Nursing care in palliative care • Neurological • Respiratory • Gastrointestinal • Skin • Genitourinary • Family support

Nursing Care for Common Palliative-Care Symptoms

A system-by-system bedside guide for emergency medicine and palliative-care students

Learning objectives

• Apply a nursing-process approach to common palliative symptoms.
• Assess symptoms using patient report, observation, vital signs, function and caregiver information.
• Provide detailed nursing interventions for neurological, respiratory, gastrointestinal, skin, genitourinary, musculoskeletal and psychosocial symptoms.
• Administer and monitor prescribed medicines safely while preventing avoidable complications.
• Teach patients and caregivers, protect dignity and escalate emergencies promptly.

1. The nursing process for every symptom

Step	Bedside action	Document
Assessment	Ask the patient first; observe behaviour, function, skin, breathing, intake/output, medicines, goals, culture and caregiver concerns. Perform ABCDE for acute change.	Onset, severity/tool, site, pattern, associated signs, risks, patient goal and baseline.
Diagnosis/priority	Identify actual or potential problems: pain, impaired gas exchange, risk of aspiration, constipation, impaired skin integrity, anxiety or caregiver strain.	Clinical reasoning, red flags and escalation level.
Planning	Set measurable, patient-centred goals such as comfortable breathing, sleep, toileting, eating or safe transfer.	Goal, interventions, review time and named responsible person.
Implementation	Use positioning, mouth/skin care, communication, medication, non-drug measures, safety and family support.	Method, dose/route/time when medicines are given, education and response.
Evaluation	Repeat the symptom tool, vital signs, function and adverse-effect assessment. Change the plan when no meaningful benefit occurs.	Before/after score, function, toxicity, new findings, referral and handover.

2. Universal nursing priorities

• Preserve dignity, privacy, warmth, choice, cultural practice and confidentiality.
• Use a single clear communicator and an interpreter when needed.
• Reconcile medicines, including opioids, sedatives, steroids, anticoagulants, chemotherapy and herbs.
• Prevent falls, pressure injury, aspiration, constipation, dehydration, medication errors and caregiver exhaustion.
• Use teach-back and return-demonstration for every important home-care task.
• Escalate symptoms that are sudden, severe, changing, disproportionate or associated with instability.

3. Neurological symptoms

3.1 Headache and raised intracranial pressure

Assess: onset, worst/first headache, morning or positional pattern, vomiting, visual change, seizure, focal weakness, pupils, consciousness, fever, neck stiffness, trauma, cancer history and medicines.

• Keep the patient in a comfortable position with the head modestly elevated; avoid unnecessary straining.
• Reduce noise and light, provide calm explanation and assess pain with a validated tool.
• Monitor neurological observations, pupils, blood pressure, pulse, respiration, oxygenation and level of consciousness according to acuity.
• Administer prescribed analgesic, antiemetic or corticosteroid; monitor glucose, infection, mood and gastrointestinal effects of steroids.
• Escalate sudden severe headache, deteriorating consciousness, unequal pupils, seizures, new weakness or repeated vomiting urgently.

3.2 Seizures

1. Stay with the patient, call help, time the seizure and protect from injury. Do not restrain or put objects in the mouth.
2. Clear hazards, use a lateral position when safe and assess airway, breathing, circulation and glucose.
3. After the seizure, provide oxygen if indicated, suction only when necessary and assess aspiration, injury and recovery.
4. Administer prescribed benzodiazepine or anticonvulsant according to the emergency protocol; monitor respiratory depression and sedation.
5. Search for reversible causes: hypoglycaemia, electrolyte imbalance, infection, medication toxicity, withdrawal, brain metastasis or raised intracranial pressure.
6. Explain the plan to the family and document duration, movements, consciousness, medicine, response and recurrence.

3.3 Delirium, confusion and agitation

Delirium is acute, fluctuating disturbance of attention and awareness. It may be hypoactive (quiet, withdrawn) or hyperactive (restless, hallucinating).

