In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of non pharmacological comfort interventions in order to:

  • Assess the client's need for alternative and/or complementary therapy
  • Assess the client's need for palliative care
  • Assess client need for pain management
  • Recognize differences in client perception and response to pain
  • Apply knowledge of pathophysiology to non-pharmacological comfort/palliative care interventions
  • Incorporate alternative/complementary therapies into client plan of care (e.g., music therapy, relaxation therapy)
  • Counsel client regarding palliative care
  • Respect client palliative care choices
  • Assist client in receiving appropriate end of life physical symptom management
  • Plan measures to provide comfort interventions to clients with anticipated or actual impaired comfort
  • Provide non-pharmacological comfort measures
  • Evaluate the client's response to non-pharmacological interventions (e.g., pain rating scale, verbal reports)
  • Evaluate the outcomes of alternative and/or complementary therapy practices
  • Evaluate outcome of palliative care interventions

Assessing the Client's Need for Alternative and/or Complementary Therapy

The number and variety of nonpharmacological interventions including complementary, alternative and integrative modalities, are numerous and varied. Some of these techniques and interventions are more successful for some clients than for others so, in addition to assessing the client's need for these therapies, nurses assess the client's preferences in terms of the therapies that they wish to do.

Some examples of alternative and complementary therapies that can provide the patient with comfort are:

  • Meditation
  • Prayer
  • Magnets
  • Chiropractic services
  • Homeopathy
  • Reiki
  • Music therapy
  • Acupuncture
  • Acupressure
  • Massage
  • Deep breathing
  • Progressive muscular relaxation
  • Distraction
  • Guided imagery
  • Biofeedback
  • Hypnosis and self hypnosis
  • Mind Body Exercises and
  • Herbs and Dietary Supplements

All of the above alternative and complementary comfort measures were fully discussed previously in the section entitled "Evaluating the Client on Alternative or Homeopathic Health Care Practices".

Assessing the Client's Need for Palliative Care

As previously stated, according to the National Board for Certification of Hospice and Palliative Nurses, "Hospice and palliative care is the provision of care for the patient with life-limiting illness and their family with the emphasis on their physical, psychosocial, emotional and spiritual needs. This is accomplished in collaboration with an interdisciplinary team in a variety of settings which provide 24-hour nursing availability, pain and symptom management, and family support. The advanced practice registered nurse, registered nurse, pediatric registered nurse, licensed practical/vocational nurse, nursing assistant and administrator are integral to achieve a high standard of hospice and palliative care as members of this team."

Many clients choose palliative care, in contrast to curative care, at the end of life. These clients are educated about hospice and palliative care and how this care differs from curative care. The benefits of this care, for both the client and their family members, include the relief of pain and discomfort at the end of life and the psychosocial and spiritual support of the client and their family members. Some of the interventions that were discussed above in the section entitled "Assessing the Client's Ability to Cope with End-of-Life Interventions" are done for and with clients when they elect to have palliative care.

Assessing the Client's Need for Pain Management

Pain is a highly complex phenomenon. Plato described pain as an emotion and not a sensation; Hippocrates believed that pain was the result of a lack of balance in terms of the body's fluids. Neither Hippocrates nor Plato believes that the brain played any role in terms of pain. Other thinkers and philosophers prior to the Renaissance believed that pain was a punishment from god. It was Descartes who introduced the notion that pain is transmitted along the nerves to the brain where the pain is perceived by the person.

Some of the more current theories relating to pain and the evolution of thought relating to pain, the nature of pain, and the client's response to pain are described below.

