A nurse is planning to perform post mortem care for a client. which of the following actions

B260 Final ATITerms in this set (39)A charge nurse is teaching a new nurse how toinitiate IV access on a client. Which of thefollowing actions by the new nurse indicates anunderstanding of the teaching?A. shaves the selected insertion site w/ a razorprior to the procedureB. washes hands w/ soap and water before theprocedureC. applies sterile gloves prior to inserting the IVcatheterD. applies the tourniquet 1 inch above theselected insertion siteB.rationale: the nurse should perform hand hygiene prior to starting theprocedureA nurse is caring for a client who is post-op. Thenurse should base her pain managementinterventions primarily on which of the followingmethods of determining the intensity of theclient's pain?A. vital sign managementB. the client's self-report of pain severityC. visual observation for nonverbal signs of painD. the nature and invasiveness of the surgicalprocedureB.rationale: b/c nurses cannot measure pain objectively, it is standard practice toaccept that pain is what the client says it is and to intervene accordinglyA nurse provides a back massage as a palliativecare measure to a client who is unconscious,grimacing, and restless. Which of the followingfindings should the nurse identify as indicating atherapeutic response? (Select all that apply.)A. the shoulders droopB. the facial muscles relaxC. the RR increasesD. the pulse is within the expected rangeE. the client draws his legs into a fetal positionA, B, Drationale: a back rub promotes relaxation, relieves muscular tension, anddecreases perception of pain. relaxation or drooping of the shoulders is apositive response to the back rubB260 Final ATIStreamline studying with Quizlet PlusStudy smarter, save time and create bettersets.Got it

A nurse is observing an assistive personnelperforming postmortem care for a client who isMuslim. Which of the following actions shouldprompt the nurse to intervene?A. leaves dentures in the mouthB. prepares to cleanse the bodyC. disconnects the cardiac monitorD. removes soiled linens from the roomB.rationale: following the death of a client who followed the Muslim faith, a Muslimof the same gender must ritualistically wash and wrap the bodyA nurse is providing pre-op teaching for a clientwho will undergo surgery. The nurse explains thatthe client will wear anti-embolism stockingsduring and after the procedure. When the clientasks what the stockings do, which of the followingresponses should the nurse make?A. "they protect your legs and heels from skinbreakdown."B. "they help keep you warm after your surgery."C. "they improve your circulation to keep bloodfrom pooling your legs."D. "they make it easier for you to do leg exercisesafter your surgery."C.rationale: anti-embolism stockings promote venous return from the legs, thushelping to prevent venous thrombosis, also known as clot formation, andperipheral edemaA nurse is providing palliative care to a clientwhose partner asks why music therapy might help

The loss of an infant through miscarriage, stillbirth, or neonatal death is perceived as a traumatic life experience. It is recognized as a tough life event, which can oftentimes cause complicated grief (CG) reactions that risk negatively influencing psychological and physical well-being. Generally, when a pregnancy ends in the death of a fetus or neonate, the loss is both unexpected and devastating for the mothers or the couple. They usually struggle with post-traumatic stress disorder (PTSD), anxiety, and depression, especially when not approached or managed properly.

The most likely causes of fetal death include chromosomal abnormalities, congenital malformations, infections such as hepatitis B, immunologic causes, and complications of maternal disease. If the death occurs before the time of quickening, the client will not be aware the fetus has died because she is not able to feel fetal movements. If a fetus dies in utero past the point of quickening, the client will be very aware that fetal movements are suddenly absent. On assessment, no fetal heartbeat can be heard. An ultrasound will confirm the absence of a fetal heartbeat.

Perinatal loss is a crisis within a crisis. Women and their partners undergoing pregnancy loss frequently talk of not getting on with their life goals, plans, and dreams. They appear stuck, off track, as if they are running in place as life passes them by. This care plan is directed at the emotional needs of the postpartum client who must cope with the death of a child.

Grieving

Grief is a deeply personal process that nevertheless follows a fairly predictable course. Although the parents have not built up a relationship with their infant, grief after pregnancy loss does not differ significantly in intensity from other loss scenarios. As has been found in bereavement involving first-degree relatives, grief symptoms usually decrease in intensity over the first 12 months. Perinatal losses have also been shown to have a substantial psychological impact on parents and families. Overall, high levels of complicated grieving are generally associated with a poorer state of mental health (Kersting & Wagner, 2022).