• Assess oxygenation, glucose, infection, pain, urinary retention, constipation, dehydration, renal/hepatic failure, medicine effects and withdrawal.
• Use a calm, well-lit environment, clock/calendar, familiar voice and minimal staff changes.
• Keep essential glasses, hearing aids and communication supports available; avoid arguing about hallucinations.
• Reduce falls and wandering risk; use least-restrictive safety measures and involve family with consent.
• Administer prescribed symptom medicine only after reversible causes and non-drug measures are addressed; monitor sedation, breathing and extrapyramidal effects.
• Urgently escalate dangerous agitation, suicidal/violent behaviour, severe withdrawal, head injury or rapidly changing consciousness.

3.4 Weakness, numbness and neuropathy

• Assess onset, distribution, strength, sensation, gait, reflexes, falls, pressure areas, bowel/bladder function and medication toxicity.
• Use safe transfers, mobility aids, pressure relief, physiotherapy and occupational therapy.
• Protect insensate areas from heat, cold, sharp objects and burns; inspect feet and skin daily.
• Escalate new focal weakness, sensory level, saddle anaesthesia, bladder/bowel dysfunction or rapidly progressive symptoms.

4. Respiratory symptoms

4.1 Breathlessness

• Perform ABCDE; note respiratory rate, effort, oxygen saturation, speech, cyanosis, chest movement, fever, pain and consciousness.
• Position upright or in the patient’s preferred posture; stay present and use short reassuring explanations.
• Direct a fan or airflow across the face if safe; loosen tight clothing and reduce crowding.
• Give oxygen when hypoxaemic or specifically indicated, not automatically for every breathless patient.
• Administer prescribed bronchodilator, diuretic, antibiotic, steroid, opioid or anxiolytic according to cause; monitor response, sedation and blood pressure.
• Teach paced breathing and energy conservation once the patient is stable.
• Escalate stridor, severe hypoxia, cyanosis, chest pain, shock, sudden onset or reduced consciousness.

4.2 Cough and secretions

• Assess sputum colour/volume, blood, fever, pain, aspiration, infection, bronchospasm and ability to clear secretions.
• Position for drainage and comfort; provide mouth care, hydration if safe and prescribed bronchodilator/antibiotic/antitussive.
• For terminal secretions, reposition gently and reassure family; avoid repeated deep suctioning that causes trauma and distress.
• Escalate haemoptysis, airway obstruction, severe wheeze, stridor, cyanosis or sudden deterioration.

4.3 Haemoptysis and airway bleeding

Keep the patient calm, position toward the bleeding side if known, protect the airway, use dark towels to reduce visual distress and call senior help. Review anticoagulants, prepare suction and oxygen if indicated, and follow the current bleeding protocol. Never leave a patient with significant haemoptysis alone.

5. Gastrointestinal symptoms

5.1 Nausea and vomiting

Assess: onset, frequency, triggers, colour/blood, abdominal pain/distension, bowel/flatus, hydration, aspiration, medicines, infection, vestibular symptoms and treatment history.

• Position side-lying or upright, protect the airway and provide an emesis bowl, tissues and mouth care.
• Withhold unsafe oral intake during repeated vomiting or suspected obstruction; follow the medical plan for fluids and route.
• Administer one targeted antiemetic at a time where possible; monitor QT, sedation, extrapyramidal effects and constipation.
• Offer small sips or ice only when alert and swallowing safely; avoid strong smells and large meals.
• Record intake/output, weight trend, electrolytes when ordered and response to treatment.
• Escalate blood, severe distension, peritonism, shock, persistent vomiting or reduced consciousness.

5.2 Constipation

• Record baseline bowel habit, last stool/flatus, consistency, straining, pain, distension and contributing medicines.
• Encourage fluids, fibre and mobility only when safe; provide privacy, a commode and regular toileting.
• Administer prescribed stimulant/osmotic laxative; check for obstruction or impaction before rectal measures.
• Monitor diarrhoea, dehydration, electrolyte change and abdominal pain after treatment.
• Teach caregivers that opioids commonly cause constipation and prevention is part of opioid care.

5.3 Diarrhoea

• Assess frequency, volume, blood, fever, pain, antibiotics, laxatives, infection, chemotherapy, overflow around impaction and dehydration.
• Use gloves/hand hygiene, skin protection, safe disposal and isolation measures if infection is possible.
• Replace fluids/electrolytes as appropriate, review laxatives and report blood, fever, severe pain, oliguria or shock.
• Avoid anti-diarrhoeal medicines when invasive infection, ileus or severe colitis is suspected unless prescribed.