  • The Specificity Theory of Pain: The Specificity Theory of Moritz Schiff in the 1850s described pain as a sensation that was different from all the other senses in that pain had its own specific nervous system pathways from the spinal cord that traveled to the brain. According to this theory, there are no psychological responses to pain.
  • Intensive Theory: This theory of pain debunked the Specificity Theory and it is based on the belief that pain is an emotional state, rather than a sensory phenomenon. Pain occurs with an intense stimulus such as intense heat and pressure.
  • The Peripheral Pattern Theory: The Peripheral Pattern Theory of pain, which is often referred to simply as the Pattern Theory of pain, was proposed by Sinclair and Weddell during the 1950s. Pain, according to this theory, is transmitted by nerve endings in the skin when an intense stimulus is applied. This theory also does not recognize the psychological aspects of pain as we know it today.
  • The Neuromatrix Theory of Pain: This theory of pain supports the fact that pain is a dynamic and multidimensional process with physical, behavioral, perceptual, psychological and social responses and one that can only be described by the person who is experiencing it. The four parts of the nervous system according to the Neuromatrix Theory of pain components of the nervous system, according to this theory, consist of the body self neuromatrix, cyclical processing, the sentient neural hub which produces the client's awareness, and the patterns of movement.
  • Gate Control Theory: Melzack and Wall are credited with the Gate Control Theory of pain. Pain, according to this theory, is a combination of sensory, cognitive, affective and psychological responses to a painful stimulus. Pain is transmitted by rapidly transmitting nerve fibers, slowly transmitting nerve fibers, small and large nerve fibers along the dorsal horn of the spinal cord and its substantia gelatinosa. The substantia gelatinosa is the "gate" that facilitates or blocks the transmission of pain. Some of the factors that open this "gate" and create pain include the person's level of anxiety and their paucity of endorphins. Some of the factors that close this "gate" are the lack of anxiety, adequate levels of endorphins and the person's belief that the pain can be managed and controlled.

The pain process consists of four phases which, in correct sequential order are transduction, transmission, modulation and perception.

Pain can be described in a number of different ways. Pain can be acute and chronic; it can also be described as nociceptive, neuropathic, superficial, deep, somatic, radicular, referred, visceral, localized, diffuse, and mild, moderate, and severe.

  • Acute Pain: Simply defined, acute pain is pain that lasts less than 3 months; it has a rapid onset, it is typically localized, it is accompanied with sympathetic nervous system responses such as pupil dilation, diaphoresis, and increases in terms of the client's blood pressure, pulse rate and adrenal hormone secretion as well as other signs and symptoms such as anxiety, muscular tension and tightness, all of which can increase the severity and the duration of the pain.Acute pain is most often self-limiting and manageable with sound pain management interventions. Acute pain is a predictable, physiological warning that something is wrong.
  • Chronic Pain: In contrast to acute pain, chronic pain is long lasting pain that can continue for extended periods of time, it is more difficult for the client to describe, it is less definable than acute pain, it is more difficult for the nurse to assess, it can be continuous or intermittent and it is also often difficult to treat than acute pain. For example, some pain, like malignant pain, is sometimes intractable. Chronic pain is typically not associated with vital sign changes as they are associated with acute pain because the body has somewhat adjusted to it; but, chronic pain is associated with physical, emotional, psychological and behavioral changes such as distress, depression, anorexia, insomnia, fatigue, and withdrawal.
  • Neuropathic Pain: This pain is typically described by the client as a burning and sharp pain.Neuropathic pain can occur as the result of damage to the nervous system; central neuropathic pain occurs as the result of damage to the central nervous system; and peripheral neuropathic pain occurs as the result of damage to the peripheral nervous system. Spinal cord injury pain is an example of central neuropathic pain and examples of peripheral neuropathic pain include the pain associated with phantom pain and peripheral neuropathy secondary to diabetes.
  • Nocicetive Pain: Nocicetive pain includes both somatic pain and radicular pain which include deep abdominal pain and the pain resulting from a herniated spinal disk, respectively.
  • Superficial Pain: Superficial pain is body surface pain.
  • Deep Pain: Deep pain is pain that it is deep inside of the body.
  • Somatic Pain: Somatic pain, which is a type of nocicetive pain, occurs as the result of injuries to the skin, bone, muscle, connective tissues and joints.
  • Visceral Pain: Visceral pain, which is also a type of nocicetive pain, is pain that originates in and around the organs of the body.
  • Radicular Pain: Radicular pain is pain that radiates to the lower extremities with transmission that occurs along the spinal nerve.
  • Referred Pain: Referred pain spreads to an area of the body which is not the source of the pain.
  • Diffused Pain: Diffuse pain is widespread pain.
  • Localized Pain: Localized pain is pain that is restricted to one identifiable area.