Nursing Diagnosis

• Grieving

• Death of fetus/infant

Possibly evidenced by

• Crying
• Verbal expression of distress, anger, loss, guilt
• Alteration in eating habits or sleep pattern

Desired Outcomes

• The client participates in self-care activities of daily living (ADLs) as able.
• The client recognizes the impact/effect of the grieving process (e.g., physical problems with eating and sleeping) and inquires for proper help.
• The client identifies and expresses feelings (e.g., sadness, guilt, fear) freely.
• The client looks toward/plans for the future, one day at a time.

Nursing Assessment and Rationales

1. Assess the magnitude of the loss for both members of the couple. Regard how strongly the couple desired this pregnancy.
The magnitude or weight of the loss is a factor (e.g., whether the pregnancy was planned, whether the couple has lost other pregnancies, length of time associated with trying to conceive) in the extent and duration of the grief response. In addition, the parents may feel the loss throughout their lives, mourning for the child they will never know or watch grow up. Ambivalent attitudes toward the pregnancy were also found to be associated with more intense grief reactions, and the loss of unplanned pregnancy was often reacted to in the same way (Kersting & Wagner, 2022). 

2. Assess the client’s/couple’s information and understanding of events surrounding the death of the fetus/infant. Provide more accurate information and correct misconceptions based on the couple’s readiness and ability to listen effectively.
Emotional reactions may prevent the couple’s ability to process information and interpret the significance of events. If the child has a congenital anomaly that led to the death, prepare them for this before bringing the child to them and explaining how the anomaly affected the child (Kersting & Wagner, 2022). Concrete thinking patterns (literal interpretation) may be the only available means of coping with information at this time.

3. Observe the client’s activity level, sleep pattern, appetite, and personal hygiene.
These areas may be neglected because of the process of grieving and associated depression. Sleep patterns may be disrupted, leading to fatigue and further failure to cope with distress. The client may require support in meeting physical needs and may need assurance that it is acceptable to resume usual activities. Be certain before the client is discharged from the healthcare facility that she has a support person she can rely on during the following week or month when the full impact of the fetal loss registers with her.

4. Consider religious beliefs, cultural processes, and ethnic background.
Perinatal loss is the only type of loss in Western society for which there are no culturally sanctioned rituals or traditions to help the bereaved to say goodbye. It is important to understand the cultural context in which these parents are forced to grieve in isolation and the psychological consequences of grieving a loss not recognized by society (Markin & Zilcha-Mano, 2018).

5. Assess the severity of depression.
The client/couple may detach themselves and have a problem making decisions. These early and late perinatal losses may have profound, negative effects on bereaved parents and have been associated with the development of severe anxiety, major depression, posttraumatic stress disorder (PTSD), increased suicidal ideation, and up to four times the rate of divorce. In subsequently healthy pregnancies after perinatal loss, increased health care use, anxiety, and depression were common, and increased postpartum depression was found after the birth of subsequent healthy infants (Hutti et al., 2018).

6. Observe the client’s/couple’s verbal cues often. 
Recognize signs of developing or increasing somatic complaints, preoccupation with the death, loss of normal behavior patterns, overactivity with no apparent sense of loss, excessive hostility, or agitated depression. This may mean a sudden alteration in the client’s or couple’s way of coping with the situation. Guilt, failure, and depression may be more pronounced in couples with a history of child loss(es). Other signs may suggest dysfunctional grieving.

Nursing Interventions and Rationales

1. Allot a private room if the client wants it, with regular contact by care providers. Encourage feelings by unlimited visiting of family and friends.
A place where family and friends can open up and share their feelings without restriction promotes comfort. Based on stress theory, social support is thought to have a buffering effect, and poor social support from family and friends is associated with complicated grieving reactions (Kersting & Wagner, 2022).

