This essay aims to critically analyse and demonstrate the nursing intervention that needs to be provided to Mr Ravi (Appendix, 2). Mr Ravi was diagnosed with Advanced Alcoholic Liver Disease (AALD) due to excessive alcohol consumption. This led to his liver function deteriorating and with the decision of no further treatment, care is being delivered at home with support from the community palliative care team (Appendix, 2).
The nursing intervention to Mr Ravi will be focused on two nursing problems. The first problem is the need to prioritise Mr Ravi’s acute anxiety which was caused by his decision of die at home, inability to visit the temple, guilty feelings, sleeplessness, and fatigue after performing small tasks.
The next problem is the chronic pain being experienced Mr Ravi due to his liver disease was identified by his verbalisation (Appendix, 2). According to Williams (2015), the Roper, Logan and Tierney (R-L-T)’s ADL (Activities of Daily Living) model was being used to assess the nursing care plan involving Mr Ravi’s condition, his needs, and independence during initial care delivery.
R-L-T model is comprised of twelve activities of daily living (ADL) which will help to systematically assess individuals in need for complex and long-term care, whereas, the ABCDE approach assesses and treats critically ill patients, for example, unresponsiveness, breathlessness (NICE, 2015).
In this scenario, Mr Ravi will be requiring activities of the daily living (ADL) assessment to meet his complex and long term care needs (Appendix, 2). Each nursing intervention to be carried out will combine both pharmacological and non-pharmacological intervention aiming at providing the most comfortable and pain-free life to Mr Ravi at the comfort of his own home.
According to Reising (2016) nursing interventions involve gathering information, assessments, defining care, planning, implementing and evaluating the care in order to meet Mr Ravi’s goals. This process has to be repeated multiple time to monitor if there are any changes in the Mr. Ravi’s condition.
Effective communication – this non-pharmacological nursing intervention helps to reduce the feeling of anxiety for Mr. Ravi. Atkin (2017) states that acute anxiety severely affects adult’s with a progressive life-limiting condition in palliative care due to the worries of nearing death. Along with anxiety, fear, helplessness, loss of control over the illness and other death connected factors also impact the adult (Atkin, 2017). Clear communication was given to Mr. Ravi with his family to establish his priorities and wishes.
Ineffective communication contributes to death anxiety to Mr. Ravi (Brown, et al. 2014) Effective communication would reduce anxiety and increase confidence. However, to manage complex emotional problems, nurses require communication skills as well as the knowledge to manage physical distress (Clayton et al. 2014).
Wallace (2001) suggests that effective communication should include honesty, empathy, trust and knowledge all making the foundation of nursing care. It is also vital for developing a therapeutic relationship with Mr. Ravi and his family (Wallace, 2001). Therapeutic relationship will encourage Mr. Ravi to open up about his feelings and wishes related to his situation in a confidential place while maintaining his privacy and dignity (NMC, 2018). For example, Mr. Ravi wishes to die at home, such a preference would be considered when making any informed decision about his care. Mr. Ravi’s would be provided with a chance to talk, express his grief, concerns and fears, while actively being listened to without any judgement. This would help to reduce Mr. Ravi’s anxiety and make him more comfortable.
Spiritual belief helps a person to cope with terminal illness better and provide them piece of mind (Walsh, 2002). Mr. Ravi’s weaknesses restricted him to visiting the temple for spiritual support. Bosek (2017) stated that individual need to have a broadend knowledge in diverse culture in order to deliver patient-centred care. This highlights the need to understand the patient’s religion and beliefs to provide them with better.
According to Rabow (2004) the spiritual factors such as connection, self-actualisation and harmony could benefit the individual’s well-being. In contrast, Gade (2008) argued that there was no difference in the persons well-being when spiritually supported.
Supporting Robow (2004), Horden (2016) too believed that spiritual belief would provide support for individual with terminal illnesss, reducing psychological morbidity, thereby improving quality of life. To encourage Mr. Ravi, he was given options such as arranging him and his family to be transported to the temple or arranging a Hindu faith leader to visit him. Additionally, he was encouraged him to write his feelings and thoughts on a piece of paper as a means of relaxing. He was also provided with some of the Hindu religious books to read, encouraged to do meditation like yoga, and pray in the house. These activities could potentially relax his mind and incorporating all these interventions, would help Ravi to free himself from stress in regards to his religious attachments (Whitman, 2007).
Mr. Ravi feels guilty that his terminal condition is as a result of his excessive consumption of which is not allowed his culture. According to Rome, et al. (2011) alcoholics usually feel shame and guilt over excessive drinking as it is forbidden within the community. Leahy, Holland and McGinn (2014) states that guilty feeling makes individuals more anxious. In order to address and resolve the guilty feeling for Mr. Ravi, psychological interventions such as counselling, cognitive behaviour therapy (CBT), psycho-education have been provided Mr. Ravi. Behavioural techniques have also been used as an approaches for resolving or addressing various aspects of feelings of guilt such as anxiety, grief and loss and emotional crisis.
