A home hospice practical nurse visits a client with end-stage heart failure who is receiving comfort measures. The client is semi-comatose, exhibiting audible oral secretions, and has not eaten for two days. The client's adult child is distressed and asks, "Should we force them to drink a nutritional shake? I feel like we are starving them." Which of the following actions should the nurse take? Select all that apply.
- Gently turn the client's head to the side or reposition them laterally to promote drainage of secretions.Answer
- Administer prescribed sublingual anticholinergic drops to help reduce the production of respiratory secretions.Answer
- Explain to the child that a natural decrease in thirst and appetite is expected and normal during the dying process.Answer
- DReassure the child by stating, "You really shouldn't worry; everything will be over soon and they will be at peace."
- EInform the child that feeling frustrated is just the first stage of grief and they will soon move on to the acceptance phase.
Answer
The correct actions include gently repositioning the client laterally to drain secretions, administering prescribed anticholinergics to dry secretions, and educating the family about normal decreased oral intake at the end of life.
Repositioning the client and administering anticholinergics are standard, evidence-based palliative interventions to manage respiratory secretions by promoting drainage and reducing fluid production. Concurrently, educating the family that the body naturally slows down and requires less nutrition helps alleviate caregiver guilt and provides accurate physiological context for the changes they are witnessing.
Step-by-Step Solution
Key Concept
End-of-Life Comfort Measures and Psychosocial Support