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Palliative Care

 is the medical specially focused on improving over all quality of life for patients and
family facing serious illness. Emphasis is placed on intensive communication.

 Pain and symptoms management and coordination of care.

 Is provided by a team of professionals working together with the primary doctor.

 Is not a one size fits all approach.

 A key benefit of palliative care is that it looks at the patient as a whole in order to meet
the individual needs of each person and family.

 Relieve symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of
appetite and difficulty of sleeping.

 It helps patient gain the strength to carry on with the daily life.

 Benefits both patient and their families.

Key of Palliative Care:
1. Symptom Management
2. Communication
3. Support for the family

Difference of Palliative Care to Hospice Care:

1.Palliative Care
- may be provided at anytime during persons illness, even from the time of diagnosis.
- can take place as curative treatment.

2. Hospice Care
- provides palliative care. However, hospice is focused on terminally ill patients.
- people who are no longer seek treatment to cure them.

 There 5 components of environment that affect health of individuals.

 External influences cam prevent ,suppress or contribute to disease or death.


 Lives in unstable environment.

 Health – implies forward movement of the personality and human process

toward creative, constructive, productive, personal and community living.

 Nursing – a significant , therapeutic , interpersonal process that functions

cooperatively with others to make health possible.

Involves problem solving.

The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery that he would
perform unaided if he had the necessary strength, will, or knowledge.



 Topology of 21 nursing problems

 Nursing – a helping profession, a comprehensive service to meet patient’s needs,
increases or restore self help ability

 Health – excludes illness , no unmet needs and no actual or anticipated impairments.

 Person- one who has physical , emotional or social needs. The recipient of nursing care


 5 interalated essential elements

Patient – the person receiving care
Goal of nursing – adapting to change
Health – being and becoming a whole person.
Direction of nursing activities – facilitating adaptation


 Caring can be demonstrated and practiced

 Caring consist of curative factors

 Caring promote growth

 A caring environment accepts a person’s as he is and looks to what the person may

 Caring promotes health better than cure

Watson’s 10 curative factors

 Forming humanistic.

 Instilling hope.

 Cultivating sensitivity to self and others.

 Developing helping trust relationship.

 Promoting expression of feeling.

6. Using problem solving for decision making.
7. Promotes teaching and learning.
8.Assisting with gratification of human needs.
9.Promoting supporting environment.
10.Allowing for existential and phenomenological forces.
Lydia hall

 CARE – hands on

 CORE – therapeutic use of self

 CURE – administration of meds. And treatment

Applying medical knowledge


History of End-of-Life Care

1967- Dame Cicely Saunders found the first modern Hospice in London and introduces
the concept in the U.S while lecturing at Yale.

1978- the first U.S hospice is founded in New Haven, Connecticut.

1978- National Hospice Organization (NHO) is founded.

1982- congress passed the medicare hospice benefit under medicare Part A.

1987- Hospice Nurses Association (NHA) was formed.

1990- WHO defines Hospice and Palliative care to set International Standards.

1990- Congress passed the patient self-determination Act. Giving patients the right to
advance directives and choices in their medical care.

1994- first nurses are certified as Hospice Specialists through the National Board of
Certification of Hospice Nurses.
1997- HNA becomes the Hospice and Palliative Nurses Association.

1999- Certification of Hospice and Palliative Nurses begins.

2000- NHO becomes the National Hospice and Palliative Care Organization.


 End-of-Life care may last moments or months depending on the circumstances and
the setting in which patient dies.

 It may involve complex drug regimen and near constant symptomatic care, or it
may involve only honest, compassionate conversations with family members.

 Either way have acted to ease a patient’s transition from life to death.
 Palliative care seeks to prevent and relieve suffering and to enhance the patient’s
quality of life.

 Seeks to ease all aspects of suffering, not just the physical ravages of the disease or

 Typically provided by an interdisciplinary team.

Philosophy of Palliative Care

 Palliative care provides support and care for persons facing life-threathening illness
across setting.

 Is based on the understanding that dying is a part of normal life cycle.

 The process of dying is a profound individual experience.

 Care is focused on enhancing the quality of remaining life by interacting, physical,

psychological, social and spiritual aspects of care.

 The goal of interdisciplinary team is to work with patients to identify their specific
needs and health goals.

 Use of interdisciplinary team is likely the key to addressing the many needs of the
dying and their families.

