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Nurses Role

Prepared by: Pe amora, Joe Louise Que, Honey Sharlotte

Nurses work to promote health, prevent disease and help patients cope with illness. They are advocates and health educators for patients, families and communities. When providing direct patient care, they observe, assess and record patient symptoms, reactions and progress. Nurses collaborate with physicians in the performance of treatments and examinations, the administration of medications, and the provision of direct patient care in convalescence and rehabilitation.

Providing direct care Advocate Counselor Collaborative Role

Providing direct care

When providing direct care, registered nurses observe, assess and record symptoms, reactions and progress; assist physicians during treatments and examinations; administer medications; and assist in convalescence and rehabilitation.

Advocacy involves promoting what is best for the client, ensuring that the client s needs are met, and protecting the client s rights. Social advocacy entails advocating on behalf of a population or a community to effect positive change. Nurses engaged in this form of advocacy can create healthy environments through political action, community education, and involvement in professional organizations.

The overall goal of the client advocate is to protect client s rights. Informs the client about their rights and provides them with the information they need to make informed decisions. Supports clients in their own decisions, giving them full or at least mutual responsibility in decision making when they are capable of it.

Values basic to client advocacy:

The client is a holistic, autonomous being who has the right to make choices and decisions. Clients have the right to expect a nurse-client relationship that is based on shared respect, trust, collaboration, in solving problems related to health and health care needs, and consideration of their thoughts and feelings. It is the nurse s responsibility to ensure the client has access to health care services that meet health needs.

Common areas requiring Nurse-Patient advocacy:

End of life decisions Technological advancements Healthcare reimbursements Access to health care Provider-patient conflicts regarding expectations and desired outcomes Withholding of information or blatant lying to patients

Insurance authorizations, denials, and delays in coverage Medical errors Patient information disclosure Patient grievance and appeals processes Cultural and ethnic diversity and sensitivity Respect for patient dignity Informed consent Incompetent health care providers Complex social problems including AIDS, teenage pregnancy, violence, poverty Aging population

Private duty nurse

Focuses on helping the person develop new attitudes, feelings, and behaviors rather than on promoting intellectual growth. Encourages the client to look at alternative behaviors, recognizes the choices, and develop a sense of control. Counseling can be provided on a one-to-one basis or in groups. Often nurses lead group counseling sessions. The nurse may be a leader, member, or resource person in any self-help group in which the nurse may assume the role of structuring activities and fostering a climate conductive to group interaction and productive work.

Counseling requires therapeutic communication skills. The nurse must be a skilled leader able to analyze a situation, synthesize information and experiences, and evaluate the progress and productivity of the individual or group. The nurse must also be willing to model and teach desired behaviors, to be sincere when caring in the welfare of the others.

Collaborative Role
COLLABORATION- Is a recursive process where two or more people or organizations work together toward an intersection of common goals. Nurse in a collaborative role help shapes relationships between nurses and clients, nurses and support persons, and nurses and colleagues. In this role, communication is important. Communication facilitates all nursing actions. The nurse communicates to other health care personnel the nursing interventions planned and implemented for each client.


There is an agreement to pursue a common purpose and a sharing of knowledge to resolve problems, decide issues, and set goals within a structure of collegiality. The partners decide together the kinds of activities and functions that each will contribute.

Allow for the separateness of each partner. Issues of power and control are discussed. The interests of each of the parties to the collaborative venture must be enumerated for all.


Communication Competence Trust Commitment to goals Consistency of purpose

Issues and Trends in Hospice Pallative Care

Palliative Care: Definition

The active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with anti-cancer treatment. World Health Organization, 1990

Palliative Care: A Therapeutic Model

Palliative care is an interdisciplinary therapeutic model targeted to the care of patients with all types of chronic, progressive illness. Palliative care focuses on maintaining a satisfactory quality of life throughout the course of the disease intensifies as death approaches to ensure the patient and family that comfort will be a priority, values and decisions will be respected, psychosocial and spiritual needs will be addressed, practical help will be available, and opportunities for closure and growth will be enhanced. Palliative care should be integrated with disease-modifying therapy as part of routine care and be available as a specialized program for those with intense needs.

Palliative Care: The Need for Specialized Care

To optimize palliative care
Integration into best routine medical practice Access to specialized care
Management of complex symptom control problems

Comprehensive care for multiple needs Comprehensive care of the imminently dying

Access to specialized care: other benefits

Education and training
Role modeling Direct teaching Formulation and testing of conceptual models Enhancing health care systems Program development and testing Quality improvement programs Development of clinical pathways Clinical research

Palliative Care: A Specialty

What is specialist level care?
Involvement of professionals and volunteers with high level of knowledge and skills, who
Function as a team Consider the family as the unit of care Direct a care plan that integrates resources at home, management of the primary medical team, and specific palliative care interventions

Focus on the care of patients with advanced disease and perceived short prognosis, often the imminently dying

Palliative Care: Targets for Care

Addresses needs in the multiple domains inherent in quality of life
Physical: Symptoms, progressive impairments Psychological: Symptoms, psychiatric disorders, mood and worries, adaptation and coping, body image, sexuality Social: Role functioning, family integration, intimacy Spiritual: Religion and faith, meaning, values, need to contribute, transcendence Others: Economic

Addresses needs that may become most prominent as death approaches

Death preparation Assurance of comfort Support for autonomy, decision making consistent with values, and preparation for surrogate decisions Intensifying family support

Care at the End of Life:

Symptom Prevalence in AIDS Symptom Worrying No energy Sadness Pain Irritability Sleep Difficulty Prevalence (%) 85.5 85.1 81.5 75.6 75.1 73.8

