Question

need NEW answer please:

Elizabeth is over 100 years old. She has very little cognitive decline and is proud of having lived in three centuries. However, her physical condition has deteriorated during the past several months. Her only surviving daughter realizes and accepts that death is near. Elizabeth has been on a variety of cardiac medications including a blood thinning regime, for years. This requires a blood test every month for controlling the pro-time. The patient moans every time she is touched or turned, and cries out in pain whenever blood is drawn. Helen has been Elizabeth's nurse for more years than she cares to remember, but today she is reluctant to draw this blood. She talks to the Director of Nursing who tells her that the physician is very particular about continuing to monitor the pro-time accurately. Elizabeth's daughter is passive and does not complain. Helen decides to call the physician who gruffly reminds her that "good medical practice requires the blood be drawn to monitor the pro-time." The nurse approaches the bedside where Elizabeth is resting quietly and ponders what to do.

1. Imagine that Helen (Elizabeth's nurse) is seeking out your assistance in determining what to do. What would your team recommend as her next step? Select one of the following options and explain your team's reasoning:

• Continue to perform the blood tests as instructed by the physician

• Refuse to perform the blood test and document her dissent in a note

• Request to be reassigned so that she is no longer Elizabeth's nurse

• Suggest to the daughter that Elizabeth be moved to comfort care (aka - provide pain management but stop the cardiac medications)

option chosen:

Reasoning:

Answer 1

ANSWER: The team should recommend  Helen to continue to perform the blood tests as instructed by the physician with training and guidance on pain relief techniques and suggestions on distraction techniques  to be explained to her by the nursing seniors in the Nursing team.

REASONING:   MOTIVATION AND TRAINING FOR HELEN TO MAKE THE PROCESS OF IV BLOOD COLLECTION FROM PAINFUL TO PAINLESS HAS TO BE ACHIEVED BY THE NURSING TEAM

IN ADDITION,.PAIN MANAGEMENT SOLUTIONS AT HOME WITH THE HELP OF PHYSICIAN WILL ADD TO ELIZABETH'S GENERAL COMFORT.

DAILY EXERCISES UNDER GUIDANCE OF PHYSIOTHERAPIST WILL HELP TO IMPROVE MOBILiTY AND GENERAL TOLERANCE OF THE PATIENT.

EFFECTIVE PAIN CARE SOLUTION FOR IV BLOOD COLLLECTION IS THE NEED OF THE SITUATION HERE.

ADOPTION OF DISTRACTION TECHNIQUES TO MAKE THE IV BLOOD COLLECTION LESS PAINFUL TO  ELIZABETH IS THE BEST CARE THAT CAN BE GIVEN IN THE CURRENT SITUATION ,ASKING HELEN TO CONTINUE AS THE CAREGIVER WITH TRAINING HER WITH WAYS AND MEANS TO MINIMIZE PAIN IS THE MOST SAFEST AND RATIONAL APPROACH.

PAIN RELIEF MEASURES:Adequate patient hydration before the blood collection will make the veins more prominent and easy to find and the collection less painful.

1.Use of local anaesthetic cream containing lignocaine on the skin to provide numbness.

2.Talking to the patient about her life and her experiences with keeping eyes closed thereby distracting the patient from the pain experience.

3.Listening to the favourite music using headphones while looking away from the arm or watching television.If there is a favourite song that Elizabeth sings,she can be encouraged to sing the song at the time of collection so that she is diverted from the pain.

4.Taking help from Elizabeth's daughter to strike a conversation with Elizabeth during the procedure of blood collection.

5.Using a vibrating device on the arm of the side of blood collection to divert the patient from experiencing pain sensation.

6.using smaller size needles and collection tube.

7.Injecting lignocaine local anaesthetic into the skin preceding the blood collection with fine needles.

8.Breathing exercises at the time of collection or asking the patient to count upto 100 can be helpful to divert the patient from the painful experience.

9.Moral support and guidance by the nursing team to Helen by sending a geriatric expert phlebotomist or senior experienced nursing staff to accompany her at the time of collection if possible till the time she is adapted to the blood collection with ease and minimal pain reactions from her client.

OTHER OPTIONS AS INFERIOR CHOICE REASONING:

1.Refusing to draw blood and documenting the dissent in the note does not provide any solution and also puts the patient at risk of bleeding due to lack of monitoring of the coagulation profile.It can endanger her life.

2.Request to be reassigned to another patient is not solving the actual problem as a similar situation of patient groaning in pain while drawing blood may be encountered in another setting too.Chronic pain experienced by the elderly patients is of common occurence and has to be handled professionally.Acclimatization of Elizabeth to a new caregiver at this age may be really difficult so continuum of care in the hands of known caregiver is safe for the patient.Familiarity of care setting and care giver plays a major role in the secure and comfort feelings experienced by the geriatric patients.

3.Stopping the cardiac medications and shifting the patient to a comfort care for pain without her regular cardiac medications is denying medical care to the patient which can endanger her life.

POINTS OF CHANGE FOR POSITIVE OUTCOME:general pain relief solutions by physician, painless blood collection by retraining and supporting Helen ,general measures like exercises,socializing,sun exposure,recreational activities,multivitamins and minerals.

1.PROVIDING ELIZABETH WITH PAINLESS BLOOD COLLECTION SOLUTIONS BY MOTIVATING AND RETRAINING HELEN.NURSING TEAM SUPPORT TO HELEN IS THE KEY FACTOR IN THIS.

2.PROVIDE ELIZABETH WITH PHYSICIAN MODULATED PAIN RELIEF MEDICATIONS TO IMPROVE THE QUALITY OF LIFE AND GENERAL WELLBEING.THE SAFEST IS ACETAMINOPHEN; STRONGEST MORPHINE,GABAPENTIN AND PREGABALIN ARE THE NEWER DRUGS WITH LESSER SIDE EFFECTS GENERALLY WELL TOLERATED BY THE ELDERLY PATIENTS. PAIN RELIEF MEDICATIONS ALONG  WITH CARDIAC MEDICATIONS AND MULTIVITAMINS AND MINERALS  ESPECIALLY VITAMIND NEED TO BE ADDED.

3.ENCOURAGING REGULAR EXERCISES AND STRETCHING UNDER GUIDANCE OF PHYSIOTHERAPIST WITH REGULAR SUN AND OUTDOOR EXPOSURE.

4.INCORPORATING SOCIALIZING,LEISURE AND RECREATIONAL FACILITY FOR ELIZABETH WITH THE HELP OF HER DAUGHTER AND EXTENDED FAMILY.