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needs to know the changes that are going on. A dying person goes through physical, psychological changes and experiences spiritual awakening. These changes require support and immediate attention.
A. Physical Needs
The dying patients undergo many physiologic changes,
slowing of body processes and homeostatic imbalance. These changes cause pain and discomfort at the end of life. Besides, that there are alterations in patient energy levels, in respiratory capabilities, in bladder and bladder control, sensory perceptions.
Elimination
Measures related to sensory changes
to maintain cleanliness of the skin, hair and mouth. Dying patients experience excessive diaphoresis. This may necessitate frequent baths and linen changes. Secretions may gather in the eyes and require cleaning of the eyelids with absorbent cotton and saline. Due to elevated temperature, the patients mouth may become dry, requiring mouth care.
2. Pain Control
Pain is unpleasant sensory and emotional experience.
findings
Changes in vital signs Diaphoresis
suctioning are indicated. b. For unconscious patients, a semiprone position facilitates drainage of mucus from mouth & throat. c. Oxygen therapy by cannula or mask may be necessary for both conscious & unconscious patients in some instances.
4. Movement
Assisting patients in & out of the bed & changing
positions is important. Bedridden patients require regular changes of position to prevent decubitus ulcers w/ progressive loss of muscle tone. The patient needs increasing support in maintaining a comfortable position. Patients should preferably be placed in lateral position so that saliva w/c cannot be swallowed will drain from the mouth. When patients are seated, it is important to elevate the lower extremities to prevent pooling of blood brought about by poor circulation.
peristalsis is reduced, there is accumulation of flatus. This condition makes patients anorexic & nauseated. Antiemetics are prescribed to control nausea. High caloric, high vitamin diets are indicated. At this stage, patients would have difficulty in swallowing due to loss of muscle tone. The nurse must assess patients gag reflex. This is to ensure effective swallowing.
6. Elimination
Patients may develop constipation, incontinence
(fecal & urinary), or urinary retention brought a bout by loss of muscle tone. Skin irritation may apply soothing ointment around the anus & perineum. A bedpan, urinal or commode should be available for incontinent patients. The nurse should assist or position the patient on the bedpan or urinal at scheduled intervals. For urinary retention catheterization may be necessary. In some cases an indwelling catheter may be placed. The nurses role to ensure that proper asepsis is maintained.
Many patients prefer a lighted room. Although the sense of touch will be diminished, the patient will sense pressure. A dying patient may hear what people are saying after he or she can no longer respond. When talking to a dying patient, nurses & visitors need to take care to speak clearly & avoid whispering since patients tend to become disturbed when unable to hear.
B. Emotional Needs
Grieving is the normal response to loss, i.e., loss of
loved one, loss of something external to us, loss of some part of us. A dying person responds to his eventual death by grieving. Kubler Ross, a psychiatrist has done studies on feelings & experiences of terminal patients. Out of her studies she identified psychological stages of grieving that are usually experienced when an individual is facing death.
Stages of Grieving
1st Stage: Denial (Hindi kaya nagkamali ang doktor sa kanyang diagnosis/) Patient uses denial to protect himself against the anguish & despair of his situation. Denial is an adoptive coping mechanism to delay the pain & shock until the patient is better able to deal with the reality.
nd 2
natamaan ng cancer) Anger & rage are felt regarding the unfairness of the diagnosis. These feelings are projected on to family & caregivers who are able to continue w/ life & activities.
rd 3
Stage: Bargaining
taon pa. Sana maka-graduate man lang siya ng high school... [Sigh] ) Bargaining is an attempt to postpone dying until certain tasks are completed. These requests are usually made to God & provide a way for the patient to deal w/ the situation in small increment.
th 4
Stage: Depression
ang mga pag-aayos ng sarili eh tutal...) Depression occurs when the patient realizes that he is about to lose many things. E.g., family, job, control, his life itself. This realization produces profound sadness & depression.
th 5
Stage: Acceptance
Please dont give oxygen, dont put me on respirator. I am 70 years old. My time has come to be w/ my Creator. I am ready to go dont delay me.) Acceptance comes when a patient acknowledges & recognizes that death is inevitable. The patient accepts it after having gone through all the other stages. She/he may become increasingly detached & show readiness to go. Some patients never reach stage & die in denial w/ anger & sorrow. The emotional needs are different at each stage. The nurse is significant. Presence & intervention are needed.
Anger
Help patient understand that anger is normal response to feelings of loss & powerlessness created by the impending death.
Do not withdraw or retaliate w/ anger. These isolate the patient & family further & increase guilt & anxiety.
Rationale: Anger is often directed at a trusted person w/ whom patient feels safe & who will accept the anger & not cease to care. Deal w/ some of the needs underlying anger.
Provide structure & continuity in patients care this increases patients feelings of security. Allowing patient as much control as possible over his or her life helps to decrease feeling of powerlessness.
Should not take anger personally or label patient or support persons as ungrateful or uncooperative.
Bargaining
When cues are present, nurse needs to listen attentively, encourage patient to talk. For some patients bargaining is based on guilt or fear of retribution for past sins, real or fake. Talking can relieve guilt & irrational fears. In some situations it may be advisable to refer the patient to a member of the clergy.
Depression
Rationale: Patient has reason to be sad & must be allowed to express sadness. Some patients review past losses:, e.g., of money or a job at this time & need a listening ear & support from the nurse.
Dont avoid the patient. Dont try to cheer the patient up.
Most helpful nursing intervention: is to communicate nonverbally, e.g., by sitting quietly & not expecting conversation or conveying caring touch.
Being with the patient in silence is very important.
Acceptance
Direct patient activities toward maintaining tyhe patients self-worth & ensuring that patient is not alone. Encourage the patient to participate as much as possible in his or her treatment program. Spend time w/ patient & convey caring can relieve patients feelings of loneliness or fear.
C. Spiritual Needs
Terminally ill persons have develop deep spiritual needs. Illness is the time when people are confronted w/ the issue of mortality. This is the time when patients question the meaning of suffering & the meaning of life. Patients become keenly aware of their failure to live up to the expectations of God, expectation of others & their own expectations. This sense of failure results in guilt. The issue of guilt can only be resolved through repentance & receiving forgiveness.
Dying is a journey taken solely by the patient. For many, making the journey alone can be fearsome. The fear of the unknown can be assuaged through connecting w/ a supreme being. By being personally related to God, his need for love & belonging is, thus adequately satisfied. In summary, a dying person experiences spiritual crises if his spiritual needs are not met satisfactorily. The spiritual needs are (1) need for meaning & purpose (2) the need for forgiveness & (3) the need for love & belonging.
This demands that the nurse cultivate sharp clinical eye for spiritual needs. Clinical sharpness is assessing unmet spiritual needs & skills in meeting these needs can be developed gradually. An efficient way of providing spiritual care is through the nursing process. Nursing process is central to nursing actions. It assists the nurse to organize those process includes assessment, needs, planning, implementation & evaluation.