5.
John is a new hospice patient with heart failure. John reports a six-pound weight gain since his discharge from the hospital 3 days ago. The nurse notes that John has dependent peripheral edema 2 +, and he reports feeling nauseated and with poor appetite. Based on these findings, what is the pathophysiology of John's heart disease?
a. Systolic dysfunction, with poor cardiac output
b. Diastolic dysfunction, with poor ventricle filling
c. Decreased ejection fraction
d. Generalized organ perfusion failure
John's symptoms are due to right sided (diastolic) heart failure, when the ventricle does not fill adequately, leading to a generalized edema of the extremities and the hepatic system. Symptoms of right sided failure include nausea, anorexia, peripheral edema, ascites, weakness, and weight gain. Poor cardiac output, decreased ejection fraction, organ perfusion failure are indicative of left-sided heart failure.
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20.
Heidi is in her last days of life, being cared for by her husband and adult children. Over the last week she has increased her sleep from 16 to 20 hours per day and is taking only sips of water and juice. Her daughter calls the nurse, concerned that Heidi suddenly became alert and clearly demanded that she needs to get up and get into line with people outside who are waiting for her. These statements by Heidi have upset the family, but Heidi is comforted by them. What is an appropriate intervention for this family?
a. Instruct the family that speaking in metaphors when patients near end of life is common, and that Heidi may be trying to communicate that she is ready to die.
b. Encourage the family to clearly state to Heidi that there are no people outside waiting for her
c. Inform the family that Heidi is delusional due to the pain medication she is receiving and that they should not respond to these statements
d. Instruct the family to increase the pain medication dose that Heidi is receiving, as this is an indicator of pain
Patients may use allegory or metaphors to describe end of life experiences, to include descriptions of visions or discussions with others, and preparatory statements such as getting ready for a trip, packing, meeting old friends and family, or standing in line preparing to go somewhere. Denying Heidi's beliefs would likely upset her without positive effect; although it is possible that Heidi has delirium, her behavior/statement does not warrant increasing her pain medication; likewise, ignoring her statements would likely upset Heidi.
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24.
Lorna has metastatic ovarian cancer, and is in her final days of life. Throughout her hospice benefit period she has rated her pain as 8 or 9 out of 10 consistently, and has required increasing doses of pain medication to be comfortable. In the last 24 hours she has become non-verbal. Her son is concerned that she will not be able to communicate her suffering to him. What would be the most appropriate educational point to make to her son?
a. "At this point she is no longer feeling any pain."
b. "We assume that her pain will escalate, so will just keep increasing her pain medication from this point on."
c. "When patients cannot communicate verbally, we look for behavioral changes that indicate that pain is present."
d. "Once a patient is non-verbal, we initiate terminal sedation as a way to manage pain."
Changes at end of life may distress family members, to include loss of direct communication with the patient. It is important to educate families that the patient's behavior will then be the best indicator of pain and may include behaviors such as restlessness, muscle rigidity, grimacing, guarding, crying, moaning, irritability, diaphoresis, passivity, or aggression. A patient who has experienced pain up to the point of being non-verbal is unlikely to stop having pain, and the nurse should assume that pain management must remain a priority; likewise, there is no reason to assume that pain will escalate, so ongoing assessment is necessary. Initiating terminal sedation simply for becoming non-verbal is inappropriate.
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