A nurse is caring for an older adult client with end-stage heart failure who has recently transitioned to comfort measures only. The client is minimally responsive, exhibits Cheyne-Stokes respirations, and has mottling of the lower extremities. The client's family is at the bedside and expresses distress about the breathing pattern. Which nursing actions are appropriate? Select all that apply.
- Elevate the head of the bed to promote respiratory comfort.Answer
- Administer prescribed sublingual morphine to alleviate signs of respiratory distress.Answer
- CAsk the family why they are feeling so distressed about the changes in the client's breathing.
- Educate the family that these specific breathing and skin changes are an expected part of the dying process.Answer
- EInstruct the unlicensed assistive personnel (UAP) to perform the initial assessment of the client's pain level.
Answer
The appropriate nursing actions include elevating the head of the bed, administering prescribed sublingual morphine, and educating the family about the expected physiological changes of dying.
Appropriate end-of-life care focuses on maximizing the client's comfort and supporting the family system. Elevating the head of the bed mechanically eases breathing effort. Morphine is the pharmacological gold standard for managing dyspnea in palliative care. Furthermore, educating the family about normal signs of impending death (such as Cheyne-Stokes breathing and mottling) reduces fear and provides necessary psychosocial support.
Step-by-Step Solution
Key Concept
Prioritizing palliative comfort measures and providing psychosocial support and education to the family during the active phase of dying.