2. Support free flow of emotional expression. Only restrict behavior that is dangerous to the well-being of the client/couple (e.g., pulling out IV, using fists to pound on the abdomen).
Expression of grief is influenced by cultural/religious beliefs and expectations, running the gamut from stoic silence to screaming and pounding one’s chest/throwing objects, etc. While expression of loss is cathartic, extended stoicism may impede the mourning process. Giving the client opportunities to express how she feels about this loss. “This must be a very difficult day for you” is the kind of statement that opens up the topic for discussion.

3. Include the partner in the planning of care. Grant opportunity for the partner to be seen individually. Reinforce discussion of concerns.
Partnership in planning and decision-making acknowledges that the partner has also lost a child and may need time to express feelings of loss and receive support without having to be supportive of the client and others. The loss of an infant during pregnancy can deeply distress a client and can put a strain on her relationship with the father, but it may also have a distinct psychological impact on the grieving father. Symptoms of grieving in men were found to be similar to those of women, except that men report less crying and feel the need to talk less about their loss (Kersting & Wagner, 2022).

4. Consider the individual nature of movement through the stages of grief; inform the client/couple that delays in the grief process or relapses of grief are normal.
The process of grieving is not usually a fluid progression through the stages to resolution; it is rather a fluctuation between stages and possibly involves skipping of stages. Knowing that grieving is individual helps the couple let each other grieve at his or her own pace. There are no set time limitations for resolving grief, and it is not unusual for the family to be actively dealing with the loss one to two years later.

5. Recognize the stage of grief being displayed, e.g., denial, anger, bargaining, depression, and acceptance. Use therapeutic communication skills (e.g., Active-listening, acknowledgment), respecting the client’s desire/request not to talk.
If the process of grieving is not completed, grief may become dysfunctional, resulting in behaviors that are disturbing to personal safety and the future of the family and marriage/relationship. The nurse can counsel the couple on the importance of sharing feelings, experiences, and needs in a non-threatening manner and encourage the partner to do the little things that show his partner that he cares for her and will not abandon her (Hutti, 2005).

6. Regarding communication patterns among the couple and support systems.
In various instances, parents display anger and blame toward one another. Anger may arise from fear of losing another child or a threat to self-esteem. Projections of guilt and blame, as well as angry feelings towards a partner and the loss of the vision of a future as a family, may put considerable stress on the relationship (Kersting & Wagner, 2022).

7. Reinforce the family’s expression of feelings and listen (remaining calm or commenting as appropriate). Observe body language. Promote a relaxed atmosphere.
Grieving families need repeated opportunities to verbalize their experiences. Verbal and nonverbal cues provide hints about the family’s degree of sadness, guilt, and fear. Active listening conveys caring, demonstrating an awareness of the unique significance of the loss to the client. Significant others should be encouraged to express how they feel about the baby’s death and the meaning this will have to the family and avoid minimizing the loss (Hutti, 2005).

8. Recognize what has happened as often as necessary, reinforcing the reality of the situation and encouraging discussion by the client.
Many families have no earlier struggle in coping with the death of a young person and have few role models to whom they can relate. The nurse can act as an educator and facilitator concerning ways to act and talk about the experience and explain and correct misconceptions. The couple may experience less stress in their relationship if each can accept how the other feels about the loss and the normality of those reactions (Hutti, 2005).

9. Take pictures of the child wrapped in newborn attire. Allow the couple to accompany or hold the child, if appropriate. Offer the couple footprints, hospital bracelets, or a lock of hair, if desired.
Pictures and touching or holding an infant can be effective and may begin acceptance of the reality of the loss. Ask if the parents wish to see the child after birth. Point out endearing features of the child as these can provide a focus for memories. However, some couples may not be able to cope with the loss. Remembrances of the infant, if not taken by the parents, should be filed with the chart so that they are prepared if the couple requests them at a later time.

10. Render physical care (e.g., bath, back rub, nourishment) as needed. Allow the client to engage at a level of ability.
Normal grief may include a period during which activities of daily living are impaired. Assisting in the client’s physical care displays caring and nurturing and helps the client conserve the energy required to meet the demands of the grieving process. Involvement in self-care maintains self-esteem and a sense of competence.

