Psychosocial Integrity / Topic 9

Make sure to:

  • Assess each clients' ability to cope.
  • Identify the individual needs of each client.
  • Provide psychosocial support to families and caregivers.

In healthcare facilities, there are clients who are nearing the end of their lives and choose not to pursue curative treatments or interventions. It is crucial for nurses to offer support to these clients, as well as to their family members and their caregivers, throughout what can be a brief or extended journey.

In this learning experience, learners will acquire knowledge about end-of-life care, concentrating on evaluating their clients' ability to cope, understanding the unique needs of each client, and providing psychological support to their families and caregivers.

9.1 Assess Each Clients' Ability to Cope

Nurses who provide care to clients at the end of their lives are responsible for identifying and managing their physical, psychological, social, and spiritual needs, as well as their cultural and religious needs (Burke, 2023). Subsequently, nurses develop care plans and intervene, continually assessing both the client's and their family's ability to cope (Burke, 2023). This ability to cope is influenced by personal, cultural, and religious values (Kaplan Nursing, 2023).

Nurses aim to assess various needs as outlined by Kaplan Nursing (2023) and discuss coping strategies and skills with their clients, families, and caregivers, all while adhering to the policies of their healthcare facility.

  • Physical Needs – Assessment includes:
    • Reduced appetite, which often leads to weight loss commonly seen in clients at the end of life.
    • Fluid and electrolyte imbalances, which can occur in clients who are anorexic, refuse food or drink, or have advance directives prohibiting tube feedings, parenteral nutrition, and intravenous fluids. Competent clients may also choose to refuse fluid and electrolyte replacement.
    • Dehydration can arise in clients who are not receiving fluids replacement, especially if they are experiencing symptoms like vomiting and diarrhea.
      • Assessment findings for clients with mild, or moderate dehydration include:
        • Headache and dizziness.
        • Orthostatic hypotension.
        • Dry skin and mucous membranes.
        • Thirst, constipation, and decreased urine output.
      • Assessment findings for clients with severe dehydration include:
        • Oliguria, anuria, or renal failure.
        • Confusion, delirium, and unconsciousness.
        • Tachypnea, tachycardia, fever, and hypotension.
        • Fluid and electrolyte imbalance, poor skin turgor, and sunken eyes.
    • Clinical manifestations of any underlying disorder or disease, such as pain.
  • Psychological Needs – It is important to identify and support the client and their family through various emotional stages:
    • The sequential stages include distress, anger, denial, rationalization, guilt, grief, depression, fear, and loss of hope and meaning.
    • In cases of confusion, which can be acute or chronic, addressing underlying causes can lead to symptoms resolution, such as administering glucose for hypoglycemia. If no underlying causes are present, nurses should provide emotional support and protect clients from injury. Clients with acute confusion may:
      • Experience hallucinations.
      • Become restless and agitated.
      • Exhibit altered level of cognition and consciousness.
    • Clients with chronic confusion may exhibit:
      • Signs and symptoms similar to acute confusion.
      • Personality changes.
      • Impaired memory and mental capacity.
    • Fatigue is common at the end of life, often exacerbated by factors like insomnia, depression, and stress, which can leave clients unable to perform daily activities. To assess the degree of fatigue, which can range between 0 to 10, nurses can use one of the following scales:
      • Lee Fatigue Scale.
      • HIV-Related Fatigue Scale.
      • Multidimensional Fatigue Inventory
      • Multidimensional Assessment of Fatigue.
      • Profile of Mood State Short Form Fatigue Subscale
      • Brief Fatigue Inventory.
      • Dutch Fatigue Scale.
    • Agitation and restlessness can result from electrolyte and fluid imbalances, renal disorders, and impaired liver function. In cases where there are no underlying medical conditions, clients may be administered antianxiety medications and sedatives as prescribed. Manifestations of both agitation and restlessness can include:
      • Use of unexpected obscene language
      • Changes in behavior.
      • Frequent complaints.
      • Psychosis.
    • Self-imposed social withdrawal can be a choice made by clients, and it is important for both the client's family and healthcare team to respect this decision.
    • Clients may also express fears related to financial concerns, loss of control and independence, and uncertainties about the future.

Additionally. When clients are unable to fulfill their roles within their families, nurses play a vital role in assisting them to cope with this eminent loss and transition (Burke, 2023).

9.2 Identify Individual Client Needs

Nurses must recognize the unique needs of their clients who are nearing the end of their lives. These needs often pertain to comfort and dignity, as well as specific end-to-life considerations (Burke, 2023). Clients may need nurses to:

  • Ensure privacy and comfort.
  • Keep them dry and clean.
  • Maintain good oral hygiene.
  • Turn and position them in accordance with healthcare facility policy.
  • Implement both alternative and traditional care methods, such as massage and the use of analgesics.
  • Manage all end-of-life related symptoms collaboratively, respecting the clients' decisions about their preferred care.
  • Educate their spouses and other family members about:
    • Advanced directives.
    • Healthcare proxy.
    • Benefits, adverse effects, and alternatives of treatment and interventions.
    • The signs and symptoms characteristic of each stage of the peri-death process.

The peri-death process, as described by Burke (2023), encompasses three distinct phases:

  • Phase one involves preparation for death by both clients and their family members. This phase is marked by various social, psychological, and physical changes in clients, including:
    • Respiratory congestion.
    • Cool, pale skin.
    • Reduced appetite.
    • Excessive sleep.
    • Disorientation and restlessness.
    • Incontinence of both urine and stool.
    • Cheyne-Stokes respirations and other changes in respiratory patterns.
    • Social withdraws, letting go, and saying goodbye to loved ones.
  • Phase two is the actual occurrence of the client's death.
  • Phase three refers to the immediate aftermath following the client's death.

Creating an emotionally supportive environment is crucial for nurses, where clients and their families can openly express their fears, concerns, and worries. Additionally, it is important to facilitate opportunities for clients and their families to spend as much time together as they wish and as is feasible, always in line with the policies of the healthcare facility.  

9.3 Psychosocial Support to Family and Caregiver

It is essential for nurses to offer and provide psychological support to the families and caregivers of their clients (Burke, 2023).

Clients and/or their families may decide to receive hospice or palliative care over treatments aimed at prolonging life (Burke, 2023). In these settings, nurses work as a part of an interdisciplinary team to deliver round-the-clock healthcare, focusing on symptom management and analgesic care, while also supporting the family.

Caregivers often feel overwhelmed or fearful due to the peri-death process they witness caring for their loved ones (Burke, 2023). They may also face psychological and physical stressors during the caregiving process. Nurses can support these caregivers by guiding them to community resources, such as respite care and support groups, to alleviate their burden (Burke, 2023).

Upon completing this learning experience, learners will have acquired comprehensive knowledge in end-of-life care. The main objectives are to prepare them for successful performance on the NCLEX examination and to enhance their clinical practice skills.

After going through the provided resources, learners should identify specific areas where they need further improvement. Focusing on these areas will significantly increase their competence in delivering end-of-life care to clients.

  • Burke, A. (2023, October 1). End of Life Care: NCLEX-RN. https://www.registerednursing.org/nclex/end-life-care/
  • Kaplan Nursing. (2023). Next Generation NCLEX-RN Prep 2023-2024: Practice Test + Proven Strategies (9th ed.).  Kaplan Test Prep.

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