HOSPICE & PALLIATIVE NURSING ASSISTANT

PRESENTED BY

ANDREA HUERTAS, MBA, BSN, RN

HOMECARE, HOSPICE & PALLIATIVE CARE ALLIANCE OF NH

BOARD MEMBER

GOALS & OBJECTIVES

• COMMUNICATING AT THE END OF LIFE

• PAIN MANAGEMENT AT THE END OF LIFE

• SYMPTOM MANAGEMENT AT THE END-OF-LIFE

• CARE OF THE PATIENT AND FAMILY WHEN DEATH IS NEARING

PATIENT CARE: ACTIVITIES OF DAILY LIVING

• THE FOLLOWING ARE ALL IMPORTANT IN CARING FOR THE DYING PATIENT

• HYGIENE

• AMBULATION & MOBILITY

• GROOMING & DRESSING

• TOILETING

• NUTRITION & HYDRATION

HYGIENE

• A PATIENT WHO USUALLY SHOWERS STATES HE IS TOO TIRED AND ASKS THE NURSE ASSISTANT TO GIVE HIM A PARTIAL SPONGE BATH. THE BEST ACTION IS

TO:

• TELL THE PATIENT THAT HE SHOULD TAKE A SHOWER.

• TELL THE PATIENT HE MAY WANT TO SHOWER LATER IN THE DAY.

• GIVE THE PATIENT A PARTIAL SPONGE BATH AS REQUESTED.

• TELL HIM HE NEEDS TO EITHER TAKE I SHOWER TODAY OR TOMORROW

NUTRITION

• A PATIENT HAS STOPPED, EATING MOST SOURCES OF PROTEIN BECAUSE OF UNRELIEVED NAUSEA AND IS RAPIDLY LOSING MUSCLE MASS. WHAT OTHER

WAYS CAN WE INCREASE PROTEIN AND CALORIC INTAKE ?

• ADD PROTEIN POWDER TO THEIR FOODS THEY ALREADY ENJOY

• HAVE THE PATIENT EAT MEAT WITH EVERY MEAL

• EXPLAIN THAT THEY NEED TO EAT LOTS OF BEANS

TOILETING

• A WOMEN IS TAKING OXYCODONE FOR PAIN AND NOW IS HAVING INCREASED CONSTIPATION AND IS UNDERGOING BOWEL RETRAINING. WHICH IS THE

BEST TIME TO ASSIST THE PATIENT TO SIT ON A TOILET OR COMMODE TO PROMOTE EVACUATION?

• AS SOON AS SHE GETS OUT OF BED

• ABOUT 20 TO 30 MINUTES AFTER SHE EATS

• WHEN SHE GETS A SENSATION TO MOVE HER BOWELS

• BEFORE BED

PATIENT STATUS & ENVIRONMENT

• WHAT DO WE NEED TO OBSERVE, THINK ABOUT & REPORT TO THE HOSPICE TEAM

• WHERE DO THEY WANT TO RECEIVE THEIR PERSONAL CARE

• DO THEY WANT FAMILY TO ASSIST IN THEIR CARE

• DO THEY NEED EQUIPMENT TO BE SAFE

• STAGES OF WOUNDS

COMMON HOSPICE DIAGNOSIS

• CANCER

• HEART FAILURE

• COPD

• DEMENTIA

PAIN

• PAIN:

• LEVEL OF PAIN (E.G., ON A 0-10

• SCALE)

• CHANGES IN PAIN

• NONVERBAL CUES

• TYPE AND LOCATION OF PAIN

• A 84 YEAR OLD MAN IS NEARING DEATH AND HAS STARTED TO DEVELOP A PRESSURE AREA ON THE SACRAL AREA BUT MOANS LOUDLY AND IS RESISTIVE

