition that requires immediate medical attention. • Stoma bleeding: It is usually seen at the time of cleaning or changing the
bag. Apply local pressure for 10 minutes and use sucralfate powder to control bleeding. Other causes of bleeding may be: • Trauma: Any
injury to the stoma site can cause bleeding. This can be due to accidentally hitting or scratching the stoma. • Infection: Infection at the
stoma site can cause bleeding. It is essential to keep the stoma site clean. • Medications: Some medications, such as blood thinners, can
increase the risk of bleeding • Stoma herniation: Stoma herniation is a condition where the intestine protrudes through the stoma site, the
opening in the abdominal wall created during the surgery for stool to pass through. Stoma herniation can cause discomfort, and pain, and
can even lead to blockages in the intestine. When the patient lies in the supine position, it usually reduces. But in some cases, the hernia
does not reduce and should be reported immediately. • Stoma prolapse occurs when the stoma protrudes outward from the abdominal wall.
It can be caused by weak muscles in the abdominal wall or excessive strain on the stoma site. Stoma prolapse can also cause discomfort,
pain, and can even lead to blockages in the intestine, and distension and needs surgical intervention. A prolapse of 1.5 cm of stoma outside
the skin level is acceptable in a colostomy. A prolapse of 5 cm needs surgical intervention. • Stoma retraction: stoma withdraws inside: If
there is no interference with bowel movement, intervention is not needed. Otherwise, surgical correction is advised. Special attention is to
be given to peristomal skin.
 102. 101 Colostomy pouch A colostomy pouch is a medical device that is used to collect waste products from the colon after a colostomy
surgery. The pouch is attached to the stoma site, which is the opening in the abdominal wall created during the surgery. Types of
Colostomy pouch There are two main types of colostomy pouches: one-piece and two-piece pouches. • One-piece pouches are made of a
single unit, combining the adhesive barrier and pouch. • Two-piece pouches have a separate adhesive barrier and pouch that can be
attached or detached from each other. Colostomy pouches are available in different sizes, shapes, and materials, including disposable and
reusable options. The healthcare provider will recommend the most suitable pouch based on the stoma's location and the individual's
needs. It is important to empty the pouch regularly and replace it when necessary. Proper care of the colostomy pouch can help prevent
leaks, skin irritation, and infection. Another classification of colostomy pouch is: closed and drainable. • Closed colostomy pouches are
designed to be used once and then disposed of. These pouches are typically used for people who have a predictable bowel routine, and the
stoma output can be easily managed. • Drainable colostomy pouches are designed to be emptied and reused. These pouches typically have
an opening at the bottom that can be emptied into a toilet or a container. They can be emptied multiple times throughout the day, as
needed. Drainable pouches are useful for people who have irregular bowel movements or a higher output from the stoma. Fig.4.7:
COLOSTOMY POUCH Fig.4.8: OPEN OSTOMY POUCH Fig.4.9: DRAINABLE OSTOMY POUCH
 103. 102 Colostomy irrigation Colostomy irrigation involves instilling a large volume of water into the stoma and colon, stimulating the
bowel to empty its contents. This is done using an irrigation set consisting of a bag or container to hold the water, a tubing system, and a
cone-shaped irrigation tip inserted into the stoma. Colostomy irrigation can benefit some people with a colostomy, as it can help them
achieve a more predictable and controllable bowel movement pattern. It may also reduce the need for a collection bag and can help with
skin irritation around the stoma. Patients with a stoma can be referred to a stoma nurse or a palliative care nurse to train themselves in
stoma irrigation. Specific teaching points to the patients. Diet A person with a stoma does not require a special diet. Like any other
individual, they require a healthy and balanced diet. Some dietary products can be odour-producing and gas-forming which the patient
may have difficulty in managing. The patients learn themselves over time to adapt to different dietary foods. It is important to avoid time
release and enteric-coated tablets as they are not absorbed completely. The following are some food items and their effect on patients with
ostomies. • Cabbage, garlic, eggs, beans and fried food may cause odour. • Corn, Nuts, cabbage and vegetable peeling may cause
hardening of stool. • Coffee, fruits, fruit juices, and oily food may cause loose stools. • Mint, Coriander reduces the smell. Travel, work,
dressing, and sports: Patients with a colostomy can travel like any other person. They may need to carry extra bags if they need immediate
change. Patients can engage in routine work that do not involve heavy lifting and strenuous exercise as an increase in intra-abdominal
pressure can cause the stoma to prolapse or hernia. The pouch can be comfortably worn underneath the clothes and is easily concealed. It
is safe to avoid contact sports that can cause injury to the stoma like kabaddi, football etc. Problems faced by patients with colostomy
Dehydration: • Except in sigmoid colostomy and descending colon colostomy, there is water loss through other stomas. These patients are
at risk of dehydration if they do not consume adequate water. On average, colostomy patients must drink 1.5 to 2L fluid per day. • It is
recommended that they always carry water with them and 'drink little and drink often'. Constipation and Diarrhoea: • Constipation in
patients with an ostomy is usually due to inadequate water intake. Usually, constipation can be managed by increasing fluid intake and
soluble dietary fibre. Insoluble dietary fibres can cause temporary obstruction and cramps. Some patients may require laxatives to manage
constipation. • Diarrhoea could be due to various causes, including diet, stress, and medications. Sometimes raw fruits, vegetables, fruit
juices, and milk can temporarily produce loose stools. It is important to differentiate diarrhoea from loose stools normally seen in more
proximal stomas • Diarrhoea that is of infective origin will require medical management. Since patients with a stoma tend to lose more
 electrolytes, hydration and replenishing electrolytes are crucial when the patient has diarrhoea. Peristomal skin problems: • If skin erosion
is present, apply karaya powder mixed with egg white for 2 to 3 days.Zinc oxide paste can be used instead of karaya powder.
 104. 103 • The right size of skin barrier around the stoma and application of barrier cream to protect and prevent skin irritation. • Some
patients can be allergic to pouching products: Choosing the right pouching system is crucial in such cases. • Advise daily cleaning with
soap and water and drying with soft towel (mopping). Caring for the psychological needs of the patient • Though an ostomy can be
lifesaving surgery, these patients will require education, constant motivation, supportive counselling, and care to cope with this major
lifestyle modification. • Concerns such as fear of leakage, physical problems, body image change, embarrassment due to odour, noisy
flatulence, and privacy need to be individually addressed in all patients to improve their quality of life. • Having a colostomy should not
interfere with sexual activity. • Counselling the patient and the spouse and exploring questions they might have, fears, and hopes is very
important in improving the patient's and family's quality of life. • Physical problems such as skin irritation and excoriation affect patients'
quality of life, increasing their distress. Hence, impeccable assessment and prompt management of physical problems will lead to a better
quality of life and improved psychological well-being. SUBCUTANEOUS INJECTION Subcutaneous injection is a method of
administering medication into the layer of tissue directly beneath the skin. This route of administration is commonly used for medications
that are absorbed slowly and steadily into the bloodstream. It is a convenient alternative route of the parenteral route of drug
administration. Family members can also learn to give necessary injections at home using this route. Subcutaneous infusions or
hypodermoclysis It is the administration of isotonic solution into the subcutaneous tissue to be absorbed into the systemic circulation.
When administered appropriately the absorption of the isotonic solution via subcutaneous route is on par with intravenous (IV)
administration. Subcutaneous catheters Subcutaneous catheters are devices that are secured at the insertion site to facilitate intermittent
subcutaneous injections or infusions. A 26G IV cannula/24-26 G Scalp vein needle can be used for subcutaneous infusions How to select
an appropriate site for subcutaneous infusion: • The site should have a good depth of subcutaneous fat • The sites that are easily accessed
such as the chest and abdomen are more ideal. • Avoid bony prominence and sites close to the joints. Fig.4.10: COMMON SITES FOR
SC INJECTIONS
 105. 104 • Alternate the sites on a regular basis. • A subcutaneous needle can be in place for a maximum period of 5-7 days Indications
for using SC route • Persistent, Nausea and Vomiting • Dysphagia. • Intestinal obstruction. • Coma. • Poor absorption of oral drugs. •
Terminal care. Contraindicated sites for subcutaneous infusion • Sites with lymphedema • Sites with pitting edema • Severe bleeding
disorder • Sites with broken skin • Sites with recent radiation • Skinfold Drugs commonly given through in subcutaneous Route •
Inj .Midazolam • Inj. Hyosine butylbromide • Inj Dexamethasone • Inj. Morphine • Inj Oxycodone • Inj. Levomepromazine • Inj.
Haloperidol • Inj. Cyclizine • Inj. Metoclopramide Drugs to be avoided in subcutaneous injections • Promethazine • Chlorpromazine •
Potassium chloride • Calcium gluconate • Phenytoin • Paracetamol Complications • Redness • Swelling • Tenderness • Pain • Warmth
Instructions for family caregivers following subcutaneous needle placement 1. Carers may be instructed on necessary hygiene measures
for handling the materials for administering medicines 2. Lumping under the skin is normal after the administration of subcutaneous
injections. These lumps will disappear within minutes to hours.
 106. 105 3. Swelling after the subcutaneous infusion is normal. This swelling will resolve on its own within a few hours. 4. Drugs that are
refrigerated should be warmed to room temperature before administration. 5. Before the administration of subcutaneous injection through
the subcutaneous catheter check the area for redness, warmth, swelling, and tenderness. If the area is red or warm or swollen or tender do
not administer the drug and call the homecare nurse immediately. Subcutaneous infusion is a valuable tool in palliative care to manage
symptoms and improve the patient's quality of life. The nurse's role in administering subcutaneous infusions is critical to ensure safe,
effective medication administration and provide compassionate care to patients and their families. ORAL HYGIENE Introduction Mouth
care/ Oral Hygiene is an important aspect of overall health, particularly in palliative care where patients may experience discomfort or
pain related to oral health problems. Oral issues are common in patients receiving palliative care and can significantly impact their quality
of life. These issues can include dry mouth, oral infections, oral mucositis, difficulty swallowing, and pain. Good mouth care practices can
help prevent infections, reduce pain, and promote patient comfort. Perhaps most importantly, these complications impair oral health with
various consequences, including malnutrition, anorexia, and cachexia. In addition, psychological disturbances related to the oral cavity's
role in communication, social life, and pleasures associated with eating. Risk factors • Debility • Dry mouth • Chemotherapy • Poor oral
intake • Local irradiation • Dehydration Purpose of Oral Hygiene • To promote hygiene • To remove debris • To provide refreshment • To
prevent and infection • To prevent and treat dryness and halitosis • To promote a sense of well being Frequency of oral care The frequency
of oral care depends upon the condition of the patients. • Healthy individuals require only twice-daily brushing. • If the patient is
bedridden and at low risk of developing oral problems oral care every 4 to 6 hours is sufficient. • For patients with oral problems, 2 hourly
oral care is required. • Hourly oral care may be required for patients with mouth breathing. Oral hygiene Oral hygiene is an important
aspect of palliative care as it helps to maintain a patient's overall comfort and well-being. Nurses should monitor patients for signs of oral
health problems, such as cavities, gum
 107. 106 disease, and mouth sores. If these issues arise, appropriate treatments should be provided to help alleviate discomfort and
prevent complications. Common Oral Problems • Aphthous ulcers, also known as canker sores, are small, painful, shallow ulcers that can
develop on the soft tissues inside your mouth, including your lips, cheeks, gums, and tongue. They are not contagious and usually go away
on their own within one to two weeks. • Stomatitis is a general term for inflammation of the mouth and lips. Symptoms can include
redness, swelling, and sores in the mouth, as well as pain and difficulty eating and drinking. A variety of factors, including viral, bacterial,
or fungal infections, allergies, and irritants such as tobacco or certain foods can cause it. • Gingivitis is a type of gum disease that occurs
when the gums become inflamed and swollen due to a buildup of plaque on the teeth. Symptoms can include bleeding gums, bad breath,
and gum sensitivity. If left untreated, gingivitis can lead to more serious forms of gum disease and tooth loss. Practicing good oral
hygiene, including regular brushing and flossing, is important to prevent and treat gingivitis. • Dry mouth, also known as xerostomia, is a
 common oral issue in palliative care patients. Various factors, including medications, radiation therapy, and dehydration can cause it. A
dry mouth can lead to difficulty speaking, swallowing, and tasting and increased risk of oral infections. Palliative care teams may manage
dry mouth with frequent sips of water or ice chips, saliva substitutes, and avoiding caffeine and alcohol. • Oral infections, such as
candidiasis and herpes simplex virus, can cause pain and discomfort in palliative care patients. These infections may be treated with
antifungal, antiviral, or antibiotic medications. • Oral mucositis, inflammation and ulceration of the oral mucosa, can be a side effect of
chemotherapy or radiation therapy. It can cause pain, difficulty swallowing, and increased risk of infection. Palliative care teams may
manage oral mucositis with topical analgesics, such as lidocaine, and mouthwashes containing saline or sodium bicarbonate. • Difficulty
swallowing, also known as dysphagia, can be caused by various factors, including neurological disorders, cancer, and radiation therapy. In
severe cases, patients with dysphagia may require a modified diet, such as pureed or soft foods, or even tube feeding. Speech-language
pathologists can provide assistance with swallowing exercises to help improve swallowing function. • Pain is a common oral issue in
palliative care patients and can be caused by various factors, including oral infections, mucositis, and cancer. Non-opioid analgesics, such
as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), may be used for mild pain, while opioids, such as Morphine or
fentanyl, may be necessary for severe pain • Halitosis, also known as bad breath, is a condition that causes unpleasant odors in the mouth.
