Nursing care for symptoms seen in patients undergoing palliative surgery – a retrospective study

Introduction and aim. Palliative care is an approach to improve the quality of life of patients and their families facing problems associated with life-threatening illnesses or old age, to manage their pain, distress, and other symptoms, improving their quality of life, and providing psychological support. This study was designed to identify the care practices planned by nurses for the health issues of palliative surgical patients. Material and methods. This is a retrospective, cross-sectional, descriptive study. The data was collected from digital records of the two state hospitals in the Western Black Sea Region of Turkey between January 2019 and January 2020. The research was completed with a total of 391 data of patients undergoing palliative surgery. Frequency and percentage distributions were used in descriptive statistics. Results. The frequency of symptoms observed in patients were determined as cough and sputum (81.8%), dehydration (73.9%), dyspnea (71.9%), fatigue (49.9%), loss of appetite-weight (49.9%), insomnia (44%), pain (37.6%), nausea (29.2%), and constipation (23.8%). The planned nursing diagnoses for these symptoms were identified as risk for falls, imbalanced nutrition, risk for impaired skin integrity, risk for infection, risk for aspiration, deficient knowledge, risk for impaired respiratory function, constipation, ineffective airway clearance, pain, risk for deficient fluid volume, sleep deprivation, impaired gas exchange respectively. Conclusion. This study highlights the insufficient planning of nursing care for the symptoms of palliative surgical patients receiving palliative care in our country. Therefore, it is recommended that palliative care nurses be supported with in-service training on appropriate care planning topics.


Introduction
The advancement of medical care with technology and the development of new treatments for chronic illnesses have increased the fight against diseases and extended survival times.However, these advancements also lead to longer experiences of chronic illness and more pain and suffering caused by these illnesses. 1,2In this sense, centers where patients and healthy individuals can easily access healthcare services, receive continuous, comprehensive, and integrated care, and particularly receive effective support in palliative care are crucial for family and community health. 3,4alliative care is an approach to improve the quality of life of patients and their families facing problems associated with life-threatening illnesses or old age, to manage their pain, distress, and other symptoms, improving their quality of life, and providing psychological support (WHO, 2020).Palliative care is provided to individuals with life-threatening illnesses such as motor neuron diseases like Alzheimer's and dementia, cancer, heart disease, cirrhosis, chronic obstructive pulmonary disease, diabetes, HIV/AIDS, kidney failure, multiple sclerosis, rheumatoid arthritis, Parkinson's disease, and tuberculosis. 3,5][8] Palliative surgery is a surgical intervention aimed at relieving a patient's symptoms and thereby improving their quality of life, typically in those with a poor prognosis or life-threatening illness.The treatment and care techniques used in palliative surgery run parallel to those used in curative surgery. 9Nowadays, "palliative surgery" is a term used for all surgical procedures aimed at alleviating symptoms caused by advanced disease and improving quality of life.Overlooking the necessity of palliative care in surgical patients can result in greater discomfort for patients in the later stages of the disease or even in the end-of-life period. 6Clinicians and nurses need to have appropriate experience and knowledge to provide good palliative care. 2,6Palliative surgery is a series of planned surgical procedures aimed at supporting patients to live as well as possible for as long as possible and determining appropriate treatment.Patient and family participation in care should be ensured to help them cope with the situation in their remaining life. 10uring this period, nurses have significant responsibilities.It is undeniable that timely and effective nursing interventions facilitate symptom management for patients requiring palliative treatment and care, and lead to positive patient outcomes such as improving patient and family quality of life. 11alliative care nursing aims to approach the patient and family holistically, in collaboration with all disciplines, in order to improve the patient's quality of life. 12n pursuit of this goal, nurses play a prominent role not only as evidence-based care providers, but also as educators and leaders. 13Given all of this, it is essential that nurses possess the necessary knowledge and skills in palliative care. 6Particularly in the palliative care phase where patients may be struggling with symptoms, nurses should have a strong understanding of symptom management and develop and implement comprehensive care plans that encompass physical, psychosocial, and spiritual dimensions. 6Studies have shown that proper symptom management in palliative care reduces treatment time and costs, and shortens hospital stays. 1,13In the literature, many studies are showing that palliative surgery reduces symptoms.On the other hand, there are findings related to symptom management and nursing care in all palliative patients.However, no data investigating the effect of nursing care on symptoms in palliative surgery patients were found.However, it is thought that the success of palliative surgery may also be affected by the quality of nursing care provided during and after the perioperative period.