 When palliative care succeeds, the patient dies what we call a “good death” free from
avoidable distress and suferring in keeping with his family’s wishes, and according to
accepted clinical and ethical standards.

Key Concepts in Hospice Palliative Care

• Unit of care – family and patient ( a core principle of palliative care).

• Interdesciplinary Team

 Address the physical, social, emotional, and spiritual needs.

 Includes physician, nurses, social workers, volunteer, coordinators, clergy and

bereavement coordinator.
3. Medical treatment
 Provides treatment for pain and other symptoms of terminal illness.

 Symptoms like dyspnea, nausea, vomiting, restlessness, agitation, fear and so on.

4. Holistic Care

 The interdisciplinary team develops a plan of care.

 The patient is treated in a holistic manner.

5. Volunteer Support

 They are trained as many as 30 hours of education in all aspects of hospice care.

 They stayed in the home of the patient.

6. Hospice setting

 Home or nursing facilities

 Home for terminally ill patient

7. Bereavement Support

 Emphasizes comfort, dignity and quality of life.

 Clergy is responsible for the support

 Focuses on spiritual and existential issue

8. Control

 The patient and family have the right to choose where end of life is delivered.

 Decide of whether to eat or drink.

Discussing death- context of hope, meaning of life and continued growth.

Result to patient realization that death is a natural part of life.

Caring for people in this phase of life acknowledges their experience and gives them a
feeling of personal wholeness and value.

Doctor: Usually acts as the care team leader; makes treatment plans and decides on
medication and dosing; may consult with other doctors such as pain specialists or
radiation oncologists.
 The doctor may be available to make home visits or may supervise the cae plan
without actually seeing the patient.

Nurse: Gives direct care to the patient.

assist with pain management and other side effects of cancer or its treatment.
 may act as a liaison with the rest of the team. When people are enrolled in home
hospice programs, nurses visit them at home several times a week and sometimes more
than once a day.

Social worker: Helps with financial issues; arranges family meetings; assists with the
discharge from the hospital to home or hospice care

Hospital chaplain or other spiritual advisor: Counsels the patient and family members on
religious and spiritual matters .

Dietitian: Helps with nutritional concerns

Physical therapist: Helps maintain movement and assists when mobility is impaired or
there are concerns regarding safety in the home

Grief and bereavement coordinator: Helps with planning memorial services and
counseling for the patient as well as family members.

Roles of Nurses

 Expert Nursing care is essential in end of life.

 Nurse spends the most time with the patient and family.

 A hallmark of quality palliative care is the collaboarative role that the nurse
develops with the physician and other interdisciplinary team members.

 Nursing care allow patient and family to grow in the dying experience.

 the nurse is the primary conduit for information, critical assessments, and
evaluation of the patient and family goal s within the interdisciplinary team.
• Clinician

• Educator

• Researcher

• Collaborator

• Consultant

Key Nursing Interventions

• Presence

 Is a nursing intervention that can be describe as a gift of self in which the nurse
is available and open to situation.

 Nurse may show his/her presence through verbal communication.

2. Compassion

 Is another fundamental element in nursing care.

 Encourage growth and healing.

 Nurse shows positive attitude towards patient and family.

3. Touch

 Most therapeutic powerful intervention.

 For a dying patient touch can be both a healing and life affirming act.

 Convey to a patient that he is safe to freely express any concerns and needs.

4. Recognition of autonomy or self rule

 typically considered to be a fundamental element of hospice care.

 The patient has the right to make all-end-of life decisions.

5. Dignity or Honesty
 Patient expect the nurse to be honest.

 The patient and family deserve honesty regarding the day to day effects of the
medical treatment.

 Resulted to building trust with the patient and family.

6. Assisting in Transcendence

 Means to triumph over something.

 In end-of-life care it refers to patient developing a sense of meaning and peace that
keeps his suffering and death from being meaningless.

 At the highest level of nursing care you can provide emotional support that let the
patient experience self-transcendence( a sort of triumph in death ).


 By developing and articulating the scope and standards of professional nursing


the specialty ;

• defines its boundaries

• informs society about parameters of nursing practice.

• guides the development of rules and regulations for the specialty.

These are authoritative statements described by the Hospice and Palliative Nurses
Association for the nursing profession inorder to;

 Identify the responsibilities for which palliative and hospice care nurses are

 Standards reflect the values and priorities of palliative care nursing and provide
the framework for the evaluation of practice.
• Divisions of Standards


 Refers to the basic level of care that should be provided to all hospice and
palliative care patients and families.

