(Test Bank) Nursing Care At The End Of Life Palliative Care For Patients And Families

Zerwekh, 1

Nursing

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1st Edition

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Test Bank for Nursing Care At The End Of Life Palliative Care For Patients And Families, The downloadable file consists of 472 pages, and the total size of the file is 1.81 MB. Purchase now only for highly discounted price.

Author(s): Zerwekh

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Nursing Care at the End of Life Palliative Care for Patients and FamiliesFABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page i pinnacle Quark4:Desktop Folder:FABK002:FM:FABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page ii pinnacle Quark4:Desktop Folder:FABK002:FM:Nursing Care at the End of Life Palliative Care for Patients and Families Joyce V. Zerwekh, RN, EdD Professor and Director, Nursing Program Concordia University Portland, Oregon F. A. Davis Company • Philadelphia FABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page iii pinnacle Quark4:Desktop Folder:FABK002:FM:F. A. Davis Company 1915 Arch StreetPhiladelphia, PA 19103www.fadavis.com Copyright © 2006 by F. A. Davis CompanyAll rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechani-cal, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of AmericaLast digit indicates print number: 1 0987654321 Acquisitions Editor: Joanne DaCunha Developmental Editor: Kristin L. KernArt and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recom- mended treatments and drug therapies undergo changes. The author(s) and publisher havedone everything possible to make this book accurate, up to date, and in accord with acceptedstandards at the time of publication. The author(s), editors, and publisher are not responsiblefor errors or omissions or for consequences from application of the book, and make no war-ranty, expressed or implied, in regard to the contents of the book. Any practice described inthis book should be applied by the reader in accordance with professional standards of careused in regard to the unique circumstances that may apply in each situation. The reader isadvised always to check product information (package inserts) for changes and new informa-tion regarding dose and contraindications before administering any drug. Caution is especiallyurged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication DataZerwekh, Joyce V . (Joyce Valborg) Nursing care at the end of life : palliative care for patients and families / Joyce V . Zerwekh. p. ; cm. Includes bibliographical references and index.ISBN-13: 978-0-8036-1128-3 (pbk.)ISBN-10: 0-8036-1128-5 (pbk.)1. Palliative treatment. 2. Nursing. 3. Terminal care—Psychological aspects.4. Terminally ill—Family relationships. I. Title. [DNLM: 1. Hospice Care. 2. Nursing Care. 3. Palliative Care. 4. Terminally Ill. WY 152 Z58n 2006] RT87. T45Z47 2006 616'.029—dc22 2005027123 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the CopyrightClearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copyis paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations thathave been granted a photocopy license by CCC, a separate system of payment has been arranged.The fee code for users of the Transactional Reporting Service is: 978-0-8036-1128/06 0 + $.10.FABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page iv pinnacle Quark4:Desktop Folder:FABK002:FM:Dionnetta Hudzinski, RN, MN Nursing Consultant: Pain and Palliative CareInstructor, Intercollegiate College of Nursing Yakima CampusWashington State University Yakima, Washington Inge Klimkiewich, RN, MSN, CHPN Fort Pierce Clinical DirectorHospice of the Treasure CoastFort Pierce, Florida Elaine McIntosh, MBA President and Chief Executive OfficerKansas City HospiceKansas City, Missouri Leslie H. Nicoll, RN, MBA, PhD Editor, Journal of Hospice and Palliative Nursing Hospice and Palliative Nurses AssociationPittsburgh, Pennsylvania Theris Touhy, RN, ND Assistant Dean for Undergraduate ProgramCollege of NursingFlorida Atlantic UniversityBoca Raton, FloridaCONTRIBUTORS vFABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page v pinnacle Quark4:Desktop Folder:FABK002:FM:FABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page vi pinnacle Quark4:Desktop Folder:FABK002:FM:Nancy Ann Cook, RN, MN Professor of NursingOklahoma City Community CollegeOklahoma City, Oklahoma Joan E. Dacher, PhD, RN, GNP Graduate Program DirectorThe Sage Graduate SchoolDepartment of Nursing and GerontologyTroy, New York Linda M. Gorman, APRN, BC, MN, CHPN, OCN Palliative Care Clinical Nurse SpecialistCedars Sinai Medical CenterLos Angeles, California Linda J. Keilman, MSN, APRN, BC Assistant ProfessorGerontological Nurse PractitionerMichigan State UniversityCollege of Nursing East Lansing, Michigan Carole