• Subject Name : Nursing

Managing Psychological Issues Inclusive of Terminal Restlessness

In the case study of Fortunato Rossi (Frank), it can be seen that various mistakes have been committed by the workforce of hospital general ward and the palliative care unit. Proper care was not provided to Frank and also to his family as this is the responsibility of the nurses to give enhanced quality care to the patient and the carers. The care should have been person-centred that will improve the quality of life of the patient (Nursing and Midwifery Board APHRA, 2020). Therefore, the whole practice of care is critically evaluated to see the errors which were committed by the nurses of both the facility. The evaluation was done by looking at the clinical practice guidelines for the care of the dying person. In addition to that, Nursing and Midwifery Board APHRA guidelines, National Palliative Care Standards and National Safety and Quality Health Service Standards were also considered.

In the case study of Fortunato Rossi, it can be seen that he was admitted to the general ward of the hospital because he experienced confusion and seizure which is of unknown origin. He also complained about a headache and blurred vision. In addition to that, he was having troubles in solving the problem and making decisions. After analyzing and diagnosing the problem, it was found out that he was experiencing increased intracranial pressure likely from brain lesions and could have Glioblastoma Multiforme (GBM). Moreover, he was transferred to the palliative care unit which was near his home. In the night time, it was reported that he had a fall overnight while he was trying to go to the toilet and then after he became confused and fall. He explained that his feet felt numb. Frank's family was informed about his progressing condition and due to that, they were devastated. With time, he lost his ability to be mobile and thus faces urinary and faecal continence. Soon after, he also refused to take his medicines and have frequent episodes of apnoea. He died in the palliative care unit with his wife on his side. He was gone much faster as it was anticipated. However, while receiving care, Frank had many incidents where quality care and standards are not met. Even, many mistakes were performed while taking care of Frank’s family.

According to the clinical practice guidelines for the care of the dying patient, pain assessment and management must be done. The chart provides a pain chart which examines whether the pain is severe, moderate, and mild or is absent. Pain assessment is necessary as it will tell about the experience of the patient with treatment. It will give information about the difficulties that he might be facing. If pain would not be assessed than the further step in treatment would remain unclear and thus, the patient will feel continuous discomfort (van Boekel, 2017; Martorella et al., 2017; Kotfis et al., 2018). In the case of Frank, his pain was not measured using any proper assessment tool while he was in the general ward and also in the palliative care unit. He also had a fall but then also, pain assessment was not done. This is the reason why the pain was not managed. In the Nursing and Midwifery Board APHRA, it is also mentioned that registered nurses have to conduct holistic assessments with the use of multiple techniques. They should also make use of the best available material or evidence for conducting evaluations (Nursing and Midwifery Board APHRA, 2020).

With that, Frank's agitation or restlessness was also not estimated by the workers of the palliative care unit. It was assumed via observing his increased internal cranial pressure that he must be having a high amount of restlessness, upon which his wife was called back to the facility. The nurse did not measure his restlessness via a proper tool. In addition to that, his breathlessness was also not assessed properly by the nurses in palliative care. For proper management of breathing discomfort, appropriate assessment and documentation must be done so that patient suffering could be relieved. If this practice is incorporated by nurses than enhanced patient-centred care can be given to him (Baker, DeSanto-Madeya & Banzett, 2017). In the guidelines of National Palliative Care Standards also, it is mentioned that correct assessment is needed to be made so that focus can be given to person physical, cultural, spiritual, psychological and social needs (National Palliative Care Standards, 2018).

In Frank's case, her wife was informed by the nurses about his severe condition just after she left him in the palliative care facility. Frank's family was there at the time de died. But the family meeting was not headed by the nurses. Nursing care should be given to the family of the person as well as they need emotional and social support at difficult times especially when the patient is receiving end of life care. Nurses could also help in decision-making about the treatment procedure or withdrawing or withholding the treatment that is given to the patient. The family member can experience stress, anxiety and depression from the death of the patient. Thus, they need professional help so that mental wellbeing has remained balance. By doing so, the situation could be more properly handled and it will also help in bereavement (Noome et al., 2016). In the guidelines of palliative care, it is mentioned that carer needs are also important and thus they should be given guidance and support by nurses (National Palliative Care Standards, 2018).

