A nurse in a palliative care unit is caring for a terminally ill client who has entered the active phase of dying. The client suddenly becomes highly restless, pulls at the bed linens, and converses with deceased relatives. The client's adult child is visibly distressed and pleads with the nurse, 'Please tell my mother she is in the hospital and her parents are not here.' Which is the priority nursing action?
- Assess the client for physiological sources of discomfort, such as urinary retention, and educate the family to avoid forcing reality orientation.Answer
- BGently inform the client that her parents are deceased and remind her that she is safe in the hospital environment.
- CRequest a prescription for a chemical restraint, such as haloperidol, to rapidly manage the client's severe agitation and prevent injury.
- DDelegate the continuous monitoring of the client's behavioral changes to an unlicensed assistive personnel (UAP) to ensure safety.
Answer
The priority nursing action is to assess the client for physiological sources of discomfort, such as urinary retention, and to educate the family to avoid forcing reality orientation.
In the active phase of dying, clients frequently experience terminal delirium or severe agitation. Following the nursing process, assessment is always the initial priority action. The nurse must first rule out and treat underlying, reversible physical causes of agitation, such as uncontrolled pain, a distended bladder, or constipation. Concurrently, psychosocial support is essential; the nurse must educate the distressed family that attempting to orient the client to reality is counterproductive and heightens the client's anxiety, whereas joining the client's reality or simply offering calm presence promotes comfort and peace.
Step-by-Step Solution
Key Concept
Terminal Delirium Management and Therapeutic Communication
Estimated Time:1m 30s