The medical-surgical nurse is planning care for a client
Item 1 of 1
- Admission Note
1416: 65-year-old female was admitted for stage IV ovarian cancer. The client decided to forego further treatment and decided on comfort measures only. She is currently receiving outpatient hospice services. The client is drowsy and reports nausea and generalized pain. Hypoactive bowel sounds in all quadrants with abdominal distention. The client makes little eye contact and reports increasing discomfort when the head of the bed is elevated. Skin is cool and mottled. The client is experiencing urinary incontinence.
For each client need, click to specify the potential nursing intervention that would be appropriate for the client's care. Each category must have at least one option selected.
For each client need, click to specify the potential nursing intervention that would be appropriate for the client's care. Each category must have at least one option selected.
| Client Need | Potential Nursing Intervention |
|---|---|
Nutritional | Keep the client nothing by mouth (NPO) Offer high calorie small frequent meals Use moist swabs to the mouth and lips |
Thermoregulation | Layer the client with warm blankets Apply heating pads to the extremities Turn on a fan to cool the client |
Comfort | Restrain the client during periods of agitation Play soothing music and aromatherapy Position the client on their side for gurgling |
Elimination | Place plastic underpads for incontinence Offer an indwelling catheter for comfort Give an enema for nausea caused by constipation |
Statistics
Subject/Lesson
Subject
Mental Health
Lesson
Mental Health
Client Need
Test Plan
Psychosocial Integrity
Related Topic
End of Life Care
Item Type
Item Type
GenerateSolutions
Explanation
- For the client receiving hospice services and comfort measures only, the nurse must collaborate with the interprofessional team to maintain the client's comfort. This client experiences discomfort when the head of the bed is elevated and drowsy; thus, the nurse should keep the client nothing by mouth (NPO) to prevent aspiration.
- The nurse should use moist swabs to the mouth and lips to prevent chapping and maximize comfort.
- Layering the client with warm blankets is appropriate, considering the client's appearance is cold and mottled.
- The nurse should not apply heating pads to the extremities as this could cause injury considering the client's drowsiness.
- Another unhelpful intervention would be turning on a fan to cool the client, considering the client's mottling skin and cool temperature.
- Comfort measures can be achieved by playing soothing music and offering aromatherapy.
- This would be helpful for the client's nausea. Placing the client on their side for any gurgling would help prevent aspiration.
- The nurse should not restrain the client for periods of restlessness or agitation. Pharmacotherapy could be utilized, such as benzodiazepines, for this symptom.
- Offering a urinary catheter is an appropriate comfort measure. This would minimize discomfort as urinary incontinence would cause skin breakdown. Infection is not a concern regarding using an indwelling catheter. In this client, achieving comfort is essential. According to the Centers for Disease Control and Prevention, this is an approved measure.
- Plastic underpads would be unhelpful as this traps moisture and contributes to skin breakdown and discomfort.
- The client's complaints of nausea may be caused by constipation; if this is the case, an appropriate nursing intervention would be administering an enema to alleviate constipation.
Related Videos
2 Key Topics
End-of-life care
13.2 End-of-Life & Grief Care
Additional Info
✓ Symptom management is the priority for the client close to death
✓ The nurse should employ measures that provide both physical (turning, oral care, pain control) and emotional (therapeutic touch, consistent caregivers) interventions
