A nurse is caring for a client in the active phase of dying. The client begins to exhibit loud, gurgling respiratory secretions. The client's family members are at the bedside, visibly distressed, and state, "Please help, they are choking!" Arrange the following nursing actions in the priority order they should be performed.
- 1Assess the client's level of consciousness and signs of respiratory distress.
- 2Reposition the client into a lateral or semi-Fowler's position.
- 3Administer the prescribed sublingual anticholinergic medication.
- 4Explain the physiological cause of the sounds to the family to alleviate their distress.
- 5Perform gentle oral care using moistened swabs.
Answer
The correct priority sequence is: 1) Assess the client, 2) Reposition the client, 3) Administer anticholinergic medication, 4) Explain the sounds to the family, 5) Perform oral care.
In end-of-life care, prioritizing actions follows the nursing process (ADPIE) and physiological needs. Assessment is always the first step. Next, non-pharmacological physical interventions (such as repositioning) provide immediate relief for terminal secretions. Pharmacological interventions (like anticholinergics) follow to address the underlying symptom medically. Once the client's physical needs are stabilized, the nurse addresses the psychosocial needs of the family through education and reassurance. Finally, routine comfort measures like oral hygiene are provided.
Step-by-Step Solution
Key Concept
Prioritization of care for terminal secretions (death rattle) utilizing the nursing process.