A variety of factors, such as poor oral hygiene, food debris, dry mouth, gum disease, and infections, can cause it. Treatment may involve
improving oral hygiene habits, using mouthwash, and addressing any underlying health conditions. • Candidiasis, also called oral thrush,
is a fungal infection that can occur in the mouth. It is caused by Candida yeast and may appear as white patches on the tongue, inside the
cheeks, or on the roof of the mouth. It can be common in individuals with weakened immune systems, such as those undergoing
chemotherapy or who have HIV/AIDS. Treatment may involve antifungal medication or improving oral hygiene.
 108. 107 Management of Oral Issues in Palliative Care In palliative care, patients may have difficulty performing regular oral hygiene
practices due to weakness, fatigue, or other physical limitations. Therefore, it is important for healthcare providers to assist with oral care
as needed. Some important oral hygiene practices for patients in palliative care include: 1. Brushing teeth and tongue: Patients should
brush their teeth at least twice a day using a soft- bristled brush and fluoride toothpaste. They should also gently brush their tongue to
remove bacteria and prevent bad breath. 2. Flossing: Patients should floss at least once a day to remove plaque and food particles from
between their teeth. 3. Mouthwashes or rinses: Patients may benefit from using mouthwashes or rinses to help kill bacteria and freshen
breath. Mouth rinses can be an important part of oral care for patients in palliative care, as they can help to reduce inflammation, kill
bacteria, and promote overall oral health. Healthcare providers should recommend products that are safe for patients with sensitive or dry
mouths. Here are some common mouth rinses that may be recommended for patients in palliative care: • Salt water rinse: A simple and
effective rinse can be made by mixing a teaspoon of salt in a cup of warm water. This can help to reduce inflammation and kill bacteria in
the mouth. • Baking soda rinse: Mixing a teaspoon of baking soda with a cup of warm water can help to neutralise acids in the mouth and
promote a healthy pH balance. This can be particularly helpful for patients with dry mouth or who are at risk of developing cavities. •
Chlorhexidine rinse: This prescription-strength mouth rinse can help to kill bacteria and prevent infections in the mouth. It may be
recommended for patients at high risk of developing oral health problems, such as those who are bedridden or have weakened immune
systems. • Saline rinse: Saline rinse is a gentle and soothing rinse that can help to moisturise the mouth and reduce dryness. It is
particularly helpful for patients experiencing side effects from medications that cause dry mouth. • Lidocaine rinse: This prescription-
strength mouth rinse contains a local anaesthetic that can help to numb the mouth and reduce pain. It may be recommended for patients
experiencing oral pain or discomfort due to conditions such as mucositis or oral thrush. 4. In addition to mouth rinses, several other mouth
care agents may be used in palliative care to promote oral health and alleviate discomfort. Here are some common mouth care agents: •
Moisturisers: Moisturisers can help reduce mouth dryness and prevent discomfort. Products such as saliva substitutes or oral lubricants
may be recommended for patients with dry mouth. • Topical anaesthetics: Topical anaesthetics can help to numb the mouth and reduce
pain, particularly for patients with mucositis or other painful oral conditions. These may include gels or sprays containing lidocaine or
benzocaine. • Antifungal agents: Patients who develop oral thrush or other fungal infections in the mouth may benefit from antifungal
agents, such as Nystatin or Fluconazole. • Antiseptics: Antiseptics can help to kill bacteria and prevent infections in the mouth..
 109. 108 • Corticosteroids: Patients with severe inflammation or pain in the mouth may benefit from corticosteroids, which can help to
reduce inflammation and pain. These may be prescribed as a mouthwash, spray, or tablet. 5. Denture care: Patients who wear dentures
should be instructed to remove and clean them daily to prevent infections and irritation. Hydration: Adequate hydration is important for
oral health as it helps to prevent dry mouth, which can increase the risk of cavities and gum disease NASO-GASTRIC TUBE
MANAGEMENT Nasogastric (NG) feeding is a method of delivering nutrition and fluids to patients who are unable to take food orally. It
involves passing a thin, flexible tube through the nose, throat, and stomach to deliver nutrients and medications directly to the patient's
digestive system. In palliative care, NG feeding may be used in patients who have lost their ability to eat or drink. However, the decision
to use NG feeding should be carefully considered in the context of the patient's goals of care, quality of life, and symptom management.
When using NG feeding in palliative care, it is important to: • Ensure that the patient or their caregiver understands the benefits and
potential risks of NG feeding. • Monitor the patient closely for any signs of discomfort, aspiration, or other complications. • Provide
adequate pain and symptom management to minimise discomfort and improve quality of life. • Use NG feeding as part of a
comprehensive palliative care plan that includes symptom management, emotional and spiritual support, and family involvement. •
Reassess the need for NG feeding regularly and adjust the treatment plan based on the patient's evolving condition and goals of care.
Nasogastric tube feeding Articles needed: Dry towel, 20ml syringe, a glass of water, a glass of liquid food. Preparation of liquid food
Simple home foods can be used depending on the patient's choice and what is available. This can include foods such as porridge, rice
gruel, soup, juice, milk or curd. More solid foods such as idly, fish, vegetables, dals or meat can be used if cooked well and ground finely.
The usual food cooked for the family can also be used. Any food to be given should be ground finely with a mixer or mashed with a large
spoon. The liquid is added to make a thin consistency and then filtered through a strainer such as that used for tea. Patients who cannot
 swallow can still taste a tiny amount which can give pleasure. Procedure of feeding • Place the patient in a sitting position. If unable to sit,
place 2-3 pillows under the head and shoulders • Wash hands well with soap and water. • Place a dry towel around the neck to catch any
spills. • Fix the syringe to the end of the nasogastric tube. • Gently pull back and make sure it fills with stomach contents. This checks the
tube is still in the correct place in the stomach. • Take off the syringe and remove the central piston or inner tube from the syringe. • Re-fix
this outer part of the syringe to the end of the tube.
 110. 109 • Pinch the tube to prevent air from going down the tube. • Hold the end of the tube about 12 inches above the patient's head. •
Slowly pour the prepared liquid food, fluid or drugs into the outer syringe. It should flow slowly and steadily. Do not force fluids to go
through. • Take care not to let air enter, as this will cause wind and discomfort for the patient. • Flush the tube at the end of the feed by
pouring enough drinking water to clear the tube. Around half a small cup (50ml) • Give small amounts of feed regularly. Usually, a small
cup or 150 ml is enough. • Remember to add salt to the feeds. Most patients require around two teaspoons of salt per day. • Once every 3-4
days, repeat this procedure using only warm saline solution to clean thoroughly and prevent coating of the tube, which may lead to
blocking. • Occasionally change the sticking plaster that keeps the tube attached to the nose. This is not needed every time.
Troubleshooting • If the fluid is not flowing well, then first check it is still in place by looking for stomach contents when you pull back on
the syringe. You may also notice that the tube has slipped out and appears much longer. • If the tube is in the correct place, it may be
becoming blocked so increase the number of times you flush and clean it with warm saline. Using soda bicarb solution to flush may be
more effective. • If the tube has come out of the stomach or is completely blocked, you will need to seek advice from your doctor or nurse.
TRACHEOSTOMY CARE A tracheostomy is an artificial opening made into the trachea into which a tube is inserted to establish and
maintain a patent airway. Tracheostomy care refers to maintaining and cleaning the tracheostomy site and the tube inserted into the
trachea to facilitate breathing. Tracheostomy Tube A tracheostomy tube is a medical device that is inserted into the trachea (windpipe)
through a surgical opening in the neck called a tracheostomy. The tube provides an alternate airway for breathing and can be used to
manage respiratory conditions such as upper airway obstruction or respiratory failure. Here are some key features of a tracheostomy tube:
1. Types: There are different types of tracheostomy tubes available, including cuffed and uncuffed tubes, fenestrated tubes, and speaking
valves. The choice of tube depends on the patient's condition and needs. 2. Size: Tracheostomy tubes come in different sizes, and the
appropriate size is determined based on the patient's age, gender, and neck size. Using the correct size tube is important to prevent
complications such as airway obstruction or tracheal injury. Fig. 4.11: TRACHEOSTOMY TUBE
 111. 110 Components of a tracheostomy tube A tracheostomy tube is a medical device that is inserted into the trachea (windpipe) through
a surgical opening in the neck called a tracheostomy. Here are the parts of a tracheostomy tube: 1. Outer cannula: This is the main part of
the tracheostomy tube that sits in the trachea. It is a curved tube with a flange at the base to secure it. 2. Inner cannula: This is a removable
tube that sits inside the outer cannula. It can be removed for cleaning or replaced if it becomes clogged. 3. Cuff: Some tracheostomy tubes
have an inflatable cuff that sits around the outer cannula. When inflated, the cuff creates a seal between the tracheostomy tube and the
tracheal wall to prevent air leaks or aspiration of secretions. 4. Pilot balloon: This small balloon is attached to the cuff and allows
healthcare providers to monitor the pressure inside the cuff. A metal tracheostomy is a more commonly used tube with an outer and inner
cannula in palliative care. The metal tracheostomy tube is made of a biocompatible metal, such as stainless steel or titanium, and is
designed to be left in place for an extended period. Compared to plastic tracheostomy tubes, metal tracheostomy tubes are more durable
and resistant to damage, which can be especially important for patients who require long-term breathing support. • Outer cannula: Outer
cannula is held in place by a ribbon or tie, which is passed through the loops on either side of the opening of the tube. • Inner cannula: Fits
inside the outer cannula. The inner tube is held in place by a small flip lock located on the top of the outer tube. Tracheostomy Care
Tracheostomy care involves maintaining the cleanliness and patency of the tracheostomy tube and surrounding area to prevent infection
and ensure proper breathing. 1. Routine care • Always wash hands thoroughly with soap and water or use hand sanitiser before performing
tracheostomy care. • Check the tracheostomy tube for proper placement, patency, and any signs of dislodgement or obstruction. Notify the
healthcare provider immediately if there are any concerns. • Clean the skin around the tracheostomy tube with a clean, damp cloth or
sterile saline solution. Protect the skin with a gauze pad, cut in the middle to be placed between the outer tube and the skin. Gently remove
any crusts or debris around the stoma. Cleaning inner tube - thorough cleaning of the inner tube should be done regularly. • Portex tube:
Remove the inner tube , clean it under running water, rinse it with normal saline, and replace it. If secretions are present, soak the inner
tube in the normal saline to soften the secretions and clean under running water using a cut piece of the suction catheter Fig. 4.12: METAL
TRACHEOSTOMY
 112. 111 or brush. Then clean the tube with normal saline or soap and wa, gently tap the tube, ensure that the lumen is clean and no
water is left inside the tube, and replace it. • Metal tube: Remove the inner tube, clean it under running water, soak it in a solution of
normal saline and replace it. If secretions are present, soak the inner tube in the normal saline to soften the secretions and clean under
running water using a cut piece of the suction catheter or brush. Then sterilise by putting it in boiling water for 5 minutes and ensure that
the lumen is clean and no water is left inside the tube, before replacing it. • The inner tube must be removed and washed under cold
running water. Soak it in a solution of normal saline to soften the secretions. Then clean it with soap and water and sterilise it by putting it
in boiling water for 5 minutes. Then re-insert it and lock it. • The outer tube should not be removed. Clean the tube plates thoroughly with
gauze soaked in saline. • Care should be taken not to allow the cleaning solution to enter the stoma while cleaning. It may be aspirated into
the lungs. • Train the patient to clean the tube by themself using a mirror. • Oral hygiene to be maintained • Prevent entry of insects into
tracheostomy tube. • Prevent the entry of water directly in to the stoma while bathing, swimming, and shaving 2. Suction As far as
possible help the patient to cough out the secretions, postural drainage is helpful to bring out the secretions. Steam inhalation will help to
loosen the secretions. Suction the tracheostomy tube as needed to remove secretions and maintain airway patency. 3. Humidification of air
Place wet sterile gauze (soaked in tap water) on the tracheostomy tube. This helps humidify the inhaled air and filters the dust. Use a
humidifier or nebuliser to moisten the air and prevent dryness in the tracheostomy tube and airway. 4. Skincare Clean the skin around the
 tracheostomy site with gauze soaked in saline. Protect the skin with a gauze pad, cut in the middle to be placed between the outer tube and
the skin. 5. Changing the tie Tie is used to fix the tube in position. Use sterile gauze o and secure it with a sterile tie or tape. Change the
tracheostomy dressing once in three days or whenever soiled. 6. Speech therapy and communication The Patient is advised to take a deep
breath, close the stoma with a finger, and speak. They may be provided with a calling bell or paper and pen for communication. Inform the
patient to report any discomfort or changes in breathing. Ensure the patient or caregiver is informed and educated on tracheostomy care
and potential complications. Common problems in tracheostomy patients Here are some common problems associated with tracheostomy:
• Infection: Tracheostomy can increase the risk of infection, particularly if the site is not properly cared for or if the patient has a
weakened immune system. • Blockage: The tracheostomy tube can become blocked with mucus, secretions, or other debris, which can
cause breathing difficulties.
