chapter010
TRANSCRIPT
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Timby/Smith: Introductory Medical-Surgical Nursing, 10/e
Timby/Smith: Introductory Medical-Surgical Nursing, 10/e
Chapter 10: End-of-Life Care
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• Introduction
– Death: Natural, universal; healthcare component
– Healthcare providers: Acknowledge death as final stage of growth and development
– Explore: Own mortality; feelings about dying and death
– Education about death: Incorporate knowledge into care
– Nurse’s role: Share emotional pain
– Denying death: Creates barrier; interferes with personal growth
The Dying ClientThe Dying Client
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Is the following statement true or false?
It is the nurse’s role to remain aloof and detached during a client’s death.
QuestionQuestion
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False.
Nurses who care for dying clients share emotional pain with them and their families. Denying death creates a barrier to becoming involved with clients and families and interferes with personal growth.
AnswerAnswer
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• Introduction (cont’d)
– Death: Inevitable; can be slow and tortuous, sudden and unexpected; prepare client and family for expected death; maintain sensitivity and compassion toward client and family
– Nurse: Factors to be considered
• Informing the Dying Client
– Nurse: Honor dying client’s right to know seriousness of condition
– Physician: Inform clients about nature and gravity of illness
The Dying ClientThe Dying Client
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The Dying ClientThe Dying Client
• Informing the Dying Client (cont’d)
– Discuss outcomes: Be frank; inform members of healthcare team about client’s prognosis
– Lack of knowledge interferes with nurse–client relationship
• Sustaining Hope
– Recognize value of communicating spirit of hopefulness
– Healthcare team: Ensure remaining days are meaningful; use appropriate treatment and comfort measures; dignify approaching death; provide palliative treatment
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• Assisting with Emotional Reactions
– Dying clients: Five stages of reactions
• Denial: Psychological defense mechanism; denial of diagnosis, followed by a refusal to accept
• Anger: Displace anger onto others
• Bargaining: Attempt to postpone death
• Depression: Mourn potential losses
• Acceptance of fate: Make peace spiritually and with those to whom they are close; detach from activities and acquaintances
The Dying ClientThe Dying Client
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Is the following statement true or false?
There are five emotional reactions to death and dying.
QuestionQuestion
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True.
There are five emotional reactions to death and dying: denial, anger, bargaining, depression, and acceptance. They are not always followed in order, and a client may experience more than one reaction at a time.
AnswerAnswer
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The Dying ClientThe Dying Client
• Supporting Final Decisions
– Nurse’s role: Present options for terminal care; respect client’s and family’s preferences
– Dying clients: Victims of decisions; advance directives; tough decisions
– Inform clients about their right to refuse medical treatment; prepare advance directive
– Living wills: Written statement of person’s wishes regarding medical care; informal; physicians abide by clients’ wishes
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The Dying ClientThe Dying Client
• Supporting Final Decisions
– Durable power of attorney
• Makes medical decisions on client’s behalf
• Identifies life-sustaining measures
• Reassurance that others will carry out wishes
• Photocopy is attached to client’s chart
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• Introduction
– Preference of settings
– Inform clients: Symptoms to be controlled; part of planning process
• Home Care
– Early stages of terminal illness
– Nurse’s role: Coordinate community services; secure needed home equipment
– Client’s comfort: Emotional, physical, security, personal integrity
Care of the Dying ClientCare of the Dying Client
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• Home Care (cont’d)
– Family members: Fewer guilt feelings; more interaction with children
– Negative factor: Burden on primary caregiver
– Home care nurses: Assess toll on caregiver’s physical and emotional health
– Arrange for respite care
• Hospice Care
– Facility: Care of terminally ill clients
– Hospice care emphasizes helping clients live according to their wishes
Care of the Dying ClientCare of the Dying Client
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• Hospice Care (cont’d)
– Provide services: Relieve physical symptoms and emotional distress
– Spiritual support
– Provides support to dying client and caregivers
• Institutionally Based Palliative Care
– Located: Hospitals, long-term care facilities, separate facilities
– 24-hour care
– Identify factors that influence decision
Care of the Dying ClientCare of the Dying Client
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• Institutionally Based Palliative Care (cont’d)
– No restriction on visiting hours, ages of visitors
– Encourage family to bring personal items for client
• Acute Care
– 24-hour staff: Nurses, medical personnel
– Readily available resuscitative equipment
– Greater variety of medications
– Most expensive
– Limited time and attention: Supportive care of dying clients
Care of the Dying ClientCare of the Dying Client
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Signs of Approaching DeathSigns of Approaching Death• Physical Events
– Cells deteriorate: Insufficient oxygen, multisystem failure
– Signs of impending death: Cardiac dysfunction, increased heart rate initially, apical pulse rate, decreased cardiac output
– Peripheral circulation changes: Impaired cellular metabolism, less heat; skin is pale and mottled
• Nail beds and lips blue, cold
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Signs of Approaching DeathSigns of Approaching Death• Physical Events (cont’d)
– Pulmonary function impairment: Heart’s pumping function fails
– Moist breath sounds, hypoxia
– Central nervous system changes: Apnea; diminished pain perception; eyes stare blankly; partially open eyes; impaired senses; intact hearing; insensitive except to extreme pressure
– Renal impairment: Low cardiac output, diminished urine volume; accumulates toxic waste products
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Signs of Approaching DeathSigns of Approaching Death• Physical Events (cont’d)
– Gastrointestinal disturbances: Slow peristalsis, gas; intestinal contents accumulate; nausea and vomiting
– Musculoskeletal changes: Hypoactive reflexes; loss of urinary and rectal sphincter muscle control; incontinence of urine and stool; jaw and facial muscles relax; noisy respirations; death rattle; restlessness
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QuestionQuestion
Is the following statement true or false?
