Some patients that you will work with as a nursing assistant are coping with particularly difficult illnesses that will impact all aspects of their lives. When working with such patients, you will find it difficult at times to handle the stress and emotional weight of their situation. It will also, however, be an extremely rewarding experience when you can give comfort and solace to patients during their difficulties.

Oncology patients can be treated as in-patients if they are having major surgery such as a mastectomy, or out-patients if they come into the hospital or clinic for regular rounds of radiation or chemotherapy. The common denominator for all types of oncology patients is fear -- fear of the unknown, fear of losing control and fear of what the future might hold.

As a nursing assistant your role is to provide the small comforts that will make the process of routines like chemotherapy and radiation treatments more bearable. Be sure to ask your patients each time they come in for treatment if they need anything; even small things like a glass of water or a trip to the bathroom before beginning treatment are greatly appreciated. Conversation will often take their mind off of what is ahead, but at the same time, it is important to gauge whether they want to talk by their reaction to you. If they are answering with few words and don't seem to want to interact, respect their silence.

There are a variety of side effects to radiation treatment, most of them mild. The most common is fatigue. It is helpful if you are understanding when a patient appears anxious or irritable because they have been left waiting longer than usual for a treatment appointment. You should also be sure to ensure each patient has all the relevant literature regarding their treatment so that they will know what to do in the event they have an unexpected reaction.

Chemotherapy is often more intensive and tends to have greater side effects, including vomiting, exhaustion and hair loss. Any of these by themselves are distressing enough; when they are experienced all at once, the patient often becomes overwhelmed and feels as if they have lost control of their life. As a nursing assistant, you will need to be alert to possible changes in the demeanor and personality of your oncology patients and make note of these and any physical changes you observe, in their chart.

The changes an oncology patient goes through during the course of chemotherapy may be very mild or severe, depending upon the type of medication they are receiving. You should familiarize yourself with the more common side effects so that you will be prepared to work with patients suffering from these side effects.

Common chemotherapy side effects include:

Exhaustion

Hair loss

Anemia

Tingling or pain in the extremities

Depression

Infection

When an oncology patient is being treated as an inpatient, you must be extremely vigilant about protecting that patient against the possibility of infection. Take extra care in all cleansing procedures, do not trim nails too closely and be sure to treat even the smallest cut with an antimicrobial ointment and daily dressing changes. Many oncology patients also develop dry, cracked skin. Gentle application of an approved moisturizing lotion will help keep the skin hydrated and may help reduce pain levels. Massage is also very relaxing for some oncology patients. Oncology patients can also be prone to blood clotting problems because of their suppressed white blood cell count.

When you check on your oncology patients, be sure to watch for these symptoms of possible clotting problems:

Small red dots just beneath the skin's surface

Unusual bruising

Nosebleeds or bleeding gums

Blood in the urine or stool

Limb(s) that are hot to the touch or feel "tight"

Complaints of a persistent headache or vision problems

Any of these symptoms should be reported to the charge nurse immediately, as blood clotting problems can lead to hemorrhaging and other serious complications.

The Terminally Ill

When faced with a terminal illness, many patients will go through various stages of acceptance and coping. They may go through various stages of grieving, including anger, denial and mourning. They also may go through a period of time when they "give up" on what life they have left. As a nursing assistant, you can help terminally ill patients cope by being supportive and empathetic.

Pain is often central to the life of a terminal patient. Chronic and acute pain, diarrhea, nausea, vomiting, weakness, shortness of breath and a host of other symptoms can become overwhelming. Combined with physical appearance issues such as hair loss, pale or lesioned skin, dark circles and weight loss, pain can lead some patients to temporarily refuse visitors. Do not make light of their concerns by dismissing them. Listening and reassuring them is fine, but making suggestions that can help is also important.

If you suggest that a touch of makeup and limiting visits to only an hour a day might be a way to allow visitors (who, after all, are concerned about them and want to show their support) while not burdening the patient too much, you will validate their concerns without encouraging complete isolation. Every situation is different, but a compassionate nursing assistant will get to know and understand her terminal patient and be able to support them effectively.

Many terminally ill patients feel completely out of control and find a sudden desire to make final plans, make peace with family members and even arrange for their own funerals. Family members may find this disconcerting and try to avoid these discussions because they are having a difficult time themselves in facing the reality of their losing their loved one.

Be an advocate for your patient by explaining the importance of these activities to his or her family. Encourage them to listen and support whatever choices the patient may make in their final days, and offer to assist in any way you can. While you are caring for a terminal patient, remember that touch is the most effective form of comfort there is. A simple squeeze of the hand, brushing back a strand of hair or a gentle pat on the leg will all let your patient know that they are still definitely in the here and now, and that they are more than simply a body to be changed, dressed and stuck with needles. The last days of any patient should be filled with comfort.

Mentally Ill/Distressed Patients

Working with patients who are suffering from any type of condition that affects their emotional or mental stability can be challenging. As a nursing assistant you will work with patients who may have diminished mental capacity due to encroaching illness (such a Alzheimer's Disease) or limited physical control (due to illnesses such as Parkinson's Disease). Either of these situations can complicate routine procedures such as ADL's and make taking vital signs more difficult. You should never force a patient who is extremely agitated to undergo a procedure that is not immediately necessary. If you take vital signs each day and a patient is particularly agitated when you enter his room, it is simpler to come back when he is calmer than to try to force him to undergo a procedure that may frighten him.

