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Difficulty: Very hardEnd of Life Care

A licensed practical nurse is providing home hospice care for a client with end-stage renal disease who has transitioned to the active dying phase. The client is unresponsive, exhibits Cheyne-Stokes respirations, and has cool, mottled extremities. The client's spouse is pacing the bedroom, crying, and states, "I should have insisted on starting dialysis last month. This is all my fault." Which actions should the nurse take? Select all that apply.

  1. Administer the prescribed sublingual morphine sulfate drops to manage the client's altered respiratory pattern.Answer
  2. B
    Apply a non-rebreather oxygen mask at high flow to reverse the client's hypoxia and regularize breathing.
  3. Elevate the head of the bed and position the client in a lateral position to facilitate the drainage of oral secretions.Answer
  4. D
    Comfort the spouse by stating, "Try not to focus on the past; you did everything the healthcare team recommended."
  5. E
    Document that the spouse is demonstrating abnormal, complicated grief by fixating on past medical decisions.
  6. Perform oral care using moistened swabs and apply a water-soluble lubricant to the client's lips every few hours.Answer

Answer

The nurse should administer prescribed morphine for respiratory comfort, position the client laterally with the head elevated to manage secretions, and provide frequent oral care with water-soluble lubricant.
The correct actions focus comprehensively on palliative comfort without introducing unnecessary distress. Morphine is a primary pharmacological intervention for managing the sensation of breathlessness (air hunger) associated with Cheyne-Stokes respirations. Positioning the client laterally with an elevated head utilizes gravity to naturally drain oral secretions, preventing respiratory rattling without the need for invasive, distressing suctioning. Frequent oral care with a water-soluble lubricant prevents painful cracking and breakdown of the oral mucosa, an essential comfort measure for patients who are mouth-breathing at the end of life.

Step-by-Step Solution

1
Analyze the client's physical symptoms (Cheyne-Stokes respirations, mottling, unresponsiveness).
These are expected signs of the active dying phase, indicating a need for palliative comfort measures rather than acute medical resuscitation.
Recognizing the active dying phase dictates a shift in nursing priorities from curative treatment to symptom management and comfort.
2
Evaluate the spouse's verbal statements and emotional state.
The statement "This is all my fault" is identified as a normal expression of anticipatory grief and guilt.
Understanding normal grief reactions prevents the nurse from using non-therapeutic communication blocks or incorrectly pathologizing the spouse's behavior.
3
Select nursing interventions that directly promote physical and psychosocial comfort.
Appropriate interventions include administering morphine for air hunger, utilizing gravity for secretions, and maintaining oral mucosal integrity, while avoiding restrictive oxygen masks and dismissive platitudes.
These specific actions align with the Practical Nurse scope of practice for delivering safe, effective, and ethical end-of-life care.

Key Concept

End of Life Comfort Measures and Therapeutic Communication
Estimated Time:3m 0s
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Topics

End of Life Care

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