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Chapter010

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  • 1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e Chapter 10: End-of-Life Care Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 2. The Dying Client • 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 3. Question Is the following statement true or false? It is the nurse’s role to remain aloof and detached during a client’s death. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 4. Answer 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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 5. The Dying Client • 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 6. The 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 7. The Dying Client • 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 8. Question Is the following statement true or false? There are five emotional reactions to death and dying. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 9. Answer 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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 10. The 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 11. The 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 12. Care of the Dying Client • 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 13. Care 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 14. Care of the Dying Client • 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 15. Care of the Dying Client • 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 16. Signs 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 17. Signs 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 18. Signs 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 19. Question Is the following statement true or false? The physical signs of impending death occur at the same time. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 20. Answer 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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 21. Signs 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 22. 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 23. Nursing 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 24. Nursing Management • 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 25. Question Is the following statement true or false? Adequate pain management in a dying client consists of administering pain medication on a regular basis. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 26. Answer True. Adequate pain management in a dying client consists of administering pain medication on a regular basis to avoid sedation and intense discomfort. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 27. Nursing 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 28. Nursing 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 29. Nursing 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 30. Nursing 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 31. Nursing 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 32. Nursing 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 33. Nursing Management • 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 34. Nursing 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
  • 35. End of Presentation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins