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Zorluk: OrtaEnd of Life Care

A home health nurse is managing the care of a client with advanced metastatic melanoma who is transitioning to the final days of life. The family expresses severe distress upon hearing the client develop noisy, rattling breathing. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

  1. Administer a prescribed anticholinergic medication to reduce the volume of respiratory secretions.Cevap
  2. B
    Tell the family that they should not worry because the noisy breathing is completely painless.
  3. Position the client in a side-lying posture with the head of the bed elevated.Cevap
  4. D
    Delegate the ongoing evaluation of the client's respiratory distress to the unlicensed assistive personnel (UAP).
  5. E
    Place the client in a flat, supine position to encourage maximum thoracic expansion.
  6. Perform frequent oral hygiene using a soft, moistened swab to maintain mucous membrane integrity.Cevap

Cevap

The correct interventions are administering an anticholinergic medication, positioning the client in a side-lying posture with the head elevated, and performing frequent oral hygiene.
Appropriate management of terminal secretions involves non-invasive methods to clear or reduce fluids. Anticholinergic medications dry up excessive secretions, reducing the auditory distress for the family and maintaining comfort. Positioning the client on their side with the head elevated uses gravity to facilitate drainage and prevent fluid pooling in the oropharynx. Furthermore, frequent oral care maintains moisture and comfort, as these clients often breathe through their mouths and cannot clear secretions on their own.

Adım Adım Çözüm

1
Identify the clinical phenomenon occurring in the scenario.
The client is experiencing the 'death rattle', which is the accumulation of secretions in the airway typical during the final days of life.
Recognizing the symptom allows for the selection of appropriate, evidence-based palliative interventions.
2
Evaluate pharmacological and non-pharmacological comfort measures.
Anticholinergics, repositioning (side-lying/elevated head), and regular oral care are identified as safe and effective comfort measures.
These interventions directly address the pooling of secretions and maintain client comfort without relying on invasive procedures like deep suctioning.
3
Identify contraindicated or inappropriate actions.
Flat positioning, delegating assessments to a UAP, and using non-therapeutic communication are identified as incorrect.
These actions violate the registered nurse's scope of practice, worsen the client's symptoms, and fail to support the family psychologically.

Anahtar Kavram

Management of terminal secretions ('death rattle') in end-of-life care
Tahmini Süre:1m 30s
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Konular

End of Life Care

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