WHEN THE NURSE ASSISTANT TRIES TO TURN HIM. THE BEST ACTION IS TO

• TURN HIM EVERY TWO HOURS

• ALLOW THE PATIENT TO BE UNDISTURBED AS MUCH AS POSSIBLE

• ASK FAMILY TO GIVE HIM MORE PAIN MEDICINE

• GET HIM ON A PRESSURE MATTRESS ASAP

• THE MOST IMPORTANT, CRITERION FOR DETERMINING THE DEGREE OF A PATIENT'S PAIN IS

• LOOK FOR FACIAL GRIMACING

• LISTEN FOR LOUDER MOANING

• ASK THE PATIENT

MORPHINE IS OFTEN USED FOR PAIN MANAGEMENT

• AFTER A PATIENT RECEIVES MORPHINE FOR PAIN, WHICH SIDE EFFECT IS MOST CAUSE FOR

CONCERN?

• MYOCLONUS (TWITCHING)

• SLOWER RESPIRATION, BETWEEN 16-18

• INCREASED SLEEPINESS

• PATIENT LOOKS LETHARGIC AND DIFFICULT TO AROUSE

SHORTNESS OF BREATH

• GIVE AN EXAMPLE OF WHAT WE CAN DO FOR A PATIENT SUFFERING FROM INCREASED SOB

AND ANXIETY RELATED TO THEIR COPD, END STAGE LUNG CANCER OR HF…

CHANGES IN RESPIRATORY STATUS

• EFFECTIVENESS OF INTERVENTIONS

• NEBULIZERS

• OXYGEN THERAPY

• INHALERS

• AIR CIRCULATION (INCLUDING USE OF

• FANS)

• RESPIRATORY CONCERNS

• CHANGE IN BREATHING PATTERNS (INCLUDING COUGH)

• INCREASED SECRETIONS

SWELLING

• GIVE SOME EXAMPLES ABOUT WHAT WE CAN DO FOR SOMEONE WHO HAS SWOLLEN FEET

AND LEGS…

• HOW COULD WE REPOSITION SOMEONE WITH SWOLLEN HANDS…

INFECTION CONTROL

• UNIVERSAL PRECAUTIONS

• BIOHAZARDOUS WASTE DISPOSAL (E.G., SHARPS, BLOOD)

• ISOLATION TECHNIQUES

• PPE

• WHICH TYPE OF PRECAUTIONS REQUIRE THAT THE NURSE ASSISTANT WEAR A MASK WHILE CARING FOR THE PATIENT WHO IS POSITIVE FOR COVID-19?

• STANDARD

• CONTACT

• AIRBORNE

• DROPLET

PATIENT & FAMILY ENVIRONMENT

• PERSONAL ENVIRONMENT (E.G., FAMILIAR OBJECTS, PICTURES, HOMELIKE)

• CALMING ENVIRONMENT (E.G., LIGHTING, IMPORTANT THINGS WITHIN REACH)

• DEATH IN PATIENT’S PLACE OF CHOICE (E.G., NOT ER, HOSPITAL)

• CARE ACCORDING TO THE PATIENT’S PREFERRED SCHEDULE

• SAFETY (E.G., FALL PRECAUTIONS, PREVENTION OF HAZARDS, OXYGEN STORAGE AND USE)

• ODOR CONTROL

• WHEN USING MUSIC TO HELP A PATIENT RELAX, THE MOST IMPORTANT CRITERION IS

• ROCK & ROLL

• PATIENT PREFERENCE

• EASY LISTENING

• COUNTRY MUSIC

CHANGES IN PHYSICAL STATUS

• ACTIVITY LEVEL

• VITAL SIGNS

• WEIGHT (E.G., RAPID LOSS OR GAIN)

• BODY IMAGE CHANGES

• SKIN IMPAIRMENT (E.G., BREAKDOWN, RASH, ITCHING)

• INJURY

• ELIMINATION HABITS

• SWALLOWING ABILITY

• NAUSEA/VOMITING

• EDEMA AND ASCITES

• SIGNS OF IMPENDING DEATH

• JOHN IS DYING AND HAS STOPPED TAKING FLUIDS FOR 24 HOURS. WHICH MEASURE IS MOST APPROPRIATE TO

ALLEVIATE DISCOMFORT FROM DEHYDRATION?

