PN Case Study Loss Grief and Death

Because Evelyn has been losing weight and she has a decreased metabolic rate due to the dying process, the healthcare provider chooses to prescribe 0.2 mg/kg oxycodone HCL (OxyFAST). Evelyn weighs 110 pounds. The medication is available as 20 mg/mL in a 30-mL bottle with a measured dropper.

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Growth and Development Jerry states that he and Evelyn have been married for 52 years. He sighs and wipes his eyes, softly remarking that he won't know what to do when he is alone. Which response will encourage Jerry to talk more about his feelings?

Ask Jerry to share memories of the couple's times together. Life review and reminiscing are positive techniques in facilitating Jerry's expression of his feelings as his wife is dying.

Legal Considerations Mrs. Kuntz's breath sounds are diminished, and crackles are auscultated in the right lung. She is also disoriented during the admission process to the hospital. What is the nurse's responsibility regarding advance directives?

Ask Mr. Kuntz if his wife has completed a living will and a durable power of attorney. The Patient Self-Determination Act (1991) requires healthcare institutions to provide written information concerning the client's rights to refuse treatment and formulate advance directives. Therefore, the PN should ask Mr. Kuntz if his wife has completed a living will and/or a durable power of attorney.

Stage 1 While Jerry was feeding Evelyn broth from chicken noodle soup, she started spitting out the broth and turning blue around her mouth. Jerry stopped feeding her and patted her back forcefully. Evelyn was able to catch her breath and the blueness resolved. Two days later, Evelyn's temperature is 103° F when the home health nurse visits. The healthcare provider is notified and Evelyn is admitted to the acute care facility. Upon admission, Mrs. Kuntz's level of consciousness (LOC) is altered. Which concern needs immediate attention?

Auscultate Evelyn's lungs for adventitious breath sounds. Evelyn's lungs should be assessed for crackles since she is at risk for aspiration pneumonia secondary to the choking incident.

Nursing Skills Evelyn is transferred to the hospice unit. She remains weak and disoriented, and subtle vital sign changes indicate that the dying process has begun. Under the guidelines of Evelyn's living will, no lifesaving measures are ordered. Care measures are instituted to keep Evelyn comfortable. She develops cheilosis and stomatitis. What nursing intervention should be instituted to care for Evelyn's mouth?

Clean her mouth frequently with oral swabs.

Cathy's 15-year-old daughter enters the room, kisses Evelyn and remarks, "I think my grandmother can get better if we just give her more time. Just because she was moved to this hospice doesn't mean she will die." The PN recognizes that the adolescent has already begun to grieve the loss of the grandmother she loves. Which stage of grief is exemplified by the adolescent's statements?

Denial The adolescent is experiencing a common initial reaction to a real or impending loss. Feelings of numbness, shock, and disbelief occur. This stage is healthy and permits the individual to develop other coping mechanisms.

Jerry tells the PN that their faith in God has seen them through life's problems and that he relies on that faith every day. What is the best response to support Jerry and Evelyn spiritually?

Do you have any wishes I should convey to the staff? The PN is correct in intervening by asking what Jerry and Evelyn prefer in terms of faith and spiritual care.

Evelyn lies quietly with her eyes closed. She no longer responds verbally, but she smiles when her family speaks to her. To assist Jerry and Evelyn in life review, what is the best intervention?

Encourage Jerry to talk to Evelyn about their life experiences. Reminiscing is a means for setting one's life in order, which is the task of Erikson's final stage of "Integrity vs. Despair." Evelyn's sense of hearing may remain intact, and Jerry's discussing significant life experiences can help both to feel a sense of meaning in their life. This also is in keeping with a Jewish focus of the value of life on earth, i.e., good deeds and the legacies.

Cathy and her husband ask the PN what they should tell their 3-year-old daughter when Evelyn dies. Which phrase should the PN recommend?