The physical signs of impending death occur at the same time.
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AnswerAnswer
False.
Although the physical signs of impending death can be similar in dying clients, they may occur at differing times in the process, depending on the client’s condition.
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Signs of Approaching DeathSigns of Approaching Death• Psychological Events
– Stage of acceptance: Look forward to dying; waiting for permission phenomenon; nurses support family members
– Near-death experiences
– Near-death awareness: Dying client’s premonition; embrace or call out name just before death
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Nursing Management Nursing Management
• Introduction
– Focus: Providing palliative care
– Primary goal: Client comfort; long-term goal is for client to die with dignity
– Other client goals: Pain control, maintenance of basic physiologic functions, relief from fears and anxieties, acceptance of death, cohesive and supportive family
– Environment: Safe and secure
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Nursing ManagementNursing Management• Assessment
– Assess: Basic physical needs; psychosocial needs of client and family
– Avoid unnecessary assessments
– Frequent checks without being physically intrusive; security
• Pain Control
– Block pain without suppressing level of consciousness or breathing
– Pain medications: Routine schedule
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• Pain Control (cont’d)
– Regular dosing: Continuous pain relief; prevents exhausting client
– Reassure: Frequent use of narcotic analgesia does not cause addiction
– Medication prescribed: Mild tranquilizers or antidepressants reduce fear and anxiety
– Other techniques: Imagery, humor, progressive relaxation
Nursing ManagementNursing Management
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QuestionQuestion
Is the following statement true or false?
Adequate pain management in a dying client consists of administering pain medication on a regular basis.
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AnswerAnswer
True.
Adequate pain management in a dying client consists of administering pain medication on a regular basis to avoid sedation and intense discomfort.
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Nursing ManagementNursing Management
• Breathing
– Fowler’s position eases breathing
– Suction if client cannot cough and raise secretions
– Pulmonary edema: Sedative; oxygen
• Food and Fluids
– Offer nourishment: Frequent, small amounts; serve at appropriate temperature
– Encourage family to bring foods
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Nursing ManagementNursing Management
• Impaired Swallowing
– Potential for aspiration of fluids; decrease in food intake
– Administer medications: Control nausea and vomiting
– Report weight loss
– Inadequate intake: Alternative nutritional and fluid administration route
– Drooling occurs: Elevate and turn client’s head to the side; suction
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Nursing ManagementNursing Management• Temperature Regulation
– Give cotton socks, light blankets and clothing
– Massage arms and legs to promote circulation; touch provides support; personal concern
• Skin and Tissue Integrity
– Blood pressure drop; rapid heart failure; poor tissue and organ perfusion
– Prevent skin breakdown with frequent repositioning
– Consult with physician while administering intramuscular injections: Inadequate absorption, decreased efficacy
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Nursing ManagementNursing Management• Self-Care and Activity
– Assist with personal hygiene
– Promote dignity and self-esteem: Keep client clean, well groomed, and free of unpleasant odors
– Prevent drying of oral mucous membranes and lips: Oral care, ice chips, petroleum jelly
– Avoid glycerin applications, which increase drying
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Nursing ManagementNursing Management• Sleep
– Disturbed sleep pattern
– Cluster necessary activities to avoid awakening client
– Lights: Turn off; dim; minimize noise
– Mask continuous hum of equipment
• Elimination
– Promote normal elimination: Bedpan; assisting in bathroom or bedside commode
– Absorbent pads: No bowel or bladder control; thorough cleaning
– Indwelling or external catheter
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Nursing ManagementNursing Management• Address Fear, Social Isolation, Hopelessness, and
Powerlessness
– Spend time with client; be flexible
– Communicate interest and willingness to listen; encourage client to continue verbalizing
• Facilitate Grieving
– Normal reaction; emotional healing
– Anticipatory grieving; expression of grief
– Family members may withdraw emotionally; draw closer
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• Facilitate Grieving (cont’d)
– Help deal with emotions: Empathy
– Listen in nonjudgmental manner
– Avoid giving criticism and advice
• Address Spiritual Distress
– Religious beliefs and cultural customs influence attitudes about death
– Religious faith provides comfort and support
– Notify appropriate clergy; pray with client; assist as needed; ask family about spiritual care
Nursing ManagementNursing Management
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Nursing ManagementNursing Management
• Promote Family Coping
– Failure to express emotions is a source of regret for grieving relatives
– Encourage family members to express feelings, listen
– Make room for family; provide emotional support
– Explain measures taken and changes in client as death draws near
– Be present at moment of death; allow privacy before postmortem care
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