Nursing Fundamentals II End of Life

olanjones's version from 2016-08-08 14:21

Nursing Process

Question Answer
Assessment: closed awarenessClient is not made aware of impending death; nurse may experience ethical problem
Assessment: mutual pretenseAll know prognosis is terminal but do not discuss; nursing focus - heavy burden on dying person/no one in whom to confide
Assessment: open awarenessAll know prognosis and feel comfortable discussing; nursing focus - client may be involved in finalizing affairs/funeral arrangements
Diagnosing: may focus on physical/psychosocial of client/familyFear, Hopelessness, Powerlessness, Risk for Caregiver Role Strain, Interrupted Family Process
Planning: maintaining physiological/psychological comfortMay include arranging for home-care/hospice, Advance directives
Planning: achieving dignified/peaceful deathWork to help client maintain personal control and accept declining health status (nurse supports the client's will/hope)
Implementing (actions)Interventions should work to minimize fear/loneliness/depression, maintain client's dignity/self-worth, help client accept losses, provide physical comfort
Evaluating (actions)Nurse should listen to client's report of feelings r/t control of environment/pain/treatment plans, observe client's relationship with sig others, observe client's thoughts/feelings r/t hopelessness
5 Wishes: Provides legal, physical & emotional directives1. Who will make decisions when I am unable 2. Tx I want/don't want 3. Comfort measures 4. How I want people to treat me 5. What I want my loved ones to know
Alaska Advance Directives: Provides legal & physical directives1. Durable power of attorney for health care decisions 2. Instructions for health care 3. Organ donation 4. Mental health tx 5. PCP to have primary responsibility for heath tx
MOST form: Medical Orders for Scope of TreatmentDesignation of treatment orders- Resuscitation, Interventions if client is breathing, Antibiotics, TPN; encompasses more aspects of tx than DNR

Definitions / Signs of Death

Question Answer
Heart-lung deathcessation of apical pulse
Indications of deathtotal lack of response to external stimuli, no muscular movement (esp breathing), no reflexes, flat EEG
Indication of death under artificial life supportabsence of brain waves for at least 24 hours
Cerebral/higher brain deathabsence of responsiveness to external stimuli, absence of cephalic reflexes, apnea (flat EEG for at least 30 mins, in absence of hypothermia/CNS depressant poisoning, supports dx of death)
Loss of muscle tonedifficulty speaking, swallowing, decreased GI activity (nausea, flatus, abd distention), urinary/fecal incontinence, diminished body movement
Slowing of circulationdiminished sensation, mottling/cyanosis of skin, cold extremities, slow/weak pulse, decreased BP
Changes in respirationrapid, shallow, irregular, abnormally slow breathing; noisy breathing d/t accumulation of mucus in throat (death rattle); mouth breathing/dry oral mucous membranes
Sensory impairmentblurred vision, impaired senses of taste/smell
Rigor mortisstiffening of body occurs 2-4 hours after death; starts in involuntary muscles, progresses from core to extremities
Algor mortisgradual decrease of body temp after death (falls about 1 C/hour), skin loses elasticity and is easily broken
Livor mortisred blood cells breakdown (release hgb) which discolors surrounding tissue

Concept of Death Developmental

Question Answer
Infancy to 5 yearsDoes not understand concept of death, believes death is reversible/temporary/sleep
5-9 yearsUnderstands death is final, believes own death can be avoided
9-12 yearsUnderstands death as inevitable end of life, begins to understand own mortality
12-18 yearsFears lingering death, may seem to reach "adult" perception of death but be emotionally unable to accept it
18-45 yearsHas attitude toward death influenced by religion/culture
45-65 yearsAccepts own mortality, encounters death of parents/friends, experiences peaks of death anxiety
65+ yearsFears prolonged illness, sees death as having multiple meanings (freedom from pain, reunion with deceased)

Kulber-Ross Grief Cycle / Nursing Implications

Question Answer
DenialVerbally support client but do not reinforce denial
AngerHelp client understand that anger is a normal response to loss/powerlessness; Provide structure & continuity, Allow clients as much control as possible over their lives
BargainingListen attentively, encourage client to talk to relieve guilt/irrational fear
DepressionAllow client to express sadness; communicate non-verbally by sitting quietly; convey caring by touch
AcceptanceHelp family & friends understand client's decreased need to socialize, encourage client to participate as much as possible in treatment plan

Loss & Grief Pattern

Question Answer
Types of lossActual, Perceived, Situational/developmental, Anticipatory
How does age influence loss and grief responses?As one ages, they become more familiar with loss, usually increasing their understanding and acceptance of life, loss, and death. Children differ not only in their understanding of loss but also in the way they may be affected (e.g. loss of a parent)
How does bereavement differ from mourning?bereavement is the subjective experience of the survivor, mourning is the behavioral process through which grief is eventually resolved/altered
How do culture and religion impact the grief response?culture may determine how death is viewed and how mourners behave, rituals (religious/spiritual) may help legitimize emotional/physical ventilation, provide a focus for managing confusion, disorganization, and loss of control which promoting social interaction
What is palliative care?care that focuses on control of symptoms and compassion - 1. Help to minimize loneliness, fear, depression 2. Maintain client’s sense of security and dignity 3. Help client accept losses 4. Provide physical comfort
What is hospice care?care that focuses on support and care of dying person and family - 1. Facilitate a peaceful and dignified death (physical & emotional) 2. Usually eligible when certified by PCP < 6 months to live 3. Supports those who remain after client's death
How may a nurse help facilitate the grieving process? Explore and respect cultural, religious, personal values, Teach what to expect, Encourage expression and sharing of grief with support system
When is the grieving process completed?grief work is never completely finished, healing occurs when the pain is less

Loss & Grief NANDA labels

Question Answer
Anticipatory GrievingIntellectual/emotional responses/behaviors by which individuals, families, communities work through the process of modifying self-concept based on the perception of potential loss
Characteristics of Anticipatory GrievingGrieving for losses experienced during deteriorating illness, and the future that will be filled with loss
What outcome/intervention can be used with Anticipatory Grieving? Outcome: Client will discuss that meaning of the anticipated loss and the functioning of the family Intervention: Develop a trusting relationship both with the client and with the family by using presence and therapeutic communication techniques
Complicated GrievingOccurs after the death of a significant other in which the experience of distress accompanying bereavement fails to follow normative (or cultural) expectations and manifests in functional impairment
Characteristics of Complicated GrievingDecreased functioning in life roles, experiencing somatic symptoms of deceased, verbalizes feeling of shock, detachment, disbelief, persistent painful memories
What outcome/intervention can be used with Complicated Grieving?Outcome: Client will express appropriate feelings of guilt, fear, anger, or sadness Intervention: Educate the client and their support system that grief resolution is not a sequential process and that the positive outcome of grief resolution is the integration of the deceased into the ongoing life of the griever

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