A. Kenner, DNS, RNC, FAAN Dean and ProfessorUniversity of OklahomaCollege of NursingOklahoma City, Oklahoma Jane Marie Kirschling, RN, DNS Dean and ProfessorUniversity of Southern MaineCollege of Nursing and Health ProfessionsPortland, Maine Carol Meadows, MNSC, FNP , APN InstructorUniversity of ArkansasEleanor Mann School of NursingFayetteville, ArkansasREVIEWERS viiFABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page vii pinnacle Quark4:Desktop Folder:FABK002:FM:Jeanne Martinez, RN, MPH, CHPN Associate DirectorNorthwestern UniversityChicago, Illinois Brother Ignatius Perkins, OP , RN, DNSC Executive Vice PresidentThe National Catholic Bioethics CenterWashington, DC Rosalee J. Seymour, RN, MSN, EdD Associate ProfessorEast Tennessee State UniversityJohnson City, Tennessee Beryl Stetson, RN, MSN InstructorRaritan Valley Community CollegeSomerville, New Jersey Iris Barrow Warren, RN, MSN Associate ProfessorUniversity of Alabama in HuntsvilleHuntsville, Alabamaviii ReviewersFABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page viii pinnacle Quark4:Desktop Folder:FABK002:FM:This book has taken shape over my 26 years in hospice nursing practice, leadership, education, and writing. I began teaching nursing in 1969. In 1997I began practicing in home health and was privileged in 1979 to join threenurse colleagues, a social worker, and a chaplain, comprising the first paidteam at Hospice of Seattle. We were one of the first hospice programs in thecountry and provided home care before the government or insurance com-panies became involved; that was when the only guidelines for practice werewritten in England. After that intense experience in developing bedside prac-tice knowledge, writing about what we had learned, and speaking about it, Imoved to inpatient hospice care to join a collaborative effort to plan andeventually open Seattle’s first inpatient hospice, Hospice Northwest. These early hospice experiences led me to co-author the 1984 Hospice and Palliative Nursing Care with Ann Blues (now Ann Widmer). In 1986, I joined the faculty at the University of Washington to teach in the last months of theTransition Services program, the end-of-life nursing graduate program that had been initiated by pioneering end-of-life nurse scholars Jeanne Benolieland Ruth McCorkle. I have followed many paths since then, including com-pleting my doctorate, teaching at several universities, and publishing a 1995qualitative study of hospice nursing practice that proposed the hospice prac-tice model, “The Hospice Family Caregiving Model,” described in Chapter 1.This text integrates my many years of teaching nursing with my hospiceexpertise and deep appreciation for the clinical wisdom of nurses practicingat the bedside. I believe that nurses can make a profound difference in thequality of life at its end. Nursing Care at the End of Life: Palliative Care for Patients and Families systematically explores the knowledge base founda- tional for effective clinical practice. With that in mind, I have chosen to organize the text into six distinct but integrated units: •UNIT ONE, End-of-Life Care, examines the ground where the End- of-Life Caregiving Tree is planted. In other words, it looks at thecontext of caregiving in the United States, the environment in whichend-of-life care can either grow or falter. •UNIT TWO, Sustaining Yourself as a Nurse, explains that the tree must be deeply rooted in a foundation of self-care, in order to sustaincaregiving. •UNIT THREE, Reaching Out and Connecting, comprises the trunk of the tree, which connects the roots (self-care) to the branches thatextend out to care for others. Unit Three explores core understandingPREFACE ixFABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page ix pinnacle Quark4:Desktop Folder:FABK002:FM:of the human experience of patients and develops the skills necessary to build relationships and provide emotional comfort. •UNIT FOUR, Ethical and Spiritual Practices, examines these dimensions as a main branch of the Caregiving Tree, arising out ofthe connecting trunk. •UNIT FIVE, Strengthening the Family, is likewise conceptualized as a main branch of the Caregiving Tree, arising out of the connecting trunk. •UNIT SIX, Comforting, is symbolized by the leaves on the tree, which represent the extraordinary variety of interventions thatprovide physical comforting. Each chapter begins with a Philosophical Reflection and Learning Objectives to focus learning. The chapters end with Concepts in Action,which is a clinical narrative and questions requiring thoughtful applicationof concepts discussed throughout the chapter. Throughout the text, thereader will find illustrative quotations from expert nurses who were inter- viewed by the author. Some can be found in my previous publications (Zerwekh, 1993, 1994, & 1995), but many are quotations from the