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Difficulty: HardEnd of Life Care

A hospice nurse is caring for a client with end-stage liver disease who acutely develops severe terminal delirium, characterized by distressing hallucinations and physical agitation. The client's family is present and extremely frightened by the sudden change in behavior. Arrange the following nursing actions in the correct priority sequence.

  1. 1Assess the client for potentially reversible physiological triggers, such as uncontrolled pain or urinary retention.
  2. 2Modify the immediate environment to ensure physical safety and reduce excessive sensory stimulation.
  3. 3Administer the prescribed rapid-acting antipsychotic medication to alleviate the severe perceptual disturbances.
  4. 4Reassure the family that these behavioral changes are a recognized component of the active dying process.
  5. 5Monitor the client's level of comfort and degree of agitation to evaluate the effectiveness of the care provided.

Answer

The correct sequence prioritizes assessment, followed by non-pharmacological safety measures, pharmacological intervention, psychosocial support for the family, and finally, evaluation.
The nursing process dictates that care must follow a logical, sequential progression: Assessment (identifying reversible causes), Implementation of non-pharmacological measures (environmental safety), Implementation of pharmacological measures (medication for refractory symptoms), Psychosocial support (educating the frightened family while the medication takes effect), and Evaluation (monitoring the physiological response to all interventions).

Step-by-Step Solution

1
Assess for reversible causes.
Identifies if the agitation is caused by a treatable condition like urinary retention or breakthrough pain.
Prevents the unnecessary use of heavily sedating medications if the underlying cause can be easily resolved.
2
Modify the immediate environment.
Creates a safe, low-stimulus physical space.
Protects the client from physical injury during severe agitation and minimizes sensory triggers.
3
Administer rapid-acting antipsychotic medication.
Alleviates severe perceptual disturbances and refractory agitation.
Provides necessary pharmacological comfort when non-pharmacological interventions are insufficient.
4
Reassure and educate the family.
Reduces family anxiety and psychosocial distress.
Helps the family understand that terminal delirium is a natural part of the dying process rather than a psychiatric emergency.
5
Monitor the client's level of comfort.
Determines the overall efficacy of the applied interventions.
Closes the loop of the nursing process by evaluating if symptom control was successfully achieved.

Key Concept

Management of Terminal Delirium
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Topics

End of Life Care

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