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CARES self-care.
Case Study
Mr F. was a 78-year-old gentleman with a history of cardiomyopathy and acute renal insufficiency. He presented to the emergency room complaining of generalized 8/10 chest pain and acute fatigue. He was short of breath, emaciated, pale, and diaphoretic with a blood pressure of 82/40 mm Hg. An echocardiogram showed an ejection fraction of less than 5%. Mr F. knew he was dying and requested do-not-resuscitate status. He was placed on a morphine patient-controlled analgesia at 1 mg/h and PRN boluses of 0.5 mg every 15 minutes PRN, and given oxygen per nasal cannula at 2 L/min. He was admitted to the medical unit with orders for comfort measures only. Hospice was to evaluate him in the morning.
Using the CARES tool as a guide, the nurse clarified what comfort measures meant to Mr F., obtained needed orders, and planned the following nursing actions:
• Comfort: Based on the comfort section of the CARES tool, the nurse obtained orders to (a) stop all laboratory draws as no follow-up treatments would be provided; (b) change obtaining vital signs to every shift given there were no plans to treat deficits and to minimize interrupting rest; (c) reduce intravenous lines to KVO, limiting the risk of fluid overload and pulmonary edema; and (d) titrate the morphine patient-controlled analgesia to control pain and to optimize coronary perfusion and reduce the workload of the heart.
• Airway: Following the CARES tool section, the nurse was aware the use of morphine is a recommended standard for the treatment of shortness of breath and planned to continue to titrate as needed. She positioned Mr F. in a comfortable upright position to promote ease of respirations and obtained an order for glycopyrrolate subcutaneous for any increased oral-pharyngeal secretions Mr F. may develop as he progresses deeper into the dying process. Mr F. found the oxygen cannula irritating and requested its removal. The nurse was aware through the CARES tool that oxygen supplementation is often ineffective in the dying process. Oxygen is considered a medication, and Mr F. had the right to refuse it.
• Restlessness and delirium: Mr F. became very restless but denied chest pain. The nurse reviewed the CARES tool section on restlessness and noted the suggestion to rule out treatable causes of restlessness such as pain and bladder distention. Mr F.'s bladder was firm and distended. An order was obtained for a urinary catheter. Mr F. had an immediate output of 500 mL and began to rest more comfortably. The nurse acted on additional prompts from the CARES tool and obtained an order for haloperidol PRN in preparation of possible future restlessness and/or terminal delirium and lowered the lights in the room to maintain a calm and supportive environment.
• Emotional and spiritual support: The CARES tool recommends the creation of a supportive and loving atmosphere through the presence of friends and family. Mr F. denied having any family and requested a friend be called and allowed to remain at the bedside. The nurse noted the friend was visibly upset upon arrival and took the time to explain Mr F.'s condition and to listen to the friend's concerns that Mr F. not suffer. The CARES tool emphasizes the importance of treating both the patient and family as a single unit, so the nurse listened attentively and provided education and reassurance. Mr F. appeared peaceful with the friend at the bedside. The nurse was aware of the CARES tool recommendation to help the patient and family avoid any sense of abandonment. His status was assessed frequently, and assurances were made that the nurse would be available if needed. The nurse was aware Mr F. was awake after the friend had fallen asleep. Based on the CARES tool, the nurse knew the importance of presence for emotional and spiritual comfort. The nurse sat by the bedside and held Mr F.'s hand providing reassurance and promoting additional patient comfort. Mr F. died peacefully a few hours later. The friend was supported by pastoral care and assisted with funeral arrangements. Based on prompts from the CARES tool, the nurse knew to obtain additional support from the palliative care team as needed.
• Self-care: The nurse became tearful when recalling Mr F.'s death while attempting to give report to the on-coming shift. Following CARES tool recommendations, the nurse sought out support from peers. A debriefing session was provided by the manager and attended by coworkers. The nurse was encouraged to verbalize feelings and felt listened to and supported. A CARES tool suggestion to take pride in knowing the last few hours of Mr F.'s life were comfortable and peaceful was explored and provided additional emotional comfort for the nurse.
The case study is a very basic, uncomplicated example of the use of the CARES tool. It provides an example of how death can be a calm and supportive experience if the nurse is prepared and knows what orders to clarify and/or obtain, what supportive nursing measures to make, and what support systems are available.
and oh heres the article
Journal of Hospice and Palliative Nursing. 2013;15(3):147-153.
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