NUR2392, MDCII – Examination Blue Print – Exam 1

End-of-Life

 Pathophysiology of Death- Death is defined as the cessation of integrated tissue and organ function, manifesting

with lack of heartbeat, absence of spontaneous respirations, or irreversible brain dysfunction.

S/S of Approaching death- As death nears,

patients often have signs and symptoms of

decline in

 physical function- manifesting as weakness

 increased sleep.

 anorexia

 changes in cardiovascular function

 breathing patterns

 genitourinary function.

 Level of consciousness often declines to lethargy,

unresponsiveness, or coma.

 Cardiovascular dysfunction leads to decreases in peripheral circulation and poor tissue perfusion manifesting as

cold, mottled, and cyanotic extremities.

 Blood pressure decreases and often is only palpable.

 The dying person’s heart rate may increase, become irregular, and gradually decrease before stopping.

 Changes in breathing pattern are common, with breaths becoming very shallow and rapid. Periods of apnea

and Cheyne-Stokes respirations (apnea alternating with periods of rapid breathing) are also common. Death

occurs when respirations and heartbeat stop.

o Management of symptoms

Patient and Family Education: Preparing for Self-Management

Common Physical Signs and Symptoms of Approaching Death With Recommended Comfort Measures

Coolness of Extremities

Circulation to the extremities is decreased; the skin may become mottled or discolored.

1. • Cover the patient with a blanket.

2. • Do not use an electric blanket, hot water bottle, or electric heating pad to warm the patient.

Increased Sleeping

Metabolism is decreased.

1. • Spend time sitting quietly with the patient.

2. • Do not force the patient to stay awake.

3. • Talk to the patient as you normally would, even if he or she does not respond.

Fluid and Food Decrease

Metabolic needs have decreased.

1. • Do not force the patient to eat or drink.

2. • Offer small sips of liquids or ice chips at frequent intervals if the patient is alert and able to swallow.

3. • Use moist swabs to keep the mouth and lips moist and comfortable.

4. • Coat the lips with lip balm.

Incontinence

The perineal muscles relax.

1. • Keep the perineal area clean and dry. Use disposable under pads and disposable undergarments.

2. • Offer a Foley catheter for comfort.

Congestion and Gurgling

The person is unable to cough up secretions effectively.

1. • Position the patient on his or her side. Use toothette to gently clean mouth of secretions.

2. • Administer medications to decrease the production of secretions.

Breathing Pattern Change

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Slowed circulation to the brain may cause the breathing pattern to become irregular, with brief periods of no

breathing or shallow breathing.

1. • Elevate the patient’s head.

2. • Position the patient on his or her side.

Disorientation

Decreased metabolism and slowed circulation to the brain.

1. • Identify yourself whenever you communicate with the person.

2. • Reorient the patient as needed.

3. • Speak softly, clearly, and truthfully.

Restlessness

Decreased metabolism and slowed circulation to the brain.

1. • Play soothing music and use aromatherapy.

2. • Do not restrain the patient.

3. • Talk quietly.

4. • Keep the room dimly lit.

5. • Keep the noise level to a minimum.

6. • Consider sedation if other methods do not work.

o Postmortem Care

• Provide all care with respect to communicate that the person was important and valued.

• Ask the family or significant others if they wish to help wash the patient or comb his or her hair; respect and follow

their cultural practices for body preparation.

• If no autopsy is planned, remove or cut all tubes and lines according to agency policy.

• Close the patient’s eyes unless the cultural or religious practice is for a family member or other person to close the

eyes.

• Insert dentures if the patient wore them.

• Straighten the patient and lower the bed to a flat position.

• Place a pillow under the patient’s head.

• Wash the patient as needed and comb and arrange the patient’s hair unless the family desires to perform bathing

and body preparation.

• Place waterproof pads under the patient’s hips and around the perineum to absorb any excrement.

• Clean the patient’s room or unit.

• Allow the family or significant others to see the patient in private and to perform any religious or cultural customs

they wish (e.g., prayer).

• Assess that all who need to see the patient have done so before transferring to the funeral home or morgue.

• Notify the hospital chaplain or appropriate religious leader if requested by the family or significant others.

• Ensure that the nurse or physician has completed and signed the death certificate.

• Prepare the patient for transfer to either a morgue or a funeral home; wrap the patient in a shroud (unless the

family has a special shroud to use), and attach identification tags per agency policy.

 Hospice vs Palliative Care

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 Impact of Pain & Pain Management

Impact of Unrelieved Pain

Physiologic Impact Quality-of-Life Impact

• Prolongs stress response

• Increases heart rate, blood pressure, and

oxygen demand

• Decreases GI motility

• Causes immobility

• Decreases immune response

• Delays healing

• Poorly managed acute pain increases risk

for development of chronic pain

• Interferes with ADLs

• Causes anxiety, depression, hopelessness,

fear, anger, and sleeplessness

• Impairs family, work, and social

relationships

Financial Impact

Costs Americans billions of dollars per year

Increases length of hospital stay

Leads to lost income and productivity

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Management of Pain

1. • Use a multimodal approach that combines analgesics with different underlying mechanisms with the desired

outcome of achieving optimal pain relief with lower doses than would be possible with a single analgesic; lower

doses result in fewer side effects.

2. • Consider the type of pain and begin therapy with the first-line analgesics that are recommended for that type of

pain.

3. • Do not give meperidine to older adults because most have decreased renal function and are unable to efficiently

eliminate its central nervous system (CNS)-toxic metabolite normeperidine.

4. • Use around-the-clock (ATC) dosing of analgesics for pain that is of a continuous nature (e.g., persistent [chronic]

osteoarthritis or cancer pain; persistent [chronic] neuropathic pain, first 24 to 48 hours after surgery).

5. • Use as-needed (PRN) dosing for intermittent pain and before painful activities, such as before ambulation and

physical therapy.

6. • Be aware of the main side effects of the analgesics that are administered and that they may be more likely to

occur or be more severe in older than in younger adults.

7. • Start low and go slow with drug dosing; increase doses to achieve adequate analgesia based on the patient’s

response to the previous dose.

8. • Teach the patient and family or other caregiver about the pain management plan (analgesics and

nonpharmacologic strategies) and when to notify the primary health care provider for unrelieved pain or

unmanageable or intolerable drug side effects.

9. • To promote adherence to the pain management plan in the home setting, suggest using a pillbox to organize

each day’s medications and keeping a diary to identify times of the day or activities that increase pain. The diary

can be presented to the primary health care provider, who can use it to make necessary adjustments in the

treatment plan.

 Psychosocial Needs

Psychosocial Integrity

• Assess the patient’s emotional signs of impending death; assess coping ability of the patient and family or

other caregiver.

• Incorporate the patient’s personal cultural practices and spiritual beliefs regarding death and dying

• Be aware that people facing death may experience fear and anxiety about their impending death and have

difficulty coping.

• Provide psychosocial interventions to support the patient and family during the dying process.

Oncology

 Characteristics of cells

o Benign

o Benign Cells: specific morphology- resemble the tissues they originated from

o Benign Cells: A smaller nuclear-to-cytoplasmic ratio-similar to normal cells

o Benign Cells: Specific differentiated function -contributes to the body function

o Benign Cells: Tight adherence- bind closely together due to the production of fibronectin

o Benign Cells: No migration- Do not invade other tissues

o Benign Cells: Orderly growth- rate of growth is normal by expansion

o Benign Cells: Euploidy- Normal chromosomes per cell 23

A benign tumor is normal cells growing in the wrong place at the wrong time. But they are not cancerous.

Benign Cell Features

o Harmless

o Do not usually require intervention

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