 113. 112 • Dislodgment: The tracheostomy tube can become dislodged or accidentally removed, which can lead to airway obstruction and
difficulty breathing. • Bleeding: Bleeding can occur during or after the tracheostomy procedure, which can be life- threatening if not
promptly treated. • Air leak: An air leak can occur around the tracheostomy tube, which can cause difficulty breathing and increase the
risk of infection. • Granulation tissue: Granulation tissue can form around the tracheostomy site, which can cause irritation, bleeding, and
difficulty breathing. • Vocal cord paralysis: Vocal cord paralysis can occur if the nerves that control the vocal cords are damaged during
the tracheostomy procedure, which can cause hoarseness and difficulty speaking. • Choking of the Patient due to dropping of food or
water into the tracheostomy opening It's important to monitor patients with tracheostomy regularly for signs of these and other potential
problems and to promptly report any concerns to a healthcare provider. Regular tracheostomy care can also help prevent or manage these
complications. ASSISTING IN THORACOCENTESIS Thoracentesis is a medical procedure used to remove excess fluid from the pleural
cavity, which is the space between the lungs and the chest wall. This procedure can be used in palliative care to relieve symptoms caused
by pleural effusions, such as difficulty breathing and chest pain. However, the decision to perform thoracentesis in palliative care should
be made on a case-by-case basis, considering the patient's overall condition and goals of care. In some cases, the risks and discomfort
associated with the procedure may outweigh the potential benefits, especially if the patient has a limited life expectancy or if the fluid
buildup is not causing significant symptoms. If thoracentesis is deemed appropriate for a palliative care patient, it is important to ensure
that the procedure is performed with sensitivity to the patient's comfort and emotional needs. This may include providing pain
management, using a calming environment, and offering emotional support and reassurance throughout the procedure. Nurses play an
important role in thoracentesis procedures before, during, and after the procedure. Here are some of the key responsibilities of a nurse in
the context of thoracentesis: 1. Pre-procedure preparation: The nurse may be responsible for preparing the patient for the procedure by
explaining what to expect, providing reassurance and support, and ensuring that the patient is comfortable and well-informed. The nurse
may also help to obtain consent for the procedure and ensure that the patient has fasted appropriately if necessary. 2. Assisting during the
procedure: During the thoracentesis procedure, the nurse may assist the physician or other healthcare provider by helping to position the
patient correctly, monitoring vital signs, providing emotional support and distraction, and handing over any necessary equipment or
supplies. 3. Patient monitoring: After the procedure is complete, the nurse may be responsible for monitoring the patient for any adverse
effects, such as bleeding, pain, or difficulty breathing. The nurse may also be responsible for documenting the procedure and any relevant
information about the patient's condition. After the procedure, the patient will be monitored for any signs of complications, such as
bleeding, infection, or pneumothorax. The patient may also be advised to avoid strenuous activity and rest for a period.
 114. 113 4. Patient education: The nurse may also play a crucial role in educating the patient and their family about the procedure, the
expected outcomes, and potential risks or complications. This can help to ensure that the patient is well-informed and can make informed
decisions about their care. 5. Providing emotional support: Thoracentesis can be a stressful and anxiety-provoking experience for patients,
so nurses may also provide emotional support and reassurance throughout the procedure. This may include offering relaxation techniques,
providing a calming presence, and encouraging the patient to express their feelings and concerns. The nurse's role in thoracentesis is to
support the patient and ensure their comfort and safety throughout the procedure while providing education and emotional support to the
patient and their family. ASSISTING IN INDWELLING ASCITIC CATHETER PLACEMENT Ascites is a medical condition
characterized by the accumulation of excess fluid in the abdominal cavity. Various underlying medical conditions, including liver disease,
heart failure, kidney disease, and cancer, can cause it. Ascites is a common symptom in patients receiving palliative care. When ascites is
present, the abdomen may appear swollen or distended, and the patient may experience discomfort or pain. In addition to the physical
symptoms, ascites can also lead to complications such as infection, hernias, and difficulty breathing. In patients with advanced cancer or
other life-limiting illnesses, ascites can be a significant source of discomfort and distress. Treatment for ascites depends on the underlying
cause and may include medications, lifestyle changes, and procedures such as paracentesis (removal of excess fluid through a needle),
placement of an indwelling ascitic catheter (a medical device used to drain excess fluid from the abdomen), or surgery. In palliative care,
ascites management focuses on relieving symptoms and improving the patient's comfort. This may involve the use of medications to
reduce fluid retention, such as diuretics. In some cases, paracentesis (removal of excess fluid through a needle) may be necessary to
provide immediate relief of symptoms. If paracentesis is required frequently or for an extended period, an indwelling ascitic catheter may
be inserted to provide ongoing drainage of fluid. The indwelling catheter allows for regular drainage of the fluid and can be managed at
home by the patient or a caregiver. This can help to improve the patient's comfort and reduce the need for frequent hospital visits.
Palliative care teams also focus on providing emotional and spiritual support to patients and their families. This may include counselling,
social support, and other resources to help patients cope with advanced illness's physical and emotional challenges. Indwelling Ascitic
Catheter An indwelling ascitic catheter is a medical device used to drain excess fluid from the abdominal cavity in patients with ascites.
The indwelling ascitic catheter is inserted through a small incision in the abdominal wall and into the peritoneal cavity. The catheter is
typically made of silicone or polyurethane and is designed to remain in place for an extended period, allowing for fluid drainage. The
catheter is attached to a drainage bag or bottle, which collects the fluid. The drainage bag or bottle can be emptied and replaced as needed,
 either by the patient or a caregiver, or during regular medical visits. Role of nurse in assisting in indwelling ascitic catheter placement A
nurse's role in placing an indwelling ascitic catheter is critical in ensuring the procedure is performed safely and that the patient receives
appropriate care and support. Some specific roles and responsibilities of nurses during indwelling ascitic catheter placement may include:
 115. 114 • Assessment: The nurse assesses the patient's medical history, current condition, and suitability for an indwelling ascitic
catheter. This includes assessing for any contraindications to catheter placement and ensuring that the patient is informed about the
procedure. • Pre-procedure care: Nurses can help prepare the patient for the procedure by explaining the procedure, obtaining informed
consent, and ensuring that the patient is in a comfortable position. They can also help the healthcare provider prepare the equipment and
sterile supplies needed for the procedure. • Intra-procedure care: Nurses can assist the healthcare provider during the procedure by helping
to position the patient, providing emotional support to the patient, and monitoring the patient's vital signs. They can also help to maintain
the sterile field and assist with the insertion of the catheter. • Post-procedure care: Nurses can monitor the patient after the procedure for
any complications, such as bleeding or infection. They can also educate the patient on how to care for the catheter site, including how to
perform regular dressing changes and signs and symptoms to watch for that may indicate an infection or other complications. • Ongoing
care: Nurses can provide ongoing care to patients with indwelling ascitic catheters by monitoring the catheter site for any signs of
infection or complications and performing regular dressing changes. • Education: Nurses can provide education to patients and their
families on how to care for the indwelling ascitic catheter, including proper hygiene, dressing changes, how to properly dispose of
drainage bags, and how to contact their healthcare provider in case of any concerns or issues. The nurse may also provide information
about how to recognise signs of infection or other complications. • Documentation in ascitic tapping includes the following: o Patient
information: This includes the patient's name, age, medical history, and any relevant allergies or medications. o Procedure details: This
includes the date and time of the procedure, the site of the paracentesis, the size and type of needle used, the amount of fluid removed, and
the presence of any complications or adverse events during the procedure. o Vital signs: This includes the patient's pre-procedure vital
signs, such as blood pressure, heart rate, respiratory rate, and oxygen saturation. o Fluid analysis: This includes the results of any
laboratory tests performed on the fluid obtained during the paracentesis, such as cell count, protein and albumin levels, and culture and
sensitivity results. o Patient response: This includes the patient's response to the procedure, including any changes in vital signs or
symptoms and any adverse events or complications that may have occurred. o Plan of care: This includes the plan for ongoing
management of the patient's ascites, such as medication management or the need for further paracentesis or other procedures. Conclusion
Nurses play a crucial role in providing palliative care to patients. Some of the specific tasks that nurses may perform include: 1. Assessing
and managing symptoms: Nurses are responsible for assessing the patient's symptoms, including pain, signs of infection, nausea, and
anxiety, and providing appropriate interventions to manage these symptoms. 2. Providing emotional support: Nurses play a vital role in
providing emotional support to patients and their families. This may involve listening to concerns, providing reassurance, and offering
counseling services.
 116. 115 3. Coordinating care: Nurses are responsible for coordinating the patient's care, including communicating with other healthcare
professionals, arranging for home care services, and making referrals to other specialists as needed. 4. Educating patients and families:
Nurses may educate patients and their families about the disease process, treatment options etc LYMPHOEDEMA MANAGEMENT
Introduction Lymphoedema is an accumulation of lymph in the interstitial space of subcutaneous tissue or is an excessive and persistent
accumulation of extravascular and extracellular fluid and proteins in tissue spaces. It occurs when lymph volume exceeds the capacity of
the lymph transport system and is associated with the disturbance of the water and protein balance across the capillary membrane.
Pathophysiology Obstruction or damage blocks the lymphatic system with gradual dilatation of the lymph vessels leading to incompetent
valves and increasing pressure inside the vessels. The fluid tends to drain into the interstitial space by diffusion, resulting in lymph stasis.
Classification of Lymphedema 1. Primary lymphedema: This type of lymphedema is caused by a congenital defect in the lymphatic
system, leading to abnormal lymphatic drainage and fluid buildup. • Congenital lymphedema: This type of primary lymphedema is present
at birth or develops within the first two years of life. 2. Secondary Lymphedema: This type of lymphedema occurs as a result of damage to
the lymphatic system, usually as a result of cancer treatment (such as surgery, radiation, or chemotherapy) or infection. • Cancer-related
lymphedema: This is caused by cancer treatments that damage the lymphatic system, such as surgery or radiation therapy. • Non-cancer-
related lymphedema: This is caused by infections (such as filariasis) or other conditions that damage the lymphatic system, such as trauma
or surgery. Fig.4.13: LYMPHEDEMA
 117. 116 Signs and Symptoms of Lymphedema • Slow onset Swelling: Slow onset swelling is a common symptom in lymphedema,
which refers to the gradual development of swelling over time. Usually unilateral unless the disease/extensive trauma is present. • Non-
pitting oedema: Non-pitting edema is a type of swelling that occurs when pressure is applied to the affected area and does not leave an
indentation, as opposed to pitting edema, which leaves an indentation when pressure is applied. In people with lymphedema, non-pitting
edema is a common symptom that occurs due to the accumulation of lymphatic fluid in the affected limb or area. • Skin changes: dry,
thickened skin, deep creases. Peaud's orange appearance, • Stemmer's sign: inability to pinch a fold of skin at the base of the second digit.