Aim
This study was designed to identify nursing diagnoses addressed by nurses for the health problems and symptoms of palliative surgical patients hospitalized in a palliative care unit.

Study design
This study is a retrospective cross-sectional descriptive research.

Study questions
-What are the common symptoms in palliative surgery patients?-What are the common treatment methods used in palliative surgery patients?-What are the commonly used nursing diagnoses in palliative surgery patients?

Sample
This retrospective study was conducted on palliative surgical patients who were treated at the Palliative Care Centers of two state hospitals located in the Western Black Sea region between January 2019 and January 2020.Palliative surgical patients who were over 18 years of age, had undergone at least one surgical procedure, had been hospitalized at least once, and had been discharged with complete data were included in the study.Patients who had not undergone palliative surgery as their hospitalization purpose but had undergone it once during their hospitalization were also included in the study.For patients with multiple hospitalizations, only the first hospitalization was taken into account.A total of 391 patient records were included in the study.

Data collection
In this study, data was collected over a period of 1 year by the researcher in the palliative care centers of two state hospitals located in the Western Black Sea region.The palliative care centers were 16-bed and 18-bed units accepting adult palliative patients.There were 12 nurses and 14 nurses working in the unit, all with at least a bachelor's degree.The nurses' years of experience ranged from 2 to 22 years.Data were obtained retrospectively by examining the hospital's digital archives of 527 patients who were followed up and treated in the palliative care center.Only the first admission of patients with multiple admissions was evaluated.136 patients who did not meet the inclusion criteria, stayed less than 24 hours or had insufficient medical records were excluded from the study.A total of 391 patients were in-cluded in the study, and their demographic characteristics, admission indications, comorbidities, presence and type of malignancy, length of stay, Glasgow coma scale, pain scale, symptoms, nursing diagnoses, and discharge status were recorded using a data collection form prepared by the literature, based on the evaluation of their first admission.

Statistical analysis
The collected data was analyzed usiwereIBM SPSS Statistics (V25.0,IBM Corporation).Descriptive statistics such as numbers, percentages, means, and standard deviations were used to evaluate the obtained data.Cross table was used for Symptoms, palliative surgery operations and nursing diagnosis.Skewness and kurtosis coefficients of the scores were examined and it was observed that these coefficients were within the range of ±2 (George and Mallery, 2010).No missing data was detected in the dataset.

Ethics approval
This study was conductedbyh the Helsinki Declaration.
The study was approved by the institutional ethics committee of Bartin University (No. 2020-BRT-08).Institutional permission was obtained from the Ministry of Health of the Republic of Turkey, the Provincial Health Directorate to which the hospital is affiliated, and the hospital (2020-05-20T-14).Oral consent was obtained from the responsible physician and nurses of the palli-ative care unit of the state hospital where the data was collected.Since this was a retrospective study and personal data ofthe patients were not included, informed consent from patients was not necessary and the data were obtained from the hospitals' digital databases.
According to Table 3, it was determined that nurses most frequently provided care to patients with a diagnosis of fall risk for all symptomsWhen evaluating nursing diagnoses related to experienced symptoms, it was found that there were relatively low frequencies of diagnoses for patients experiencing specific symptoms.Among patients with pain symptoms, the diagnosis of pain was given in 3.3% of cases.For those experiencing insomnia, disruptions in sleep patterns were diagnosed in 4.3% of cases.Constipation diagnoses were assigned for patients with constipation issues at a rate of 4.1%.In cases where patients developed wounds, the diagnoses of infection risk (59.3%) and impaired skin integrity risk (67.5%) were more prevalent.For patients with dehydration, the diagnosis of fluid volume imbalance risk was identified in 8.7% of cases.Similarly, among patients complaining of cough and sputum, nursing diagnoses such as ineffective breathing pattern (40.2%), ineffective airway clearance (13.6%), and impaired gas exchange (5.4%) were identified by nurses with less frequency compared to the diagnosis of fall risk.Nursing diagno-ses of nutritional imbalance (45.5%) and fluid volume imbalance (5.4%) were also assigned less frequently as nursing diagnoses compared to the diagnosis of fall risk in patients experiencing appetite and weight lossPatients experiencing dyspnea were diagnosed with a risk of impaired breathing pattern at a rate of 32.7%, ineffective airway clearance at a rate of 11.3%, and impaired gas exchange at a rate of 7.9%.In patients suffering from weakness and fatigue, the most common diagnosis was a risk of falls, accounting for 48.6% (Table 3).
According to Table 4, the most common palliative surgical treatments were as follows: percutaneous endoscopic gastrostomy (PEG) at a rate of 71.6%, wound surgery at a rate of 71.1%, tracheostomy at a rate of 60.9%, colostomy at a rate of 31.4%, cystostomy procedure at a rate of 30.6%, and biopsy at a rate of 27%.Table 4 includes a cross-tabulated table comparing nursing diagnoses according to palliative surgical treatments.According to this, the most commonly assigned nursing diagnosis in patients, regardless of the type of palliative surgical procedure, was the risk of falls.In patients with PEG, the nursing diagnosis of risk of falls was followed by diagnoses of nutritional imbalance (60.3%), risk of aspiration (44.4%), and fluid volume imbalance (8.5%).In patients who underwent tracheostomy, nursing diagnoses included a risk of aspiration at a rate of 34.4%, risk of impaired breathing pattern at a rate of 30.6%, ineffective airway clearance at a rate of 9.6%, and impaired gas exchange at a rate of 6.1%.In patients who underwent wound surgery procedures such as grafting, flaps, debridement, and vacuum-assisted closure (VAC), the most common nursing diagnosis after the risk of falls was impaired skin integrity risk, which was identified at a rate of 50.7%.Among patients who underwent biopsy procedures, the highest percentage of diagnoses was the risk of falls at 25.9%, followed by impaired skin integrity risk at 20.9%, knowledge deficit at 13.8%, and pain at 3% (Table 4).