5.4 Dysphagia and aspiration risk

• Assess cough/voice after swallowing, wet breathing, pocketing, weight loss, alertness, oral condition and preferred foods.
• Sit upright, offer small supervised amounts and follow speech/swallow assessment. Do not force oral medicines or fluids.
• Provide mouth care and discuss alternative medicine routes and goals if swallowing fails.
• Escalate choking, recurrent aspiration, cyanosis, new fever or reduced consciousness.

5.5 Anorexia, cachexia and thirst

• Explore nausea, pain, constipation, mood, mouth problems, taste change, treatment effects and the patient’s wishes.
• Offer small preferred foods, flexible timing, oral comfort and family education; avoid force-feeding.
• Explain that reduced appetite is common in advanced illness and is not necessarily caused by caregiver neglect.
• Monitor hydration, swallowing, pressure risk and distress rather than imposing burdensome nutrition goals.

5.6 Hiccups and abdominal obstruction

Assess triggers, reflux, distension, bowel movements, medication effects and electrolyte abnormalities. Keep the patient upright, provide oral comfort, administer prescribed medicine and escalate persistent hiccups, severe vomiting, complete obstipation, guarding or shock. Do not give bulk laxatives or prokinetics blindly in complete obstruction.

6. Skin and wound symptoms

6.1 Pressure injury prevention and care

• Assess risk, skin colour/temperature, moisture, nutrition, sensation, mobility, perfusion and pain at admission and regularly.
• Reposition for comfort and pressure relief; use pillows, heel protection, pressure-relieving surfaces and safe lifting.
• Keep skin clean and dry, manage incontinence promptly, avoid friction/shear and use barrier preparations where indicated.
• Document site, size, depth, tissue, exudate, odour, surrounding skin, pain and infection signs; follow local wound protocol.
• Escalate necrosis, spreading erythema, fever, severe pain out of proportion, exposed bone or suspected sepsis.

6.2 Malignant and fungating wounds

• Assess bleeding, odour, exudate, pain, infection, dignity, clothing and psychological distress.
• Use non-adherent dressings, gentle irrigation, absorbent layers and odour control according to wound-team guidance.
• Prepare for bleeding: calm environment, dark towels, pressure only when safe and emergency referral for major haemorrhage.
• Do not debride a fragile tumour without specialist direction; involve wound, oncology and palliative teams.

6.3 Pruritus and dry skin

• Check cholestasis, renal failure, opioids, allergy, scabies, dry skin, infection and psychological amplification.
• Use tepid bathing, fragrance-free moisturizers, short nails, loose cotton clothing and a cool room.
• Avoid scratching injury, hot water and irritant soaps; administer prescribed antihistamine or cause-directed medicine.
• Escalate jaundice with confusion, widespread rash, facial swelling or breathing difficulty.

7. Genitourinary and continence care

Urinary retention

• Assess lower abdominal pain, palpable bladder, urine output, catheter patency, constipation, medicines, clots and neurological signs.
• Provide privacy, running water or a warm environment where appropriate; catheterize only when indicated and trained.
• Monitor urine colour, output, haematuria, infection, trauma and comfort. Escalate retention with fever, flank pain, shock or neurological deficit.

Incontinence

• Use scheduled toileting, pads, barrier protection, prompt cleansing and dignity-preserving communication.
• Consider catheterization only when it improves comfort, prevents skin injury or manages retention; review necessity daily.
• Screen for diarrhoea, infection, constipation overflow, delirium and caregiver burden.

8. Musculoskeletal symptoms and immobility

• Assess pain, weakness, posture, range of motion, contracture, fracture risk, gait, falls, bone metastases and spinal stability.
• Use positioning, splinting, gentle range of motion, safe transfers, pressure relief and physiotherapy.
• Coordinate prescribed analgesia before activity; avoid dragging or twisting a patient with possible fracture/spinal instability.
• Provide mobility aids, footwear, commode and environmental modifications; document functional goals.

