Case Study - Hospice

Case Study – Hospice Meet the Client Community/public health nurses often make visits to client’s homes. Home visiting nursing services are offered to new parents, children with special needs, and their families, older homebound adults, and client’s discharged home from the hospital who require ongoing care. Palliative and hospice care are often delivered by nurses working in the community. The goal of palliative and hospice care is to support the client and family though the dying process. Section 1 1. A primary care provider makes a referral to the nurse. Which statement by the client indicates an understanding of palliative care? • Treatments and medications will be utilized to control my pain and increase my comfort. Interventions will be utilized to control pain, to increase comfort, and to improve quality of life and quality of death for the client and family. During the initial visit, the nurse explains the purpose of palliative and hospice nursing care to the client and their family. 2. When talking with the family, what information should the nurse include? (SATA) • The care provided is client and family focused. • Hospice nurses regard dying as a normal process. • Bereavement follow-up is provided after the client’s death. • Interdisciplinary care focuses on symptom management. Section 2 The nurse completes a comprehensive assessment of the client and family. 3. In conducting a home visit with a new client, which problem should the hospice nurse address first? • The problem that the client identifies as the first priority, the problem that most concerns the client. Highest value should be placed on the problem the client identifies as the first priority. The client tells the nurse that they are worried about falling in the bathroom when bathing or showering. The nurse assesses the client’s ability to perform activities of daily living. 4. Which action should the nurse take first when addressing the client’s fear of falling in the shower? • Determine if safety equipment is needed for bathing or showering. Safety is the first priority to protect the client from injury. The facility used for bathing and showering should be inspected by the nurse. After assessing the client’s abilities, the nurse determines that a shower chair is needed. The nurse collaborates with the primary healthcare provider to obtain a prescription for the durable medical equipment. The nurse explores with the family whether they can assist with the client’s care. The nurse offers them referrals to community resources and assists them to access public assistance if the client is eligible for services. 5. The client qualifies for in-home county support services and the family hire a home care aide. Which information about the client’s care should the nurse convey to the home care aide? • Place hygienic supplies within the client’s reach when the client is using the shower chair. This will promote independence and decrease the risk for falls. Section 3 During the initial assessment, the nurse asks the client about their family. The client cries and reports they have two daughters, ages 19 and 15, and a 12-year-old son. The 15-year-old is having the hardest time with the client’s prognosis. She seems irritable and angry when she is with the client and has recently been disruptive in school. 6. How should the nurse respond to the client about their family concerns? • Anger is part of the grieving process. I would suggest you encourage her to talk about her feelings. A variety of strong emotions may be experienced during the grieving process. Family members should be encouraged to talk about their feelings of grief. The nurse revises the family’s plan of care. 7. Based on the client’s concern about their daughter, which nursing diagnosis should the nurse add to the plan of care? • Anticipatory grieving related to potential loss of parent. Grieving for the client’s death is still anticipatory at this time. Section 4 The nurse has worked with hospice clients for 5 years and has experience communicating therapeutically with the dying client. The nurse explains some of the common expressions of grief and asks what the client has experienced. 8. The nurse schedule a home visit with the family unit to discuss common expressions of grief. What information should the nurse include during the discussion about the grieving process? (SATA) • It is common to have several emotional responses to grief and loss. • Grief is a normal reaction to loss. • Grief includes both physiological and psychological responses. • Grief is a complex and intense emotional experience. 9. The nurse observes the client’s emotional responses when discussing their desires about death. Which emotional response is uncommon? • Confusion and disorientation. These are not common responses to grief and the nurse should assess the client for delirium or possible dementia. 10. Which technique should the nurse use when communicating with the client about their terminal illness? • Respect the client’s pattern of communication and ways of dealing with stress. The nurse should respect the client’s readiness to talk about and deal with the illness while offering support when needed. Section 5 The nurse assists the client with advance care planning. The client expresses interest in obtaining the help of a volunteer to write letters and make some short videos to be passed along to the children and partner after the client’s death. 11. Which of the following statements by the nurse identifies the purpose of advance care planning? • During advance care planning, I will help you identify what you want your healthcare team to do if you cannot speak for yourself. The client tells the nurse they feel as if they have been stamped with an expiration date. They are concerned because their healthcare provider anticipated they had 4 to 6 months left to live. The client explains that they feel overwhelmed. There is so much they would like to do with their children before they die. 12. The client asks the nurse what physical experiences occur at the end of life. Which of the following physical occurrences are likely at end of life? (SATA) • There is a decreased perception of pain. • Mottling on hands, feet, arms and legs occur. • Breathing becomes slowed and irregular. 13. Which is the best response to the client’s concerns about their children? • Ask the client if they are interested in having a volunteer help record their thoughts. This is a service offered by trained hospice volunteers that helps clients pass along information to their family and friends. Section 6 The nurse continues to manage hospice care for the client and family. Over the next 2 months, the client’s physical condition deteriorates and they become unable to get out of bed. The bed the client and their partner shared for 23 years is replaced with a hospital bed, and the partner chooses to sleep in a recliner at the bedside. The partner explains to the nurse that the client wakes up in the middle of the night in pain. The partner is afraid that if the client takes pain medication at night, they might not wake up in the morning. 