 Demonstrated by the nursing process, involving assessment, diagnosis, outcome

identification, planning, implementation and evaluation.

• Standards of Rerformance

 Refers to the standards for activities related to quality of care.

Moral Standards Include:

• Keeping promise

2. Avoiding and preventing harm

3. Respecting persons

2. Teleological Moral Theories- theories determine an action to be right or wrong based

on consequences of the action.

Utilitarianism- a moral theory that asserts there is only one basic principle. The
principle of utility which declares that ought always to produce the greatest possible
balane if value over disvalue for the greatest number of persons.

Ethical Concepts:

• Respect for persons and principles of autonomy

 Most fundamental ethical principle

 Requires that individual be treated as unique and entitled to treatment that is

respectful of their human dignity.

Autonomy- having a minimum of relevant information, self determined choice

 Freedom to act on the basis of one’s choices.

 Self governance

2. Limiting autonomy- ( Interference )

Types of interference:

a. Paternalistic- actions such as deception, breaking promises or interfering with adult

choices are violations of moral rules that morally are never permitted unless morally
adequate reasons are provided.

Example: 1. under this rule, we would be clearly justified intervening if we discovered a

patient attempting to jump out of a hospital window.
2. Refuse to drink and eat.

 Before an act of paternalism can be considered justified, each of the following

conditions must be present:

• The patient’s capacity for rational reflection must be significantly impaired. This
autonomy condition must be clinically determined and substantiated.

• The patient is likely to be significantly harmed unless interfered with.

• It is reasonable to assume that the patient will at the later time with recovery of
capacity for rational reflection.

 Ratify or agree to the decision made to interfere.

3. Questions about capacity for autonomous choice

 Patient should be assumed to have the capacity to make decisions for themselves
unless there is clear evidence.

 Capacity is best understand as task-specific in that higher level of capacity is

required for decision associated with serious consequences.

 A capacity determination is clinical judgement made by caregiver who know the

patient best.

4. Assessing decision-making capacity

 A decisionally capable person is able to understand a proposed intervention,

deliberate regarding major risks and benefits, make a decision in light of that
deliberation and communicate the choice to others.
The following are information that decisionally capable patient should understand:

• His or her condition for which the intervention is recommended.

2. The nature of the recommended intervention.

3. The risks and benefits of the recommended intervention, of alternative intervention
including no intervention or treatment.

Caregiver should also determine the following:

• The patient acknowledge that treatment is recommended.

• The patient understands treatment or lack of treatment can affect their quality
of life.

• The patient decision is not substantially based on delusional belief.

5. Deciding for others

 If the patient lacks the capacity to make informed choices, other means must be
identified for surrogate decision - making.

 Use of advance directives

6. Beneficence and non-maleficence

a. BENEFICENCE- a duty to do good to others and to maintain a balance between

benefits and harm..

Principles of Beneficence include four rules:

• One not to inflict evil or harm.

• One ought to prevent evil or harm.

• One ought to remove evil.

• One ought to do good or promote good.

 The principle of maleficence is understood as requiring clinicians to
intentionally avoid patient unnecessary harm or pain, whether psychological or

 We often do harm to patient in order to benefit them or to prevent a greater harm

from occurring.

Ex. 1. administering chemotherapy

2. pain management- they are harmed when pain is not managed adequately due to
nurse’s fear that the patient’s death might be hastened as a result of increase high dose

Note: entails the risk of hastening life

 Do harm to patient in order to benefit them or prevent a greater harm from


 Patient at the end of life are vulnerable to harm.

7. Balancing Good and Evil- (the principle of Doubt effect)

 Any discussion that includes attempts to distinguish between harming and

benefiting. Patient’s must be consider the principle of doubt effect.

4 conditions be met before an act with both good and bad consequences may be morally

• The action itself must good or at least morally indifferent.

• The individual must sincerely intend only the good and not evil.

c. The evil effect cannot be the means to the good effect.

d. There must be a proportionately grave reason for permitting the evil effect, that is
there must be a favourable balance between the good and the evil effect of the action.


• The action of giving morphine is itself morally indifferent.

• The intended effect is to relieve pain not to depress the respiration.