According to McLeod and Mcleod (2011) counselling helps patient to explore, re-define and re-discover methods to live a resourceful and self-satisfactory social life. Counselling also creates a sense of individualism and independence (McLeod, 2011)
Therefore nursing intervention was implemented non-judgementally, respecting Mr. Ravi’s values and feelings. The staffs acknowledged Mr. Ravi’s fear of dying and guilty feeling regarding alcohol consumption, which provided him with a feeling being of heard and not been judged, eventually aiding staffs in the re-examination of his feeling and thoughts in different angles, guiding to plan intervention aiming at lessening his anxiety.
There is an increased feeing of stress and anxiety among Mr. Ravi and his family members as he is reaching the final stage of his life. According to Carolan et al. (2015) the key for successful palliative care lies in the delivery of support to family members before and after the loss of loved ones, which is cardinal of all professional care. Therefore, actively listening to Mr. Ravi’s family member’s thoughts and opinions only with the permission of Mr. Ravi is crucial. For example, helping with his personal care, shopping, arranging transportation to go to temple, giving medication to him, the planning of his care- depends on his situation, providing social care – informal counselling, emotional support, domestic care support – cleaning house, preparing meals for Mr. Ravi, which should be done in best interest of him (Hudson, 2003).
As a method to improve family – centered palliative care, regular meetings would be scheduled to discuss Mr. Ravi and his family needs (economical) due to his early retirement age and written information. Bereavement support will be arranged for the family members to make sure Mr. Ravi is comfortable for his family members to be part of his care, hence revised care goals are achieved (Hudson, 2003).
Mr. Ravi was jaundiced due to his liver disease and he is suffering from itchy skin. This is as a result of high bilirubin concentration in the blood due to impairment of liver functions, which leads to deposit of bilirubin in the skin causing yellowish skin colour (Butler and James, 2018). Butler and James (2018) also stated that irritation of skin’s sensory nerve due to retention of bilirubin cause the itchy skin. Antihistamine was prescribed by Local GP (General Practitioner) to treat the itchy skin. Antihistamine for example, chlorapheniramine, is a pharmacological intervention which reduces the itchiness and helped Mr. Ravi to sleep better. It also reduces the abnormal secretion of histamine by blocking histamine 1 receptor, thereby reducing inflammation and irritation caused by bilirubin in the skin and pruritus (Butler and James, 2018). Antihistamine can be used in liver failure patients (Wang and Yousipovitch, 2010).
There would be a significant reduction in Mr. Ravi’s quality of life, limiting his participation in everyday activities. However, with treatment like the application of emollient cream, this is the cream has helped to moisturize his skin by acting as a barrier and preserve moisture in the skin hence reducing dryness. The emollient which Mr. Ravi was advised to use was aqueous cream 1% (Walling and Wenger, 2019). Which helped to maintain his healthy skin. Hegade, et al (2015) states that untreated itchy skin heavily impact a persons sleep, mood as well as contributing to anxiety and depression. Therefore Mr. Ravi was treated pharmacologically and the drugs policy and procedure followed when giving medication to Mr. Ravi(NMC, 2019).
Hayward, et al. (2015) recommends paracetamol as mild analgesic but prior to administration, a Liver Function Test should be carried out with patient having chronic liver disease and along with conditions such as diabetics, hypertension and malnutrition. Mr. Ravi had multiple of these disease conditions (Appendix. 2). Paracetamol is metabolised by the liver, where some gets excreted as without changes, remaining non-toxic glucuronide and sulphate are excreted the bile and urine. In addition, excretion of paracetamol in chronic liver disease is slower, the cause of this is reduced his liver function. This is the reason paracetamol is not given to Mr. Ravi.
Hence Mr. Ravi is prescribed with Oromorph 15mg per day, can add on plus 5mg as PRN ( per request) in palliative care and it is prescribed by his doctor to immediately relieve his pain (NICE, 2016). A strict time management has to be followed as PRN Oromorph should be administered every 2-4 hourly (NICE, 2016). Imani, (2014) says that liver distribution and elimination of most drugs including analgesic compounds.and opioids (oromorph) drugs biotransformed by liver. As Mr. Ravi has impaired liver functions, protein binding and metabolic activity are unable to filter oromorph effectively in the liver. Therefore, close monitoring and documentation of oromorph is carried out for Mr. Ravi (Palatini, 2016).
This Morphine (oromorph) acts by blocking nociceptive signals by activating the pain modulating neurons of spinal cord. Morphine acts as agonists of the mu and kappa opioid receptors which derive later into analgesia.
