Category: Tips For Nurses
Articles for nurses caring for terminally ill patients including how to manage challenging situations.
The Hospice Nursing Visit from a Nursing Perspective — Home Patients
This article offers guidance for new visiting hospice nurses struggling with work-life balance. It covers strategies like maintaining a recertification journal, pre-charting before visits, assessing end-of-life status, educating families, and preparing for a "good death." By following these tips, nurses can take less work home while delivering focused, compassionate care.
Best Practices for Approaching Combative Dementia Patients
Dementia is a progressive brain disorder that affects a person’s cognitive abilities, memory, and behavior. In the later stages of the disease, some patients can become combative and aggressive, making it difficult for caregivers to provide the necessary care. As a hospice nurse, it’s important to know how to approach and manage combative dementia patients to ensure their comfort and safety. Here are some best practices to consider:
Recognizing and Treating Common End of Life Symptoms
Guide to Recognize and Treat Common End of Life Symptoms provides tips on managing symptoms experienced by those at the end of their lives - Topics such as pain, shortness of breath, respiratory distress, and anxiety, and provides suggestions for medications and complementary therapies to help manage these symptoms.
Delirium vs Terminal Restlessness
As an experienced hospice nurse, I understand how difficult it can be to distinguish between delirium and terminal restlessness. Both conditions can cause significant distress for the patient and their loved ones, and nurses must be able to tell the difference between them to provide the best possible care. In this article, I will share my knowledge and experience to help new hospice nurses understand the differences between delirium and terminal restlessness and how to rule out delirium.
The Importance of Documenting Hospice Visits at the Bedside
Our primary focus for our patients is comfort at the end of life as hospice nurses. We work tirelessly to ensure that our patients receive the best possible care during their end-of-life journey. An aspect of that care that is often overlooked, but incredibly important is timely documentation.
Documenting hospice visits at the bedside is crucial for several reasons. Not only does it help ensure that our patients are receiving the best possible care, but it also helps the hospice team as a whole and reduces issues when the caregiver must be involved in triage services. Here are just a few reasons why documenting hospice visits at the bedside is so important:
End-of-Life Determinations for Newly Admitted Patients
Admitting a patient to hospice services is a complex and sensitive process that requires careful assessment and communication. One of the challenges that hospice nurses face is to determine if the patient is close to the transitioning phase of dying, which is the final stage of life when death is imminent. This phase usually lasts for one to two weeks, and it is essential to prepare the family and provide a plan for increased hospice involvement during this time. However, on admission, hospice nurses do not have the luxury of having visited with the patient over the past several weeks to months to observe the changes that often signal that death is approaching. Therefore, they need to rely on other indicators to help them identify whether the patient is transitioning.
Air hunger management at end-of-life
I can count the times I’ve run into air hunger at the end of life as a visiting RN Case Manager for going on five years on one hand. Over the years, I’ve managed patients with pulmonary fibrosis, lung cancers (diverse types), breast cancer, COPD, congestive heart failure, B-cell lymphoma, leukemia, and other diseases that can impact one person’s ability to breathe correctly. Air hunger is rare in my firsthand experiences, but it can happen.
Air hunger often sounds like the person is gasping for breath without regard to the actual respiratory rate (how fast they are breathing); it can also sound like stridor (YouTube videos below where you can hear the difference).
Liquifying Ativan pills for easier delivery
Ativan, generically called Lorazepam, pills can be easily melted into liquid, and given to your loved one in a syringe. This is typically done vs. putting the pill under the tongue if your loved one has a dry mouth, and the Ativan pills are not melting under the tongue.
The process of melting lorazepam into a liquid will require the following resources:
Validation Therapy: A Valuable Tool for Families and Healthcare Teams
Naomi Feil is an expert in gerontology and the creator of validation therapy, which is a means of communicating and acknowledging the internal reality of patients with dementia. When properly utilized, validation therapy can enhance the quality of life of patients with dementia as well as reduce stress on the family and caregivers.
While Naomi Feil and her followers (of which the writer of this article may be considered one, at least in form) focus on using this method of communication to maintain health with the potential for a level of restorative health, I want to share how the concepts of this method can be used during times of crisis.
Interviewing and Observation as part of the assessment
There are observation and interviewing skills you can develop which will help you learn:
What could cause the current change in condition
Determining if a patient is having terminal restlessness
Determining if your patient is within two weeks or less of life to live
Knowing where your patient is in the dying process
While this article is primarily meant for new nurses, what I’m sharing is also valuable for family members and loved ones. Anyone with patience and love toward the person being observed and interviewed can hone and develop these skills.
Fall Reduction – Reducing Falls in Personal Care Homes and Private Homes
Falls among the elderly can have severe consequences, including hip fractures, which can be life-threatening. As an experienced hospice registered nurse case manager, I understand the importance of fall prevention, especially in private homes, personal care homes, and assisted living facilities. This article aims to provide practical tips for reducing falls in these settings by following the nursing process: assessment, diagnosis, planning, implementation, and evaluation.
General Inpatient (GIP) Level of Care for Hospice Explained
GIP, or General Inpatient Hospice, is an often misunderstood aspect of hospice care. Both hospital staff and families sometimes have misconceptions about GIP. Families may assume it's readily available upon request, while hospital professionals may believe it allows patients to remain in the hospital indefinitely, even when death is weeks away. This article will clarify the basics of GIP for hospice, including eligibility requirements, doctor's orders, care plans, documentation, and education. We'll conclude with two real-life cases to illustrate these points.