Pain is assessed by the nurse by collecting and analyzing subjective and objective data. Pain is a subjective experience that cannot be scientifically proven to be or not be present. Current research clearly supports the fact that the client's subjective complaints of pain are far more accurate than other indicators of pain, such as the client's vital signs and behavioral changes such as crying and guarding the area of the body affected by the pain.

The PQRST method is a useful way for nurses to assess pain. The PQRST method consists of:

  • P: Precipitation: What precipitated the pain symptoms? What things precipitate an increase in the amount of pain and what things precipitate a relief from the pain?
  • Q: Quality: What is the quality of the pain? Is it dull, sharp, deep, superficial, burning, aching, or stabbing?
  • R: Region: Where is the pain? What region or area is painful? Does the pain travel and radiate to another area of the body like the jaw and your leg?
  • S: Severity and Symptoms: What is the intensity of the pain on a scale of 1 to 10 with 1 being minimal pain and 10 as the most intense pain? What other symptoms are you experiencing in addition to the pain?
  • T: Triggers and Timing: What triggers and starts your pain? What triggers make the pain worse and more severe? When did the pain begin? Tell me about the timing of the pain. How long does the pain last? How often does the pain appear?

The quality of pain as sharp, burning, etc. is also described by the client as the nurse is assessing the client's pain. At times, the quality of the pain can suggest its cause. For example, cramping may indicate that the source of the pain is musculoskeletal in terms of its origin. The standardized McGill Pain Questionnaire has a large number of these quality of pain descriptors including descriptors like unbearable, hot, and pricking needle like pain.

Behavioral signs and symptoms associated with pain can include insomnia, anorexia, muscular tension, rigidity, a narrow focus of attention and crying. Some of the objective physiological signs and symptoms of pain include like increased blood pressure, diaphoresis, tachycardia, adrenal hormone secretion and dilation of the pupils. The signs and symptoms are assessed for by the nurse, particularly when the client, such as an infant, is not able to provide the nurse with full subjective data which describes their pain.

Observational behavioral pain assessment scales for the pediatric population are used among children less than three years of age. Some of these standardized pediatric pain scales include the FACES Pain Scale, the neonatal CRIES Pain Scale, Toddler Preschooler Postoperative Pain Scale (TPPPS), the Neonatal Infant Pain Scale (NIPS), the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), the Faces Legs Activity Cry Consolability Pain Scale (FLACC), the Visual Analog Scale (VASobs) the Observation Scale of Behavioral Distress (OSBD), the COMFORT Pain Scale and the Pre-Verbal Early Verbal Pediatric Pain Scale (PEPPS) that is used with toddlers.

At the current time, most nurses use a pain scale from 0 to 10 along the scale with 0 being the absence of pain and 10 being the worst possible level of pain for adults who are cognitively aware and other tools like faces pain assessment scale with adult clients who are affected with the lack of cognitive abilities, such as those who are demented or in a lethargic state of consciousness..

The consequences of uncontrolled pain are severe and they adversely affect the client's quality of life. Many clients, like the population at large, have misconceptions about pain and pain management. Some of these misconceptions include:

  • The belief that pain is inevitable and a normal part of illness.
  • Addiction occurs when a client takes narcotic analgesics.
  • Neonates and infants do not feel pain.
  • Clients who have a past personal history of a substance related abuse should not be given any narcotic analgesics

None of the above statements are true.

Recognizing Differences in the Clients' Perceptions and Responses to Pain

Like all other things, clients vary in terms of their perceptions of pain and their responses to pain. Some of the factors that impact on the clients' perceptions of and responses to pain include:

  • Social factors including one's support systems
  • Ethnic factors and values
  • Cultural factors and values
  • Level of development
  • Economic factors
  • The individual client's personal definition of pain and its meaning
  • The client's past experiences with pain
  • Level of fatigue
  • Genetic factors
  • Levels of fear and anxiety
  • Level of cognitive functioning

Applying a Knowledge of Pathophysiology to Non-Pharmacological Comfort/Palliative Care Interventions

As previously listed in the Introduction to "End of Life Care", some of the signs and symptoms associated with the end of life include those below. These signs and symptoms and some possible non-pharmacological comfort and palliative care interventions are discussed below.

