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Principles of Patient and Family

Assessment
Chapter 3
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Dr. Sharifah Alsayed BSN,MS, PhD
KSBAU, College of Nursing-JD
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Course Code: 312 Byre'M
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Lecture objectives
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 Aims
❑ Conduct an assessment for palliative care patients and
their needs using valid tools.
❑ Use Ferrell’s quality-of-life framework to organize the
assessment.
❑ The four quality-of-life domains in this framework are
physical, psychological, social which will be combined to
Psychosocial domain at this lecture , and spiritual
well-being.
❑ These quality-of-life assessments are examined at
stages along the illness trajectory: at the time of
diagnosis, during treatments, after treatments and
(long-term survival or terminal phase).
 Introduction
❑ An effective assessment is key to establishing an
appropriate nursing care plan for the patient and family.
❑ The initial palliative care nursing assessment may vary
little from a standard nursing good
assessment.
dtime
❑ In order to assess effectively, members of the health care
team need to maximize their listening skills and minimize
quick judgments.
❑ The goals of the palliative care plan that evolve from the
initial and ongoing nursing assessments focus on
enhancing quality of life.
 Understand the Palliative
care assessment as a staging
procedure
Use Ferrell’s quality-of-life framework ( example of breast
cancer)
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 Assessment at the Time of Diagnosis
The goals of a palliative care nursing assessment at the time
of diagnosis are as follows:
Determine the baseline health of the patient and family.
Document problems and plan interventions with the patient
and family to improve their quality of life.
Identify learning needs to guide teaching that promotes
optimal self-care.
Recognize patient and family strengths to reinforce healthy
habits and behaviors for maximizing well being.
Discern when the expertise of other health care
professionals is needed (e.g., social worker, registered
dietitian).
 Physical Assessment at Diagnosis

• When the patient has finished telling his or her story about
the illness, the nurse needs to do an individualized, focused
physical assessment, based on data previously collected
from the medical record.
• This assessment might use the general categories of head
and neck, shoulders and arms, chest and spine, abdomen,
pelvis, legs and feet.
• The format, policies, procedures, and expectations of the
health care agency in which the assessment occurs guide
the specific details that are collected and documented.
 Physical Assessment at Diagnosis
• Because the family is so important to the palliative care
focus on quality of life, the overall health of other family
members needs to be documented
• Identification of the major health problems, physical
limitations, and physical strengths of family members serves
as a basis for planning
• The physical capabilities and constraints of the caregivers
available to assist and support the patient may affect the
plan of care, especially in relation to the most appropriate
setting for care
• This information also provides direction for the types of
referrals that may be needed to provide care
 Psychosocial Assessment at Diagnosis

• Normalize the patient’s and family’s experiences: “Many

people share similar reactions to this kind of news.”
• Use active listening skills to facilitate grief work: “Of all
that is happening to you right now, what is the hardest part
to deal with?”
• Create a safe space for self-disclosure, and build a
trust relationship: “No matter what lies ahead, you will not
face it alone.”
 Psychosocial Assessment at Diagnosis

• Develop a collaborative partnership to establish a

mutual plan of care: “What would help you the most right
now?”
• Respect the patient’s or family’s use of denial in the
service of coping with harsh realities: “It must be hard to
believe this is happening”
• Assess the patient’s and family’s coping styles: “When
you have experienced difficult times in the past, how did you
get through them?”
• Reinforce strengths. “It sounds like this has helped you
before”
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 Psychosocial Assessment at Diagnosis

• Maximize a sense of control, autonomy, and choice. “It

seems you really have a handle on this.”
• Assess the patient’s need for information: “What do you
know about your illness?,” “Are you the kind of person who
likes to know as much as possible, or do you function on a
need-to-know basis only?,” “What would you like to know
about your illness now?”
• Check the need for clarification: “What did you hear?” or
“Summarize in your own words how you understand your
situation now.”
 Psychosocial Assessment at Diagnosis

• Avoid “med-speak,” which is medical terminology

unfamiliar to the average person, such as the use of
abbreviations, acronyms, etc. (for example, UTI, CHF,
PEG).
• Mentor patients and families who have had little
experience with the health care system, including
coaching them in conversations with their physicians and
teaching them ways to navigate the complexities of the
health care system.
 Spiritual Assessment at Diagnosis

• Spiritual goals at this phase are to normalize initial concerns, to

provide information that fosters positive coping, and to
encourage the patient and family to seek supportive spiritual
resources.
• Determine the patient’s and family’s level of hopefulness
about the future: “What are you hoping for?” or “How do you
see the future at this time?”
• Inquire about how the patient and family have dealt with past
crises of faith, meaning, or loss: “What helped you get through
that?”
• Determine the patient’s and family’s comfort level in talking
about the spiritual life: “Some people need or want to talk
about these things; others don’t. How is it for you?”
 Spiritual Assessment at Diagnosis
• Inquire about spiritual support persons available to
the patient and family (e.g. counselor, spiritual
advisor).
• Determine the patient’s or family’s need or desire to
speak with a spiritual support person.
• Ask about spiritual self-care practices to promote
healthy coping: “How are you taking care of yourself at
this time?”
• Listen for comments from the patient and family
regarding the importance of their religious traditions
and practices.
 Assessment During Treatments
The goals of palliative care assessment during active
treatment are as follows:
Assess the patient’s systems in all domains that are at
risk for problems, considering both the patient’s baseline
problems and any side effects of the treatments.
Record the current and potential problems and plan
early interventions with the patient and family.
Discover the need for teaching to prevent, minimize, and
manage problems with the goal of maximizing quality of
life.
 Assessment During Treatments