Learning Psychosocial Skills as a Hospice Nurse
One of the hardest lessons to learn as a nurse, in my experience and opinion, is the psychosocial skills necessary to help patients and their families work towards their healthcare goals. These skills are applicable to every field. While I, myself, am still growing as a registered nurse (heading towards my 5th year at the time of writing this article), I would like to share with you some of the lessons learned. These lessons are based on real-life cases where I will present the scenario, what I did that worked, and what I internally thought of opposite scenarios.
Coughing Up Blood (hemoptysis) Symptom Management
Hemoptysis, or coughing up blood, can be a distressing symptom for patients at the end of their life journey. As a hospice nurse, your expertise in managing this symptom is crucial in ensuring a peaceful and comfortable experience for your patients and their families.
Explaining Vital Signs to Patients and Families on Hospice
I don’t know about you, but every time I see a patient and their family for the first time and take their vitals as part of the nursing assessment, either after each vital or at the end of the vital checks, I’m asked something to the effect of “is that good?”
As you, my friendly readers, bloom as hospice nurses, you will learn that the vital sign portion of the assessment is just a smidge of the entire assessment as to whether someone is approaching the end of life, going through reversible or terminal restlessness, or just having a difficult day. Let me share how I educate families that get hyper-focused on vitals.
Assessing pain in non-verbal patients
Pain is a subjective sensation that can affect a person’s physical, emotional, and spiritual well-being. While pain can be measured objectively by using vital signs such as temperature, pulse, blood pressure, and respiration count, these indicators may not reflect the true intensity of pain that a person is experiencing. This is especially true for non-verbal patients, who cannot communicate their pain verbally. Non-verbal patients may include those with advanced dementia, terminal illness, or other conditions that impair their speech. In this article, I will discuss the importance of assessing pain in non-verbal patients, the tools and methods that can be used to do so, and the benefits of providing adequate pain relief for these patients.
Recognizing the Approaching End of Life
When I first started working in the field of hospice, my clinical manager told me (I’m paraphrasing), one day you will be able to walk into the room, and without getting a single vital sign, just by visual observation, be able to tell that the person is dying or will be shortly dying. That was about three years ago. Today, it’s almost chilling for me (as it is both a blessing and tremendous responsibility) to be able to share she told the truth, and that over time — if you give yourself patience and grace and take the time to listen, observe, and remember — you too will learn how to tell when someone is close to or otherwise is dying.
Please allow me to share some of my insight as to how I know a person has less than a month left to live, and often far less. First off, let’s go into the important discussion you should have with the family, friends, and the patient themselves that provides an overall background to the prognosis. That discussion should be centered around what types of decline (downward, negative) changes have been taking place in the patient’s life over the last six months making note as to whether the decline is minor, medium, or major and the frequency (once a month, once a week, etc.) of those changes.
Properly entering doctor orders
You are in with a patient with whom you believe will benefit from a treatment/medication. You call the provider who either goes with the recommendation you made as part of the SBAR (situation, background, assessment, nursing recommendation) or otherwise adjusted it to better fit the situation.
Most EMR (electronic medical record systems) now requires you to enter a doctor (provider) order. For visiting staff, most EMR systems will send an electronic communication to the doctor to “sign” the verbal order over the next 24 hours (some systems, the next business day).
Can you imagine how many orders the provider must sign in a day? How do you protect your patient and your nursing license in the written documentation of the doctor’s order you enter into whatever system you are using?
Buccal vs Sublingual for Liquid Medications
Your dying patient has lost their gag reflex as part of the dying process. One of the questions I implore you to ask yourself is what’s the safest route to administer liquid medications? Well, before even going to answer this question, unless contraindicated, make sure the patient’s head of the bed is at least at a 30 to 45-degree angle (I prefer the latter).
The buccal route is the safest route to administer liquid medications at the end of life in my experience. In practice, I strongly encourage you as well as the families we mutually teach to give any liquid medications on the side of the mouth least likely to have spillage — this depends on the position of the patient — and slowly over time giving the medication in 0.25 ml increments allowing for the absorption of the medication switching cheeks as applicable.
Understanding Terminal Restlessness
Navigating the final days of a loved one's life can be a challenging and emotional journey. One of the signs that can be observed during this time is known as terminal restlessness. As someone deeply rooted in hospice care, I have witnessed various manifestations of this restlessness. Understanding its types, causes, and management strategies is crucial for providing compassionate end-of-life care. This article aims to illuminate the different kinds of terminal restlessness, identify reversible causes, and discuss effective management techniques. By equipping caregivers, families, and healthcare professionals with this knowledge, we can ensure that terminally ill individuals experience comfort and dignity in their final days.
Time Management Tips for New Visiting Nurses
One of the main challenges of new nurses is time management. In a hospital or nursing home setting, you often have coworkers to rescue you in a pinch in case you are overwhelmed; on top of having nearby coworkers, most orientation programs, as well as nursing schools, focus on time management skills in a facility setting. Yet what about time management as a visiting nurse — in home health or home hospice or both?
Let me share with you my wisdom and experience in time management in the field of a visiting nurses to hopefully help you have more time for life compared to work — a better work-life balance.
Tips for new hospice nurses doing an admission
If you are a new nurse to hospice, one of the tasks you probably dread is doing an admission especially if you have scheduled visits the same day as the admission.
I would like to share with you some tips that when applied may help lower your stress level, and help you remain on time even in cases where you have three to four visits including recertification to do the same day.
Tips for new Hospice Registered Nurse Case Managers
Here are some ideas that may be beneficial to those of you who are relatively new visiting hospice nurses: