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Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 32: Psychological Needs of Patients With Medical Conditions Instructor’s Manual Thoughts About Teaching the Topic This chapter will help students gain awareness that patients on medical-surgical units are more than a collection of physical symptoms. Certain emotional reactions are shared by a majority of hospitalized individuals (e.g., anxiety), but the chapter teaches that patients’ emotional responses may be much more complex. Use of videos allows students to become aware of these intense emotions in a safe setting. Use of computer-assisted instruction allows participation in decision making, also in a safe environment. Key Terms and Concepts coping skills holistic approach psychiatric consultation liaison nurse (PCLN) stigmatized persons with medical conditions Objectives Describe the influence of stress on general medical conditions. Construct a nursing diagnosis for an individual who has HIV and depression. Explain the importance of nurses’ teaching relaxation techniques and coping skills to patients with medical illnesses. Perform a comprehensive nursing assessment for a patient with a medical illness. Assess the patient’s coping skills by identifying (a) areas for psychoeducation teaching and (b) areas of strength. Identify two instances in which a consultation with a psychiatric consultation liaison nurse might have been useful for your medical-surgical patients. Chapter Outline Teaching Strategies Psychological Factors Affecting Medical Conditions Both the medical and mental health communities recognize the interrelationships between psychiatric and medical co-morbidities. Psychological factors may present a risk for medical disease, or they may magnify or adversely affect a medical condition. Psychological Responses to Serious Medical Illness Some of the concerns of people faced with a severe physical illness include: Will I be disfigured? Will I have a long-term disability? Will I be able to function as a (wife or husband, parent, and person in society)? Depression Depression is a risk factor for medical nonadherence. Depressed patients are three times more likely to be nonadherent to medical treatment recommendations than those who are not depressed. Anxiety Anxiety accompanies every illness. Verbalization is an effective outlet for anxiety, but ability to verbalize may be compromised by Instructor’s Manual 32-2 cultural expectations, disability, or lack of a listener. Helplessness often accompanies anxiety. Self-centredness, characterized by unreasonable requests of caregivers, may also cover inadequacy and anxiety. Long-term pervasive anxiety or an anxiety disorder can be a risk factor for a medical disorder. It is important for nurses to identify and assess coexisting or resulting psychological response or disorders. Substance Abuse Long-term abuse of various substances can lead to medical complications such as hepatic conditions from alcohol use, lung disease from marijuana use, cardiac toxicity from cocaine use, and similar damage. Or patients who are diagnosed with serious medical conditions turn to alcohol or other substances (or both) in order to cope with overwhelming feelings of hopelessness, fear, anxiety, depression, or pain. Grief and Loss Serious medical illnesses are nearly always accompanied by grief and loss. Any type of treatment or procedure that is intended to treat a physical illness and that creates a major permanent change is accompanied by feelings of loss. Dynamics involved in coping with these feelings are similar to those operating in a person who is dealing with his or her own imminent death or the death of a loved one. Grieving involves spiritual changes, as well as emotional changes, and as such requires patient spiritual assessment. Denial Denial may cause minimizing of symptoms such as pain or may cause the patient to focus on the positive while leaving negative information about an illness unnoted. Caregivers may unwittingly collude with the person in denial by not performing complete assessments or accepting the person’s subjective appraisals. Fear of Dependency Responses to being dependent may take the form of anger, inability to accept nurturing, and refusal of treatment. Others may fear that dependency needs will go unmet and do not express any negative feelings to caregivers. Suppressed negative feelings may gain expression as somatic complaints. Nursing Care of Patients With Medical Conditions Psychosocial Assessment A psychosocial assessment is done in tandem with a thorough physical workup and mental status exam. An outline for a psychosocial assessment is given in Chapter 9. Quality of Life The nurse must understand how a person’s medical conditions affect quality of life. How is the medical illness affecting the ability to function in the home, at work, or in school? How is the patient’s ability to function in general? What is the patient’s normal routine, and has it been changed? Coping Skills People who undergo a life-threatening disease or chronic illness most often deal with distressing physical side effects and change in their body image. Typical concerns of patients with new colostomies and patients with breast cancer are reviewed. It is important for the nurse to know if patients have the coping strategies and social supports to help them deal with the consequences of their illness. 