  • Excessive sleeping: Excessive sleeping is more of a concern for the family members than it is for the client. Family members should be instructed about the fact that excessive sleeping is a commonly occurring occurrence at the end of life. They should also be taught about the importance of their mere presence and gentle touches are comforting to the client even when they are sleeping.
  • A decreased desire for food and fluids: Anorexia and a lack for fluid and food intake are common at the end of life. Many clients elect to forgo tube feedings and intravenous fluids for fluid rehydration in their advance directive so these choices must be supported.
  • Incontinence of the bowels and bladder: The end of life is probably not the time to do bowel and bladder training so the nurse must, instead, insure that the client is always clean and dry.
  • Respiratory secretions congestion: Respiratory congestion results from the accumulation of respiratory secretions in the airways. The pulmonary hygiene procedures discussed above such as coughing, deep breathing, incentive spirometry, postural drainage, percussion, vibration and inspiratory respiratory exercises, in addition to suctioning may be indicated for the relief of the respiratory congestion.
  • Changes in respiratory patterns, including Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized with deep and rapid breathing that is then followed with periods of apnea. Apnea is often disturbing and upsetting to the client's family members, therefore, the nurse should explain the fact that Cheyne-Stokes respirations are normal during the perideath period and that clients with Cheyne-Stokes respirations report that these episodes did not cause them to experience any distress.
  • Restlessness and agitation: Some clients at the end of life may experience agitation and restlessness. In addition to insuring the safety of the client, the underlying cause of this agitation and restlessness must be identified and treated if possible. For example, restlessness can occur as the result of hypernatremia, renal impairment, poor hepatic function, blood pH changes and other causes. When the underlying cause cannot be determined and treated, the client may be given an antipsychotic medication like haloperidol or an antianxiety agent like lorazepam to correct restlessness and agitation.
  • A lack of orientation: Nurses assess the clients' level of orientation to person, time and place. When a lack of orientation occurs as the result of an identifiable and treatable cause like delirium, the underlying cause should be treated and corrected. When the cause of the lack of orientation is not identifiable and/or not treatable, the client should be frequently oriented by the nurse and other members of the health care team.
  • Body pallor and coolness: Pallor can result from a number of causes including anemia, a low blood glucose level and exposure to cold. When correctable, treatable causes of this body pallor are identified, and then they should be treated when the client at the end of life chooses to have these treatments.
  • Social withdrawal: Many clients want to be alone at the end of life. Again, this choice should be supported and upheld by the members of the health care team and the family.
  • Vision like experiences: It appears that many clients at the end of life have vision like experiences of relatives and friends that have predeceased the client. According to clients who have experienced these visions, they find them comforting and with a lot of meaning. If, and when, clients and family members express concerns about these visions and appearances, they should be told that these things commonly occur at the end of life for some clients.
  • Saying goodbyes to loved ones: Although saying goodbye to a loved one is a sad experience and often associated with grief, saying goodbye allows the client and their loved ones to express their love, to ask for forgiveness and, for family members, it is a time to tell the loved one that they have your permission to let go and leave when the client is ready.
  • Letting go: Letting go, ideally, occurs when the client has reached a level of acceptance about their own death. This letting go facilitates the client to reconcile with others and tap into the spiritual dimension when this is something that the client is connected to.

Nurses monitor the client's responses to non-pharmacological interventions in terms of the client's level of comfort. As with pharmacological interventions, nonpharmacological interventions have expected outcomes like a reported or observed decrease in the levels of pain and discomfort and increased levels of comfort as reported by the patient or observed by the nurse.

In essence, the outcomes of palliative care interventions are evaluated in terms of whether or not the client and family members have had their physical, psychological, emotional, religious, social and spiritual needs effectively met, including the client's freedom from pain.

Incorporating Alternative and Complementary Therapies Into the Client's Plan of Care

As fully described above in the section entitled "Evaluating the Client on Alternative or Homeopathic Health Care Practices", nurses assess the clients' needs for alternative and complementary therapies such as progressive relaxation and music therapy and then incorporate these therapies into the client's plan of care.