Symptoms in 200 Patients During the last 48 Hours of Life

Symptom Prevalence (%) Noisy, moist breathing 56 Urinary dysfunction 53 Pain 51 Agitation 42 Dyspnea 22

Caregiver Burden
20% of family members quit work to provide care Financial devastation
30-40% of Americans report loss of most family savings while caring for a dying relative

Status of Palliative Care in the US: SUPPORT Study

SUPPORT Study : Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments Approx. 10,000 patients, 5,000 deaths related to 9 serious illnesses during admission to 5 US teaching hospitals

SUPPORT: Phase I Findings

46% of DNR orders were written within 2 days of death 47% of physicians knew when their patients wanted to avoid CPR 38% of patients spent 10+ days in ICU 50% of dying patients suffered severe pain High hospital resource use

SUPPORT: Phase II Findings

Compared to control patients, those patients whose preferences and prognoses were communicated experienced no change in:
incidence and timing of written DNR orders Patient-MD agreement on CPR preferences Days in ICU, comatose or on ventilator Pain Hospital resource use

SUPPORT Study: Conclusions

Substantial shortcomings in care for seriously ill Improving doctor-patient communication through intermediary is inadequate to change practice

Care at the End of Life: Reasons for Deficiencies

Deficiencies in professional training and focus Deficiences in the system of care Problems with the professional
Lack of physician training in symptom control, communication skills, ethics, use of technology in end of life care Death as medical failure No medical role in dying Palliative care skills undervalued Role of the physician ends when care shifts from curative to palliative Always more biotechnology Anxiety about one s own mortality

Problems with the system

No systems (policies and procedures) established to support excellence in palliative care as part of routine inpatient management No access to specialized programs in palliative care

Department of Pain Medicine and Palliative Care

Inaugurated in 1997
First program jointly devoted to pain and palliative care A certified hospice program, the Jacob Perlow Hospice, within the palliative care division

Clinical Programs

Inpatient consultation team

10-15 consults per week, 80% palliative care

Ambulatory practice

550 visits (100 new patients) per month, 80% pain

 Inpatient unit

14 beds, 80% palliative care/hospice occupancy

 Jacob Perlow Hospice

105 patient daily census (>80% home care)

Institute for Education and Research in Pain and Palliative Care

Source of programs to improve routine practice
Conferences, professional training, website Special projects

Palliative Care for Advanced Disease (PCAD)

A guideline for the interdisciplinary management of imminently dying patients Offers instruments to track process and outcome data related to institutional EOL care

PCAD: Key Elements

Respect patient autonomy, values, and decisions Continually clarify goals of care Minimize symptom distress at EOL Optimize the delivery of appropriate supportive interventions and consultation Reduce unnecessary interventions Support families by coordinating services Provide bereavement services for families and staff Facilitate the transition to alternative care settings, such as hospice, when appropriate

Pain Medicine and Palliative Care: Nurses, Physicians, Social Workers, Psychologists, Hospice Team Patient Care Services (Nursing) Quality Improvement and Tools Experts Evaluation and Research Ethics Chaplain Pharmacy Social Work Leadership Teams and staff of pilot units (Oncology, Geriatrics, Hospice)

PCAD Care Path

Treatment/Interventi ons/Assessments Pain Management Tests/Procedures Medications Fluids/Nutrition Activity Consults Psychosocial Needs Spiritual Needs Patient/Family Education Discharge Planning

PAIN MANAGEMENT ASSESS PAIN Q 4 HR and evaluate within 1 hr post intervention. Complete pain assessment scale. Anticipate pain needs. TESTS/PROCEDURES Usually unnecessary for patient/family comfort (All lab work and diagnostic work is discouraged)

Medication regimen focus is the relief of distressing symptoms.

DIET: Selective diet with no restrictions

y Nutrition to be guided by patient s choice of time, place, quantities and type of food desired. Family may provide food. y Educate family in nutritional needs of dying patient IVs for symptom management only TRANSFUSIONS for symptom relief only Intake and Output consider goals of care relative to patient comfort Weights consider risks/benefits relative to patient comfort

ACTIVITY DETERMINED BY PATIENT S PREFERENCES AND ABILITY. Patient determines participation in ADLs, i.e.,turning and positioning, bathing, transfers

Initiate referrals to institutional specialists to optimize comfort and enhance Quality of Life (QOL) only.

PSYCHOSOCIAL COMFORT ASSESSMENT of: y Patient y Primary caregiver y Grieving process of patient & family PSYCHOSOCIAL SUPPORT: Referral to Social Work y Offer emotional support y Support verbalization and anticipatory grieving y Encourage family caring activities as appropriate/individualized to family situation and culture y Facilitate verbal and tactile communication y Assist family with nutrition, transportation, child care, financial, funeral issues y Assess bereavement needs

y Spiritual supports y Spiritual needs and/or distress

SPIRITUAL SUPPORT: Referral to Chaplain

y Provide opportunity for expression of beliefs, fears, and hopes y Provide access to religious resources y Facilitate religious practices


y y y y

Goals of Palliative Care for Advanced Disease Physical and psychosocial needs during the dying process Coping techniques/Relaxation techniques Bereavement process and resources

FOR DISCHARGE TO COMMUNITY: Referral to Pain Medicine & Palliative Care/Hospice/Home Care/Social Work as needed. FOR DEATH: y Post mortem care observing cultural and religious practices and preferences y Provide for care of patient s possessions as per family wishes y Bereavement support for family and staff