Discussion
Palliative care has become an important field that the whole world has been giving importance to in recent years due to the increasing aging population and related chronic diseases.In the terminal phase of patients, it is evident that palliative care is necessary for maximizing their quality of life as much as possible in their final moments, and for the participation of both the patient and their family.This retrospective cross-sectional study was conducted with 391 patients to determine the palliative care profile in Turkey and the interventions of nurses.
In our current study, the most common symptoms were coughing, dehydration, wounds, dyspnea, fatigue, insomnia, pain, nausea, and constipation.In a study on care in the terminal phase, 72% of the patients had cancer. 14Thrane et al. found that 60.5% of patients were admitted to palliative care due to pain, 53.9% due to neurological diseases, and 51.2% due to congenital disorders. 15In a systematic review of palliative care in Australia, the main reasons for admission were cancer (42%), non-cancer diseases (8%), and terminal conditions (12%), such as heart failure and renal failure. 16The same study reported that pain was more common in male patients, and the most common symptoms for all patients were difficulty breathing, nausea/vomiting, and dementia. 16In a study conducted in Turkey, the most common reasons for admission were inadequate nutrition, care education, pain, and pressure ulcers.The frequency of reasons for admission to palliative care can vary from region to region, and the low number of patients admitted for cancer in our study may be due to the lack of oncology specialists in our region.Another study conducted in Turkey showed similar reasons for admission to palliative care. 17Therefore, while our study is parallel to Miniksar and Aydın's study, it differs from other studies in terms of reasons for admission.However, differences in reasons for admission were observed in all other studies.
In our study, the most common symptoms observed were cough, dehydration, dyspnea, weight loss, fatigue, insomnia, pain, nausea, and constipation in order of frequency.According to an analysis conducted by Pang et al., fatigue was identified as the most frequently encountered symptom, with a rate of 96%.This was followed by sleep problems at 94.8% and pain at 92.5%. 18In a study conducted by Cantero et al. on symptom management in palliative care patients, the most common symptoms were ranked as pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, anorexia, sleep disorders, and malaise. 19In a study conducted in 2022, the most common problems in palliative patients were reported as nausea, pain, fatigue, and sleep problems. 20n a study conducted on 145 patients in Denmark, the most common symptoms were recorded as pain and deterioration in physical condition. 21In another study, the most common symptoms in palliative patients were reported as nausea, pain, drowsiness, shortness of breath, and loss of appetite, respectively. 22Considering all these results, similar symptoms were observed in palliative care patients at different frequencies.This may be due to cross-cultural differences in the populations of patients admitted to palliative care clinics and shortcomings in healthcare.When examining the nursing diagnoses used according to patients' symptoms, it can be observed that nurses most frequently assigned the diagnosis of fall risk for all symptoms.It has been determined that nursing diagnoses consistent with the symptoms were assigned; however, the rates were found to be quite low.This situation suggests that nurses may not be actively and accurately utilizing nursing diagnoses according to patients' symptoms.Furthermore, the diagnosis of anxiety was assigned to a total of 8.4% of all patients.No nursing diagnoses related to the spiritual and religious care of palliative patients were found.In previous studies, it has been noted that the most common nursing diagnoses in palliative patients are anxiety and spiritual care diagnoses. 23,24ccording to our research, the most commonly performed palliative surgical procedures for patients in palliative care clinics include PEG placement, wound surgery, tracheostomy, colostomy, cystostomy, and biopsy procedures.It has been observed that the most commonly used nursing diagnosis in patients, regardless of the type of surgical procedure, is the risk for fall.The utilization rate of diagnosis specific to surgical procedures is indeed quite low.This situation indicates that nurses are not utilizing specific diagnoses for palliative surgical patients.On the other hand, it is also considered that this situation may stem from the nurses' inadequacy in documentation, despite providing comprehensive care in all areas.
Patients receiving palliative care require planned and comprehensive nursing care during their end-of-life period.When evaluating the data obtained, it was found that the most common diagnosis given to patients was malnutrition.However, it is noteworthy that diagnoses such as risk for fall, risk for infection, risk for impaired skin integrity, and risk for impaired respiratory function followed closely.According to a study published by Carpenter et al., nursing interventions focused on three main strategies: (1) advanced care planning, (2) personnel education (e.g.. teaching general concepts in a classroom or sem-inar) or patient/family education (e.g.guiding practical palliative care skills), and (3) integration of the palliative care team. 25In their study on palliative patients with lung cancer, Naito et al. conducted a feasibility study that included early multimodal interventions for nutrition, exercise and mobility, and risk for fall, and found that early interventions were beneficial for patients. 26A study conducted by Zongo et al. in oncology patients who underwent palliative surgery in Africa, it was reported that patients experienced an 80% reduction in symptoms after palliative surgery. 27However, no extensive nursing diagnoses or interventions specifically targeting symptoms seen in palliative care patients have been found in the literature.Nevertheless, our study identified similar nursing diagnoses such as the risk for fall and imbalanced nutrition based on limited data.However, our research revealed that the nursing diagnoses were not specific to patient symptoms, and there was a statistical increase in the same diagnoses.On the other hand, it is notable that risk diagnoses were used more frequently than actual diagnoses.Therefore, according to the research results, patients should be primarily diagnosed with actual diagnoses such as impaired respiratory function, imbalanced fluid volume, fatigue, sleep deprivation, pain, nausea, and constipation.Considering the characteristics of the nurses working in the palliative care centers where the data was collected, it is worth considering that palliative care nurses may be inadequate in determining the current situation of patients and planning appropriate nursing care and diagnoses.