Counseling the Client Regarding Palliative Care

Clients have the innate right to self-determination and to make their own decisions about care without any coercion from members of the health care team. Many clients at the end of life may not be knowledgeable about palliative care and hospice care. They may be exhibiting some of the signs and symptoms that they may potentially want met with a palliative care philosophy and palliative care interventions. For this reason, the nurse, in collaboration with other members of the health care team, educates the client about palliative care and how this care differs from curative care.

After this education and counseling, the client should be encouraged to make a decision about whether or not they want palliative care after they have become knowledgeable about it and what it has to offer to clients at the end of life. Again, this informed consent, and decision, is the decision of the client and it must be supported and respected by the nurse and other members of the health care team and family members.

Respecting the Client's Palliative Care Choices

Clients should be provided with complete information about palliative care and they should also have the opportunity to discuss all of their alternatives and options. This education should also include the benefits and risks associated with alternative choices and their choices in the same manner that is done with all informed consents.

Assisting the Client in Receiving Appropriate End of Life Physical Symptom Management

Some of the intervention for hypovolemic shock, in addition to correcting an underlying cause such as bleeding and dehydration, are intravenous fluid replacements with fluids like lactated Ringers, the administration of blood, blood components and plasma expanders, and placing the client in the Trendelenburg position.

Some of the non-pharmacological interventions for symptom management at the end of life were previously discussed in the section entitled "Applying a Knowledge of Pathophysiology to Non-Pharmacological Comfort/Palliative Care Interventions".

Some of the other physical symptom management intervention will be discussed now, according to body system. Many of these physical disorders and related symptoms occur most often among clients at the end of life who have terminal cancer.

Dehydration

Fluid and electrolyte imbalances may occur at the end of life as a result of the client's loss of appetite and their refusal of food and fluids as the end of lie is near. The signs and symptoms of moderate dehydration include dry skin, thirst, oral dryness, constipation, headache, a diminished urinary output, orthostatic hypotension, and dizziness; the signs of severe dehydration have the signs and symptoms of moderate dehydration in addition to possible anuria and renal failure, hypotension, poor skin turgor, tachycardia, delirium, tachypnea, sunken eyes, confusion, a high fever, and electrolyte imbalances.

Some clients at the end of life may elect to have fluid rehydration and other things like total parenteral nutrition and tube feedings to correct dehydration and, others choose to not have these interventions at the end of life. Some of the interventions that should be rendered to clients with dehydration for symptom relief include things like ice chips or an ice pop for oral dryness, antipyretic medication for a high temperature, and the maintenance of safety when the client is adversely affect with dizziness, orthostatic hypotension, confusion and/or hypotension.

More information about fluids and electrolytes, and fluid and electrolyte imbalances will be fully described in detail later in this NCLEX-RN review with the section entitled "Fluid and Electrolyte Imbalances".

Superior Vena Cava Syndrome

Superior vena cava syndrome is characterized with the compression of the vena cava of the heart to the extent that this compression decreases and prevents the return of blood to the heart. A tumor in the mediastinal area is the most common risk factor associated with superior vena cava syndrome. Some of the signs and symptoms associated with superior vena cava syndrome are a rapid respiratory rate, cyanosis, dyspnea, edema, a decreased level of consciousness, seizures, venous stasis, respiratory distress, and respiratory arrest

The treatment of superior vena cava syndrome, depending on the severity of it and the client's choices at the end of life, can include respiratory support with oxygen supplementation and mechanical ventilation, dexamethasone or another corticosteroid medication to decrease the edema, and seizure precautions.

Cardiac Tamponade

Cardiac tamponade results from the collection of fluid in the pericardial sac around the heart which impedes the compression, filling and pumping actions of this vital organ. Oncology clients who are affected with tumors near or invading the pericardial sac, those who had therapeutic radiation to this area, and clients who have had a traumatic chest puncture wound are at risk for cardiac tamponade.

Oliguria, a narrow pulse pressure, tachycardia, diminished peripheral pulses, jugular vein distention, high central venous pressure and hypotension are some of the signs and symptoms of cardiac tamponade. Treatments for this life threatening disorder can include medication to correct hypotension, oxygen supplementation, intravenous fluids and, at times a pericardicentesis may be indicated for the client affected with cardiac tamponade.