• Hyperkeratosis: thickening of the outer layer of the skin, known as the epidermis. In people with lymphedema, hyperkeratosis can occur
as a result of chronic swelling, which can cause skin changes and thickening over time. • Papillomatous lesion: abnormal growths or warts
that can occur on the skin's surface in people with lymphedema. These growths can develop in areas of the skin that are affected by
lymphedema due to chronic inflammation, poor lymphatic flow, and impaired immune function. • Lymphorrhoea: lymphatic fluid leaks
from the skin's surface due to damage or obstruction of the lymphatic vessels. The lymphatic fluid is a clear fluid that circulates
throughout the lymphatic system and plays a crucial role in immune system function. • Joint stiffness and muscle strain • Discomfort,
heaviness, and pain Some of the problems that people with lymphedema may face include: • Swelling: The most common symptom of
lymphedema is swelling in the affected limb or area, which can cause discomfort, heaviness, and limited mobility. • Infection: The
accumulation of lymphatic fluid in the affected area can create a breeding ground for bacteria, leading to infections such as cellulitis or
 lymphangitis. • Skin changes: Lymphedema can cause changes to the skin in the affected area, such as thickening, hardening, or
discolouration, which can make it more susceptible to infections, ulcers, or wounds. • Reduced flexibility: Swelling and stiffness in the
affected limb or area can reduce flexibility and range of motion, making it difficult to perform daily activities or exercise. • Pain:
Lymphedema can cause pain and discomfort in the affected limb or area, affecting the quality of life and leading to depression or anxiety.
• Emotional impact: Living with lymphedema can be challenging, and it can affect a person's emotional well-being, self-esteem, and body
image. • Financial burden: Lymphedema treatment, such as compression garments, bandaging, or manual lymphatic drainage, can be
expensive and may not be covered by insurance, which can create a financial burden for people with lymphedema. . Psychological issues •
Altered body image • Anxiety and depression • Reduced adjustment to illness • Difficulty in wearing clothes • Reduced working capacity •
Reduced social contact
 118. 117 • In cancer, fear of recurrence Aim of lymphoedema care • To maintain a healthy tissue condition • To reduce the risk of
infection, Daily care • Meticulous hygiene • Inspection of the limb and adjacent trunk • Moistening of limb and adjacent trunk Four
cornerstones of management 1. Skincare 2. Compression (bandage/hosiery) 3. Massage 4. Exercises 1. Skincare: Proper skin care is
essential in managing lymphedema. People with lymphedema are at higher risk of skin infections, so keeping the skin clean and
moisturised can prevent bacterial infections and reduce the risk of skin breakdown. Health Teaching for Skin Care • Wash the affected
arm with water. • Keep the skin clean and moist. • Do not use too much soap, which will dry the skin. Use only mild soap. • Give special
attention to creases between digits and joints. • Avoid perfumes. • Pat dry with a soft, clean towel. • Do not rub the affected limb. • Apply
coconut oil from the distal to the proximal end of the limb. • Use loose clothing. • Avoid o Injections in the swollen arm, including blood
sampling o Blood pressure measurement on the swollen arm. o Vene punctures o Jewellery on the affected limb o Injury to the limb o
Lifting heavy weight o Mosquito bites • Take care when cutting toe nails or fingernails using a nail cutter. • Treat cuts, scratches insect
bites promptly by cleaning well and applying antiseptic cream or solution. • Seek medical aid if the skin becomes red and inflamed. •
Protect from direct heat/sunlight. • If lymphorrhoea or any injury, clean with saline and apply a sterile dressing. • If cellulitis – do not start
lymphedema care, treat cellulitis. 2. Compression. Compression therapy involves applying pressure to the affected area to reduce swelling
and improve lymphatic flow. This can be achieved through various techniques, such as wearing compression garments, bandaging, or
pneumatic compression devices. Compression therapy helps to maintain the reduced size of the limb after it has been reduced by manual
lymph drainage.
 119. 118 • Compression can be given with proper bandaging and unique hosiery. • Before applying compression, measurements of both
limbs should be recorded and repeated every six months. Benefits of Compression • Improved lymph drainage. • Improve movement and
function of the limb. • Improve distorted limb shape. • Improve thickened fibrotic skin. Bandaging: Bandaging in lymphedema involves
wrapping the affected limb or area with specialised bandages designed to provide compression. The bandages are applied in a specific
sequence, starting at the base of the limb and working upward, to encourage lymphatic fluid to flow towards the trunk. The bandages are
designed to provide more compression at the base of the limb and gradually decrease in compression as they move upward. The duration
and frequency of bandaging will depend on the severity of the lymphedema and the individual's specific needs. In general, bandages may
be worn for several days or weeks at a time and should be changed and re-applied by a trained healthcare professional. Bandaging also
helps limit fluid accumulation in the subcutaneous tissue and provides the muscles with a firm outer casting by stimulating lymph flow.
Principles of bandaging • Apply graduated pressure. • Reshape limb in a cylindrical manner with cotton and gamgee pad and crepe
bandage. • Apply for 24 hrs (most preferred) • Low resting pressure increases during exercises. Procedure • Wash and dry the limb
carefully. • Manual lymphatic drainage has to be done before bandaging. • Moisturise with coconut or moistening cream before
bandaging. • Artiflex cotton padding is done to bring the limb into a cylindrical shape. • Short stretched small, width bandages are applied
from the distal to the pommel end of the limb. Post bandage assessment After a bandaging session for lymphedema, it is essential to
perform a post-bandaging assessment to evaluate the effectiveness of the treatment and identify any potential issues that may need to be
addressed. The post-bandaging assessment typically involves the following steps: 1. Measure the limb: Measure the circumference of the
affected limb at specific points, such as the ankle, knee, or wrist, to evaluate the degree of swelling reduction achieved by the bandaging.
2. Inspect the skin: Inspect the skin for any signs of irritation, redness, or skin breakdown. Any areas of concern should be documented
and monitored closely. Fig.4.14. LYMPHEDEMA BANDAGING
 120. 119 3. Check for proper fit: Ensure that the bandages are properly applied and do not cause discomfort or constriction. The patient
should be asked if they are experiencing any pain or discomfort, and the bandages may need to be adjusted if necessary. 4. Evaluate range
of motion: Evaluate the patient's range of motion and functional abilities to assess the impact of the bandaging on their mobility. 5. Plan
for ongoing care: Based on the results of the post-bandaging assessment, the healthcare provider can develop a plan for ongoing
lymphedema management, which may include additional bandaging sessions, compression garment therapy, manual lymphatic drainage,
or exercise. 6. Report to doctors and remove the bandage immediately if any of the following is noted. • Pain (pins and needles) •
Numbness • Discoloration of toes and fingers Hosiery Hosiery, also known as compression stockings or compression garments, is a
common treatment option for lymphedema. Hosiery is designed to provide graduated compression to the affected limb, which helps to
reduce swelling and improve lymphatic flow. Hosiery is easy to use and can be worn during daily activities. Indication for hosiery
application • The limb shape is not distorted. • Mild oedema • No deep creases • Skin is tough enough to cope with hosiery. • No
lymphorrhoea NB: Hosiery is removed at bedtime. 3. Massage: Lymphatic massage is the procedure used to encourage lymphatic fluid
away from swollen, congested body areas to areas where it can drain away normally. Lymphedema massage, also known as manual
lymphatic drainage (MLD), is a type of massage therapy that is used to help reduce swelling and improve lymphatic flow in individuals
with lymphedema. It is a gentle, hands-on technique that uses specific movements to stimulate the lymphatic system and encourage the
movement of lymphatic fluid out of the affected area. Aim of Massaging • To stimulate contractions of superficial lymphatics • To
facilitate lymph flow from congested to non-congested areas Contraindications for Massaging • Acute cellulitis /erythema • Renal failure •
 Deep Vein Thrombosis • Unstable hypertension • Severe cardiac insufficiency • Hepatic cirrhosis with ascites • Superior vena cava
obstruction Fig. 4.15: HOSIERY
 121. 120 • Untreated tuberculosis or malaria • When a patient is on active treatment (e.g.: chemotherapy or radiotherapy) Techniques •
Keep the patient in a relaxed and comfortable position(lying/sitting) • While massaging, always clear non-swollen side first to clear the
way ahead. • Use dry hands while performing massage. Cream or powder should not be applied. • The patient should ideally wear
compression garment during massage. • For head and neck swelling work with nodes at back and front of neck, under chin, occipital
nodes, cheeks and lips. 4. Exercise: Exercise can be a helpful component of a comprehensive lymphedema management plan, as it can
help improve lymphatic flow and reduce swelling. However, it is important to approach exercise cautiously and work with a healthcare
professional or therapist familiar with lymphedema management to ensure that exercise is safe and appropriate for your individual needs.
Exercise reduces soft tissue oedema and improves joint mobility, enhancing the lymphatic pump's efficiency. Wearing a compression
bandage during exercise enhances lymph flow and protein re- absorption more efficiently. Aim of exercise • To encourage regular activity
e.g., walking • To prevent stiffness. Assessment before exercise • Posture • Joint range • Muscle power • Function • Ease of movement. •
Changes in sensation. Exercise for Swollen Arm • Patient should be sitting comfortably and arm stretched out at a level with shoulder
supported along its length on a pillow. • The best way to exercise is while wearing a compression garment or bandage. • Stretch fingers
out. Hold for 5 seconds then relax (20 repetitions). • Make a strong fist. Hold for 5 seconds then relax (20 repetitions). • Point fingers
down towards the floor bending at the wrist. Hold for 5 seconds then relax (20 repetitions). • Bend hand up pointing fingers towards the
ceiling. • Hold for 5 seconds then relax (20 repetitions). • Slow circular clockwise and anti- clock-wise movements at wrist joint (20
repetitions each).Stretch fingers out. Raise arm bending at elbow. When arm is fully bent, make a tight fist and twist hand so that palm
faces body (supination). Hold for 5 seconds then relax (20 repetitions). Exercise for Swollen Legs • These exercises are best done lying on
the floor with the legs raised on pillows or cushions. • Slowly and firmly rotate the feat, making a circular movement with pointed toes. •
Slowly and firmly point your foot towards the floor, then bring it back as far as it will go.
 122. 121 • Slowly and firmly, bring your knees up to the chest. • Slowly straighten your legs and lower down to the pillows. • Bring knees
up to chest slowly and firmly to do bicycling movements. Health Education • Limb elevation is achieved by using 2-3 pillows while lying
on the bed. • Make sure the limb is straight and above the heart level. • Do not dangle the legs if swollen • Avoid crossed legs. • Exercise
is to be performed every day, morning and evening. • Active and passive range of movement exercises. • A slow and rhythmical rest
period must be followed. • All joints in the affected quadrants will be moved through the pain-free range. • Exercises are done within the
ability of the patient. BLADDER CARE Bladder care is an important aspect of palliative care, particularly for patients experiencing
symptoms related to urinary dysfunction or who can no longer control their bladder function. Effective bladder care requires a
comprehensive approach that addresses the patient's individual needs and goals of care. Here are some key considerations for bladder care
in palliative care: • Assessment: A thorough assessment of the patient's bladder function is essential to develop an appropriate care plan.
This may involve evaluating the patient's urine output, assessing for urinary tract infections, and identifying any urinary symptoms such as
urgency, frequency, or incontinence. • Hydration: Adequate hydration is important for bladder health and can help prevent urinary tract
infections. Patients should be encouraged to drink fluids throughout the day, and healthcare providers may recommend interventions such
as IV hydration or subcutaneous hydration if necessary. • Incontinence management: For patients experiencing incontinence, a range of
interventions may be used to manage symptoms, including absorbent pads, catheterisation, or medications to reduce bladder spasms. •
Catheterisation: Indwelling or intermittent catheterisation may be used to manage urinary retention or incontinence in palliative care
patients. Patients and families should be educated about catheter care to prevent infections and other complications. • Comfort measures:
For patients who are nearing the end of life, comfort measures may be the primary focus of bladder care. This may involve using
absorbent pads or other interventions to manage incontinence and prevent skin breakdown. • Family support: Family members and
caregivers may be involved in providing bladder care to palliative care patients. They should be educated about the patient's care plan and
provided with the necessary resources and support to manage bladder symptoms effectively.