Grandma died and that makes us feel very sad. This statement is truthful and acknowledges the parents' feelings of sorrow and grief. The parents may also want to tell the child that the person who died is not coming back and then answer any questions. This process may need to be repeated many times.

Evelyn has become very difficult to arouse. What is the safest manner to give oral care to Evelyn?

Have two PNs or unlicensed assistive personnel (UAP) perform the procedure. The PN is correct to first ensure that two staff members are available to provide safe oral care.

Based on the findings, what action should the PN take?

Inform Cathy that Evelyn's condition is worsening. The PN should keep family members informed of Evelyn's worsening condition to provide them the opportunity to communicate with Evelyn and to notify their rabbi if desired.

Grief Process The Kuntzs' daughter, Cathy, arrives to visit her mother. Her husband and children accompany her. Cathy last saw her mother 3 months ago, and she is alarmed that her mother has lost weight, is weaker, and is not eating. Cathy acknowledges to the PN that her mother talked to her about the living will but says angrily, "Don't you think you should do something? This is a hospital, isn't it?" What is the best response by the PN?

It must be difficult to see the changes in your mother. Empathetic statements are therapeutic and can help Cathy in moving through the grief process.

End-of-Life Care Jerry decides to go home for the evening to sleep in his own bed and Evelyn's daughter, Cathy, spends the night at the bedside. Early the next morning, Evelyn's vital signs are as follows: pulse 50 and thready, respirations 10 and shallow, BP 70/30, Glasgow Coma Scale 3. What other physical symptom should the PN anticipate?

Mottling of hands and feet. Cyanosis and mottling occur first in the hands and feet and then progress centrally.

Evelyn's inability to swallow salivary secretions causes frequent episodes of coughing and choking. The PN identifies the nursing diagnosis of ineffective breathing pattern for Evelyn. What intervention will help Evelyn breathe more comfortably?

Oral suctioning of secretions from mouth and throat. Oral suctioning of accumulated secretions is gently done with a tonsil tip or Yankauer suction device to provide more effective breathing and add to Evelyn's comfort.

Mr. Kuntz has a copy of Evelyn's living will and durable power of attorney for health care. He states, "I do not want her to suffer." How should the PN respond to Jerry's remarks?

Place a copy of the living will in the medical record and document its presence. The PN is responsible for placing a copy of the living will in the medical record and documenting its presence.

hildren and Death Cathy expresses concern about her daughter's statement. The PN invites Cathy to step out of Evelyn's room to get a cup of coffee, and Cathy's husband joins them. The PN explains the stages of grief and ways that Cathy and her husband can support their daughter as she moves among the stages. Cathy states that since receiving the news of Evelyn's hospitalization, she and her husband have been reading age-appropriate books and talking about death with their younger children (ages 8 and 3). Cathy's husband expresses concern because their 8-year-old son repeatedly asks questions about what happens to a body after death, and the child wants to know specific information about what the funeral home will do to the body. How should the PN respond?

Recommend that their son's questions be answered honestly in simple terms. Children at this age are often interested in the physical and biological aspects of death. They usually recognize that death is permanent and are very concrete in their thinking. Questions should be answered honestly and simply, giving the child enough information to answer the question but not overwhelming the child with information. Parents can expect that repeated explanations will be necessary.

Postmortem Care The family members are at the bedside very early the next day when Evelyn stops breathing. The healthcare provider arrives and pronounces the death. As the rabbi is being consulted regarding the preparation of the body, a group of women from the synagogue arrive to assist with postmortem care. How should the PN respond?

Remain available to assist the women of the synagogue as needed. It is not uncommon for a group of persons from the synagogue to come and prepare the body. Men will come for men who have died, and women come for women. While there are specific ways that the body must be cleansed, positioned, and wrapped, the PN can assist by removing all external catheters and medical equipment attached to the body and ensuring that all incisions and wounds are dressed.

