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Nursing Care Plan

Nursing Diagnosis
Anticipatory Grieving r/t perceived impending death

Long Term Goal:
Patient will plan for the future one day at a time

Short Term Goals / Outcomes:
Patient will express feelings of guilt, anger and sorrow.
Patient will identify physical problems associated with anticipatory grief.
Patient will seek help in dealing with problems associated with impending death.

Intervention

Rationale

Evaluation

Assess the patient for any evidence of suffering – including pain and point of view of the world around them.

Suffering includes pain and the patient’s point of view of their world around them.  Asking about suffering can help to relieve it merely by acknowledging its existence.

Patient is able to reveal things that are causing suffering, including pain and anything in their world that is contributing to their suffering.

Actively listen to the patient and family’s expressions of grief – do not offer your own opinions or interrupt.

Listening and spending time with the patient and family can be one of the most helpful things that the nurse can do for the patient and their family.

Patient and family will be able to express their feelings of grief .

Listen to the dying patient and family for signs of denial.  If they are present, listen to the patient and family so they will feel they are understood and supported in dealing with the situation.

Denial may be a coping mechanism to help deal with the reality of death.  Denial can help to protect the patient and family from a feeling of hopelessness.  Hope is available, not matter how poor the prognosis and should never be taken away from the patient or the patient’s family.

Patient and family will express any feelings of denial and feel that they are understood and supported in dealing with the situation of the patent’s dying process.

Use therapeutic communication and open-ended questions with the patient and family.

The patient’s and family’s expressions of their thoughts and fears can help to improve the quality of the dying experience for both the patient and their family.

Patient and family members will be able to express their thoughts and fears related to the dying process.

Keep family members informed about the patient’s condition.

Lack of information related to the patient’s condition helps  contribute to the increased anxiety and distress of family members and can results in the family’s lack of trust in the patient’s health care providers.

Family members will be informed of changes in the patient’s condition when they occur.

 

Encourage the patient and family members to cry and express feelings of sadness, anger  and grief.

Grief is best treated as an active process in which the patient and family feel and actively express their grief.

Patient and family will be able to cry and express their feelings of grief and sadness.

Encourage the patient to take care of any unfinished business, including advance directives if appropriate.

It is important for the patient to make decisions related to their physical condition, treatments and financial affairs with their support systems (family and/or friends).  It is important for the patient and family to have these decisions in writing and to know that their physician and health team members are comfortable in discussing these decisions with the patient and family.

Patient and family with have their personal and financial business in order and will have an advanced directive plan of care in place for the patient.

Help the dying client build memories for their loved ones by writing letters, a journal, audio and/or visual tapes, planning their own funeral and writing their own obituary.

Creative and meaningful mementos for family members that help preserve the patient’s memory can result in nurturing the patient/family relationship for years following the patient’s death.

Patient is actively involved in creating memories of them self for family members.

Spend time in the room with the dying patient and family and check in frequently if you are not able to stay with the patient.

Provides a sense of trust and support to the dying patient and family.

Patient and family feel that the nurse is supportive of the patient and family during the patient’s dying experience.

Encourage family members to talk to the patient and touch them during the dying process.

Dying persons can often hear and feel until death.  Both of these measures help provide support to the patient and family and help to improve the bereavement process.

Family actively talks to and touches patient until death occurs.

Help family members to let their loved one go and give them permission to die.

Dying people sometimes wait until they know their loved ones are strong enough to accept their loss before they will allow themselves to die.

Family will give the patient permission to die.

Help the family to experience feelings of loss and encourage them to practice self-care.

Family will suffer feelings of loss for the dying patient.  If the family has had involvement and intimacy with the patient prior to their death, it will result in a positive bereavement outcome.

Family will be able to positively care for themselves following the death of their family member/loved one.

If bereavement services are available in the facility, refer the family to these services.

The use of trained bereavement facilitators can result in improved outcomes and ability to deal effectively with grief for family members/loved ones.

Family/loved ones will receive the use of bereavement services available in the facility.

Encourage the family/loved ones to live one day at a time following the patient’s loss and to realize that grieving is an expected and natural process necessary for healing.