 123. 122 Care of urinary catheter There are several types of urinary catheters used in clinical practice, including: 1. Indwelling catheters:
These are also known as Foley catheters and are the most commonly used type of urinary catheter. They are made of soft, flexible silicone
or latex and are inserted through the urethra into the bladder. A small balloon at the end of the catheter is inflated with sterile water to hold
the catheter in place. Indwelling catheters are used for longer-term catheterisation and can remain in place for several weeks. 2.
Intermittent catheters: These are also known as in-and-out catheters and are used to empty the bladder intermittently. They are made of
silicone or polyurethane and are inserted into the bladder through the urethra. Once the bladder is emptied, the catheter is removed.
Intermittent catheters are typically used for short-term catheterisation, such as in patients with urinary retention. 3. Suprapubic catheters:
These are inserted through a small incision in the lower abdomen and into the bladder. They are used when an indwelling catheter cannot
be inserted through the urethra, such as in patients with urethral trauma or obstruction. Suprapubic catheters are typically used for longer-
term catheterisation. 4. Condom catheters: These are also known as external catheters and are used in male patients. They consist of a
condom-like device that is placed over the penis and attached to a drainage bag. Condom catheters are used for short-term catheterisation,
such as in patients with urinary incontinence. The choice of urinary catheter depends on the patient's individual needs and the duration of
catheterisation. Indwelling catheters are generally preferred for long-term catheterisation, while intermittent catheters may be preferred for
short-term catheterisation or in patients who require frequent bladder emptying. Suprapubic catheters are used when an indwelling catheter
cannot be inserted through the urethra, and condom catheters may be used in male patients with urinary incontinence. Care of patient with
Urinary Catheter The nurse plays a crucial role in caring for catheterised patients to ensure their comfort, safety, and overall well-being.
Here are some key roles that nurses play in caring for catheterised patients: 1. Catheter insertion and removal: The nurse may be
responsible for inserting or removing the urinary catheter, which requires proper sterile technique to reduce the risk of infection. 2.
Monitoring catheter function: The nurse should monitor the catheter's function to ensure proper drainage and prevent any obstructions,
 kinking, or dislodgement that may cause discomfort or complications. 3. Managing catheter drainage: The nurse should monitor the
catheter bag's output, color, and consistency to identify any changes that may indicate an underlying condition. They should also ensure
the catheter bag is emptied regularly and kept below the level of the bladder to prevent reflux. 4. Preventing infection: The nurse should
follow proper infection control practices when caring for the catheter to prevent urinary tract infections or other complications. They may
also administer prophylactic antibiotics or antiseptic solutions as ordered. 5. Providing comfort and support: The nurse should ensure the
patient is comfortable and provide support and education regarding catheter care, including proper hygiene, pain management, and
minimising the risk of complications. They should also perform regular assessments to evaluate the patient's urinary system's health and
function.
 124. 123 6. Assessing for complications: The nurse should assess for any signs of complications, such as fever, chills, pain, or bleeding,
and report any changes to the healthcare provider promptly. 7. Skin care: The nurse should perform regular skin assessments to prevent
skin breakdown, especially in patients with long-term catheterisation. They should provide appropriate skin care to prevent infection and
irritation. 8. Nutrition and hydration: The nurse should monitor the patient's nutritional and hydration status to prevent dehydration or
malnutrition, which may affect the urinary system's function. 9. Bladder training: The nurse should assess the patient's ability to void, and
if possible, initiate bladder training to help the patient regain bladder control and improve their quality of life. 10. Education and support:
The nurse should provide the patient and their family with education and support regarding catheter care, proper hygiene, pain
management, and minimising the risk of complications. The nurse should also help the patient cope with the emotional and psychological
effects of long-term catheterisation. Health Education Preventing Infection • Clean hands before and after touching the catheter or bag. •
Always keep the drainage bag below the bladder level and off the floor. • Keep the catheter secured to the thigh to prevent it from moving.
• Shower daily to keep the catheter clean. • The spout of the drainage bag should never touch the side of the toilet or any emptying
container. Regular Care • Instruct the patient and the family caregiver not to raise the drainage tube or urine bag above the hip level. This
is to prevent the backflow of urine into the bladder. • The patient should consume plenty of oral fluids (2 to 3L per day) unless
contraindicated. This reduces the risk of urinary tract infection. • The bag should be emptied when it is more than half full. This ensures
the continuous flow of urine from the bladder. • Instruct the caregivers to empty the bag before the patient goes to sleep and also in the
morning at waking hours. This is to prevent the overfilling of the bag. • Ensure that the tube is not kinked. A kinked tube obstructs the
flow of urine. • Instruct the carers to anchor the urine collection bag to the side of the cot and not at the leg end. This is to avoid traction
on the tube. • Instruct the patient and the family caregivers to inform the homecare team if the patient has fever, chills and lower
abdominal pain. This could be a sign of a urinary tract infection. Don'ts • Do not lie on or block the flow of urine in the tubing. • Don't
reuse catheters. • Don't forget to burst a water packet when using hydrophilic catheters.
 125. 124 • Do not let the tube fold or bend. Don't forget to bring catheter supplies with the patient while travelling • Instruct the patient
and the family caregivers to in- form the homecare team if they notice urinary sediments, peri-catheter pus discharge and cloudy urine.
This could be a sign of a urinary tract infection. Nurse's role in caring for catheterised patients is critical to ensure their safety, comfort,
and overall well- being. Effective communication with the patient, their family, and the healthcare team is essential to provide
coordinated, compassionate care. Conclusion Nurses play an important role in assisting procedures in palliative care. Palliative care
focuses on improving the quality of life for patients with serious illnesses by managing symptoms and providing emotional and spiritual
support. Their responsibilities include managing pain and other symptoms, providing wound care, providing end-of-life care, and assisting
with various procedures as needed. The goal of their role is to provide comfort and support to patients with serious illnesses, as well as
their families and loved ones.
 126. 125 Activity for Unit 4 I. Multiple-Choice Questions 1. What is the best immediate action by the nurse if the patient with colostomy
is bleeding from the stoma site while removing the dressing? a. Give local compression for 10-15 minutes. b. Remove the complete
dressing. c. Irrigate the wound with saline. d. Inform the doctor 2. The following action cannot prevent maggots in the wound. a. Use
mosquito nets. b. Maintain personal and environmental hygiene. c. Dry dressing d. Cover the wound always. 3. Bad odour in fungating
wounds can be controlled by a. Local betadine application b. Activated charcoal dressing. c. Systemic antibiotics only d. Local Hydrogen
peroxide dressing 4. What type of stool would you expect in the ascending colostomy stoma? a. Liquid stool b. Lose to partly formed stool
c. Similar to normal stool d. Semi-solid stool 6. The cornerstone of lymphoedema management includes all except a. Massaging b.
Bandaging c. Exercise d. Adequate nutrition 7. Lymphedema is: a. A type of cancer in the lymph nodes. b. A type of blood clot in the arm
or leg. c. A build-up of fluids in the tissue d. A deficiency of nutrients in the tissues. 8. An unconscious client needs frequent mouth care.
When performing mouth care, the best position of a client is: a. Fowler’s position b. Side-lying c. Supine d. Trendelenburg II. True or
False 1. Putting pressure on the stomal bleeding site is contraindicated. 2. The malignant wound does not have a foul odor.
 127. 126 3. An ileostomy is a surgical opening created to bring the large intestine to the surface of the abdomen. 4. Tracheostomy patients
can clean the inner tube by using a mirror. 5. The inner cannula of the tracheotomy tube should be replaced within 30 minutes to prevent
blockage of the outer tube by secretions. III. Short notes 1. What dietary advice will you give to a patient with a colostomy? 2. What are
the complications of colostomy? 3. What is the other name for the malignant wound? 4. Explain the care of the patient with a
tracheostomy? 5. Explain home teaching for a patient with NG tube IV. Group activity Objectives: To reinforce the key points while
caring for patients with specific conditions. Activity instruction: Students will be divided into groups and given a case scenario. They will
be instructed to give health education using appropriate AV Aids. a) Case 1:Mr Kumar, a 49-year-old man had a spinal cord injury in a
road traffic accident. His wife is 40 years homemaker with two daughters, 16 and 10. He is on tracheostomy and nasogastric tube feeding
and has no bowel and bladder control. He is at his home now. Discussion Points: As a palliative care nurse, provide health education on
home care management for Mr Kumar b) Case II:Mr Joseph, a 65-year-old male has Fungating wound on his cheek (Ca Buccal mucosa),
on nasogastric tube feeding. He is complaining of pain and a crawling sensation at the wound. Discussion Points: As a palliative care
 nurse, explain the nursing management of this patient. OSCE 1. Demonstrate catheterisation of a female patient. 2. Demonstrate wound
dressing. 3. Demonstrate tracheostomy care.
 128. 127 Unit 5 OPTIMIZATION OF CARE Introduction Optimization of care refers to improving the quality of healthcare services
and increasing efficiency. Optimization of care in end-of-life care involves ensuring that patients receive the bestpossible care to meet
their physical, emotional, social and spiritual needs. This may involve a rangeof interventions, including pain and symptom management,
emotional support, and spiritual care. Key aspects of optimization of care • Communication between patients, families, and healthcare
professionals: This may involve discussions about end-of-life care planning, including decisions about life- sustaining treatments, advance
directives, and goals of care. By facilitating open and honest communication, healthcare professionals can ensure patients receive care
consistent with their wishes and values. • Use of evidence-based interventions to manage symptoms and improve quality of life: This may
involve using medications, such as opioids or other pain relievers, as well as non-pharmacological interventions, such as massage or other
forms of complementary therapy. By using evidence-based interventions, healthcare professionals can ensure patientsreceive safe,
effective, and appropriate care. • Addressing the emotional and spiritual needs of patients and their families: This may involve counseling,
support groups, or other forms of therapy to help patients and families cope with the challenges of a terminal illness. Chaplains or other
spiritual leaders may also be available to provide spiritual support or guidance. Optimization of care also involves providing care that is
culturally sensitive and respectful. This may involve understanding and respecting patients' and families' cultural beliefs and practices and
incorporating these beliefs into the care plan. • Patients receive coordinated and integrated care across different settings, such as hospitals,
hospices, and home care: By working together as a team, healthcare professionals can ensure that patients receive seamless, high-quality
care that meets their needs and preferences. It is crucial to evaluate, acknowledge and optimize the total needs ofpatients with a terminal
illness and their families with early, honest and empathetic communication. For caring to happen, we must understand the patients' and
their families' needs and priorities. Making individualized shared decisions aiming at "Quality of Life" would be considered an appropriate
line of management. As nurses, we should facilitate to take shared decisions based on discussions with the patientand family. The
decisions to be taken are regarding goals of care, emphasizing what is "quality oflife" for them and not what we decide based on organ
function. The five priorities focus on: recognizing that someone is dying; communicating sensitively with them and their family;involving
them in decisions; supporting them and their family; and creating an individual plan of care that includes adequate nutrition and hydration.
Essential components of optimization of care 1. Quality of life 2. Essential care 3. Anticipatory prescription 4. Dying with dignity 5. Care
during the terminal phase 6. Ethics-based decision making
 129. 128 1. Quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perceptionof their
position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and
concerns. Quality of life is the degree to whichan individual is healthy, comfortable, and able to participate in or enjoy life events. Quality
of lifeis a broader concept concerned with whether disease or impairment limits a person's ability to fulfila normal role (for example,
whether the inability to climb stairs limits a person at work). The feeling of being at peace and having a sense of meaning in life is more
important to patients than being active or physical comfort, and spiritual well being. Quality of life is a dynamic concept that may change
throughout illness and treatment. The definition of quality of life is subjective as individuals have very personal descriptions of their
concept of quality of life. People also differ in the importance they place on various aspects of illness, which causes a differential impact
on the experience of life. Different responses about perceived QOL may be observed even in people with the same clinical condition.