• Respiratory depression is not the means by which the pain relief is obtained.

4. The relief of pain and the related reduction of suffering combined to provide
sufficiently important reason or proportionately greater good than the harm that is
incurred respiratory distress and likely death.

 The equitable distribution of potential benefits and tasks; determining the order in
which clients should be cared for.


• Establishing trust and refocusing hope

2. Providing consideration

3. Maintaining confidentiality

4. Relieving pain

5. Withrawing treatment

Legal Consideration

• Informed decision - making

 Peace of mind for the patient that his wishes will be carried out even if he can’t

 Clear directions for family and significant others about the patient wishes.

 Clear directions for health care providers about patient’s wishes.

 Prevention of family arguments and increase stress of an emotionally difficult


2. Advance directives

 Is a written document ( living will ) recognized by state law that provides directions
concerning the provision of care when a client is unable to make his or her own
treatment choices.

 It may include the a naming of a relative or friend

( health care proxy )who will make health decisions in the event of the client’s

 It includes the living will, the durable power of attorney, and directive for organ
 Living will- an advance directive lists of the medical treatment that a client chooses
to omit or refuse if the client becomes unable to make decisions and is terminally ill.

 States have their own requiremens for executing living wills , but generally two
witnesses, neither of whom can be a relative or physician, are needed when the client
signs the living will.

 Durable power of attorney

- is a legal document that appoints a person ( health care proxy ) chosen by the client
to carry out the client’s wishes as expressed in the advance directive or to make
decisions on the client’s behalf when the client can no longer make decisions.

Preparing an advance directives

• Obtain information about the types of life sustaining treatments available.

2. If you are currently physically ill, obtain information regarding the expected progress
of your disease.

3. Discuss with your physician the expectation of your treatment and the risk of
undergoing those treatments.

4. Make sure your family and significant others are familiar with your value system and
spiritual beliefs.

5. Decide with treatments you would not want to receive.

6. Document the types of treatment you would and would not like to receive if you can
no longer communicate you wishes.

7. Prepare several copies of the document and give one to your physician, your attorney
and your chosen surrogates. Keep a copy in hand for emergency or future health care


Key Principles of Symptom Management

• In implementing any intervention or treatment related to the management of

symptoms, the preferred choice of the pt. should be at the forefront of the minds of

 This includes agreeing to non-treatment as an option.

2. Open communication including not only patients and family members but also all relevant
health professionals will facilitate informal decision-making.
3. Listening to the patient’s own story.
- Including past and present life experiences, will assist the professional to understand the
impact of symptoms from the patient’s perspective.

 Symptom Management in palliative care is much more than using evidence-based

- it also includes fostering hope and showing by your actions and wonder that we consider
pts. to be worthwhile even if they themselves do not.

- achieving this involves a degree of giving of oneself in facilitating a therapeutic relationship

and the pt.

- Are multidimensional in nature and therefore symptom management is best achieved by

adopting a multi-professional approach.

- This model allows members to share information through discussion and working together
to formulate goals.

- The task at hand determine who take the leadership role, rather than the most senior
member of the team assuming leadership.

The Process of Symptom Management

Mnemonics can be useful (will remind you of the key points to cover when managing

• Evaluation
- established the cause if the symptoms includes taking a history including general trends
and recent changes.
- attention should be performed and investigations carried out is appropriate, given an
individual’s prognosis & goals of care.
- a PE should be performed & investigations carried out if appropriate given an individual’s
prognosis & goals of care.
2. Explanation

- explanation about care & treatment options is vital to the delivery of effective care &
empowers patients and cares to be involved as equal partners in the decision-making process.

- information about the disease process & significance of symptoms should be provided to
patients when they need it & not at a time convenient for the professional included in the care.
3. Management
- builds on the assessment process.
- first stage is to identify the cause & determine what is reversible or treatable.

4. Monitoring
- will not only determine the efficacy of interventions but also facilitate regular re-
assessment of the security of the symptoms and impact on the patient.

5. Attention to detail
- this can perhaps have the most significant ramifications for the patient if done badly.
- throughout the process of symptom management the missing of details by health
professionals can have done consequences.