Study limitations
This research was obtained from the records of a palliative care clinics in the two state hospitals located in the Western Black Sea region of Turkey.Due to the lack of an oncologist and the responsible physician being a general surgeon in the hospital where the study was conducted.patients admitted to the clinic are mostly followed up for palliative surgical purposes.Therefore, this study cannot be generalized to all palliative patients and palliative care services.

Conclusion
This study highlights the wide range of symptoms are frequently seen in patients receiving palliative care surgery in Turkey.It is seen that the duration and variety of medical treatments given with these symptoms may increase.In addition, it was found that the nursing diagnoses planned for symptoms were not parallel and related to the symptoms and that similar diagnoses were often made for all patients.Considering the effects of nursing care on symptom management in palliative surgery patients, it emphasizes that the nursing care planning applied for symptoms in patients is inadequate.Therefore, it is recommended that palliative care nurs-es be supported with in-service training on appropriate care planning.On the other hand, it is recommended that future studies be conducted on repeated hospitalizations in palliative patients in order to determine the frequency of recurrence of certain symptoms and needs analysis for this purpose.

Table 1 .
Characteristics of patients (n=391) a a SD -standard deviation; BMI -body mass index; * -the VAS (Visual Analog Scale) pain scale has been used

Table 2 .
Nursing diagnoses applied to palliative care patients (n=391) a a Multiple responses

Table 3 .
Distribution of nursing diagnoses according to patients' symptoms in palliative care centers (n=391) a a * -multiple responses; ** -diabetic ulcers, pressure ulcers, arterial ulcers, venous leg ulcers