32-3 Spirituality and Religion Beliefs and practices are forces that have been evidenced to promote resilience; practising healthy coping depends upon the capacity to create meaning from experiences (Meyerstein, 2005). Social Support As time proceeds, many patient supports begin to wane. The nurse can assist the patient in creating sufficient supports such as family, friends, neighbours, and church or other religious connections over a period of time, including a medical support group. General Intervention Useful interventions for reducing stress and inducing relaxation include meditation, guided imagery, breathing exercises, progressive muscle relaxation, and biofeedback. Cognitive approaches such as journal keeping, restructuring, setting priorities and goals, cognitive reframing, and assertiveness training may be useful. Human Rights Abuses of Stigmatized Persons with Medical Conditions Stigmatized medically ill persons include those who are HIV positive and those who have transgender surgery or treatment. Stigmatization can result in inadequate care, undue stress, worsening of physical illness, and even death. Examples of human rights abuse include neglect in fully investigating somatic complaints in the emergency department, avoidance of contact with or refusal to care for such persons, hasty labeling with a psychiatric diagnosis, and inappropriate psychiatric admission. These situations occur more frequently in cases of people who lack family support, those from lower socioeconomic classes, newly arrived immigrants, and other stigmatized and marginalized populations. Psychiatric Liaison Nurse The psychiatric liaison nurse, a resource for staff, is a master’s degree–prepared nurse with expertise in both psychiatric and medical-surgical nursing. This individual functions as a nursing consultant in the management of psychosocial concerns and as a clinician in helping the patient deal more effectively with physical and emotional problems. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 33: Care for the Dying and for Those Who Grieve Instructor’s Manual Thoughts About Teaching the Topic Although nearly everyone has experienced a loss, many nursing students cannot conceptualize the depth and breadth of the experience of losing a loved one. Certainly everyone’s experience of grief and loss is deep, personal, and individual. Learning activities in this chapter are designed to sensitize students to the feelings experienced by those who are dying and those who are grieving. Rather than pathologizing grief, new theory and practice emphasizes understanding when grief is complicated, and when other mental illnesses coexist and are also complicated by grieving—for instance, in separately diagnosable and treatable depression, substance use problems, anxiety, sleep–wake disorders and so on. Students may benefit from a one-day observation in a hospice unit or, if available, with a palliative home care nurse. Key Terms and Concepts anticipatory grief bereavement complicated grief disenfranchised grief Four Gifts of Resolving Relationships grief hospice palliative care mourning palliative care Objectives Compare and contrast specific goals of end-of-life care inherent in the hospice palliative care model with those of the medical model. Analyze the effects of specific interventions nurses can implement when working with a dying person and his or her family and loved ones. Analyze how the Four Gifts of Resolving Relationships (forgiveness, love, gratitude, and farewell) can be used to help people respond to a dying loved one. Explain the distinction between the terms grief and mourning as presented in this chapter and how the effectiveness of a holistic approach can be beneficial to the person. Differentiate among some of the characteristics of normal bereavement and complicated grieving. Explain how various models of understanding grieving (dual process, four tasks of mourning) can enhance your care of those who grieve. Discuss at least five guidelines for dealing with catastrophic loss, and identify appropriate support for someone in acute grief. Chapter Outline Teaching Strategies Care for the Dying Caring for patients who have terminal illnesses or are near death due to other conditions challenges and rewards nurses in deep and personal ways. The Canadian hospice palliative care treatment model and the advanced-care-planning national framework provide tools that promote patient- and family-centred care for people facing potentially lifethreatening situations. Hospice Palliative Care The hospice movement, which had its beginning in England in the 1960s, began to address the needs of dying patients by seeking to effectively manage physical symptoms, especially pain, as a way of palliating the process of dying. Kübler-Ross began her work with dying patients in the United States in the late 1960s. She identified distinctive phases or cycles in our response to