- is an unpleasant sensory and emotional experience associated with actual or potential
tissue damage.

 pt. become withdrawn, unable to focus and their whole personality can appear to be
changed as their quality life diminishes.
Three Types of Pain Response:

• Neuropathic pain
- caused by the damage of nerve fibers resulting to the injury of the spinal cord or brain.

 associated in pt. with tumor compression, infiltration of peripheral nerves, nerve roots or
other type of spinal cord pain that occurs as a result of neurologic injury

 Describe pain as “lancing”, a constant dull ache with a vice like quality or as a paroxysms
of burning or electrical-shock-like sensation.
2. Somatic pain
- is described as aching and dull, increased by movement, and able to be localized to the
injured area

• Pain arises from skin, bone, muscle, connective tissue, and blood vessel.
ex.: Arthritis and bone metastasis

3. Visceral pain
- can be aching, but can also feel like squeezing and cramping.

- arises from the internal organ lining of body cavities

- can be localized to superficial tissues and radiate to a larger area of skin muscle.
ex.: pain of myocardial infarction


- pt. should be asked to quantify their pain using a subjective rating scale

 Severity of pain number from 0 to 5 or 0 to 10


1. Visual analogue scale
2. Numeric pain rating scale
3. Descriptive words pain rating scale

- is a well-tested widely used instrument to elicit patient’s verbal description of pain.

- some pain may always be present and is termed baseline pain.


- the following questions are useful to determine how pain may impact spiritual life:

 What are your religious beliefs about pain?

 Have your beliefs changed since you started to live with pain?

 Has there been any value to your living with pain?

 Has the pain affected your spiritual practice?

 Has the pain affected your spiritual beliefs or your relationship with GOD?

W1 – where is the pain located?

W2 – words to describe

W3 – when does the pain occur? What is the pattern during the day?

W4 – what worsens and relieves the pain

W5 - whole

1. Developing a caring relationship
2. Teaching
3. Anticipating comfort needs

 A hallmark of palliative nursing

4. Hands on comforting
5. Attending to stimulating and rests
6. Complementary Therapies

 Such as music, herbs, or acupressure

 Palliative nursing roles regarding complementary therapies include:

 Gaining knowledge about specific types of complementary therapies.

 Informing patients and helping them decide about using these therapies.

 Referring patients qualified and respected complementary therapies

 Learning to utilize and incorporating selected types of complementary therapies in nursing

practice to comfort
1. Energy therapies that are intended to influence energy fields of body
Ex.: therapeutic touch
2. Physical Manipulation of Body
Ex.: chiropractic, massage therapy, osteopathic manipulation
3. Biological Therapies
Ex.: herbal therapies, dietary therapies
4. Mind Body Intervention
Ex.: prayer, art, music, dance, hypnosis, meditation
5. Alternative Medical System in Contrasts to Western (allopathic medicine) Medicine
- Ajurvedic medicine, traditional medicine of india that includes meditation, breathing,
diet, exercise, massage, herbs, diet
- traditional chinese medicine, including herbs, massage, qi gong, acupuncture
- Homeopathy, which uses small doses of mineral and plant extracts to strengthen the
body’s defense mechanisms
- Naturopathy, which incorporates herbs, diet, homeopathy, acupuncture, spinal
manipulation, counselling, and physical therapies.

7. Managing pharmacologic therapies

- ex.: acetaminophen or non steroidal anti-inflammatory drug.
Has few side effects
Side effects: hepatotoxicity and liver damage.

Patient with severe pain.
ex. Morphine
Side effects of morphine: Nausea and vomiting, pruritus, constipation, respiratory
depression, hallucination and sedation.
1. Confusion

2. Myoclonic jerks

3. Pinpoint pupil


 This maybe result of the cancer treatment itself, for example chemotherapy causing anemia
or radiation therapy.

 All communication should be clear so as to minimize the anxiety component.

 This can exacerbate the problem by increasing oxygen consumption.

 Eating and talking may also increase breathlessness, so measure should be taken to
minimize the effort required during mealtime.

 Bring pt. in an unconfined spaces and fresh air.

 Turn on the fan in an oscillating mode. Provide information to the visitors and folks about
this matter.

 Sitting upright in a supported position or leaning slightly forward resting arms on a table
may be of benefit.

 Ensuring restful nights is very important to avoid fatigue.

 Sleeping on a reclining chair in a semi-recumbent position may facilitate ease of breathing.

 If patient is fearful, the presence of someone at the bedside or the use of a night light may
be of some help

 Aromatherapy, different oils can have a positive or negative effect on respiration.