Situations like this are common with elderly patients suffering from dementia or Alzheimer's disease. Because the disorientation and emotional instability comes and goes, you should be able, over time, to determine the hours when your patient is at his best. If a procedure must be performed immediately, do not attempt to handle a distressed patient by yourself. This can lead to injury to either the patient or yourself. Call for another nursing assistant or the charge nurse.

Dementia and/or Alzheimer's Disease

Dementia is actually a symptom of a brain disorder that causes a loss of intellectual ability and emotional control, but is not technically considered to be a disease. Dementia can have a variety of causes, but in elderly patients the most common cause is Alzheimer's Disease. For that reason, the terms are sometimes used by people interchangeably. If you are working with a patient who suffers from dementia, you should know what to expect as their condition gradually worsens.

In the earliest stages of dementia, individuals usually begin showing signs of mild memory loss. They misplace objects more frequently, they forget about appointments and they may become confused more easily. They will also exhibit a mild drop in mental acuity or concentration.

In the mid-stage, confusion will become more apparent, and individuals may begin to show more significant memory loss, such as forgetting the names of people they have known for years. They will also have difficulty with daily tasks such as dressing themselves, performing simple tasks, etc. They may wander off and become lost and will need to be monitored closely.

Mood swings will become evident, and a temper that hasn't been noticeable before may show itself. At this stage, it is important to be calm and reassuring, and not confrontational. Yelling at or disciplining an adult with dementia is not only degrading, it accomplishes nothing except to escalate the situation. Anger and mistrust are two emotions that mid-stage victims of dementia frequently exhibit.

Late-stage dementia may send an individual back to their past, losing all memory of the present. They can forget their grown children and grandchildren, become confused about what year it is and will resist any efforts to be convinced otherwise. Dementia at this point will also cause severe deterioration of language skills. Patients with late-stage dementia may stop speaking except for a few repetitive, comforting phrases (a favorite hymn, etc.) that they have known for years. Repetitive movements such as rocking or pacing are also common. They will seldom make eye contact and no longer recognize themselves in a mirror.

Some helpful tips to cope with dementia patients include:

• Try to understand a behavior; if you cannot, simply accept it.
• Do not interfere with what appears to be a self-comforting behavior unless it is harmful to the patient or others.
• When with a patient who is self-comforting (rocking, etc.), you can sometimes reach them for a few moments by joining them in their activity. For instance, holding a patient's hand and rocking with him or her.
• Continue to interact with conversation, even when the patient doesn't answer or is abrupt. By making the effort you are reinforcing the belief that they are still interesting, vibrant people and you are still hopeful that they will share with you.
• Daily routines become increasingly important as dementia progresses. If you bathe a patient at the same time every morning and brush their teeth afterward, do not change the order or switch the times unless absolutely necessary. A bedtime routine is also very comforting -- stop in and say goodnight every evening, tuck the patient in or have a brief chat.
• Remember to discuss the possibility of the patient's family participating in activities with the patient. Bringing old family photos or mementos from years ago or simply retelling older family stories can be mentally stimulating since the recent past is often lost to them.

Pediatric Patients

One the other end of the spectrum of care are pediatric patients. If you work in a facility that treats children, you may be interacting with children of all ages. These patients have a completely different set of needs and require a different type of care protocols than adult patients. In fact, because there are so many different types of pediatric specialties (orthopedic, cardiac, oncology, etc.), we can't cover them all here. We can, however, give you an overview of the sometimes unexpected situations that can come up when working with children in a hospital or clinic situation.

First and foremost you must remember that children in any kind of health care facility are usually frightened. Everything is foreign to them and they are most likely in pain or sick or they wouldn't be there. Even the simplest procedures, such as taking vital signs, can seem threatening to them. Here are some tips that will make things easier for both of you:

Be reassuring and positive and always explain each procedure fully before you begin.

• Children are curious -- allow them to try pumping the blood pressure cuff a few times, let them listen for your pulse, etc. -- anything that will help them see how painless and interesting the procedures can be.
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• When the parents are in the room (which is most of the time, especially with infants and young children), be sure to include them in discussions and encourage them to participate.
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• Stress to parents that no foods can be brought in to their child without the doctor's approval, especially if he or she is on a restricted diet.
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• Following the sterile procedures of your facility are extremely important in pediatric units, where germs abound.

• Many children are especially fussy and clingy while hospitalized. They will also show regression behavior, returning to habits they had outgrown months or even years before, such as thumb sucking. Do not give any of these activities too much attention; they are self-comforting mechanisms and will slowly fade after hospitalization is over.

• If you are going to be in a facility where children will be a part of your responsibilities, supplement your training with a brief course on child development or find a good text book on the topic. Understanding where each child is at on the emotional and intellectual developmental scale will help you to be the most supportive, helpful nursing assistant you can be.