Grief is a natural and expected process in the acceptance of a loved one’s death and is necessary for healing to take place.

Patient’s family and loved ones will be able to verbalize positive ways to deal with grief and support systems that are available to help them within their community.

 


Nursing Diagnosis
Ineffective breathing related to the dying process

Long Term Goal
Patient will remain comfortable and respiratory distress will be managed as effectively as possible throughout the dying process.

Short Term Goals / Outcomes:
Patient will remain free of copious secretions.
Patient will have no psychological distress related to ineffective breathing.
Patient will maintain a patent airway.

Interventions

Rationale

Evaluation

Assess respirations: quality, rate, pattern, depth and respiratory effort, confusion and lethargy.

Hypoventilation and rapid respirations affect gas exchange by increasing carbon dioxide levels.  Assess the patient for signs of respiratory distress, including flared nostrils, increased respirations, use of accessory muscles and hypoventilation.  Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO2 levels.  Signs of respiratory distress require nursing intervention to help prevent acid/base imbalances.

Patient will have even, regular, non-labored respirations.

Auscultate lung sounds, noting decreased or absent sounds, crackles, or wheezes.

Respiratory secretions result in impaired gas exchange and tachypnea.  Secretions should be effectively suctioned to promote optimal gas exchange and resulting decrease in respiratory effort.  Abnormal lung sounds can indicate a respiratory pathology associated with alterated breathing patterns.

Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, or presence of respiratory secretions and/or rhonchi.

Assess the patient for factors that precipitate or exacerbate episodes of ineffective breathing patterns (pain, anxiety, stress).

Awareness of precipitating factors can help the patient avoid them and decrease the risk of ineffective breathing episodes.

Patient will identify source leading to ineffective breathing pattern.

Assess patient for signs of hypoxemia.

Indications of hypoxemia are restlessness, confusion, lethargy, diaphoresis, tachycardia and tachypnea.

Patient will be free of signs of hypoxemia and respiratory distress.

Monitor respiratory patterns.

Increased secretions in airway result in increased respiratory rate.

Patient will have even, non-labored respirations.

Assess patient’s level of consciousness.

Restlessness and confusion are early indicators of hypoxia.  Hypoxia affects blood flow to the brain and results in decreased level of consciousness.

Patient is awake, alert and oriented to person, place and time.

Position the patient to achieve optimal oxygenation and respiration.

Maximal lung expansion occurs when the patient is in an upright position.  Head of bed (HOB) should be elevated to 45 degrees and patient repositioned every 2 hours. A flat position causes abdominal organs to shift toward the chest crowding the lungs and making it more difficult to breathe.

Patient will be repositioned every two hours with HOB 45 degrees.

Clear secretions from pharynx by offering the patient tissues or by using gentle suctioning of the oral pharynx if needed.

Removal of secretions will help increase oxygenation.  Gentle suctioning may help stimulate coughing and removal of secretions.

Oral pharynx will remain clear of respiratory secretions.

Assess skin color for development of cyanosis.  Assess for circumoral cyanosis, mucous membranes and nail beds.

Hypoxia results in decreased oxygenation to tissue resulting in cyanosis of the skin, mucous membranes and nail beds.

Patient is free of cyanosis.

Use deep suctioning to remove respiratory secretions that cannot be removed by suctioning the oral pharynx, hyperoxygenating patient before and between suctioning sessions.

Hyperoxygenation helps prevent oxygen desaturation in a suctioned patient.  Pain relief and sedation if necessary may reduce stress, anxiety and pain in the patient prior to suctioning.

Patient is free of respiratory secretions.

Administer Morphine Sulfate as ordered to help manage dyspnea near death.

Morphine sulfate is the standard treatment for dyspnea near death.  The intervention helps alleviate the stress associated with increasing dyspnea near the end of life.

Patient remains comfortable with increasing dyspnea associated with the dying process.

Provide the patient and family emotional support in dealing with increasing respiratory distress associated with the dying process.

Emotional support helps relieve anxiety and the sense of powerlessness that the patient and family may experience with the patient’s increasing respiratory distress.