Septic Shock

Septic shock at the end of life is a risk for clients at the end of life particularly if they are immunosuppressed and not able to combat infections as the result of the client's disease process such as can occur with HIV/AIDS, leukemia, and lymphoma. Some of the signs and symptoms of septic shock include a high temperature, confusion, pulmonary edema, massive vasodilation, lethargy and hypoxia.

Some of the treatments used for septic shock, should the client want these treatments, are intravenous fluid replacements, antibiotics, oxygen supplementation, mechanical ventilation, dialysis, and medications to increase the blood pressure.

Hypovolemic Shock

Hypovolemic shock can occur at the end of life and at other times as the result of severe and prolonged dehydration, hemorrhage, and other causes of bodily fluid losses such as vomiting and diarrhea. In addition to death from hypovolemic shock, the client can be affected with progressive and severe dehydration, metabolic acidosis, decreased cardiac output, and multisystem failure and shutdown.

Some of the intervention for hypovolemic shock, in addition to correcting an underlying cause such as bleeding and dehydration, are intravenous fluid replacements with fluids like lactated Ringers, the administration of blood, blood components and plasma expanders, and placing the client in the Trendelenburg position.

Hypercalcemia

Hypercalcemia, which is elevated calcium in the blood, occurs at the end of life especially among clients who are affected with bone cancer, multiple myeloma, and breast cancer. Some of the signs and symptoms of hypercalcemia include anorexia, nausea, vomiting, paresthesia, muscular weakness, and pain.

The symptomatic relief of hypercalcemia at the end of life, in addition to intensive intravenous fluid replacement therapy, are increasing oral fluid intake, vitamins D and A, pain medications to relieve the pain, and medications such as diuretics to increase urinary output and clear the body of the calcium, and other medications like pamidronate and alendronate. Client safety is also important because the client with hypercalcemia is at risk for pathological bone fractures secondary to bone decalcification. Again, some clients may elect to have one or more of these interventions and other clients may not elect to have one or more of these interventions.

Tumor Lysis Syndrome

Tumor lysis syndrome is an oncological emergency that is most often found among clients who are affected with group of metabolic complications, which can occur as the result of cancer treatments. Tumor lysis syndrome produces the release of phosphates, nucleic acids and potassium into the client's blood. Risk factors for tumor lysis syndrome include tumors that are large and aggressive and clients affected with dehydration, lymphoma, leukemia and also when clients have had chemotherapy for cancer.

Some of the signs and symptoms associated with tumor lysis syndrome include lethargy, pain, muscular weakness secondary to hyperkalemia, renal failure, and sudden death. Some of the treatments for tumor lysis syndrome include dialysis, intravenous fluid hydration, and medications like allopurinol and rasburicase.

Increased Intracranial Pressure

Increased intracranial pressure can occur secondary to a traumatic closed head injury, a subdural hematoma, an epidural hematoma, brain tumors, and structural deficits such as occurs when a neonate is born with spina bifida, for example. The signs and symptoms of increased intracranial pressure are Cheyne-Stokes respirations, a widened pulse pressure, bradycardia and Cushing's signs and symptoms.

Treatments include medications such as mannitol which is a cerebral osmotic diuretic that decreases the fluid buildup, anticonvulsant medications to decrease the risk of seizure activity, the relief of edema using corticosteroids, and the correction of any hypertension. When this disorder is profound and severe, mechanical ventilation can be initiated and a barbiturate coma may be induced.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

The syndrome of inappropriate antidiuretic hormone secretion most often affects clients who have cerebral tumors, leukemia, lung cancer, pancreatic cancer, and brain tumors. Physiologically, the syndrome of inappropriate antidiuretic hormone is the result of the hypersecretion of antidiuretic hormone from the pituitary endocrine gland.

Some of the signs and symptoms of signs and symptoms associated with the syndrome of inappropriate antidiuretic hormone include irritability and other mood changes, alterations in the client's mental status, lethargy, the retention of fluids, and hyponatremia. The symptoms of this disorder can be corrected and treated, at times, with the permission and consent of the client, with the symptomatic relief of pulmonary and cerebral edema, as discussed above, increased fluid intake and the administration of hypertonic intravenous fluids, lithium carbonate that minimizes the adverse effects of excessive antidiuretic hormone, and demeclocycline to promote urinary elimination and diuresis.