terminal illness—denial, anger, bargaining, depression, and acceptance—and realized that personal growth did not cease in the last stages of life. Like those before him, Canadian physician Balfour Mount found that treatments for the terminally ill were abysmally inadequate, so he set up a hospital-based palliative care unit at the Royal Victoria Hospital in Montreal, taking the name palliative from its meaning, “to improve the quality of something.” Dr. Mount is known as “the father of palliative care,” an approach that evolved into a pan-Canadian movement, with goals of relieving suffering and improving quality of life for those who are living with or dying from an illness. This movement eventually led to the development of the Canadian Hospice Palliative Care Association (CHPCA), established in 1991, which is the national voice for hospice palliative care (HPC) in Canada. HPC is defined as whole-person health care aimed at relieving suffering and improving quality of life rather than aiming for a cure. Nursing Care at the End of Life Providing nursing care for those at the end of life (EOL), and supporting their families in any setting, calls for a holistic approach, assisting people as they progress through the final stage of life. Hospice Palliative Care Nursing In addition to providing practical care, nurses need to demonstrate enhanced communication, coordination, and management skills, selfcare, and the ability to “recognize and attend to the meaning in suffering” (Vogel, 2011, p. 418). The Art, Presence, and Caring of Nursing Caring for patients at the end of life requires a shift in professional expectations. It involves not only curing but also healing concepts of care: valuing, connecting, empowering, doing for, and finding meaning. To approach nursing work with art, presence, and caring, two essential skills to practise are listening and observing. Assessment for Spiritual Issues Spirituality, the dimension of human experience that can provide meaning for life, is integral to EOL care. Conducting a comprehensive spiritual assessment is important to understanding how a patient’s spirituality may enhance comfort. In addition to thoroughly assessing connections to a specific religion, nurses can become skilled at listening for the patient’s intrinsic spirituality. For many patients, religion provides context, community, and comfort when facing EOL challenges. Some examples of questions may be, Tell me how you are doing spiritually. What gives your life meaning? What role do your beliefs play in regaining your health? Awareness and Sensitivity of Cultural Contexts Spiritual and cultural contexts and care are often inextricably intertwined. While it is impossible for the nurse to know all things about all cultures, it is imperative as professionals to be aware of the need to explore cultural contexts, history, and practices important to patients and families and supportive of care (see Chapter 7). Palliative Symptom Management Excellent symptom management is a hallmark of hospice palliative care. Each symptom should be assessed individually. Treatable, reversible, and temporary conditions can be mistakenly attributed to the terminal diagnosis. For example, if a patient reports feeling depressed, it is important not to assume that the feelings are due to the dying process. If the patient becomes confused or lethargic, it is essential to rule out causes such as medication effects, dehydration, delirium, urinary tract infections, and constipation before attributing the symptom to terminal decline. The Importance of Effective Communication Effective communication skills are at the heart of developing a therapeutic relationship, assessing the patient, and providing holistic care to the patient and family. A strong therapeutic relationship will guide discussions and decision making for patients and families in times of loss (see Chapter 10). In addition, effective communication helps decrease distress and total pain and suffering. Anticipatory Grief Anticipatory grieving, when not understood, can cause family members to withdraw prematurely from the patient so as to avoid pain. The nurse can teach about the symptoms and facilitate open discussion of the patient’s and family’s experiences. Naming the experiences and talking about them normalizes the process and makes it less frightening. The Four Gifts of Resolving Relationships Sharing four important “gifts” is a way of healing relationships before the person dies. The gifts are forgiveness, love, gratitude, and farewell. The individual speaks or writes of resentment or hurt and willingly lets go of blame and anger. In addition, the person asks, “Is there anything I have done, or not done, for which I need to say I’m sorry?” The second gift is to express love to each other. The third gift is thanking the person for what she or he has been in the person’s life. They can reminisce; listen to favourite stories; and acknowledge things usually taken for granted. The fourth gift is to acknowledge the coming separation. This gives and receives permission for the death to occur. Practise Good Self-Care The greater call for human-to-human presence in end-of-life