Therefore, ensuring the quality of life represents a challenge because cultural, ethnic, religious and other personal values determine how
the quality of life is judged. 2. Essential care Essential care in end-of-life care focuses on providing comfort and support to patients as they
approach the end of their lives. The goal is to ensure that patients can live their remaining days with dignity and respect and minimize
their physical and emotional suffering. Essential care in end-of-life care involves a multidisciplinary team of healthcare professionals,
including doctors, nurses, social workers, chaplains, and other specialists. The team works together to provide a rangeof services that
address the patient's and their family's physical, emotional, and spiritual needs. Fig.5.1: NURSE FACILITATING FAMILY MEMBERS
TO CARE Physical care is an important aspect of end-of-life care and may involve pain management, symptom control, and other
interventions to ensure that the patient is comfortable. Patients may be taking several medications. Essential medications such as anti-
hypertensive, hypoglycemic agents, anticoagulants, etc. must be reviewed. Considering the patient's poor food intake, cachexia,and
hemodynamic status, except for the essential medications, the rest must be discontinued. Thismay include using medications, such as
opioids or other pain relievers, and non-pharmacological interventions, such as massage or other forms of complementary therapy.
 130. 129 Emotional support is also a crucial component of end-of-life care. It may involve counselling, support groups, or other forms of
therapy to help patients and their families cope with the challenges of a terminal illness. Chaplains or other spiritual leaders may also be
available to provide spiritual support or guidance. Social support is also an important aspect of end-of-life care. It may involve connecting
patients and their families with community resources, such as hospice services, home care services, or other programs that can provide
practical support and assistance. In summary, essential care in end-of-life care involves a holistic approach that addresses the physical,
emotional, and spiritual needs of patients and their families. By providing compassionate and comprehensive care, healthcare
professionals can help patients live their remaining days with comfort, dignity, and respect. 3. Anticipatory prescription Anticipatory
prescribing is a practice in end-of-life care where medications are prescribed in advance to manage symptoms that may arise as a patient's
condition deteriorates. Anticipatory prescribing aims to ensure that patients receive prompt and effective treatment for symptoms without
unnecessary delays or discomfort. Anticipatory prescribing enables prompt symptom relief at whatever time the patient develops
distressing symptoms. Anticipatory prescribing means ensuring that someone has access to medicines they will need if they develop
uncomfortable symptoms at home or in a care home. The medications are prescribed in advance so that the person can access them as soon
as needed. Although each patient has individual needs, many acute events during the palliative period can be predicted, and management
measures put in place. Before discharge from the unit, patient's families must be empowered to manage issues like dyspnea, panic attacks,
 delirium, pain, extra. A clear discharge summary and medications need to be provided for each symptom. If the familyneeds any
assistance linking with local general practitioners to support the family will be helpful. 4. Dying with dignity Dignified dying: Dignified
dying refers to the process of dying with respect, compassion, and comfort, while maintaining the patient's autonomy and dignity. The
goal of dignified dying is to ensure that patients are able to die on their own terms, with their physical, emotional, and spiritual needs
addressed in a compassionate and respectful manner. It is a natural death free from avoidable distress and suffering for patients, families
and caregivers, following the wishes of patients and families and consistent with clinical, cultural and ethical standards Key aspects of
dignity in end-of-life care are:  Respect, which includes self-respect, mutual respect, and respect for privacy.  Autonomy involves
having and providing choices, as well as competence and independence.  Empowerment can involve self-esteem, pride, and modesty. 5.
Care during the terminal phase The terminal phase is when day-to-day deterioration occurs, particularly of strength, appetite, and
awareness. At this phase, nurses must ensure the patient's comfort physically, emotionally, and spiritually and make the end of life
peaceful and dignified. We can also make the memory of the dying process as positive as possible for those left behind by our care and
support. End of Life Care (EOLC) is the way of caring for a terminally ill patient that shifts attention to symptom control, comfort,
dignity, quality of life and quality of dying instead of trying to cure or increase the life. Recognizing the terminal phase Remember, these
signs and symptoms are very common, but wide variations can occur, so it is
 131. 130 impossible to predict accurately. • Increasing weakness, the patient becomes bedbound • Loss of interest in surroundings and
food • Difficulty in swallowing • Drowsiness • Cool hands and feet • Change in breathing (jerky, noisy, very slow, gasping) Goals of care
• Explaining and communicating with caregivers so that they are mentally prepared. o Find out how much they understand. o A person
important to them should be present during the discussion. o Find out if they wish to know more about the prognosis and discuss it
accordingly. o Address their fears and concerns. o Provide contact information (ambulance, your contact, nearest doctor, hospital, etc.) o
Find out if they have any religious, cultural, social or spiritual needs. o Explain the uncertainty about the exact time of death. o Document
the discussion along with the names of the persons discussed. o Discuss the case with the doctor concerned and document it o Make the
patient as comfortable as possible. o Give 'individualized care'. o Assess the level of consciousness. o Find out the patient's wishes. o
Record and document preferred place of care (home, hospital, etc.) o Find out the wishes of the caregivers. o Remember! the wishes and
plans may change. Giving Fluid If swallowing is difficult, feeding with a spoon is helpful. Ensure that the first sip is swallowed before the
next sip. • Discuss the risk of aspiration. • Encourage caregivers to give lip and mouth care. • What the patient can be given depends on the
level of consciousness, ability to swallow, and level of thirst. • Adverse effects of Intravenous fluids o Difficult at home o Expensive o
Needs supervision o Infection can occur o Fluid can collect in the lungs. Review • All medicines taken by the patient need to be reviewed
with the doctor and find out if any 'non-important' medicines can be stopped. • The doctor will decide on the best route for the medicines. •
Intramuscular and intravenous routes are avoided. • Subcutaneous injections can be used. • Regular review is needed.
 132. 131 Good symptom control • Provide 'non-drug' methods of symptom control. • Control of pain: continue pain medicines after
discussion with the doctor. • The patient is likely to pass urine and stool in bed. The caregivers should be taught how to clean the patient. •
After discussion with the caregivers and doctor, catheterization may be needed. • If the patient cannot swallow, a feeding tube can be
inserted after discussion with the doctor and with the consent of the patient and/or caregivers. The caregivers should then be taught how to
administer nasogastric feeds. Breathlessness ▪ Consider non-pharmacological methods - Switching on the fan - Staying with the patient
and boosting morale - Gently stroking the back ▪ Do not start oxygen therapy routinely without discussing it with the doctor ▪ Consider
drug therapy (Morphine, alprazolam) after discussing with the doctor and document Anxiety, restlessness, and confusion  Look for
causes like pain.  Ask the doctor for medication.  Noisy secretions (death rattle) are due to collected secretions at the back of the throat
when the patient is too weak to swallow them. They do not cause discomfort to the patient, but relatives may be worried that he is choking
or in pain.  Explain to caregivers that it does not cause distress to the patient.  Try non-drug measures.  Place the patient in the
recovery position.  Remove the secretion from the angle of the mouth using a finger wrapped in a gauze piece by 'hooking' the finger and
'swiping'.  Ask the doctor for medication. - Seizure • Prevent the patient from self-harm. Do not force any object, like a spoon, into the
mouth • If possible, give intravenous, subcutaneous, or intramuscular Midazolam or any other drug suggested by the doctor. • Continue
anti-epileptics as prescribed. Severe bleeding • Plan for this possibility and discuss it with the family in advance. • Apply firm and steady
pressure wherever possible using dark towels or bed sheets. • Sedate the patient quickly with intravenous, subcutaneous or intramuscular
midazolam or any other drug suggested by the doctor. Supporting the Family • The family will be suffering physically, emotionally,
socially and spiritually. Hence address these issues and support accordingly. • Address religious, social and spiritual needs. • Arrange extra
help, including help from a doctor.
 133. 132 Dying Phase The key to "getting it right" is anticipating that this stage has been reached. Carers who regularly look after the
patient and spend the most time with the patient intuitively pick up subtle signs of deterioration. They are often entirely accurate at
predicting the approaching death than professionals. Symptoms Signs Profound weakness/bedbound Gaunt appearance Needs assistance
for basic needs Drowsiness Diminished intake of food and fluids Loss of skin turgor Disoriented in time, place and person Dry mouth and
conjunctiva Difficulty in concentrating and cooperating Cold extremities Table 5.1: SYMPTOMS AND SIGNS OF THE DYING PHASE
Care of Dying Caring for the dying is not only based on scientific principles but it is an art. Unfortunately, the concept is not dealt with
due to its importance during the training of nurses. As a result, most traditionally trained nurses cannot provide the necessary care when
confronted with dying patients. With adequate training and simple measures, good quality care can be given to these patients and their
family members. Providing comprehensive and holistic care will give a sense of satisfaction for the caring team. The changes that occur
before death The dying process is unique to each person, but in most cases, there are common characteristics or changes which indicate if
a person is dying. Anyone of these signs can be attributed to something other than dying, so remember that the events described here are
happening to a personwhose illness is already so severe that life is threatened. The main changes are: Decreased intake: • As a person
approaches the End of Life (EOL) phase, the body's nutritional requirement decreases drastically. So, the person may have decreased
 appetite and decreased thirst. • It is essential to remember that this is a natural process and not distressing to the patient. But it may be
uncomfortable for the family caregivers to see the patient not eating or drinking fluids. • Reassuring and encouraging them to provide sips
of water and applying moist swabs on their lips can promote the patient's comfort. On the other hand, forcing feeds may increase the The
last 48 hours is crucial in caring for the person, family and caring team. There is only one chance to “get it right”, and when things do not
go well, families and staff can be left with long-term guilt and regrets.
 134. 133 patient's distress with little to no benefit. Increasing weakness: • As the person moves closer to death, weakness becomes more
and more profound. • As the weakness increases, general activity decreases. • Towards the late terminal stage, they may find it challenging
to continue conversations and even tolerate personal care. • The goal at this juncture is to avoid routine care that makes the person
uncomfortable and provide care aimed at improving comfort. Increasing drowsiness: • As patients drift into the End-of-Life phase, they
become increasingly tired, drowsy, and difficult to arouse—the time they spend sleeping increases gradually. • There may be decreased
speech, and they may appear withdrawn. • In some patients, there may also be confusion, inability to recognize people and restlessness. •
Terminal delirium and restlessness can be effectively managed by Haloperidol or Benzodiazepines based on the cause. • Family caregivers
should be advised to talk to the patient when the patient is fully alert and talk calmly and gently. Changes in respiration: • As a person
approaches the terminal phase, respiration becomes shallow. • Some patients' respiratory rate may increase, but respiration usually
becomes shallow and spaced out. • Jaw breathing can be seen in some patients. • Carers should be reassured that this is a typical dying
process that is not distressing to the patient. • Another distressing symptom for the family carers to watch is the 'death rattle'. It occurs due
to salivary secretion and mucus accumulation at the throat as swallowing and coughing reflexes disappear during the end-of-life phase. •
The gurgling sound produced by the oscillating Fluid with each respiration can be distressing to the carers but not the patient. • It can be
managed effectively by turning the patient to the sides and draining the secretions. Anticholinergic like Glycopyrrolate given sublingually
or subcutaneously can reduce these secretions. • The collected secretions should be drained first as these drugs only prevent further
accumulation. Temperature: • During theterminalstage,the bodytemperature drops. This may be due to reasons like decreased metabolism
and slowing down circulation. • The feet and hands may appear pale, cold and clammy. • An extra blanket may be required if the person
indicates that they are feeling cold. • At this point, the room should be well-ventilated and less crowded. Changes in excretion: • Urinary
and faecal incontinence is observed in only a fewpatients during end-of-life phase. • The urinary output decreases drastically; the urine
may appear dark and brown. • There may be oedema due to fluid retention. • It is vital to keep patients' comfort as apriority at this point. •
Maintaining good perineal hygiene and preventing pressure sores are crucial to maintaining comfort.
 135. 134 Nursing Management Allow the family to voice their concerns. Clarify expectations and prognosis. Ask the family if they wish
to take the patient home or continue terminal care in thehospital. • Check if appropriate medicines have been ordered for troublesome
symptoms, e.g. pain and breathlessness, according to palliative policies and relevant to the care setting (home/ hospital.) • Check if
inappropriate interventions need to be tapered or discontinued. • Encourage the family to support the primary caregiver and allow them
respite. • Check that nursing care for the patient with attention to oral hygiene and skin, bowel and bladder care is continued. • Remain
sensitive to changes in the patient's and family's physical and emotional needs. Care in the Terminal Phase  Allow the family to voice
their concerns.  Clarify expectations and prognosis.  Involve the Counsellor or Chaplain/ religious representatives like Panditji, Priest,
Maulavi oras preferred Signs of approaching death • Facial appearance: Facial muscles relax; cheeks become flaccid, moving in and out
with each breath. • Change in sight, speech and hearing: Sight gradually fails. The pupils fail to react to light. Eyes are sunken and half-
closed, and a film appears over the eyes. Speech becomes increasingly difficult, confusing, disoriented, slurred and finally impossible.