• PROVIDE MOUTH CARE, KEEPING HIS MOUTH MOIST IS IMPORTANT

• PUT ICE CHIPS IN HIS MOUTH

• USE A STRAW AND DRIP WATER INTO HIS MOUTH

• MARY HAS END-STAGE LIVER DISEASE AND BEEN HAVING MONTHLY PARACENTESES TO RELIEVE DYSPNEA. WHAT

MEASURE IS ROUTINELY DONE TO ASSESS THE DEGREE OF ASCITES?

• RESPIRATORY RATE

• URINALYSIS

• WAIST AND HIP CIRCUMFERENCE

• WEIGHT AND WAIST CIRCUMFERENCE

• THE NURSE ASSISTANT IS IN THE ROOM AND ATTENDING THE IMMEDIATE AND EXTENDED FAMILY OF A DYING INFANT DURING THE DEATH VIGIL. THE MOTHER

IS VERY UPSET AND ANGRY WITH THE DOCTOR FOR NOT SAVING HER CHILD. THE MOST APPROPRIATE ACTION FOR THE NURSE ASSISTANT IS

• REASSURE THE FAMILY THAT THE CHILD'S SUFFERING WILL SOON BE OVER.

• SIT QUIETLY AND INTERACT WITH FAMILY IF THEY DESIRE.

• EXPLAIN TO THE MOTHER THAT THE DOCTOR IS NOT TO BLAME.

• HUG THE MOTHER TO PROVIDE COMFORT

• WHAT IS A COMMON RESPIRATORY PATTERN FOUND IN DYING PATIENTS IS

• CHEYNE-STOKES RESPIRATIONS

• WHAT’S BEST WAY TO EXPLAIN THIS TO THE FAMILY THE GURGLING SOUND THE PATIENT MAKES NEAR DEATH”

• CONGESTION IN THE THROAT AND LUNGS OCCURS AS FLUIDS ACCUMULATE

• THIS IS NORMAL DEATH RATTLE

• THIS IS NORMAL IN ALL DYING PATIENTS

CHANGES IN MENTAL STATUS

• CONFUSION

• RESPONSIVENESS

• EMOTIONAL CHANGE (E.G., ANXIETY, FEAR, DEPRESSION)

• AGITATION

• TERMINAL RESTLESSNESS

• NEAR DEATH AWARENESS

• A PATIENT NEARING DEATH HAS BEEN EXPERIENCING DELIRIUM, WITH MARKED CONFUSION AND HALLUCINATIONS. THE PATIENT BELIEVES THE NURSE

ASSISTANT IS HER CHILD, WANT SHOULD YOU DO?

• CORRECT THE PATIENT BY SAYING I’M NOT YOUR CHILD

• AGREE YOU ARE HER CHILD

• TELL HER YOU’RE HER NURSING ASSIST, STATE YOUR NAME

CHANGES IN FUNCTIONAL STATUS

• MOBILITY

• WEAKNESS

• SLEEPINESS

• FATIGUE

PSYCHOSOCIAL/SPIRITUAL CARE OF THE PATIENT & FAMILY

• SPIRITUAL CARE

• RESPECT DIFFERENCES

• THE FAMILY OF A BUDDHIST PATIENT WHO HAS JUST DIED, ASK YOU NOT TOUCH THE BODY FOR THE NEXT FEW HOURS, EXPLAIN WHY…

• THE NEEDS TIME TO GRIEVE

• THERE ARE SEVERAL PRAYERS THEY MUST GO THROUGH

• THEY WANT TO WASH THE BODY

• BUDDHIST BELIEFS, THE SOUL NEEDS TIME TO PEACEFULLY LEAVE THE BODY

PATIENT & FAMILY SUPPORT NEEDS

• EDUCATION

• RESPITE

• COMPANIONSHIP

• ADVOCACY

• EOL CONCERNS

• ADVANCE DIRECTIVE

• YOU WALK IN TO REPOSITION THE PATIENT BACK TO BED AFTER THE DOCTOR WAS IN WITH

HER, SHE IS CRYING AND SHAKING…WHAT SHOULD YOU DO?

