Integrated Nursing Practice

Health Issues Rationale

Pressure injury- Patients having an advanced and terminal illness are at a significant risk of developing soft tissue ulceration. This can be closely related with malnutrition to the body and skin of the patient. Patients having terminal illness also suffer from catabolism. This can include clinical features like cachexia, weakness, debilitation, weight loss, muscle loss and muscle atrophy. These clinical elements can cumulatively bring about a reduced body fat reserve, which provides the bones with a natural padding and support (Artico, 2018). This can be one of the major reasons of increasing the vulnerability of skin to breakdown after being subjected to over pressure. The patient in the given case study can also be observed to be spending most of his time lying down and unresponsive and thus, it adds to the underlying risk factor of enhanced development of pressure injuries. With prolonged immobilization, the friction is increased and thus, causes an increased risk of injury to the skin. There is also an increased exposure to moisture, that can be brought about by excess perspiration. Sweat can also be considered as one of the major causative factors for bringing about skin injury (Haesler, 2018). Given the state of progression of patient’s condition, the impact can rise in terms of health deterioration for the patient, leading to further difficulty in managing these pressure injuries.

Risk for development of anxiety or depression- Depression and anxiety can be attributed as two of the most common mental health concerns, observed to be developed in patients being treated for palliative care and management. Depression has been found to be associated with the physical impairment of the patient. This can also be due to few other symptoms such as sleep disorder, fatigue, dyspnea or lack of functional capability, due to the terminal illness. Conditions like constant pain, sleeping disturbances, gastrointestinal irritabilities and so on, have been found to be closely associated with increased physical suffering (Thalén, 2017). It can also be worsened by the increased cognitive impairment, as observed in the form of unresponsiveness of the patient. Psychological distress can also be considered as one of the major causes of suffering for the patients as well as for their families. It is also found to be directly linked with significantly reduced quality of life and an amplified pain observed by the patient. The impact of mental health disorders can be directly observed on patient’s social and existential concerns. This can have a deeper impact on the overall physical symptoms as well. Decreased quality of existential issues can also be directly associated with the quality of life index, which indirectly determines the development of depressive and anxiety symptoms in patients (Mercadante, 2017). Thus, eventually linking the higher risk of the same in people dying from terminal illness, as reflected in our given case study.

Role of Nurse

Palliative care and support targets at improving the overall quality of life of the person, who is heading towards its end of life. The intervention is to be planned not only for the patient, but also to provide care for the family of the patient (Brant, 2019). They are also very often subjected to psychological stress while managing care for their loved ones. The palliative care is to be addressed from the point of view of addressing to the overall needs which can include, physical, psychological or spiritual as well. Nurses can play a vital role in delivering care to the patient by managing the same, with the help of palliative care team and specialist in providing care for the patient.

Nurses can act as a leader for a multidisciplinary team, to enable holistic care solution to the patient. The care model is to be calibrated, to overcome the hurdles and provide evident support to the family and the care givers. The main aim of the palliative care is to promote the dignity of the patient and reduce the overall physical and emotional suffering (Henderson, 2019).

Various team members with whom the nurses can work in close collaboration can include as follow:

  1. Dietician- They can help in providing the nutritional support and guidance to the patient for managing the smooth facilitation of transition of the process. As the patient in the given case study is on heavy pain medication and chemotherapy drugs as well, it is imperative that a good nutrition is maintained as well (Vanbutsele, 2018).
  2. Physical therapist- They can help with the mobilization of patient in bed to ensure that the physical miseries can be reduced for the patient. They can work along with the nurses to provide the physical mobilization of the patient and positioning the patient in bed to help with pain reduction (Möller, 2018).
  3. Physician- They can help with medication reconciliation for the patient to provide the required pain medication for the patient, to reduce the suffering of the patient. This is crucial to provide smooth transition of end of life care to the patient. Patient is suffering from severe pain and requires the same for ensuring to end the misery of the patient (Hannon, 2016).
  4. Social worker- They can help in providing care through the means of helping the family members with the required support services for the patient. They can also work in close collaboration with the family members to help them with the preparation for the emotional phase of losing their close ones. Support services can also be provided to the patient’s family by closely engaging themselves with group sessions, who can provide an empathetical support to them (Stein, 2017). This will help in promoting enhanced care to the family to manage the end of care for the patient, through positive reinforcement.