nursing leads to increased vulnerability to emotional attachment. This increases the need for the nurse to be continuously attentive to self-care. The nurse must establish an emotionally healthy balance and continuously rely on support of the multidisciplinary team to practise good self-care. This invites nurses and other health care personnel to greater self-understanding, wisdom, and compassion, and the team approach is integral to this process. Nursing Care for Those Who Grieve Loss is a part of life, and grief is the normal response to loss. Losses include loss of relationships, loss of health, loss of status or prestige, loss of security, loss of self-confidence or self-concept, symbolic losses, and change in circumstances. Bereavement is a physically painful experience. Grief Reactions to Bereavement and Mourning Grief refers to the subjective feelings and affect precipitated by loss. Mourning refers to the processes by which grief is resolved. Mourning involves disengaging strong emotional ties from a significant relationship and reinvesting them in a new and productive direction. Bereavement refers to the social experience of dealing with loss of a loved one through death. For nurses to be helpful to patients, they must first examine their own feelings and their personal experience of loss. Understanding theories, models, tasks, and other factors can help nurses facilitate their own grief and reduce bereavement overload. Types of Grief Grief is a multifaceted, deeply personal human response to loss. Disenfranchised grief can occur when losses are not always openly acknowledged, supported, or recognized as significant, such as a loss through suicide, the loss of a friend, the loss of a pet, or the grief of someone thought incapable of grieving (e.g., a child, a person with dementia) (Nelson, 2011). A sense of isolation can occur, and nurses need to recognize the grief as real and intervene by acknowledging the loss, supporting feelings, and encouraging the person grieving to reach out to supportive networks. Nurses also need to recognize when grief complicated—prolonged, dysfunctional, or maladaptive. In the past, there was debate about how best to recognize and manage more severe reactions to grief, with some supporting the need to consider complicated grief a separate entity under the Diagnostic and Statistical Manual of Mental Disorders, and others arguing the need to stop trying to pathologize varied grief experiences (Collier, 2011; Harris, 2010; & Worden, 2009). The DSM-5 has addressed this debate and cautions clinicians to differentiate normal grieving from a mental health diagnosis of major depressive or adjustment disorders, following clear criteria for these distinct disorders. The goal is to ensure that those who need intervention receive an accurate diagnosis. Theories: Dual Process Model Stroebe & Schut (2010) identified loss-oriented stressors, which include concentrating on the loss experience, feeling the pain of grief, remembering, and longing. Restoration-oriented stressors re-engage the mourner with the outer world, as in overcoming loneliness (seeking social support), mastering skills and roles once performed by the deceased person, finding a new identity, and facing many practical details of life. By identifying specific coping activities on both sides of the model, the nurse can strengthen a grieving person’s skills and reinforce positive meanings. Theories: Four Tasks of Mourning J. William Worden organizes aspects of mourning into four tasks: accept the reality of the loss, experience the pain of grief, adjust to an environment without the loved one (externally, internally, and spiritually), and relocate and memorialize the loved one. Helping People Cope With Loss Some people who are grieving are resilient, and limited counselling support, focusing on grief education, normalizing of experiences, and skilled supportive presence, seems to be helpful for them. Other helpful interventions include writing letters (both to and from the deceased), performing simple rituals and ceremonies, “dosing” times of grieving throughout the day or week, working on projects to memorialize the deceased (e.g., planting a tree, creating a Web site), and planning ahead for holidays and anniversary dates. Table 33-3 offers other suggestions. Palliative Care for Patients With Dementia The incidence of Alzheimer’s disease and related dementias in Canada continues to grow at a staggering rate (Alzheimer Society, 2010). All caregivers should receive education on the unique elements of palliative dementia care in order to increase comfort and enhance quality of life. Caregivers must remember to focus on the person rather than the disease and recognize the numerous opportunities that arise with every interaction to affirm the meaning of the individual’s life, uphold dignity, and provide pleasurable sensory and spiritual experiences. It is also important to address health care decisions for advanced dementia such as resuscitation, hospitalizations, antibiotics, and nutrition/hydration. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400

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