• ASK WHAT HAPPENED

• ASK HER IF THE DOCTOR UPSET HER

• EVERYTHING WILL FINE

• ACKNOWLEDGE SHE’S SHAKING & APPEARS WORRIED

DIGNITY & HONOR

• TIME OF DEATH

• WHAT WE SHOULD DO

BEREAVEMENT & GRIEF

• OVERVIEW OF THE BEREAVEMENT PROGRAM

• MEMORIAL SERVICES

• CONDOLENCE CARDS, LETTERS, OR

• TELEPHONE CALLS

ASSIST IN FACILITATING COMMUNICATION

• BARRIERS TO COMMUNICATION

• ACTIVE LISTENING

• READING

• LIFE REVIEWS

• GOALS OF CARE

• ADAPTIVE COMMUNICATION DEVICES

OPPORTUNITIES TO ENHANCE SOCIALIZATION

• VOLUNTEER VISITS

• PROVIDE SUPPORT FOR ACTIVITIES PATIENT MAY ENJOY

• READING

• COOKING

• CRAFTS

• GARDENING

• JUST LISTEN

ABUSE & NEGLECT

• WE ALL HAVE A RESPONSIBILITY TO REPORTS

• IDENTIFY ISOLATION

• TALK WITH THE TEAM LEADER

• WHAT DO YOU DO IF YOU ARE CARING FOR A CONFUSED PATIENT WHO HAS A GUN SITTING ON HIS NIGHT STAND?

• LEAVE AS SOON AS POSSIBLE & CALL THE SUPERVISOR

• MOVE IT AWAY FROM HIM

• CALL THE COPS

INTERDISCIPLINARY COLLABORATION

• PLAN OF CARE

• ENCOURAGE PATIENT & FAMILY PARTICIPATION

• PROVIDE INPUT TO TEAM MEMBERS FOR THE PLAN OF CARE

• CHANGE IN CONDITION

• IMPENDING DEATH

• WORK WITH THE TEAM TO CARRY OUT THE PLAN OF CARE

• COMMUNICATE PATIENT/FAMILY GOALS AND WISHES

ETHICS, ROLES, & RESPONSIBILITIES

• CONFIDENTIALITY

• BOUNDARIES

• DOCUMENTATION

• EDUCATION

• MENTOR/PRECEPTOR FOR STAFF & VOLUNTEERS

PRACTICE QUESTIONS

• AS DEFINED BY KUBLER ROSS, THE FIVE STAGES OF DEATH AND DYING ARE

A. DENIAL, ANGER, BARGAINING, DEPRESSION, ACCEPTANCE.

B. ANGER, BARGAINING, DEPRESSION, PSYCHOSIS, RESISTANCE.

C. ANGER, BARGAINING, SADNESS, DENIAL, ACCEPTANCE.

D. DENIAL, ANGER, BARGAINING, SADNESS, RESISTANCE.

• THE MOST COMMON DISORDER ASSOCIATED WITH PAIN IN THE ELDERLY IS

A. CANCER.

B. OSTEOARTHRITIS.

C. FRACTURED BONES.

D. OSTEOPOROSIS.

• A PATIENT APPEARS TO BE IN PAIN. THE NURSING ASSISTANT SHOULD ASK THE PATIENT TO RATE THE PAIN

BECAUSE THIS PROVIDES

A. EVIDENCE OF DISEASE PROGRESSION.

B. PSYCHOSOCIAL SUPPORT TO THE PATIENT.

C. THE BEST WAY TO EVALUATE THE PAIN.

D. COMPLIANCE WITH FEDERAL REGULATIONS.

• WHICH OF THE FOLLOWING IS AN EXAMPLE OF OBJECTIVE DATA?