Reinforce patient and family strengths, healthy habits,

and behaviors to maximize well-being
Recognize when other health care professionals’
expertise is needed and make appropriate referrals
(e.g., physical therapist, pharmacist)
 Physical Assessment During Treatments

• Reassessments during treatment determine the

changes that have occurred since the initial
assessment.
• Knowledge of the usual disease process and the
side effects of treatment assists the nurse in
focusing reassessments on those body systems
most likely to be affected.
 Physical Assessment During Treatments

• In addition to the patient’s physical assessment,

the nurse should make periodic observations and
inquiries about the health of other family members.
• It is important to document any changes in their
health problems or physical limitations and
physical strengths that might have an impact on
the patient’s care and the family’s overall quality of
life.
 Psychosocial Assessment During Treatments

• Assess for signs of anxiety and depression, which

remain the two most common psychosocial
problems associated with severe illness.

• Inquire about the patient’s newly emerging identity

as a result of the illness: “What activities and which
relationships bring you the most joy and meaning?”
or “Have you been able to define a new purpose
for yourself?”
 Psychosocial Assessment During Treatments

• Screen for suicidal ideation in cases of depression:

“Have you been feeling so bad that you’ve been
thinking of a way to hurt yourself?” and “Do you
have a plan for how to do it?”
• Refer for counseling and possible psychotropic
medication to enhance positive coping and comfort
 Spiritual Assessment During Treatments
• The health care team’s goals are to reinforce positive
coping, mobilize existing spiritual resources, invite the
patient and family to develop new skills for self-care,
and continue disclosures in an atmosphere of trust.
• Inquire about the patient’s and family’s hopes for the
future.
• Assess the level and quality of support they are
receiving—for instance, from other family members,
faith community, and neighbors.
• Explore expressions of anxiety and fear by asking,
“What is concerning you the most at this time?”
 Spiritual Assessment During Treatments
• Assess how the patient and family are coping with
the rigors of treatment: “What is the most
challenging part of this for you?” and “What is
helping you day by day?”
• Inquire about the patient’s and family’s definitions
of quality of life and the impact of treatment on
these aspects of their lives: “What is most
important to you in life now?”
• Determine their use of spiritual practices and offer
assistance in developing these (e.g., meditation,
relaxation, prayer).
 Spiritual Assessment During Treatments
• Ask how the patient or family members feel about their
current practices: “Are these helpful or not?”
• Discuss the completion of advance directives: “Who
would you want to make your health care decisions for
you if you were not able to make them yourself?” Also,
revisit the subject of code status.
• If patients say they would want to be revived and put on
life support, explain to them what usually happens if life
support cannot be removed in about two weeks: that is,
the placement of a tracheostomy and feeding tube
(PEG).
• Encourage patients to discuss all these matters and
options with their loved ones, especially their surrogate
decision makers.
 Assessment After Treatments
(Long-Term Survival or Terminal Phase)

The goals of a palliative care assessment after

treatments are as follows:
❖ Examine the benefits and burdens of all
interventions to manage the residual symptoms
remaining from the treatments and/or the disease
process.
❖ Determine the current physical problems that are
most distressing to the patient and family, and plan
rehabilitative interventions.
 Assessment After Treatments
(Long-Term Survival or Terminal Phase)

❖ Assess learning needs and provide teaching to aggressively

manage problems with the goal of maximizing quality of life.

❖ Continue to reinforce patient and family strengths, healthy habits,

and behaviors to enhance well-being and to prevent problems.
 Physical Assessment After Treatments
• The patient is reassessed after treatments are
finished to determine the changes that have
occurred since previous assessments; the focus is
on the systems that have been affected and altered
by the disease and treatments.
• Thorough assessment of the residual problems and
changes in the patient’s body are critical to
successful symptom management.
• Effective management of symptoms with
rehabilitative interventions achieves the goal of
maximizing the patient’s and family’s quality of life,
whether in long-term survival or during the terminal
phase.
 Psychosocial Assessment After Treatments
• Revisit the quality versus quantity of life preferences
as the patient and family weigh the benefits and
burdens of further treatment.
• Be sensitive to the patient’s readiness to discuss a
transition in emphasis from curative to comfort care
only.
• Consider a discussion about hospice if the patient
begins to question the efficacy of treatments.
Present hospice as the gold standard for end-of-life
care.
 Spiritual Assessment After Treatments

• The main spiritual goal of this phase of illness is to provide the

patient and family a “place to stand” in order to review the past
and look toward the future
• This encourages grieving past losses, creating a sense of
meaning, and consolidating strengths for the days ahead.
 Spiritual Assessment After Treatments

• Determine the quality and focus of the patient’s

and family’s hopes for the future.
• Assess the patient’s and family’s use of spiritual
practices: “What are you doing to feel calmer and
more peaceful?”
• Assess the level and quality of community
supports: “Who is involved in supporting you and
your family at this time?”
 Reference
Ferrell, B. R., & Coyle, N. (2006).
Text Book of palliative nursing.2nd ed
New York: Oxford, University Press,
Inc.