The nurses in addition to that did not review whether the patient is hydrated or have been assisted with proper nutrition while he was at the palliative care unit. This is important because he was refusing to intake his medicines and also he has the problem of confusion. Due to confusion, he might have forgotten to take water or food. Thus, the nurse needs to keep a check on his diet and hydration status. In the literature, it is also found that older patients generally have dehydration problem due to their diseases and because of fluid loss from skin and urine. This leads to poor outcomes and generally longer stays at the hospital. This could be rectified by assessing individuals who have cognitive impairment and by the use of simple interventions (Oates & Price, 2017). In the NMBA code also it is mentioned that nurse needs to develop a plan for nursing. The plan should be made by looking at the best material and learning about the needs of the patient. The nurse should also appraise the relevant information and should work with proper documentation and communication (Nursing and Midwifery Board APHRA, 2020). Therefore, in the case of Frank also, a proper care plan was needed so that all his requirements could be looked at.

In the case of Frank, he was not given any medication for the confusion or delirium that he was facing. He was only given medication for pain and breathing difficulty but the problem of confusion was not regarded and because of which he also had a fall in the night. Moreover, he was having trouble with problem-solving and decision-making, that was also not taken into consideration while he was at a general ward and also in the palliative care unit. Management of confusion was necessary because the patient has to face injuries due to fall and other medical complications. It also causes distress to the carer and the family of the patient. This problem should be assessed by checking the level of awareness and taking mental tests (Shenkin et al., 2019; Tieges et al., 2020). Therefore, for this, comprehensive care standards should be followed by nurses as this will help in recognizing the potential harm to risk to the person (National Safety and Quality Health Service Standards, 2017).

Frank's family and his wife were not provided with a grief counsellor as the death of any person in the family is a very emotional and stressful time. Majority of people cope with grief in a normal way but sometimes people associate bereavement with negative physical and mental health outcomes. Physical risks that are connected to this are increased danger of mortality, morbidity and suicidality. Mental health illness or disorder can include post-traumatic stress disorder (PTSD), depression and problem in grieving which is usually referred to as complicated grief. Therefore, psychological interventions must be implemented that would help with grief and bereavement. Interventions should be aimed for taking care of people with a high level of distress so that risk of mortality could be reduced. In the case of Frank, no support to the family was given during his end moments and also no details about help were provided after his death (Newsom et al., 2017; Newsom et al., 2019; Lundorff et al., 2019). This suggests that Frank’s wife and family were not given any grief counsellor who could help them in grieving. In palliative care standards also it is mentioned that culturally appropriate resources and information should be given to carer and families during the time of grief and loss so that they can be supported. With that, the risk assessment should also be done (National Palliative Care Standards, 2018).

Another mistake which was committed by nurses working in palliative unit commit was that they left Frank all alone after his wife’s visit. The nurse who found him later saw that his vitals were altered and he was having a problem with normal respiration. With that, he was highly restless and was trying to get out of bed by crawling. This shows negligence on the part of the nurse. Mentally ill patient like frank should not be left alone as it can major implications on his health. The patient could also self-harm himself (Troya et al., 2019; Troya et al., 2019; Chew-Graham et al., 2019). In NMBA code also, it is mentioned that nurses should provide safe and quality practice which is person-centred. The nurse should also work with her knowledge, feelings, experience and actions and therefore, should do comprehensive and timely documentation (Nursing and Midwifery Board APHRA, 2020).

In the conclusion, it can be said that, while taking care of Frank, multiple errors were made in the general ward of the hospital and the palliative care unit. The first error was that no pain assessment was done on Frank so as to know about his level of pain. With that, his agitation or restless was also not estimated by the workers of the palliative care unit. He was also experiencing frequent episodes of breathlessness that also was not assessed in a proper manner. There was no family meeting held to offer support and help to Frank's family members and his wife. It was also not checked that he was hydrated or not. Nurses did not monitor his nutrition level also. No intervention was provided to him for his confusion and Frank's family was also not given the help of a grief counsellor who would help them in a difficult time. Moreover, he was left alone in his room which was very dangerous for him. Therefore, it can be said that the nursing practice which was given to Frank and his family was full of errors.

