Download NSG-430 Exam 1 Questions: End-of-Life Care and Palliative Care and more Exams Nursing in PDF only on Docsity!
NSG-430 Exam 1 Questions With Complete Solutions palliative care correct answer: -Care or treatment focusing on reducing the severity of symptoms -Begins during curative or restorative health care -Extends into end-of-life care -Bereavement care follows death Goals: -Regard dying as a normal process -Provide relief from symptoms, including pain -Affirm life and neither hasten nor postpone death -Support holistic patient care and enhance quality of life -Offer support to patients to live as actively as possible until death -Offer support to the family during the patient's illness and in their own bereavement -Indication: diagnosis of a life-limiting illness such as cancer, heart failure, COPD, dementia, or ESRD -Involves: -Interprofessional collaboration: includes physicians, nurses, social workers, pharmacists, chaplains, and others -Ongoing communication: important for optimal care -Care in multiple settings: home, long-term care, acute care, mental health facilities, rehabilitation centers, and prisons hospice correct answer: -Curative care is forgone
-Requires physician certification that life expectancy is 6 months or less -Initiated only after the decision is made by the patient or a proxy not to pursue a cure death correct answer: -Occurs when all vital organs and body systems cease to function -Irreversible cessation of cardiovascular, respiratory, and brain function brain death correct answer: -Irreversible loss of all brain functions including the brainstem -Cerebral cortex stops functioning or is destroyed -Exact definition of death can be controversial -Technological developments in life support have led to questions about when death actually occurs: •When the whole brain (cortex and brainstem) ceases activity •Or when function of the cortex alone stops. -The American Academy of Neurology developed the diagnostic criteria that must be validated by a physician: •Coma or unresponsiveness •Absence of brainstem reflexes •Apnea -Currently legal and medical standards require that all brain function must cease for brain death to be pronounced and life support to be disconnected. -In some states and under specific circumstances, registered nurses are legally permitted to pronounce death. -Diagnosis of brain death is of particular importance when organ donation is an option.
Respiratory System: -Irregular breathing that gradually slows and becomes more shallow -Breath sounds may become wet and noisy, both audibly and on auscultation. -Cheyne-Stokes respiration: pattern of breathing characterized by alternating periods of apnea and rapid deep breathing -Inability to cough or clear secretions: grunting, gurgling, or noisy congested breathing ("death rattle") -Noisy, wet-sounding respirations, termed the death rattle or terminal secretions, are caused by mouth breathing and accumulation of mucus in the airways. Hearing, Touch: -Hearing is usually last sense to disappear -Decreased sensation -Decreased perception of pain and touch -The sense of touch is decreased first in the lower extremities because of circulatory alterations Taste, Smell, and Sight: -Blurring of vision -Blink reflex absent -Patient appears to stare -Eyelids remain half-open -Decreased sense of taste and smell Integumentary System: -Mottling on hands, feet, arms, and legs: looks faintly like purple and white leopard skin -Cold, clammy skin
-Cyanosis of nose, nail beds, knees -"Waxlike" skin when very near death -The skin cools first on lower, then upper extremities and finally the torso unless a fever is present. Urinary System: -Gradual decrease in urinary output -Incontinent of urine -Unable to urinate Gastrointestinal System: -Slowing of digestive tract -Accumulation of gas -Distention and nausea -Loss of sphincter control -Bowel movement may occur before imminent death or at the time of death -Pain relieving drugs can accelerate the loss of GI function Musculoskeletal System: -Gradual loss of ability to move -Trouble holding body posture and alignment -Loss of facial muscle tone -Sagging of jaw -Difficulty speaking -Loss of gag reflex -Swallowing can become more difficult Cardiovascular System: -Increased heart rate -Later slowing and weakening of pulse
Nursing Management: -Encourage the dying person and family to share their feelings of sadness, loss, forgiveness and to touch, hug, cry. -Allow the patient and family privacy to express their feelings and comfort one another. -Assess spiritual needs. Allow patient to express his or her spiritual needs. -Encourage visit by appropriate spiritual care service provider, chaplain, or family member. -Encourage the family to talk with and reassure the dying person. -Affirm the dying person's experience as a part of transition from this life. -Converse as though the patient were alert, using a soft voice and gentle touch. Anxiety and Depression: -Uncontrolled pain and dyspnea -Psychosocial factors from disease process or impending death -Altered physiologic states -Drugs used in increasing doses -Management: •Pharm and non-pharm interventions (relaxation, breathing, muscle relaxation, music, imagery) •Encouragement, support, and education Anger: -Anger is a common and normal response to grief -A grieving person cannot be forced to accept the loss.
