Chapter010

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Chapter 10: End-of-Life Care


• 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


Is the following statement true or false?

It is the nurse’s role to remain aloof and detached during a client’s death.

QuestionQuestion


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


• 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




• 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


• 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




There are five emotional reactions to death and dying.

QuestionQuestion


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



• 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



• 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


• 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


• 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



• 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



• 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



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


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


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


QuestionQuestion


The physical signs of impending death occur at the same time.


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.


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


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


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


• 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


QuestionQuestion


Adequate pain management in a dying client consists of administering pain medication on a regular basis.


AnswerAnswer

True.

Adequate pain management in a dying client consists of administering pain medication on a regular basis to avoid sedation and intense discomfort.



• 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



• 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


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


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


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


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


• 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




• 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


End of Presentation

Chapter010

Documents

clients death

dying client contd

dying client nurse

emotional health

hour care

ill clients hospice

terminal care respect

care nurses role