11. Talk about anticipated physical and emotional responses to loss. Evaluate coping skills.
This aids the couple in recognizing the normalcy of their initial and subsequent responses. Grieving is individual, and the extent and nature of the response are influenced by personality traits, past coping skills, religious beliefs, and ethnic background. Reactions to the loss of a significant person often include temporary impairment of day-to-day function, retreat from social activities, intrusive thoughts, and feelings of yearning and numbness, which can continue for varying periods (Kersting & Wagner, 2022).

12. Review role changes and plans to deal with loss. Note the presence of siblings.
Most families anticipate a healthy pregnancy and positive outcomes and are not prepared to focus on funeral arrangements, what to do with the nursery, how to carry on their lives, and how to plan for the care of the other children. Logsdon (2003) asserted that for social support to be perceived as helpful, it must match the needs and expectations of the recipient, the cost of returning the favor must not be excessive, and preferred support should come from an individual with whom one has a trusting and intimate relationship (Hutti, 2005).

13. Consider means for the parents to talk with siblings. Allow the parents to give simple, honest explanations, using correct words, at the level of the child’s understanding.
This provides the parents with an approach to handling challenging new experiences. Siblings’ sleeping patterns may be interrupted by their perception that they may also die. Siblings may feel guilt or responsibility for the death, especially if they had negative thoughts about the pregnancy or infant. If there are older children, it might help to explore how the client plans to explain the fetal death to them.

14. Refer to, or contact, clergy, according to the family’s wishes.
The family may want to meet with a minister or spiritual advisor to provide baptism, last rites, cultural rituals, and/or counseling. Note: Baptism is not acceptable in some religions (e.g., Jehovah’s Witness, Seventh Day Adventist). Religious communities are beneficial as another source of social support, as greater religious participation has been related to increased perception of social support contributing to less grief-related distress for parents (Kersting & Wagner, 2022).

15. Assist in obtaining requests and signatures for the performance of an autopsy if appropriate. Review the benefits and limitations of the autopsy.
Families may want or need an explanation of the cause of death, which may not be possible. Explain hospital procedures such as when the body will be released or what additional permission for an autopsy is needed.

16. Give information about the disposition of the infant’s body. Contact a mortician of the family’s choice if assistance is required.
Bodies of children, like those of adults, must be transferred from hospitals to mortuary facilities or other dispositions, usually within 24 hours of death. While burial may be delayed in most instances, Jewish tradition requires burial within 24 hours, which may further complicate the client’s grieving process if she cannot attend the ceremony. Israeli society is becoming more aware of the potential negative consequences of certain traditional attitudes around perinatal loss, and starting in 2014, parents of stillborn babies or fetuses that died toward the end of pregnancy are permitted to participate in funerals (Markin & Zilcha-Mano, 2018).

17. Refer to, or contact, social services, if necessary.
The family may need support in planning the cost of a funeral and other necessities. Effective social and professional support matches the needs and expectations of the recipient comes from a preferred individual, and does not have an excessive payback cost of returning the favor. Professional support interventions should be as close as possible to the parent’s standard of the desirable after the caring process of “knowing” has commenced (Hutti, 2005).

18. Plan follow-up meetings or phone calls, as appropriate. Refer to community resources/support groups (e.g., visiting nurse services, Compassionate Friends, etc.).
This provides the client or the couple with the opportunity to discuss and ask questions. This assists the client or couple at crucial moments in the grief process, providing role models and the opportunity to discuss the loss with others who share the same experience. Support is often viewed as most credible when it comes from someone who has previously experienced and successfully managed a similar crisis. Some parents will appreciate and use a referral to a support group for bereaved parents; others will not. However, this information should always be made available to them in case they change their minds (Hutti, 2005).

19. Refer for counseling or psychiatric therapy, if necessary.
Severe grief response may be noted in older women and those with longer-term pregnancies. In addition, carrying the fetus for one or more days after death increases the risk. In cases of pathological grief, ongoing counseling may be necessary to help the individual(s) identify possible causes of the abnormal reaction and resolve the grieving process. Note: The risk of a major depressive episode is highest during the first month following the loss, whereas women without other children or who have had a prior depressive episode remain at increased risk for six months.

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