9. Psychological, social and spiritual symptoms

Anxiety and fear

• Listen, name the emotion, explain what is happening and offer choices. Reduce noise and unnecessary staff changes.
• Assess pain, breathlessness, delirium, withdrawal, depression, trauma, substance use and safety.
• Use breathing, grounding, family support and counselling; administer prescribed anxiolytic only with respiratory/sedation monitoring.

Depression, hopelessness and suicidal risk

• Ask directly and privately about hopelessness, self-harm thoughts, plan, means, previous attempts and protective supports.
• Do not leave a high-risk patient alone; remove immediate means where possible and obtain urgent mental-health/senior help.
• Continue symptom relief and compassionate communication; document safety planning and referral.

Spiritual or existential distress

• Ask what gives meaning, strength or peace; offer the patient’s chosen spiritual/cultural support.
• Do not impose beliefs or interpret symptoms as spiritual failure. Document preferences and rituals.

10. Medication-safety nursing

• Use the medication rights: correct patient, medicine, indication, dose, route, time, allergy, documentation and response.
• For opioids, check concentration, respiratory rate, sedation, bowel plan, renal function and other depressants.
• For steroids, monitor glucose, infection, mood, sleep, gastrointestinal symptoms and muscle strength.
• For antiemetics/anticholinergics, monitor QT risk, constipation, urinary retention, delirium, extrapyramidal effects and sedation.
• Use oral syringes for liquids; never estimate with household spoons.
• Reconcile prescribed, over-the-counter, traditional and borrowed medicines. Report omissions, duplications, errors and controlled-drug discrepancies.

11. Family and caregiver nursing interventions

• Assess understanding, skills, fatigue, sleep, finances, transport, food, safety and available help.
• Demonstrate repositioning, mouth care, medicine measurement, bowel care and warning-sign recognition; observe return-demonstration.
• Give a written plan with named contact, review time, emergency route and what to do if the patient cannot swallow.
• Invite questions and normalize respite; do not equate exhaustion with lack of love.
• Offer private safeguarding assessment and refer for violence, neglect, coercion or unsafe caregiving.

12. Last-hours nursing priorities

• Use comfort observations rather than unnecessary vital-sign routines that disturb the patient.
• Convert essential medicines to a feasible route; stop non-essential preventive medicines when consistent with goals.
• Provide mouth, eye, skin, pressure, continence and positioning care.
• Explain reduced intake, irregular breathing, noisy secretions and reduced consciousness to the family.
• Support goodbyes, prayer, cultural rituals and a peaceful environment.
• Document symptom response, family questions, decisions, death notification and bereavement referral.

13. Clinical cases

14. Quick self-test

1. What are the five stages of the nursing process?
2. Name six respiratory or neurological red flags requiring escalation.
3. Why should opioids trigger a constipation plan?
4. List four pressure-injury prevention measures.
5. What must be taught before sending a caregiver home with a palliative patient?

Answers

1. Assessment, diagnosis/priority, planning, implementation and evaluation.
2. Examples: airway obstruction/stridor, severe hypoxia, shock, new weakness, seizure, altered consciousness, severe headache, cyanosis or sudden breathlessness.
3. Opioids reduce bowel motility and secretion, and constipation usually persists without tolerance.
4. Reposition/pressure relief, skin inspection, moisture/incontinence control, barrier care, nutrition/hydration goals and safe lifting.
5. Medicine measurement and schedule, symptom interventions, warning signs, swallowing/aspiration plan, bowel care, safe storage, named contact, review time and emergency route.

Key take-home points

• Nursing care is active symptom assessment, prevention, treatment, education, advocacy and coordination.
• Assess the whole person and use ABCDE for every sudden or severe change.
• Comfort measures, medicines, family support and cause-directed treatment should be integrated.
• Protect skin, airway, bowel, bladder, mobility, dignity and medication safety.
• Reassess, document and escalate; “comfortable” is not a sufficient clinical note.

Further study and references

• Nursing Management of Patients with Common Signs and Symptoms — supplied Slideshare reference
• WHO: Palliative care
• Related lesson: Principles of symptom control and assessment
• Related lesson: Palliative-care emergencies
• Related lesson: Non-pharmacological pain management

Educational resource for supervised learning. Apply current Uganda nursing standards, emergency protocols, formularies and senior clinical advice.