5.3.5: FRAME 5- Take Action

CORRECT Answer

Question Type: Matrix Multiple Choice

Scoring: 0/1

NCSBN Item Type and Scoring: https://www.ncsbn.org/public-files/p...main_stage.pdf

The nurse has reviewed the medical record to determine what actions are appropriate for Rhys at this time. Indicate on the table below what nursing actions would be appropriate or not appropriate for Rhys at this time. Each row must have a selection.

Nursing Actions	Appropriate	Not Appropriate
Administer Morphine 10 mg orally
Administer Acetaminophen 650 mg rectal suppository
Inform family of transition
Suction secretions
Allow family time alone with client
Create a comforting environment; low stimuli
Offer culturally appropriate spiritual support

RATIONALE

Changes in breathing patterns often change from a normal rate and rhythm to a new pattern including periods of apnea and Cheyne-Stokes breathing. Cheyne-Stokes breathing is indictive of impending death, generally minutes to hours (National Institute on Aging, 2022). Because death is imminent for Rhys, comfort care should not include medications such as morphine or acetaminophen. When a client is in their final hours and minutes of life, humanistic care is imperative when considering medication administration. Nursing actions should focus on the transition and supporting family by creating a comforting, low stimuli environment, offering culturally appropriate end of life support, providing time alone with the client. Suctioning the person during transition is not recommended. The irritation from the plastic tube can cause more secretions to be produced.

During end-of-life, it is important the nurse engage and maintain in a therapeutic relationship with the family and communicate the signs and symptoms during the end-of-life transition. Care for the family may need support and coaching as death approaches. Care continues through the death pronouncement, family notification of the death, and bereavement support (Harman et al., 2023). Many hospice programs offer bereavement services for families 12 months following the death of their loved one.

FOCUSED GUIDE

Nurse-family and nurse-client therapeutic relationships are of utmost importance in providing end-of-life care. Role playing end-of-life conversations and scenarios can be helpful in developing therapeutic communication skills, especially with students who do not have experience with or are uncomfortable with end-of-life care. Use the graph and ask students to work in groups or individually to complete one more action for each of the signs and symptoms or to create additional signs and symptoms including nursing actions, non-pharmacologic and pharmacologic interventions.

The nurse should provide a holistic assessment of the client’s condition and the benefit of any pharmacologic and nonpharmacologic interventions. For example, when considering if an analgesic should be administered if the client is febrile, assess if the client appears uncomfortable and whether or not breaking the fever will be more uncomfortable than the fever itself.

Sign/Symptom	Nursing Actions
Change in Breathing	Reassure family a change in breathing pattern is common and indicates decrease circulation. Non-pharmacologic Interventions: Elevate head of bed or turn client on their side. Pharmacologic Intervention: Morphine can help with breathing and respiratory congestion by decreasing fluid in the lungs and altering how the brain responds to pain.
Respiratory Congestion	Reassure family respiratory congestion is not uncommon and does indicate pain. Non-pharmacologic Interventions: Gently turn client head to the side to drain secretions. Wipe their mouth with a cool cloth. Pharmacologic Intervention: Morphine can help with breathing and respiratory congestion by decreasing fluid in the lungs and altering how the brain responds to pain.
Fever	Reassure the family that a fever is not uncommon with end-of-life transition. Non-pharmacologic Interventions: Apply a cool moist compress to forehead or neck, cooling blankets or sponging. Focus on core temp, not peripheral temps due to impaired perfusion Pharmacologic Intervention: Assess need for analgesic or NSAID.
Sleeping or Unresponsiveness	Reassure the family that increased amount of time sleeping is common. The client may become unresponsive, uncommunicative, or difficult to arouse are not uncommon responses. Non-pharmacologic Interventions: Comfort client by holding their hand, being present, speak in a normal voice.
Changes in color and temperature of hands and feet	Reassure family that changes in the color and temperature is not uncommon. The skin may become grey, pallor, purple, mottled, and cool to touch. Changes in color and temperature of hands are due to impaired perfusion. Non-pharmacologic Interventions: Keep client warm and comfortable with soft blankets floating heals in bed or on pillow.
Restlessness	Reassure the family that restlessness is not uncommon during the end-of-life transition. Restlessness is in part due to decreased oxygen and impaired circulation. Non-pharmacologic Interventions: Avoid restraining the client or interfering with the movements. Soft natural light, speaking in a calming voice, light massage to forehead, or soothing music are examples of therapeutic interventions for restlessness. Pharmacologic Intervention: Lorazepam can help the client to relax if they are experiencing apprehension, agitation, and/or restlessness.
Confusion	Reassure the family that confusion is not uncommon during the end-of-life transition. Do not correct the client These can present of delusion, or hallucinations symbolic language or actions Non-pharmacologic Interventions: identify yourself before you speak, explain actions before you implement the plan, speak normally and clearly.