 Hypnotherapy, same as deep relaxation, can benefit pt. with anxiety.

 Accupressure
 Placebo effect of treatment

 Occupational therapy

1. Bronchodilator

2. Steroids

3. Nebulized furosemide

4. Opiods

5. Used of sedation

6. Psychostimulants (ex. Benzodiapine)

Nursing Management of Patient with Impaired Fluid Balance

 The manifestation appeared is azotemia with elevated urea, creatinine, and uric acid level.

 Lying pt. who are dehydrated have normal blood chemistry.

 Signs and symptoms are tachycardia, postural hypotension, reduced skin turgor and dry
mucous membrane.

 Pt’s. also complaint of dry mouth and thirst.

 Fluid deficits at the end of life are associated with cognitive impairment and altered

 Water requirement for a dying pt. is 800 to 1000ml.

- intravenous or subcutaneous infusion can sometimes correct fluid and electrolyte

 1 liter of fluid daily

 Hypodermoclysis
- process of introducing fluid through subcutaneous infusion in hospice and palliative
- contraindicated in pt with bleeding disorder or generalized edema
- butterfly needle is use
- inserted subcutaneously in the thighs, outer arm, abdomen, in bedridden pt.

- Abdomen and upper chest if ambulatory

- Rate is 40 to 60 ml per hour in bedridden pt.

Advantage of Subcutaneous Fluid Infusion

 Inexpensive

 Lasts 5 to 7 days

 Minimal technical skill to initiate and maintain

 Minimal pain with needle insertion

 Lower incidence of adverse reaction than IV access

 Minimal need for restraint to avoid needle reinsertion

- rectal administration of fluid, low-techmethod of infusion.
- 22 french nasogastric catheter is inserted to about 40cm and saline or tap water is
infused several times a day.

Palliative Management of Patient with Fatigue and Impaired Mobility

• Psychostimulants
- such as methylphenidate (Retalin, Concerta) to boost energy
- subcutaneous injection of epoetin alpha (Epogen, Frocit) increase hemoglobin and
b. Promoting sleep, improving nutrition, reducing the burden of other symptom managing
decreased energy.
-recommendation of assistive equipment, occupational and physical therapy
- nurse can encourage period of rest and activities to restore emotional energy, such spending
time with family, surrounding oneself with nature, listening to music or meditating.
c. Teaching the families and caregiver.

• Bony prominences is most affected

• Malnutrition and wt. loss are also factors

- Frequent repositioning, pillows, cushion, special mattresses and maintenance of clean,
dry skin.

• Betadine soaked gauze dressing control the odor

- example of ointment for bedsore are calmoseptine, maalox

 Some dying pt. suffer from cancerous skin lesion

 Fungating lesion-look like craterous ulcers assume a cauliflower or fungus appearance

- they sometimes grow out of control at the end of life when radiation or chemotherapy no
longer works.
- accompamied by offensive odor and discharges

• Irrigation and moist dressing

- Metronidazole gel or solution-antiinfective that kills odor-causing anearobic bacteria
b. Charcoal dressing to reduce odor.

 The following assessment question are useful

- how severe is your nausea? 1 to 5 rating scale
- how often are you nauseated during a 24 hours period?
- are you also throwing up? How often in 24 hours?
- what trigger the nausea and vomiting?
- what relieve the nausea or vomiting?
- are the anti-nausea drugs helping? Are they causing side effects?

 Can caused by increase intracranial pressure, by medication, by metabolic abnormalities,

by constipation and by bowel construction?

• Pharmacological Intervention

 Antiemetics include phenothiazine, haloperidol, metoclopramide, cortecosteroid, serotonin

antagonist, cannabinoids, anticholinergic and antihistamines.

 Given round the clock

 May be given in combination-antihistamine and corticosteroid might be added to


 Be aware that the high dose of the dopamine antagonist alone or in combination can cause
extrapyramidal effects like akathisia and dystonia.

 Lorazepam (Ativan) diphenhydramine(Benadryl) – meds for the prevention of extrapyramidal

 Can be given in the form of suppositories ex. Is BDR suppositories containing benadryl 25
mg, decadron 4mg and reglan 20mg.