Patient and family will receive emotional support from the nurse and health care team.

If the patient’s dyspnea cannot be relieved:

  • Relieve psychological distress.
  • Provide medication for comfort.
  • Provide emotional support to patient and family.

The goal for the patient with dyspnea near the end of life is to treat the primary cause and relieve the psychological distress and autonomic response associated with increasing dyspnea.  Sedatives such as benzodiazepines are commonly used when Morphine does not control the patient’s dyspnea.  Lorazepam (Ativan) is the most commonly used drug administered orally or sublingually around- the- clock to prevent or control dyspnea.

 

Patient remains calm and comfortable throughout the dying process.

Provide pharmalogical treatment as ordered to help manage loud, wet respirations (referred to as “death rattle”) during the dying process.

 

Anticholinergics, such as oral or sublingual hyoscyamine (Levsin) or transdermal scopolamine help reduce the production or secretions.  The “death rattle” is very disturbing to family and caregivers even when it does result in dyspnea or respiratory distress.

 

Patient will remain free of loud, wet respirations (“death rattle”).

 


Nursing Diagnosis
Risk for spiritual distress r/t challenged beliefs and value systems

Long Term Goal
Patient will express meaning and purpose in life and a sense of connectedness with self and others.

Short Term Goals / Outcomes:
Patient will express acceptance of their health status.
Patient will express their personal response to dying.
Patient will express the ability to forgive.

Interventions

Rationale

Evaluation

Assess the patient for loss of meaning, purpose and hope in life.

Spirituality is associated with a sense of meaning and purpose in life and hope.

Patient will express a sense of purpose and meaning in life.

Assess the patient for signs of depression.

Spirituality has a significant negative correlation with depression and meaning and peace.

Patient will express a sense of peace.

Assess the patient for signs of spiritual pain.

Patients who have been alienated from their spiritual community may have difficulty in approaching death.

Patient will express their beliefs and needs.

Respect the patient’s beliefs.

Respecting the patient’s beliefs promotes trust and connectedness.

Patient will express their spiritual beliefs.

Promote the visitation of family and friends.

Spirituality is enhanced through a sense of connectedness with other people.

Patient will have the support of family and friends.

Be physically present and actively listen to the patient.

Attentive listening and physical presence can be spiritually nourishing.

Patient will express concerns to nurse.

Instruct the patient in the use of meditation and guided imagery.

These activities are often used to promote spiritual well-being.

Patient will be able to use meditation and/or guided imagery.

Offer to notify the patient’s pastor/spiritual advisor of patient’s admission.

Hospitalized patients place a high priority on spiritual needs and support.

Patient will request that their pastor/spiritual advisor visit.

Assist the patient in identifying meaningful experiences.

Meaningful experiences promote spiritual well-being.

Patient will identify experiences that meet their spiritual needs.

Hold the patient’s hand or place or place hand gently on their arm if the patient is comfortable with touCh

Touch helps to support a patient’s spirituality.

Patient will express that they feel comforted with touCh

 

Assist the patient in exploring reasons for living and promote hope.

Instilling hope helps to promote spiritual well-being.

Patient will express reasons for living and importance of self.

Actively listen to the patient’s feelings about spirituality and death.

Supporting the patient who is suffering gives meaning their experience.

Patient will express feelings related to spirituality and death to nurse and family members/clergy.

Assist the patient in any religious rites/rituals that they request.

Religious rites/rituals can enhance meaning in life and promote a sense of connectedness with a higher power.

Patient will receive any religious rite/ritual that is important to them.

Allow the patient privacy and a quiet place for prayer.

Prayer improves clinical outcomes and provides a sense of spirituality and well-being.

Patient will be able to pray in a quiet, private manner.

Discuss with the patient the importance of forgiveness.

Forgiveness is an important part of spirituality.

Patient will verbalize forgiveness to family and loved ones.

 

References:
Ackley, B.J. and Ladwig, G.B. (2006)  Nursing Diagnosis Handbook: A Guide to Planning Care.  Mosby: St. Louis






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