A. THE PATIENT FEELS WARM TO THE TOUCH.

B. THE PATIENT’S TEMPERATURE IS 98.6OF.

C. THE PATIENT SAYS HE IS WARM.

D. THE PATIENT’S FAMILY DECLARES THE PATIENT HAS A FEVER.

• WHICH STATEMENT ABOUT HOSPICE CARE IS FALSE?

A. HOSPICE CARE PROVIDES COMFORT WHEN CURE IS NOT POSSIBLE.

B. HOSPICE CARE FOCUSES ON THE WHOLE PERSON AND THEIR FAMILY.

C. HOSPICE CARE CONTINUES AFTER THE PATIENT DIES.

D. HOSPICE CARE IS PROVIDED ONLY IN THE PATIENT’S HOME.

• A PATIENT IS DYING AND HER FAMILY IS AT HER BEDSIDE. THE PATIENT BEGINS TO CALL OUT HER DECEASED HUSBAND’S

NAME, WHICH IS UPSETTING TO THE FAMILY. WHICH OF THE FOLLOWING SHOULD A NURSING ASSISTANT DO?

A. TELL THE PATIENT THAT HER HUSBAND IS NOT THERE.

B. TELL THE PATIENT TO RELAX AND TRY TO SLEEP.

C. TELL THE FAMILY THAT THIS IS NORMAL.

D. TELL THE FAMILY THAT THE NURSE WILL MEDICATE THE PATIENT.

• A PATIENT IS CRYING AND DECLARES THAT HE WANTS TO SEE HIS SON BEFORE HE DIES. WHICH OF THE FOLLOWING SHOULD A

NURSING ASSISTANT NOTIFY?

A. THE PATIENT’S FAMILY

B. THE PATIENT’S DOCTOR

C. THE PATIENT’S ROOMMATE

D. THE PATIENT’S NURSE

• A PATIENT HAS CANCER AND HAS BEEN BEDRIDDEN FOR SEVERAL DAYS. SHE IS RESTLESS AND MILDLY CONFUSED. HER SISTER HAS BEEN

WITH HER FOR THE PAST TWO DAYS WITHOUT REST AND HAS FINALLY GONE HOME TO SHOWER. WHICH OF THE FOLLOWING

SHOULD A NURSING ASSISTANT DO?

A. TALK TO HER & APPLY ARM RESTRAINTS

B. CALL HER SISTER AND ASK HER TO RETURN

C. SIT WITH HER AND STROKE HER GENTLY

D. TELL HER RELAX AND CLOSE HER DOOR

• ADVANCE DIRECTIVES PROVIDE WHAT KIND OF INFORMATION?

A. THE PATIENT’S MEDICAL TREATMENT WISHES IF THE PATIENT IS UNABLE TO SPEAK.

B. THE PATIENT’S MEDICAL INSURANCE COVERAGE IF THE PATIENT IS CONFUSED.

C. THE PATIENT’S PRIVATE FINANCIAL INFORMATION IF THE PATIENT IS UNABLE TO WRITE CHECKS.

D. SURGICAL CONSENT FOR EMERGENCY SURGERY IF THE PATIENT IS UNABLE TO SPEAK.

• THE ASSUMPTION THAT HEALTH CARE WORKERS WILL NOT KNOWINGLY ACT IN A MANNER THAT IS HARMFUL

TO THE PATIENT IS AN EXAMPLE OF WHICH OF THE FOLLOWING?

A. AUTONOMY

B. NONMALEFICENCE

C. JUSTICE

D. BENEFICENCE

ANSWER KEY

QUESTIONS & COMMENTS

• THANK YOU!

• REFERENCES/RESOURCES

• HPCC CHPNA CANDIDATE HANDBOOK

• MOMETRIX CHPNA EXAM SECRETS