Nutritional Issues The healthcare provider reviews Evelyn's chest x-ray results and confirms her diagnosis of aspiration pneumonia. Intravenous antibiotics are prescribed for 10 days. The clinical dietitian assesses Evelyn's nutritional status. Evelyn continues to have significant difficulty swallowing, so the dietitian posts a "Swallow Precautions" sign on the wall by Evelyn's bed. Jerry notices the sign and asks the PN what it means. The PN explains that liquids may go into the trachea and the lungs instead of the stomach since Evelyn does not have adequate swallowing ability. Suddenly Jerry gets a shocked look on his face and says, "Oh, no! I did that. I gave her pneumonia!" How should the PN reply?

Saliva entering the lungs can also cause pneumonia. The PN is correct in giving Jerry reassuring information that aspiration pneumonia can also be caused by Evelyn's inability to swallow saliva. The pneumonia is being treated, and it will do no good at this point to speculate about the cause of the pneumonia.

Spiritual Care Evelyn rests more comfortably after the medication is initiated, and she speaks with her family when she is awake. Evelyn awakens while the rabbi is visiting, and she asks him to read from the Book of Psalms and to pray. The PN enters the room to obtain vital signs while the rabbi is praying. Jerry asks the PN to remain with them while the rabbi prays and then obtain the vital signs. What action should the PN take?

Stand quietly until the prayer is over. This action expresses respect for the family's spiritual needs and offers support to the family and clergy. Respecting spiritual needs is one of the many priorities of hospice care. The PN does not need to be of the same religion or denomination as the client to remain in the room during readings and prayer.

Cathy tells the PN that she feels helpless and does not know what to do to make her mother more comfortable. She asks the PN if it would be all right to have a massage therapist come in and gently massage her mother's limbs and back. Question 10 of 23 How should the PN respond to Cathy's request?

Tell Cathy that massage therapists are welcome in the hospice. Nontraditional therapies are encouraged in the hospice environment if they give comfort to the client and are not harmful. Additionally, supporting Cathy will give her a sense of control.

Managing Discomfort Evelyn begins to sleep more, and she has less alert time. Over the last few days, she has become more restless, has increased grimacing, and periodically clenches her fists. The PN notes an increase in pulse, respiration, and blood pressure during these episodes. The healthcare provider is contacted, and oxycodone HCL immediate-release concentrate solution (OxyFAST) is prescribed to be administered via the oral transmucosal route every 4 hours as needed for pain. Jerry asks the PN why oxycodone is given in this manner. The PN answers Jerry's question based on which information?

The medication is rapidly absorbed and acts quickly. Because the oral mucosa has a thin epithelium and abundant blood vessels, drugs administered via this route are rapidly absorbed. Passing directly into the bloodstream, medication acts quickly while avoiding the damaging effects of gastric juices and liver metabolisms. This route is particularly beneficial in the client with cancer who is unable to tolerate oral administration because of nausea/vomiting or the client with dysphagia.

Four days later, Evelyn becomes more disoriented, and she is not able to swallow thickened liquids or pureed foods without choking. Her weakness has progressed, and she cannot bear weight or sit in a chair. The healthcare provider suggests inserting a nasogastric feeding tube to provide nutrition. Evelyn's living will excludes tube feedings and intravenous nutrition. Jerry says that he supports Evelyn's decision and that this information has been shared with their daughter. Which response demonstrates that the PN understands the underlying premise of a living will?

We will honor Evelyn's directives in her living will. The PN demonstrates support and gives reassurance to Jerry that Evelyn's decision will not be ignored by her providers, which is the intent of a living will.

Cathy, who has been observing the PN and the UAP perform oral suctioning for Evelyn says, "I know Mama is dying. I can do the suctioning. Would you watch me once?" How should the PN respond?

Yes. I would be happy to watch you. Cathy wants to participate in the care of her mother. Allowing her to help will lessen her sense of helplessness during the dying process.