Hearing is thought to be retained longer. • Change in the Respiratory System: Respiration becomes irregular, Cheyne stokes, rapid and
shallow, or very slow and noisy due to secretions. • Circulatory system: - Pulse becomes slow then stops. There is a fall in BP. •
Gastrointestinal System: Nausea, vomiting and abdominal distension are present. The patient may find it difficult to swallow. Patient's
appetite gradually decreases, and they stopor refuse to eat and drink. The nurse should not force the patient's family to feed the
patient.Offering them ice pops helps them to stay hydrated. • Skin and Musculoskeletal System: The skin may become pale, cold and
clammy. Muscle tone is lost. • Excretory System: bowel or bladder incontinence or both. • Central nervous System: Reflexes are gradually
lost. The patient may be restless, confused and may have altered sensorium. • Hallucinations: It is not unusual for a dying person to
experience hallucinations or distorted visions. It is best not to correct them about these visions, as doing so may cause additional distress.
Although this may seem concerning, the nurse can provide reassurance and should explain to the families. The psychological needs of a
dying person • Relief from loneliness, fear, and depression. • Maintenance of security, self-confidence, and dignity. • Maintenance of
hope. • Meeting the spiritual needs according to his religious customs. Care of the dying person • Provide psychological support to the
patient and the near and dear ones. Be warm, supportive and understanding. Do not whisper in the patient's vicinity, which may increase
fear.
 136. 135 • Provide privacy, as it will help prevent adverse effects on other patients. • Need to think about oxygen therapy, IV Fluids and
NGT feed, as in palliative care for dying patients, these interventions may not be helpful. • As the patient may have incontinence, keep
him dry and comfortable. The patient can be catheterized. Use pads. • Provide routine skin care and maintain hygiene. • If the patient has
pain, provide analgesics or other drugs for relief. • If the patient or relatives desire to perform religious rites, permit them to do so.
Depending upon his religious faith, the patient may welcome a visit from a Panditji, Priest, Maulvi or as preferred. Care of body after
death Diagnosing and declaring death • Any doctor, preferably from the palliative care unit, can certify death • Inform the relatives •
Certify death & fill in the necessary forms • Assist the family in decisions regarding transportation, embalming, mortuary care, etc.
Criteria for declaring death • Apnea • Absence of mechanical cardiac activity (absence of heart sounds on auscultation & absenceof central
pulses on palpation) • After 5 minutes, check for the following: o Absence of pupillary light reflexes (pupils non-reactive to light and
fixed) o Absence of corneal reflexes (remove contact lenses) o Absence of motor response to supraorbital pressure/pain • If the above
features are fulfilled, death can be declared. The time of death should be noted. The record should be signed and dated with the ID
 number. Last office/death care is like any other case in a hospital or homeLast office/death care Purpose: • To maintain normal body
alignment before rigor mortis sets in • To prepare the body for transport to mortuary/residence • To reduce mental distress of family
Articles A tray with • Long artery clamp • Bandage • Non-absorbent cotton • Absorbent cotton • Mortuary card in transparent plastic cover
• Towel • Hospital gown or patient's clothes draw sheet • Long mackintosh • Equipment needed for bath Procedure • If there are oral
secretions, turn the patient to the side and drain the secretions. • Eyes should be closed by applying light pressure for 30 seconds • Remove
all internal devices like urinary catheters, nasogastric tubes and intravenous catheters
 137. 136 and document them in the patient's case sheet. Secure absorbent cotton pads with adhesive tape on the puncture site and wound
to prevent leakage and soiling. • Make the deceased lie supine and straighten all the joints. When rigor mortis sets in, manipulating the
joints become difficult; hence all the joints should be straightened early. • Place a pillow under the head. This keeps the alignment and
holds the jaw closed. • Since the final bath is included as one of the last rites of the deceased, discuss it with the family • Wash the person's
face, gently closing the eyes before beginning, using the soft pad of the fingertip. Close them and hold them in place for a few minutes
following death. They may stay closed on their own. If they do not, close them again and place a small soft cotton pad over them. • Use
saline-moistened gauze if corneal or eye donation is likely to take place. • Clean the mouth and replace dentures after death as soon as
possible. Do not remove dentures because you may have difficulty replacing them as the body stiffens. If dentures cannot be replaced,
handover to the family in an identified receptacle. • Keep the jaw closed by placing a towel roll under the chin or preparing a jaw strap
with a bandage tied loosely around the head. If the strap is too tight, it can leave pressure marks. • Tidy the hair and arrange it into the
preferred style, if known • Shaving too soon after death can cause bruising, which may be done later. Explain this to the family if they
request shaving. Remember, some faith groups prohibit shaving • Clear leaking or secretions from the oral cavity or tracheostomy sites by
suctioning and positioning, then cover exuding wounds and unhealed surgical incisions with a clean absorbent dressing and secure with an
occlusive dressing • Pack nose and mouth with Non-absorbent cotton using forceps. • Pack the anus and vagina (if female) with Non-
absorbent cotton. • As the sphincter relaxes, urine and faeces may leak; placing absorbent cotton pads will prevent soiling. • Clean and
dress the deceased person appropriately. Clean the body using a facecloth with water and a small amount of soap. Begin with the arms and
legs and then move to the front and backof the trunk. Take assistance from someone to roll the person to each side to wash the back.
Fragrant oil may be added to rinse water. Dry one part of the body before moving to another. Some families or cultures may also apply a
special lotion, oil or fragrance to the person's skin. • Dress or cover the body according to personal wishes or cultural practices. • Remove
all valuables in the presence of another staff member and document this. If any jewellery is removed, provide a signature while handing
over this to relatives. Document jewellery as yellow metal or white metal and never as gold or silver • Bring hands over the chest.
Interlace fingers and tie the two thumps together with a bandage (or according to their preference). • Attach one tag to the wrist. Ensure
the deceased person is identified with a name band on the wrist. • Bring the legs together and tie the great toes together. • Wrap the body
with a sheet. Using the clean sheet placed under the patient, wrap the body and secure all limbs within the sheet. Ensure that the feet are
also covered, and then cover the face. Apply tape to secure the sheet. Attach the other tag at the center. • Clear the room of unnecessary
clutter and use a clean cloth to cover the patient. • Cover the prepared body with a sheet and notify the nurse I/c. Call for the messenger to
take the body to the mortuary with a copy of the death certificate. After Care • Honour the deceased and their family's religious or cultural
wishes/requirements while meeting legal obligations.
 138. 137 • It is essential to give time and space to the family to grieve over their loved one. Offer support to the family through quiet and
compassionate presence, active listening and gentle touch. • Offer support to the family through quiet and compassionate presence, active
listening and gentle touch. • Ensure the deceased privacy and dignity. • Ensuring the health and safety of everyone who comes into contact
with the deceased is protected. • Replace the articles used for death care. • Returning the deceased's possessions to the next of kin. • Screen
off the patient's bed area while the removal of the body takes place to avoid causing distress to other patients • In most hospitals, the body
is never handed over to relatives directly. It is always dispatched to the mortuary • Send the body to the mortuary with a death certificate
as soon as possible • Send information about the death to all concerned • If the nurse provides death care, document the same • If there is a
risk of infection, a body bag should be used and a hazard labelmust be attached to the body bag and any accompanying documentation.
Some hospitals usebody bags for all deceased patients, so follow the hospital policy and SOP of the institution. • Ensure that the patient's
belongings are handed over to the patient's family and document the same. • Plan for bereavement support visits and document the same in
the case sheet Documentation: The nurse should write a detailed report on the death, including the:  The time  Who was present/
declared dead  The nature of the end  Details of any relevant devices or treatments  Death care provided by Care of unit after death
(if in hospital): • Dispose of used equipment according to hospital policy. Use clinical waste bags to dispose of any waste considered
infectious or hazardous. To reduce the risk of cross-infection, wash hands thoroughly and decontaminate hands by using alcohol hand gel
• Terminal disinfection of the unit should be done as per hospital policy DEATH CARE AT HOME What to do in the event of death? In a
clinical setting, a doctor is required to confirm and declare death. Nurses are not authorized to do that. But when death occurs at home, the
practice of confirming death differs in different states. It will be prudent to follow the policy of the state when such an event occurs.
General guidelines: 1. No matter how much the family is prepared to accept death, it is painful. Giving the family time and space to grieve
over their loved one is very important. The first hour after death can be very peaceful. Family can feel sadness and a deep sense of relief,
especially if the patient has 'suffered'. 2. If possible, encourage the family to have time and space 3. Record the time, nature of death, who
was present and details of death confirmation in the
 139. 138 patient's case sheet. 4. While performing post-death care, discuss patient and family preferences and local cultural practices to
be followed. 5. Ensure that privacy and dignity are provided to the deceased and the family while providing death care. 6. If the family
wishes, allow the family to be involved in the deceased's post-death care. 7. If the nurse provides death care, document the same in the
patient's case sheet. 8. Homecare team members should wear appropriate personal protective equipment and follow standard precautions
while providing death care. If there is a potential source of infection, advise the family caregivers to wear PPE. (Refer to the chapter on
 Standard precautions) Bereavement Support for the family • Palliative care does not stop with the patient's death. It continues after the
patient's death in the form of bereavement support for the family. • After the death, pay a bereavement visit to the family. • Collect back
any unused opioids and hand them to the palliative team. • The family may need support for a few months after the death • People may
grieve for six months to one year after death and then slowly resume normal life • Some people may find it very difficult to accept,
especially the death of an earning member or a child and go into depression. They will need a referral to a counsellor or psychiatrist. Grief
Grief is the natural response to losing something or someone they hold or feel dear. Bereavement is the state of this loss. It affects a
person's physical, social, spiritual and emotional states. Grief as a response to the death of a loved one is to be critically handled. Grief is
naturally expressed by mourning (i.e., crying or talking about the loss). Understanding the process of grieving will help us to handle it
better. There is no apt process of grieving or reacting to bereavement. It depends on many variables such as personality, nature of the
relation, situational conditions and social supports available. The support for grief should be ideally initiated before death. Any
pharmacological intervention cannot suppress grief. A loss of a person with whom we have had a lot of memories will create a void that
cannot be filled, leading to a lot of pain. This will be showcased in different ways. Stages of Grief Grieving is a normal process that
usually begins before an anticipated death. The five stages of grief, also known as the Kubler-Ross model, is a widely recognized
framework for understanding the emotional and psychological process that individuals may experience after a significant loss. These
stages are not necessarily linear, and not everyone experiences them in the same order or at the same intensity. However, they can provide
a helpful guide for understanding the grieving process: • Denial: In this stage, the individual may feel disbelief or numbness, and may
have difficulty accepting the reality of the loss. • Anger: As the reality of the loss sets in, the individual may feel angry, frustrated, or
resentful. They may lash out at others or at the situation itself. • Bargaining: In this stage, the individual may try to negotiate or make deals
with a higher power or with themselves to avoid the reality of the loss. • Depression: This stage involves feelings of sadness, despair, and
hopelessness. The individual may withdraw from social interactions and may struggle with daily tasks or routines.
 140. 139 • Acceptance: In this final stage, the individual comes to terms with the reality of the loss and begins to find ways to move
forward with their life. This may involve developing a new sense of purpose or finding meaning in the loss. Fig.5.2: STAGES OF GRIEF
The grieving process is unique to each individual and can vary depending on factors such as personality, coping style, and cultural
background. It is important to note that not everyone goes through all of these stages, and some individuals may experience additional
emotions or reactions that are not included in this framework. If needed, it is also important to seek support from family, friends, or mental
health professionals. In all these stages, the nurse needs to be truthful but prudent in all their dealings with the patient. Maintain a genuine,
honest attitude of interest. Be warm, supportive and understanding. The patient may ask many questions and clarify many of his doubts.