The first process in managing pain is to perform a pain assessment to determine the cause of pain. This will an individual’s impact in life’s quality and help to recognize the current treatments effectiveness (Taylor, 2010). A validated pain assessment tool will be used to assess Mr. Ravi’s pain. The SOCRATES (Site, Onset, Character, Radiation, Associations, Time course, Exacerbating and Severity) (Revolvy) and (Swift, 2015), this tool is effective in palliative pain management as it assess the effect of pharmacological and non-pharmacological nursing interventions on pain (Hughes, 2012).
Mr. Ravi experiences a generalised dull pain in the left side of the abdomen and changing position aggravates the pain, making it impossible for him to comfortable sleep in bed. The pain does not radiate but is often associated with nausea. Recurrent accumulation of ascetic fluid aggravates this pain, but the analgesics and positioning helps to relieve the pain. Numerical rating scale 0 – 10, with 0 being no pain and 10 being most severe pain was used to assess the severity of pain in Mr. Ravi and it is necessary to repeat the pain assessment for better pain management (Hughes, 2012). Self-report is a goal standard for pain assessment in patient with ability to communicate (Cox, Cannons and Lewis, 2015). Mr. Ravi’s level of pain that pharmacological and non-pharmacological nursing interventions are assessed by SOCRATES pain tool. Moreover, the proper pain assessment of Mr. Ravi will improve the following nursing intervention as they will be more informed about his needs.
Chronic pain has a serious impact on individuals and their families; it is also hard to treat (NICE, 2018). Here Mr. Ravi experienced generalised pain, typically around the upper abdomen region because of the end stage of live failure. His pain was brought under control through the non-pharmacological approach of mindfulness meditation which is a more effective solution for chronic pain with long term conditions ( SIGN, 2013). This meditation is a sequential programme, which is a practise of meditation combined with yoga (SIGN, 2013). Mindful meditation helps individual to have awareness of the pain they experience and teaches them to observe and accept, which will help Mr. Ravi to have control over the pain (Lim et al, 2018).
Psychological interventions are found to reduce stress and anxiety, thereby reducing pain (Wong et al., 2011). Respondent behaviour therapy is reducing muscular tension while focusing on alternating the physiological response (Henschke et al. 2010). Hence Mr. Ravi and his family been advised to participate in relaxation therapy such as deep breathing exercise, yoga, short walk, listening to music and was advised to get sound sleep at night (Wong et al, 2011).
Heat And Cold Therapy
Heat and cold therapy helps in the reduction of both muscular and joint pain, which is an non-pharmacological nursing intervention (Abraha, et al. 2014 and Minnis, 2017). Ingraham, (2007) states that heat therapy is very relaxing and relieves pain safely. However, heat therapy should not be provided in cases of infected tissue for example, redness or puffy skin. In Mr. Ravi’s situation, hot water bottle, heat pad, which can be used in microwave and warm water bath was given to alleviate the generalised pain.
Heat therapy improve blood circulation and relaxes muscles, especially chronic pain (Minnis, 2017) Cold therapy for example, cold compression or chemical cold pack applied on inflamed area helps to reduce inflammation through vasoconstriction resulting in reducing bleeding and swelling. Mr. Ravi had ascetic fluid drainage which can lead to an inflammation of the abdomen. This may be one of the reason for Mr. Ravi’s pain , where applying cold compression could help Mr. Ravi in reduction of his pain (Minnis, 2017).
Positioning To Reduce Chronic Pain
Romanek and Avelar (2014) both argue that non-pharmacological nursing intervention such as , positioning help to Mr. Ravi to reduce his pain resulting in him “feeling good” ends up helping resistance to pain. Mr. Ravi sleeps in his chair (Appendix 2), and is encouraged to make frequent positional changes for pain relief and to reduce exacerbations. Position change also decrease breathlessness and joint stiffness (Herr, 2002).
Pulmonary ventilation and partial pressure of arterial oxygen change when there is a change in body position. Hence, proper positioning is mandatory for Mr. Ravi to recover from ascites. The semi-Flower’s position, which is elevating one’s head up between 30 to 45 degrees to improve his oxygen saturation and pulmonary ventilation (Hus et al. 2014).
It is difficult for Mr. Ravi to sleeps in his chair (Appendix. 2). Therefore, he has been referred to OT (Occupational therapist – Multi Disciplinary Team) for a chair and bed assessment for Mr. Ravi to sleep comfortably. Air cushion and a special bed with pillows for support, will reduce pressure on his bone and joints and increase blood circulation. Thus will ensure he feels comfortable and reduce his level of pain (Romanek and Avelar, 2014).Both a comfortable chair and a bed can be easily accessed and altered by any family member to better suit the needs of Mr. Ravi and make him comfortable thus providing a sense of independence.