originalinterviews that have never before been published. Planting the Seeds boxesoffer practice-centered advice, and takeaway tips for nurses to use and inte-grate into their own work. Internet Reference Boxes call the reader’s atten-tion to strong information sources available on the Web. UNITONE: End-of-Life Care: Chapters 1 and 2 This unit examines the ground where the Caregiving Tree is planted. Chapter 1 describes the context in which nurses practice at the end of life by identifyingcommon characteristics of dying in America. Then it explores ten competen-cies of hospice nursing originally identified by the author. Chapter 2, Hospice and Palliative Care, describes the end-of-life care- giving movements that continue to influence the quality of end-of-life caresignificantly. Modern-day hospices are programs to care for the dying thatcombine compassionate care with the finest pain and symptom manage-ment. The ideals of the hospice movement emphasize care of body, mind,and spirit, with judicious use of medical technology. Hospice emphasizesspeaking the truth about dying and encourages patients to choose how theywill spend their last days. Hospice care focuses on the needs of the entirefamily and fosters living fully until death. Palliative care also focuses oncomforting at the end of life. Palliation involves reducing discomfort withoutcuring. The contemporary palliative-care movement expands beyond theway hospice has been organized in the United States to incorporate palliativemeasures while still offering aggressive life-sustaining measures. UNIT TWO: Sustaining Yourself as a Nurse: Chapters 3 and 4 Self-care and working with others comprise the roots of the End-of-Life Care- giving Model. The roots of the tree receive nourishment from the soil so thatx PrefaceFABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page x pinnacle Quark4:Desktop Folder:FABK002:FM:Preface xi they can provide sustenance to the rest of the tree. Similarly, nurses receive nourishment from self-care and collaboration with other health-care practi-tioners so that they can nurture and care for patients and their families. Chapter 3, Strategies to Stay Healthy, asserts that the effectiveness of work with the dying is determined by the nurse’s self-awareness and effortto maintain personal well-being. The ability to care for dying individuals issustained by tending to oneself. We bear up against difficulties because ofour strong roots. We must deliberately nourish our body and spirit throughhealthy nutrition and exercise, as well as other strategies, such as developinga supportive community and finding meaning in transcendent spiritual real-ity. Only through deliberate self-care are we able to be strong enough,grounded enough, to confront the fear and suffering of patients and families. Chapter 4, Collaborating with an Interdisciplinary Team, describes working relationships with many other caregivers. Nurses do not workalone. Consider the trees of the forest. On the surface, they appear to standalone. Under the ground, their roots are intertwined. So it is that our roots areintertwined with those of other team members. The tree is rooted in andupheld by these collaborative relationships. The composition of each team isdifferent. Hospice teams commonly include nurses, social workers, physi-cians, spiritual counselors, pharmacists, nursing assistants, therapists, andvolunteers. Interdisciplinary teams work together to develop shared goalsthat consider the family and the patient as a whole entity. This requiresmutual respect and careful listening to perspectives different from one’sown. UNIT THREE: Reaching Out and Connecting: Chapters 5, 6, 7 , and 8 Firmly rooted in the ground, the crown is the neck of the root where it emerges above the ground and becomes the trunk of the tree. Nursing at theend of life involves reaching out to face fear and be in the presence of dying.The trunk of the tree connects the roots to the branches and is the ascendingstructure from which branches and leaves eventually develop. In the End-of-Life Caregiving Model, the trunk represents Reaching Out and Connecting.Connecting is defined as the process of joining in a relationship with thepatient and loved ones. This unit explores the human experience of the dyingperson and the process of developing an authentic relationship with peoplewho are dying. It also includes an examination of grief and cross-cultural differences because these components affect the human experience and theability to make connections. Chapter 5, Understanding the Dying Experience, considers how dying changes living. Connecting with the dying requires a fundamental under-standing of the human experience at the end of life. This chapter explores thedifferent types of death awareness. The experience of dying involves pro-found suffering that is unrelated to physical