14. How should the nurse respond to the partner’s concern? • We can collaborate with the primary care provider to try to find a dose of pain medication that works for your partner. It is important to collaborate to find a pain regimen that will keep the client’s pain under control, even in the middle of the night. Section 7 The nurse collaborates with the primary healthcare provider, who prescribes the client a 50 mcg/hr transdermal fentanyl patch to be changed every 72 hours. 15. Which medication does the nurse expect to give to prevent a common side effect of the fentanyl patch? • Docusate sodium. This is a stool softener and it is given to help prevent constipation, a common side effect of this medication. The nurse teaches the client’s partner how to apply the transdermal fentanyl patch. 16. Which information is most important for the nurse to teach the client’s partner? • Remove the old patch before applying the new patch. It is most important to do this to prevent and overdose. The primary healthcare provider also prescribes morphine sulfate elixir 8 mg by mouth every 4 hours as needed for breakthrough pain. 17. The morphine sulfate elixir is supplied 5 mg per mL. What is the maximum volume in mL that the client can receive per day? • 9.6 mL. The client tells the nurse that the new pain regimen is working much better but they have started having burning, electric-like pain in their hands and feet. The nurse collaborates with the primary healthcare provider who prescribes an additional medication for the client. 18. Which medication would the nurse expect the healthcare provider to prescribe to treat the type of pain the client described? • Gabapentin. The drug is an anticonvulsant commonly used to treat neuropathic pain because of its effect on the CNS. The exact mechanism of action is unknown. Section 8 The client’s primary healthcare provider adds an additional medication to the pain care regimen to help alleviate neuropathic pain. The nurse also encourages the use of nonpharmacological complimentary therapies to increase comfort and improve quality of life. 19. Which nursing intervention describes the use of guided imagery to control pain? Visualize a pain free mental scenario while achieving a deep state of relaxation. • 20. The nurse offers which of the following statements about complementary therapies? • Reimbursement for complementary therapies is lacking. The client learns to use guided imagery to help with pain control. Section 9 Over the next few weeks, the nurse collaborates with the client’s family to continue to offer comforting interventions. The nurse notices that the client’s partner appears to be losing weight. The nurse discovers that they have only been sleeping about 2 hours per night. When questioned, the partner reports feeling as if they might collapse if they are not able to take a break from caring for the client. 21. Which action should the nurse take? • Discuss with the family the possibility of a brief hospitalization for respite care. Respite care can allow caregivers time to regain strength and mental health. Section 10 After much discussion, the client is admitted to a hospice respite care program. During the hospital stay, the nurse encourages the family members to rest. The nurse maintains communication with the family, providing them with updates about the client’s condition. After a few days, the client returns home and, 4 months after hospice care we started, they being to lapse in an out of consciousness. The nurse recognizes end of life signs and prepares thee family for the client’s imminent death. 22. What intervention should the nurse implement at this time? • Reinforce prior education about the dying process. When the client is awake and conscious, they are often restless and agitated. The nurse assesses possible causes and offers several relief measures. 23. Which interventions provided during the end of life are secondary prevention interventions? Select all that apply. • Assessing levels of consciousness. • Asking the family members about their stress levels using a scale of 1 – 10 • Using the faces pain rating scale to determine the client’s level of pain. The client becomes unconscious. Their pulse becomes weak and thready, and they begin to diaphorese profusely. Mucous collects in their airway, and respirations become extremely noisy. 24. Which intervention should the nurse implement? • Administer prescribed atropine drops sublingually. Atropine will reduce terminal secretions and quiet the noisy breathing. Section 11 The client’s respirations quiet. Despite having Cheyne-Stokes respirations for 2 hours while unconscious the client suddenly regains consciousness. 25. Which explanation should the nurse offer to the family about this change in status? • An unexpected alertness, referred to as a ‘rally,’ sometimes occurs when a client is near death. This is not an uncommon experience. Nurses prepare families for the possibility of a rally, but a rally does not mean that there is an improvement in the client’s condition. The client’s consciousness lasts about 15 minutes, but they are able to recognize their partner and children who are at the bedside. Until now, the 15-year-old daughter has been distant, but she is able to use this time to tell the client they are loved and will be missed. Section 12 The client again becomes unconscious, their respirations deteriorate, and their pupils become fixed and dilated. The client's partner begins to panic and tells the nurse to revive the client if they stop breathing. 26. Which response by the nurse is therapeutic, given the partner’s anxiety? • Tell me about the conversations you had with your partner about this moment. This response will remind the partner of the client’s wishes. Section 13 27. Which intervention by the nurse will facilitate the anticipatory grieving process? • Encourage their partner to verbally give the client permission to die. May help alleviate guilt for both the client and family. The family members cry and the client’s partner reports they are ready to let the client die. Section 14 Shortly thereafter, the client stops breathing and shows no signs of life. The hospice nurse is legally qualified to pronounce the client’s death in the state where they live. 28. Which nursing intervention is therapeutic for the family immediately after the client dies? • Allow the family to spend as much time as they request at the client’s bedside. The family spends some time saying their final goodbyes/ Section 15 When the family has given their permission, the nurse calls the staff at the selected mortuary to inform them of the client's death. Although the client has died, the nurse continues to provide nursing care to the family members. The nurse makes follow-up phone calls and a home visit. The purpose of the visit is to assess each family members' well-being, offer emotional support, and provide referrals as needed. The nurse recommends that they attend a bereavement support group to talk about their feelings of grief and loss.