Let the patient tell you what he knows about his condition. Try to use his own words when talking to him. Points to remember: • It takes
time to accept the loss, after which the person undergoes depression and slowly recovers. • The depression phase can be troubling, and the
grieving person can even have suicidal tendencies or feel as if he is going crazy. • The mere presence of a person would be considerable
support for the family. The time required for support may vary considerably from few days to years. • The foundation for supporting a
person in grief is to listen. • Listening rather than speaking can help the person recover. • The nurse should motivate the grieving person to
talk more about the death, enquiring about their feelings. • This would help them in accepting the loss and pain of bereavement. Never
compare their losses with yours, and avoid remarks or platitudes. • Major changes in sleeping patterns, considerable differences in weight
(loss or gain), feeling confused, inability to concentrate, and inability to stop crying are all associated with grief. Ifthe person recognizes
these problems and can talk about them, they will likely be able to recover in time. • Persistence of these symptoms for more than a few
months, suicidal thoughts, thoughts of harming oneself or others, uncontrollable anger, or worries about one's behavior all indicatethe
need for professional help 6. Ethics Based Decision Making Ethics-based decision making in end-of-life care involves balancing the
values and goals of the patient with the ethical principles of healthcare. The goal is to ensure that the patient's wishes
 141. 140 are respected and that care is provided in a way consistent with the patient's values and beliefs. There are several ethical
principles that guide decision-making in end-of-life care, including autonomy, beneficence, non-maleficence, and justice. Autonomy
refers to the patient's right to make decisions about their care, while beneficence refers to the obligation to do good for the patient. Non-
maleficence requires that healthcare providers do no harm, and justice requires that resources be distributed fairly. In end-of-life care,
ethical dilemmas often arise when patients can no longer make decisions for themselves. In these situations, healthcare providers must
consider the patient's values and beliefs and the opinions of family members and other caregivers. It may be necessary to consult with a
medical ethics committee or seek legal guidance to ensure that the patient's wishes are respected. One common ethical issue in end-of-life
care is the use of life-sustaining treatments such as ventilators and feeding tubes. While these treatments can prolong life, they may also
cause discomfort and suffering for the patient. In some cases, it may be appropriate to withhold or withdraw these treatments in order to
provide the patient with a more comfortable and peaceful end-of-life experience. Overall, ethics-based decision making in end-of-life care
requires careful consideration of the patient's values and beliefs and the ethical principles that guide healthcare practice. By balancing
these factors, healthcare providers can ensure that end-of-life care is provided in a respectful, compassionate way, and in line with the
patient's wishes. The foundation of medical ethics is supported by the four pillars, namely; 1. Autonomy- Patient has the right to choose or
refuse a particular treatment. In the event the patient has diminished decision-making capacity, surrogates acting on the patient's behalf
can communicate the patient's previously expressed wishes. 2. Beneficence- The doctor should act in the best interest of the patient. In the
context of an advanced progressive illness with no scope for reversal, the patient's best interests are controlling the patient's pain and
symptoms, reducing the sufferings of the patient and his family, providing emotional support and protecting the family from financial ruin.
3. Non-Maleficence- Do no harm to the patient. Thus, withholding and withdrawing the life support, in this context, is a humane approach
to 'allowing natural death,' that is, allowing the patient to die of the underlying illness, with symptoms well–controlled, in a dignified
manner, in the presence of his family and loved ones and this in no way amounts to euthanasia. 4. Justice- Equitable distribution of service
and equal right to care for all patients. Fig.5.3: PILLARS OF MEDICAL ETHICS
 142. 141 Added to the above four are two more aspects which form the cornerstones of medical practice: 1. Dignity - the patient and the
persons treating the patient have the right to dignity 2. Truthfulness and honesty - the concept of informed consent and truth-telling should
be engrained in the practice of end-of-life care. Thus, it is crucial to integrate the ethical principles in the practice of palliative care and
end- of-life care in the background of cultural and social influence. End-of-life care must be embedded in the ethical principles of
palliative care. Palliative care is important in advanced health-related suffering and life-limiting illnesses. The different aspects of
palliative care, such as pain and symptom control, psychosocial care, and end- of-life issues, should be managed ethically. The cardinal
ethical principles to be followed are autonomy, beneficence, non-maleficence and justice. • The palliative care experts and team members
should carry out their responsibilities with honesty and dignity. • Suffering due to unrelieved pain and unavailability of Morphine are
recognized as negligence of human rights. • There are practical ethical challenges which need to be resolved. Truth-telling, place of care,
continuity of effective palliative care till the last days of life, confidentiality, use of antibiotics and blood transfusion, nutrition and
advance directives can be the key points which confront a palliative care team. • Progress in palliative care will come out of good research
and medical professionals should undertake trials and studies in a legal and ethical manner. • The delivery of palliative care and medical
ethics are complementary, and use of the two together maximizes the protection and satisfaction available to the vulnerable patient and
family members. • Decisions are made on the grounds of benefits/burdens proportionality. To justify a particular intervention, the
expected benefits of that intervention must outweigh the burdens. Burdens might include intractable pain, disability, emotional suffering
or other factors which seriously compromise the patient's quality of life. Treatments considered reasonable in the early stages of illness
when the patient is enjoying a good quality of life may be seen as unreasonable later in the illness. Furthermore, each intervention should
be individually subjected to this consideration. For example, a patient who is not expected to benefit from ventilation may be helped
symptomaticallyby administering oxygen.Importantly, the withholding or withdrawal of life-sustaining interventions should never mean
the withdrawal of care. Adequate symptom control and emotional and spiritual support for the patient and family must be ensured.
Collective decision making Dying is a very special and unique event for each individual. In palliative care approach exploring the patient's
wishes about death and dying should be done in the beginning itself. Relatives need to be involved and patient’s wishes would need to be
balanced with the palliative care team's views. Most patients wanted to be at home during the lost weeks or days around the relatives.
Relatives should determine who and how the body is dealt with after death. This is an important part of their last 'duty’. It is important to
be sensitive to the cultural and religious beliefs because different religious and cultural groups have different approaches the dying
processes. Role of palliative care nurse • Coordinate with the other health care members and facilitate a death that's as dignified and
comfortable as much as possible and that honours the patient's and family's wishes.
 143. 142 • Provide a culturally sensitive, practical, and timely interventions that reduce physical, emotional, and spiritual suffering. •
Provide ongoing education to the patient and family members, who may have had little experience with death and may not understand the
dying process. • Provide information about the patient's condition, discuss the risks and benefits of medical treatments, and answer family
members' questions about care options for their loved one. • Guide the discussion and address the questions but do not dictate what
decisions the patient and family should make. • Nurses must understand that the death approaches, the patient's comfort and the patient's
and family's emotional and spiritual well-being and take precedence over clinical priorities. • Provide reassurance and physical presence
are critical at this time to ease the patient's and family's fear and loneliness and to facilitate the transition. • Discuss patient preferences
about withholding hydration and nutrition, the timing for discontinuing treatments, and the selection of a surrogate decision maker. •
Adjust the temperature and lighting in the room, as needed • Observe for signs of terminal delirium, such as a decreased level of
consciousness or unresponsiveness, confusion, disorientation, hallucinations, agitation, or restlessness. • Note that agitation is common in
the final hours of life and may be due to the effects of medications, changes in metabolic status, organ failure, faecal impaction, bladder
distention, hypoxia, and unresolved emotional or spiritual issues. • If the patient is experiencing agitated delirium, collaborate with the
interdisciplinary team to identify and treat reversible causes if possible, such as discontinuing unnecessary medications. • Administer
Haloperidol or another antipsychotic agent as prescribed following safe medication administration practices. • Treat the patient’s pain
using non-pharmacologic, pharmacologic, or a combination of approaches. • Don't abruptly discontinue opioid pain medication, even if
the patient is unresponsive. • Although a hypoxemic patient may benefit from supplemental oxygen, it isn't routinely used for air hunger at
the end of life. • If the patient can't clear secretions, reposition the patient and elevate the patient's upper body and head. Administer an
anticholinergic or antispasmodic, as appropriate and as needed and prescribed, following safe medication administration practices to dry
secretions. • Note that sounds made by the patient with excessive secretions are often more distressing to family members than to the
patient. • If the patient is experiencing nausea, collaborate with the interdisciplinary team to identify and treat reversible causes if possible.
Administer anti-emetics, as needed and prescribed, following safe medication administration practices. Provide non-pharmacologic
interventions, such as limiting movement and removing noxious odors, as appropriate. • Assess the patient for the effects of dehydration,
such fatigue, dizziness, headache, dry mouth or eyes, scant or dark-colored urine, and muscle cramps, • Offer (but don't force) oral fluids
if the patient can still swallow. Administer artificial hydration if ordered and consistent with the patient’s care goals. Advise the patient
and family that administering fluids via the enteral or parenteral route doesn't reverse the underlying disease process or significantly
increase survival and may contribute to the physiologic burden of dying. • Although increasing oral intake is the preferred method of
providing fluids, especially in the home environment, artificial hydration via the IV, subcutaneous (hypodermoclysis), or rectal
(proctoclysis) route may be considered in some patients if the potential benefits, such as increased alertness and reduced myoclonus,
outweigh the potential risks related to fluid
 144. 143 retention, such as edema, nausea, pain, and dyspnea. • Provide oral care, taking care to moisturize the patient's oral mucosa and
lips as needed, to prevent or relieve discomfort. • Lubricate the patient's eyes with an ophthalmic solution (such as artificial tears) or
ointment, as needed and ordered, to prevent or relieve discomfort. • Assess the patient's skin for temperature, moisture, color, and
breakdown. Note that as peripheral circulation decreases and death approaches, the skin is typically cool and moist and becomes mottled,
 especially on the soles of the feet and over bony prominences. Skin darkens in dependent areas, such as the sacrum (when the patient is
supine), as blood pools in these areas. • Reposition the patient as tolerated, change the patient's clothing and linens when soiled or moist,
and provide skin and wound care as indicated. (See the "Wound palliative care, home care" procedure.) Make sure that the linens cover the
patient loosely to reduce discomfort caused by pressure from the linen. • Assess the patient for urinary and bowel incontinence, which can
occur as the patient's sphincters relax as death approaches. • Change fluid-impermeable pads and provide perineal care, as needed. If the
patient is incontinent of urine and can't tolerate repositioning and perineal care, insert an indwelling urinary catheter (if ordered) to
promote comfort. • Encourage family members to participate in the patient's care and teach them how to provide comfort measures to the
patient, such as positioning, mouth care, skin care, and gentle massage. • Teach the patient and family members to use non-pharmacologic
strategies, such as relaxation techniques, guided imagery, and distraction, to ease symptoms (such as discomfort, nausea, anxiety,
depression, and fatigue) that may be present at the end of life. If the patient and family are interested in using complementary therapies
(such as music therapy, massage therapy, and aromatherapy) to control symptoms, notify the patient’s practitioner for appropriate orders
and referrals. • Reassess and respond to the patient’s pain by evaluating the response to treatment and progress toward pain management
goals. Assess for adverse reactions and risk factors for adverse events that may result from treatment. • Provide the family with
anticipatory guidance on the signs of impending death. • Support the patient and family in expressing cultural, spiritual, or religious
traditions related to the end of life. Encourage the family to provide objects that comfort the patient, such as religious items or
photographs. • Allow the patient and family to express their feelings, which may include acceptance, anxiety, denial, disappointment,
loneliness, regret, resentment, and sadness. Actively listen without rushing them, and display empathy. Acknowledge their feelings and
provide emotional support. • Encourage the patient and family to reminisce and appropriately express affection. Remain present or provide
privacy according to their wishes • Ask the patient and family about organ and tissue donation when appropriate. Explain the process or, if
the patient has already registered to become a donor, verify the registration in the patient's medical record. Contact a regional organ
procurement organization for specific
 145. 144 organ and tissue donation criteria. • Review progress toward the goals in the patient’s plan of care with the patient and family as
appropriate. • Make arrangements for the next visit as appropriate and ensure the patient and family members have adequate supplies for
caring for the patient themselves until then. • Provide and review written educational materials, the visit schedule, and contact information
should concerns arise between visits. Conclusion Living with a life-limiting illness and awareness of approaching death creates unique
stressors and new challenges. Patients and families must manage the new demands associated withthe illness while maintaining the quality
of life and meaning within their relationships. By optimizing the care, we should ensure that the suffering is minimal and symptoms are
managed,the family has closure, unfinished issues are resolved, dignity is preserved, feelings of being lovedand valued are addressed, a
peaceful atmosphere is achieved, and a supportive presence is provided. The end-of-life decision must begin at the point of diagnosis of
advanced, progressive or metastatic cancer when the primary team is certain that the disease-modifying treatment or intensive medical
management will not benefit the patient or lead to health deterioration. Once theprimary treating team recognizes the medical
inappropriateness of a particular treatment; they could call upon the other teams involved in caring for the patient and the palliative care
team anddiscuss all the possible options for correcting the reversible cause. If the team members have reached a consensus of saturating all
the options, they could then call upon a meeting with the patient and the family members.