discomfort as the person facesdisintegration of identity and threat to the continued existence of the self.FABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page xi pinnacle Quark4:Desktop Folder:FABK002:FM:xii Preface Nevertheless, many assert that dying can be considered to be a final stage of human development in which both families and patients can find meaning-ful growth and reconciliation. Chapter 6, Connecting and Caring Presence, establishes a commitment to caring and compassion and provides concrete recommendations for estab-lishing relationships with people nearing the end of their lives. Connectinginvolves active deep listening (often to difficult experiences of the dying),speaking the truth, and encouraging patient and family choice. Connectingrequires the deliberate practice of caring presence, in which we deliberately focus attention on the other person, letting go of distractions, and being con-scious of the other person as a human being. Chapter 7, Grief and Mourning, explains current understanding of unhealthy and healthy grief. Elisabeth Kubler-Ross described five psycho-logical reactions common to the grief process: denial, anger, depression, bar-gaining, and acceptance. Initially, these were understood as stages throughwhich a person should proceed in a stepwise process in one direction towardhealing. Now these reactions are understood as predictable dimensions ofgrief through which people move back and forth in a far more unpredictableway. Likewise, our understanding of how to help the grieving person haschanged. Freud and other therapists once asserted that a grieving personmust directly confront feelings through “grief work” in order to heal. Con-temporary research demonstrates, however, that sharing feelings with othersdoes not necessarily reduce the distress or foster readjustment of those griev-ing loss of a love. This means that nurses should offer active listening to thebereaved and those anticipating bereavement without forcing expression inany way. Grieving individuals should choose the extent to which they wantto disclose feelings. Chapter 8, Cross-Cultural Competency at the End of Life, asserts that we must go beyond the Golden Rule, which mandates that we should care forothers as we ourselves would want. Instead, we should care for others asthey would want. This requires opening our mind to ways of thinking andbehaving that may be difficult to comprehend from our own perspective.Sometimes, cross-cultural competency requires bridging cultural gaps thatchallenge essential beliefs of the hospice and palliative-care movement. Forinstance, we believe that there comes a time when aggressive care is futileand causes purposeless suffering. At that point, it is time to focus entirely oncomfort. However, African Americans and other minorities who have livedwith discrimination in their lives sometimes believe that withdrawal ofaggressive interventions is tantamount to neglect and abandonment. UNIT FOUR: Ethical and Spiritual Practices: Chapters 9 and 10 Ethical and Spiritual Practices branches out from the connecting trunk in the End-of-Life Caregiving Model. One component of every relationship isattention to ethical and spiritual caring. Impending death causes us to con-front ultimate moral and spiritual issues.FABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page xii pinnacle Quark4:Desktop Folder:FABK002:FM:Preface xiii Chapter 9, Ethical Issues at the End of Life, presents major ethical issues that challenge us as nurses who provide care at the end of life. There may beconflicts around doing good and not doing harm. Individual decision-mak-ing is encouraged by the hospice movement, but when individuals lose theircapacity for decisions, families can fall into extraordinary conflict over whatis good and not harmful for their loved one. Chapter 10, Spiritual Caring, differentiates between spirituality and reli- gious faith and explains how spiritual understanding is essential to a holisticunderstanding of the person at the end of life. Spiritual needs at the end oflife include hope, meaning, reconciliation, and transcendence. Nursing inter-ventions can foster hope, meaning, and reconciliation in the dying patient,regardless of specific religious belief. The practice of being a healing or car- ing presence is a vital spiritual intervention that involves authentic listening,staying at the bedside, watching, and simply being there. UNIT FIVE: Strengthening the Family: Chapters 11 and 12 Strengthening the Family branches outward from the connecting trunk. Car- ing relationships are integral to strengthening the family. Patients cannot beconsidered in isolation. They are members of families and have circles offriends. Their dying profoundly affects family functioning, and often thefamily provides extensive caregiving at the end of life. Families need