 Metoclopramide (Reglan) and Haloperidol (Haldol) can be given subcutaneous infusion

without local tissue irritation.
b. Diet
- bland diet food is highly recommended

 Odors need to be minimized

 Eat small amount slowly and sip small amount of fluid frequently

 Ginger can reduce nausea and vomiting

c. Alternative intervention

 Herbal meds like

- chamomile, peppermint and slippery elms
Birth to age 2 to 4

• Can’t differentiate death and separation

• Believe death is reversible

• Experience separation anxiety

• Concerns expressed by crying

Ages 4 to 6 years

• Come to understand that death is irreversible is final

• For younger child, death appears equivalent to sleep

• May believe they can cause death

• May have anxiety about separation and sleep

Ages 7 to 11

• Understand that death is reversible and universal

• Developing logical thought, realistic understanding of causes of death

• May perceive human death as punishment

• Contributing concerns with separation

Age 12 to Adolescent

• Now have abstract understanding

• Death may be perceive as heroic or tragic

• Death associated with old age

• Commonly dislike showing emotion

• May choose escapism, denial, acting out

Children’s Grieving
Apparently around the age of 2 years

Signs of grieving:

• Somatic symptoms
- difficulty sleeping and eating, bed wetting, headache, stomach ache

b. Psychological symptoms
- separation anxiety, loneliness, guilt, fear that others will die, fantasizing about death,
learning difficulties and school problems.
c. Behavioral symptoms
- crying, emotional outburst, temper tantrums, extreme shyness, dis interest in playing,
demand for attention, overdependence and aching out.

- revisit grief periodically as they develop
Nursing Intervention for Ages 3 to 5 years

 Strengthening the parent’s ability to provide support for the child by realizing the child’s
need to stay close to parent

 Using simple explanation and providing opportunities to ask question

 Recognizing that expression of strong feelings can frighten the child

 Using play and drawing to express feeling

 Preparing for regressive symptoms after death and expecting the child to need to talk

• Referring for counseling those children with persistent difficulty playing; persistent fears;
aggressiveness; difficulty separation from the parent; preoccupation with dying; and
regression in toilet training, eating or sleeping.

Nursing Intervention Ages 6 to 8 years

• Remembering that parental support is central

• Joining with the parents to inform them of the parents’ illness when death is imminent.

• Sharing controlled expression of emotion so that they are not overwhelmed\encouraging

continuation of developmentally appropriate activities

• Encouraging participation in traditional rituals

• Not being surprised by a child's brief episodes of mourning alternate with desires desire to
return to normal activities

• Communicating with school personnel

Ages 9 to 11 years old

• Giving them information as soon as it is known about diagnosis and prognosis

• Encouraging participation in care of the patient

• Involving teachers

• Encouraging involvement in after school activities

• Encouraging participation in rituals after death and activities that remember parent

• Structuring family activities and returning to predictable routines

• Referring for counseling those children who do not return to previous levels of functioning
in school activities and peer relationship
Adolescent 12 to 14 years old

• Providing detailed information

• Understanding their emotional withdrawals as developmentally related

• Allowing them to help but limiting caregiving tasks that may be excessively burdensome to
a child so young

• Helping them express grief

• Letting them choose their rituals after death

• Supporting their desire to return to normal activities

• Setting limits on destructing behavior

• Referring for counseling those teens with clinical depression, suicidal thoughts, fears and
phobias, refusal to attend school, injury, regression to childish behavior, and somatic
symptoms that do not disappear.

Adolescents 15 to 17 years old

• Informing them fully about illness and prognosis.

• Anticipating come withdrawal from normal functioning.

• Discussing ways they can be helpful.

• Involving them in rituals after death, in roles they choose.

• Anticipating intense mourning and helping them understand the process.

• Communicating with the school.

• Anticipating conflict around responsibilities and the need for independence.

• Helping them identify a positive legacy of the deceased person.

• Referred.
Using play with grieving children
• Dolls, action figure, puppets

• Toys that re-create life, such as doll house, telephones, doctors kits

• Aggression releases activities like beating drum, punching bags, kicking balls, running, and

• Construction toys

• games
Using creative arts with grieving children and adolescents

• Drawing and painting

• Drama

• Making up songs and changing the lyrics in songs

• Playing musical instrument like drums or triangles

• Writing poetry and stories

• Pounding and sculpting clay

• Making collages
Using Children’s Literature

• Evaluate the book for its fit with the particular children and select titles that fit individual

• Examine the limitation of the book’s explanation.

• Match the book to the concerns of individual child.

• Read and discuss together.