Planning Measures to Provide Comfort Interventions to Clients with Anticipated or Actual Impaired Comfort

Measures and interventions to provide comfort to the client with potential and anticipated as well as actual alterations of comfort can include both dependent and independent nursing interventions. Some of these interventions are pharmacological and others are non-pharmacological, and some of these interventions are consented to by the client and other clients may refuse these interventions.

Independent nursing functions include those things such as the initiation of coughing and deep breathing exercises and back massage, and dependent nursing functions, which are interventions that the nurse can only perform with a doctor's order, include things like the administration of analgesic medications and intravenous fluid replacements.

Non-pharmacologic comfort measures, of which there are many to select from, have been previously listed and discussed in the section above entitled "Introduction to End of Life Care". Pharmacological pain management will be fully discussed below in the section entitled "Pharmacological Pain Management" and the assessment of clients in reference to pain and their level of pain was fully discussed above in the section entitled "Assessing the Client's Need for Pain Management".

Providing Non-Pharmacological Comfort Measures

Non-pharmacologic comfort measures have been previously listed and discussed in the section above entitled "Introduction to End of Life Care".

Evaluating the Client's Response to Non-Pharmacological Interventions

In actuality, this topic heading is somewhat misleading because both the non-pharmacologic comfort measures and the pharmacologic comfort measures are evaluated in the same manner. Both are evaluated in terms of the expected outcomes that were established for the client in terms of their level of comfort and their freedom from pain and discomfort.

Some of these expected outcomes that are considered in terms of whether or not the client has achieved them include, for example:

  • The client will express relief of pain after performing progressive relaxation techniques
  • The client will decrease their level by 4 on a scale from 1 to 10 with a numeric pain assessment scale
  • The client will demonstrate the procedure for meditation
  • The infant will demonstrate a decreased level of pain according to the CRIES pain scale
  • The preschool age client will demonstrate a decreased level of pain according to the FACES pain scale
  • The cognitively impaired client will demonstrate a relief from pain with better periods of rest and sleep
  • The client will have an expressed decreased level of pain after the administration of the ordered narcotic analgesic
  • The client will have an expressed decreased level of pain after the administration of the ordered NSAID for the relief of pain
  • The client will list and describe five non-pharmacological pain control methods that they can use for the relief of pain

Evaluating the Outcomes of Alternative and/or Complementary Therapy Practices

As stated immediately above, both the non-pharmacologic comfort measures which include alternative and complementary therapy practices, and the pharmacologic comfort measures are evaluated in the same manner. Both are evaluated in terms of the expected outcomes that were established for the client in terms of their level of comfort and their freedom from pain and discomfort.

Evaluating the Outcome of Palliative Care Interventions

Evaluating the outcomes of palliative care interventions are determined and measured by comparing and contrasting the client's physical, psychological, social and spiritual/religious current status to the pre-established client goals or expected outcomes. For example:

  • Have the client and family members verbalized a knowledge of palliative care?
  • Have the client and family members demonstrated an understanding of the end of life signs and symptoms?
  • Have the client and family members demonstrated a lack of depression and a level of acceptance in terms of the imminent death?
  • Is the client without any signs of respiratory distress?
  • Is the client without any signs of pain or discomfort?
  • Is the client without any signs of skin breakdown?
  • Are the family members participating in the end of life care for the client?
  • Are the client and family members free of psychological and emotional distress?
  • Are the client and family members free of anger and hostility?
  • Are the client and family members free of guilt?
  • Are the client and family members effectively coping with grief and loss?
  • Is the client meeting their spiritual and/or religious needs?
  • Does the client have a sense of meaning and connectedness?
  • Is the client free of any spiritual and religious distress?
  • Are the client and family members free of depression?
  • Are the client and family members free of fear and anxiety?
  • Are the client's choices at the end of life supported and accepted by family members?
  • Is the client free of any agitation and restlessness?
  • Have the client's last wishes been expressed to others and accepted by others?

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