specialhelp when children are involved, either as survivors or as patients. Chapter 11, Understanding and Strengthening Families, describes work- ing with American families when a family member is dying to provide emo-tional support and to strengthen their caregiving ability. The family goesthrough a major transition that involves redefining the entire family life andstruggling with the paradox that the patient is both living and dying. Theburden of caregiving is highly stressful as caregivers learn to manage the ill-ness and respond to the suffering of their loved one. Nurses guide familiesby assisting with the transition and redefinition of family life, and develop-ing the families’ capacity to provide physical and emotional care. Chapter 12, Children Facing Death, describes normal behavior of griev- ing children at each developmental stage and presents caring strategies foreach age group. The chapter also describes essential features of palliativephysical and emotional care when the child is the one who is dying. Childrenoften suffer needlessly because of the contemporary compulsion to save lifeat all costs. Both clinicians and parents have difficulty accepting it when lifeprolongation no longer makes sense. Likewise, both clinicians and parentsmay fail to acknowledge the child’s suffering; children’s pain is notoriouslyundertreated. UNIT SIX: Comforting: Chapters 13, 14, 15, 16, and 17 Five chapters comprise this unit on comforting. Providing physical comfort is illustrated as foliage on the End-of-Life Caregiving Tree. The extensiveFABK002-FM[i-xviii].qxd 11/22/05 2:06 PM Page xiii pinnacle Quark4:Desktop Folder:FABK002:FM:xiv Preface number of leaves illustrates the multiplicity of ways to relieve a person’s discomfort. Chapter 13, Understanding and Anticipating the Course of Terminal Disease, examines the process of end-of-life prognostication and explains thepathophysiology and predictable set of symptoms for the top causes ofdeath. Predicting the course of end-stage disease enables the nurse to antici-pate patient needs, provide anticipatory guidance for patient and family, andprevent crisis instead of waiting for crisis to occur. One important nursingrole is to encourage patients to ask questions and speak truthfully about con- cerns. Permission to speak openly about difficult subjects, like pain and fear,is a hallmark of effective nursing at the end of life. Chapter 14, Comforting and the Essentials of Pain Relief at the End of Life, presents foundational concepts for pain control. The subjectivity of thepain experience leads many clinicians to doubt patients when they reportpain. This leads to a significant problem with undertreatment. Nurses mustnot accept pain as a normal experience that patients must endure as a conse-quence of their illness or surgery. Unfortunately, we risk being in the pres-ence of pain without seeing, hearing, or comforting. Unrelieved pain isknown to shorten life, cause hopelessness, and consume the energy of thedying so that they are unable to have any quality of life in their final days. Chapter 15, Medicating for Pain at the End of Life, provides a founda- tion for understanding analgesic drugs. Selected essential concepts includearound-the-clock scheduling of drugs to maintain a stable blood level; use oflong-acting preparations to sustain the blood level; oral administration as thefirst choice of route; careful adjustment and readjustment of drug, dose, andinterval; and use of opioids, nonopioids, and adjuvant medication. Fear ofopioids remains a major barrier to comforting the dying. When carefullytitrated to terminal pain, opioids cause neither addiction nor death from res-piratory depression. Chapter 16, Management of Physical Nonpain Symptoms, provides detailed guidance to understand medical and nursing interventions torelieve common end-of-life symptoms. As with pain, the foundation of symptom assessment is carefully questioning patients about their symp-toms. End-of-life nurses should continually refocus family and professionalcaregivers on maintaining comfort for the dying person. The nurse needs toassume a courageous role as patient advocate when physical suffering isignored. Chapter 17, Caring in Different Settings When Death Is Imminent, pre- sents the signs and symptoms that are indicators of imminent death andexplains their management. At the very end of life, nurses support patientsletting go and provide spiritual caring. This chapter describes the challengesof creating a caring environment for life to end in the intensive care unit,nursing home, and home. Death at home requires a trained family that isclear about whether it will call paramedics when breathing and heartbeatslow and stop. Medications must be on hand to manage the common, pre-dictable symptoms that may arise. 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