Nurses can very well play the vital role of promoting multidisciplinary team approach to enable full capacity of all of the team members. They can help in collaborating all of the healthcare professionals aligned in patient care, to enable care through the means of justifying all of the social determinants of health (Sekse, 2018). They can also deliver profound healthcare solutions by the means of suitable leadership form required to ensure smooth and holistic facilitation of services to the patients. Nurses being the front-line manager can help in palliative care by formulating supportive organizational structure, through the means of required team dynamics needed for the end of life care of the patient. They can also help in providing the patient with the required support, by closely abiding by the legal and ethical principles designated for treating patients in their terminal illness phase of health. This will make sure of the support system based on various aspects of multiple paradigms that are required to be covered under the palliative care system (Head, 2018). Thus, enabling a care model encircling around all basic elements of physical, social and psychological needs of the patient and their family members to be catered to in this process.

References for Palliative Care Case Scenario

Artico, M., D'Angelo, D., Piredda, M., Petitti, T., Lamarca, L., De Marinis, M. G., ... & Matarese, M. (2018). Pressure injury progression and factors associated with different end-points in a home palliative care setting: a retrospective chart review study. Journal of Pain and Symptom Management56(1), 23-32. https://doi.org/10.1016/j.jpainsymman.2018.03.011

Brant, J. M., Fink, R. M., Thompson, C., Li, Y. H., Rassouli, M., Majima, T., ... & Lascar, E. (2019). Global survey of the roles, satisfaction, and barriers of home health care nurses on the provision of palliative care. Journal of Palliative Medicine22(8), 945-960. https://doi.org/10.1089/jpm.2018.0566

Haesler, E., Carville, K., & Haesler, P. (2018). Priority issues for pressure injury research: An Australian consensus study. Research in Nursing & Health41(4), 355-368. https://doi.org/10.1016/j.ijnurstu.2020.103760

Hannon, B., Swami, N., Pope, A., Leighl, N., Rodin, G., Krzyzanowska, M., & Zimmermann, C. (2016). Early palliative care and its role in oncology: A qualitative study. The Oncologist21(11), 1387. https://dx.doi.org/10.1634%2Ftheoncologist.2016-0176

Head, B. A., Song, M. K., Wiencek, C., Nevidjon, B., Fraser, D., & Mazanec, P. (2018). Palliative nursing summit: Nurses leading change and transforming care the nurse’s role in communication and advance care planning. Journal of Hospice & Palliative Nursing20(1), 23-29. 10.1097/NJH.0000000000000406

Henderson, J. D., Boyle, A., Herx, L., Alexiadis, A., Barwich, D., Connidis, S., ... & Sinnarajah, A. (2019). Staffing a specialist palliative care service, a team-based approach: Expert consensus white paper. Journal of Palliative Medicine22(11), 1318-1323. https://doi.org/10.1089/jpm.2019.0314

Mercadante, S., Adile, C., Ferrera, P., Masedu, F., Valenti, M., & Aielli, F. (2017). Sleep disturbances in advanced cancer patients admitted to a supportive/palliative care unit. Supportive Care in Cancer25(4), 1301-1306. https://doi.org/10.1007/s00520-016-3524-4

Möller, U. O., Stigmar, K., Beck, I., Malmström, M., & Rasmussen, B. H. (2018). Bridging gaps in everyday life–a free-listing approach to explore the variety of activities performed by physiotherapists in specialized palliative care. BMC Palliative Care17(1), 20. https://doi.org/10.1186/s12904-018-0272-x

Sekse, R. J. T., Hunskår, I., & Ellingsen, S. (2018). The nurse's role in palliative care: A qualitative meta‐synthesis. Journal of Clinical Nursing27(1-2), 21-38. https://doi.org/10.1111/jocn.13912

Stein, G. L., Cagle, J. G., & Christ, G. H. (2017). Social work involvement in advance care planning: Findings from a large survey of social workers in hospice and palliative care settings. Journal of Palliative Medicine20(3), 253-259. https://doi.org/10.1089/jpm.2016.0352

Thalén-Lindström, A., Glimelius, B., & Johansson, B. (2017). Development of anxiety, depression and health-related quality of life in oncology patients without initial symptoms according to the Hospital Anxiety and Depression Scale–a comparative study. Acta Oncologica56(8), 1094-1102. https://doi.org/10.1080/0284186X.2017.1305124

Vanbutsele, G., Pardon, K., Van Belle, S., Surmont, V., De Laat, M., Colman, R., ... & Deliens, L. (2018). Effect of early and systematic integration of palliative care in patients with advanced cancer: A randomised controlled trial. The Lancet Oncology19(3), 394-404. https://doi.org/10.1016/S1470-2045(18)30060-3

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