-Surviving family members may be angry with dying loved one who is leaving them. -You may sometimes be the target of anger and must understand what is happening and not react on a personal level. -Encourage expression of feelings, at the same time realizing how difficult it is to come to terms with loss. -You may remember reading about the five stages of death and dying, these are chronologically: denial, anger, bargaining, depression and acceptance. The model was first introduced by Swiss-American psychiatrist Elisabeth Kübler-Ross in her 1969 book On Death and Dying, and was inspired by her work with terminally ill patients. Hopelessness, Powerlessness, and Fear: -Feelings of hopelessness and powerlessness are common during the EOL period. -Allow patient and family to deal with what is within their control and help them to recognize what is beyond their control. -Encourage realistic hope within the limits of the situation -Decision making about care can foster a sense of control and autonomy -Four specific fears: 1.Pain 2.Shortness of breath 3.Loneliness and abandonment 4.Meaninglessness -Management: •Relaxation and coping strategies Fear of Pain: -Physiologically:
-Presence of people provides comfort, support, and a sense of security -Many dying patients are afraid that loved ones who are unable to cope with the patient's imminent death will abandon them. -Holding hands, touching, and listening are important nursing interventions. -Life review -Intentions during life -Actions -Regrets about what might have been Communication: -Communication is essential -Use empathy: identification with and understanding of another's situation, feelings, and/or motives -Active listening: paying attention to what is said, observing nonverbal cues, and not interrupting. -Allow patients and families time to express their feelings and thoughts -Accept silence: may be related to overwhelming feelings experienced at the end of life. It can allow time to gather thoughts. -Listening conveys acceptance and comfort. -Consider ethnic, cultural, and religious backgrounds. -Prepare family for unusual patient communication -Patients and families may have difficulties expressing themselves emotionally. -Make time to listen and interact in a sensitive way to enhance the relationship among you, patient, and family. -A family conference can create a more conducive environment for communication.
-Prepare family members for changes in emotional and cognitive function that occur at end of life. -Unusual communication may take place. -Patients may: •Speak to or about family or others who have predeceased them •Give instructions to those who will survive them •Speak of projects yet to be completed. -Listening carefully: •Helps identify specific communication patterns •Decreases risk for inappropriate labeling of behaviors. spiritual needs correct answer: -Spirituality: beliefs, values, practices that relate to the search for existential meaning and purpose -May or may not include a belief in a higher power -Does not necessarily equate to religion -Preferences should be noted -Question beliefs about a higher power, their own journey through life, religion, and an afterlife -Spirituality is associated with decreased despair at EOL -Spiritual distress may occur -A person may be of no particular faith but have a deep spirituality -Some patients may choose to pursue a spiritual path. Some may not. Their individual choice needs to be respected -The patient's and family's preferences related to spiritual guidance or pastoral care services should be assessed, and appropriate referrals made culturally competent care correct answer: -Cultural beliefs affect:
-In the Islamic cultures the traditional rites of washing, shrouding, funeral prayers, and burial are done as soon as possible. -Families with non-English-speaking members are at risk for receiving less information about their family member's critical illness and prognosis. -Cultural variations also exist in symptom expression (e.g., pain expression) and use of health care services. -Providing culturally competent care requires assessment of nonverbal cues such as grimaces, body position, and decreased or guarded movements. legal and ethical issues correct answer: -Patients and families struggle with many decisions during the terminal illness and dying experience -Decisional capacity refers to the ability to consent or refuse care. It means that the individual has an understanding and appreciation of the information that is shared and has the capacity to engage in the reasoning process. -Organ and tissue donations -Advance directives -Resuscitation -Mechanical ventilation -Tube feeding placement organ and tissue donation correct answer: -Any body part or the entire body may be donated -Decided by a person before death -With family permission after death -Follow specific legal guidelines for organ or tissue donation.
