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Difficulty: EasyEnd of Life Care

A nurse is caring for an older adult client who is actively dying in a hospice unit. The client is unresponsive, experiencing noisy respiratory secretions, and exhibiting restlessness. Which actions should the nurse take? Select all that apply.

  1. Administer a prescribed anticholinergic medication to reduce respiratory secretions.Answer
  2. Turn the client to a side-lying position to facilitate the drainage of oral fluids.Answer
  3. C
    Reassure the family by stating, 'Do not worry, everything is going to be fine.'
  4. D
    Delegate the evaluation of the client's nonverbal pain indicators to the unlicensed assistive personnel (UAP).
  5. E
    Explain to the family that the client's confusion is simply a normal expectation of advanced age.
  6. Provide gentle mouth care using moistened swabs to maintain oral comfort.Answer

Answer

The nurse should administer prescribed anticholinergic medications, turn the client to a side-lying position, and provide gentle mouth care.
End-of-life care focuses on promoting comfort, dignity, and symptom management. Turning the client to a side-lying position allows gravity to drain pooled secretions, naturally reducing noisy breathing. Anticholinergic medications are medically appropriate to dry up excessive respiratory secretions. Frequent mouth care prevents the severe discomfort of dry, cracked mucous membranes, which is common in dying clients due to mouth breathing and decreased fluid intake.

Step-by-Step Solution

1
Assess the client's presenting symptoms and physiological needs.
The client is actively dying, unresponsive, and experiencing noisy secretions and restlessness.
Identifying symptoms allows the nurse to prioritize appropriate palliative care interventions over aggressive or non-therapeutic measures.
2
Select interventions that directly alleviate the client's physical discomfort.
The nurse chooses to reposition the client, administer secretion-drying medications, and perform oral care.
These actions address the 'death rattle' and maintain mucous membrane integrity without causing harm.
3
Ensure safe delegation and therapeutic communication principles are maintained.
The nurse retains the responsibility of assessing pain and avoids giving the family false reassurance.
Nursing assessments cannot be delegated, and therapeutic communication requires honesty and active listening rather than dismissive clichés.

Key Concept

End of Life Comfort Measures and Palliative Care
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Topics

End of Life Care

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