References for Effectiveness of Bereavement Counselling

Baker, K. M., DeSanto-Madeya, S., & Banzett, R. B. (2017). Routine dyspnea assessment and documentation: Nurses’ experience yields wide acceptance. BMC Nursing16(1), 3. https://doi.org/10.1186/s12912-016-0196-9

Chew-Graham, C. A., Morgan, C., Webb, R. T., Emery, A., Carr, M. J., Kontopantelis, E., ... & Ashcroft, D. M. (2019). Reducing risk following self-harm: The need for careful prescribing. British Journal of General Practice, 69(682), 224-225. https://doi.org/10.3399/bjgp19X702317

Kotfis, K., Strzelbicka, M., Zegan-Barańska, M., Safranow, K., Brykczyński, M., Żukowski, M., & Ely, E. W. (2018). Validation of the behavioral pain scale to assess pain intensity in adult, intubated postcardiac surgery patients: A cohort observational study-POL-BPS. Medicine97(38). 10.1097/MD.0000000000012443

Lundorff, M., Thomsen, D. K., Damkier, A., & O'Connor, M. (2019). How do loss-and restoration-oriented coping change across time? A prospective study on adjustment following spousal bereavement. Anxiety, Stress, & Coping32(3), 270-285. https://doi.org/10.1080/10615806.2019.1587751

Martorella, G., Boitor, M., Berube, M., Fredericks, S., Le May, S., & Gélinas, C. (2017). Tailored web-based interventions for pain: systematic review and meta-analysis. Journal of Medical Internet Research19(11), e385. DOI:10.2196/jmir.8826

National Palliative Care Standards. (2018). Available at https://palliativecare.org.au/wp-content/uploads/dlm_uploads/2018/11/PalliativeCare-National-Standards-2018_Nov-web.pdf

National Safety and Quality Health Service Standards. (2017). Available at https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Newsom, C., Schut, H., Stroebe, M. S., Wilson, S., Birrell, J., Moerbeek, M., & Eisma, M. C. (2017). Effectiveness of bereavement counselling through a community-based organization: A naturalistic, controlled trial. Clinical Psychology & Psychotherapy24(6), O1512–O1523. https://doi.org/10.1002/cpp.2113

Newsom, C., Stroebe, M. S., Schut, H., Wilson, S., Birrell, J., Moerbeek, M., & Eisma, M. C. (2019). Community-based counseling reaches and helps bereaved people living in low-income households. Psychotherapy Research29(4), 479-491. https://doi.org/10.1080/10503307.2017.1377359

Noome, M., Beneken genaamd Kolmer, D. M., van Leeuwen, E., Dijkstra, B. M., & Vloet, L. C. (2016). The nursing role during end‐of‐life care in the intensive care unit related to the interaction between patient, family and professional: An integrative review. Scandinavian Journal of Caring Sciences30(4), 645-661. https://doi.org/10.1111/scs.12315

Nursing and Midwifery Board APHRA. (2020). Registered nurse standards for practice. Available at https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Oates, L. L., & Price, C. I. (2017). Clinical assessments and care interventions to promote oral hydration amongst older patients: A narrative systematic review. BMC Nursing16(1), 4. https://doi.org/10.1186/s12912-016-0195-x

Shenkin, S. D., Fox, C., Godfrey, M., Siddiqi, N., Goodacre, S., Young, J., ... & Steven, J. (2019). Delirium detection in older acute medical inpatients: a multicentre prospective comparative diagnostic test accuracy study of the 4AT and the confusion assessment method. BMC Medicine17(1), 138. https://doi.org/10.1186/s12916-019-1367-9

Tieges, Z., MacLullich, A. M., Anand, A., Brookes, C., Cassarino, M., O'Connor, M., ... & Agarwal, K. (2020). Diagnostic Accuracy of the 4AT for delirium detection: Systematic review and meta-analysis. MedRxiv. https://doi.org/10.1101/2020.06.11.20128280

Troya, M. I., Chew-Graham, C. A., Babatunde, O., Bartlam, B., Mughal, F., & Dikomitis, L. (2019). Role of primary care in supporting older adults who self-harm: A qualitative study in England. British Journal of General Practice69(688), e740-e751. https://doi.org/10.3399/bjgp19X706049

Troya, M. I., Dikomitis, L., Babatunde, O. O., Bartlam, B., & Chew-Graham, C. A. (2019). Understanding self-harm in older adults: A qualitative study. EClinicalMedicine12, 52–61. https://doi.org/10.1016/j.eclinm.2019.06.002

van Boekel, R. L., Vissers, K. C., van der Sande, R., Bronkhorst, E., Lerou, J. G., & Steegers, M. A. (2017). Moving beyond pain scores: Multidimensional pain assessment is essential for adequate pain management after surgery. PLoS One12(5), e0177345. https://doi.org/10.1371/journal.pone.0177345

van Boekel, R. L., Vissers, K. C., van der Sande, R., Bronkhorst, E., Lerou, J. G., & Steegers, M. A. (2017). Moving beyond pain scores: Multidimensional pain assessment is essential for adequate pain management after surgery. PLoS One12(5), e0177345. https://doi.org/10.1371/journal.pone.0177345

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