-Some tissues must be used within hours after death so require immediate physician notification. -Provide information so that care outcomes are based on wishes and values. -Organ Donation: •Can be made by legally competent persons •Can be made by immediate family following death •Can be specified on donor cards or, in some states, on drivers' licenses •Handled by various agencies that differ by state and community (organ bank, organ-sharing network, organ-sharing alliance) •Follow specific legal guidelines for organ or tissue donation. •Some tissues must be used within hours after death so require immediate physician notification. resuscitation correct answer: -A common health care practice -Patients and families have the right to decide whether CPR will be used -Physician's orders should specify: •Full Code •Chemical Code •No Code - DNR or AND -CPR is given for respiratory or cardiac arrest unless otherwise ordered by a physician. -However, whether and to what extent CPR is used is no longer the sole decision of the physician. -The ANA supports patient's right to self-determination, and a primary role of nurses is supporting patient and family decisions.
-Your moral obligation is to relieve suffering, which includes giving medications that have the potential of producing harm, such as with opioids. -As a nurse, your role is to teach the patient and family regarding addiction, tolerance, and dependence to medications. -The person with terminal illness should not be concerned with addiction when the goal of treatment is comfort. end of life nursing management correct answer: -Nurses spend more time with patients near the end of life than any other health care professionals -Respect, dignity, and comfort are important for patient and family -Nurses need to recognize their own needs when dealing with grief and dying -After the event debrief with a peer or the team. It is okay to feel the emotion, yes, you are human too, you may have a relationship with the family. -What Guides Our Care?: •Code of Ethics for Nurses-relieve suffering •Principle of beneficence-means that care is provided to benefit •Standard of care- used to define the nursing acts that are required for safe and competent nursing practice Assessment: -If patient is alert: •Brief review of body systems to detect signs and symptoms •Assess for discomfort, pain, nausea, or dyspnea -Follow specific legal guidelines for organ or tissue donation.
-Some tissues must be used within hours after death so require immediate physician notification. -Assess coping abilities of patient and family -Promptly address discomfort. -Use evidence-based tools for symptom assessment including numeric scales or visual analog scales for pain rating. -Evaluate and manage co-morbid health care problems. -Gather information about abilities, intake, rest, and general response to the terminal illness and its prognosis. -Determine family's ability to manage and cope with the needed care and consequences of the illness. -Stability determines frequency of assessment -At least every 8 hours in the inpatient setting -More frequently as changes occur -Document -Monitor for system failure as death approaches -Attention to subtle physical changes requires vigilance -Neuro, circulation(CV), respiratory, I&O, integumentary -What type of changes/symptoms are seen? -Physical assessments are abbreviated and focused on changes that accompany terminal illness. -Assessment may occur weekly for patients cared for in their homes by hospice programs. -In the final hours of life, physical assessment may be limited to essential data. -Key elements of social assessment include: •Family relationships •Communication patterns •Differences in expectations
•Interprofessional EOL care that includes the physician, social worker, chaplain, as well as other members of the palliative and/or hospice care team is important. •Consult palliative care specialists for dealing with sudden or traumatic deaths such as those that occur in the ICU Implementation: -Ongoing information on disease, dying process, and care -Teaching of coping strategies for patients and families -Denial and grieving may be barriers to learning physical care at end of life correct answer: -Symptom management and comfort -Physiologic and safety needs --Dying patients deserve and require the same care as people who are expected to recover -Pain, delirium, anxiety, dysphagia, fatigue, dehydration, dyspnea, myoclonus, skin breakdown, bowel changes, urinary incontinence, N/V, candida -Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. -Skin integrity is difficult to maintain at the end of life because of immobility, urinary and bowel incontinence, dry skin, nutritional deficits, anemia, friction, and shearing forces. -If possible, it is important to discuss with the patient and family the goals of care before treatment begins. An advanced directive should be completed so that the patient and family wishes are followed.
postmortem care correct answer: -After death is pronounced, the nurse prepares or delegates preparation of the body for immediate viewing by the family -Close patient's eyes -Replace dentures -Wash and position body -Consideration must be given for: •Cultural customs •State law •Agency policy and procedure. -May be important to allow family to prepare or assist in preparing body in some cultures and some types of death -Remove tubes and dressings if appropriate. -Straighten the body, leaving the pillow to support the head and prevent pooling of blood and discoloration of the face. -In the case of an unexpected or unanticipated death, preparation of the patient's body for viewing or release to a funeral home depends on state law and agency policies and procedures. -Never refer to the deceased person as "the body." -Care of and discussion related to the person should continue to be respectful even after death. Needs of Caregivers: -Caregivers are important in meeting patient's physical and psychosocial needs. -Often face high levels of stress and emotional, physical, and economic consequences from caring for a dying member. -Responsibilities do not end when the person is admitted to an inpatient facility. -Allow family privacy and as much time as they need with deceased person
