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Maslow's Hierarchy of Needs

  • Concept: A theory by Abraham Maslow explaining that physiological needs must be met before psychosocial needs; framework used by nurses to prioritize resident-centered care and plan outcomes.
  • Levels (from lowest to highest):
    • Physiological Needs
    • Nutrition (water and food), elimination (toileting), breathing/circulation (vital signs), sleep, sex, shelter, and exercise
    • Safety and Security
    • Injury prevention (call lights, hand hygiene, fall precautions, assistive devices, close observation)
    • Build trust (communication, reassurance, empathy)
    • Ensure a clean, safe environment (free from harm, recognition, and alleviation of fears) and provide resident and family education
    • Love and Belonging
    • Supportive relationships free from social isolation
    • Therapeutic communication skills
    • Meaningful relationships
    • Self-Esteem
    • Acceptance into a community or facility
    • Personal achievement
    • Sense of control or empowerment
    • Accepting one's physical appearance and mental capabilities
    • Self-Actualization
    • Empowering environment
    • Spiritual growth
    • Ability to recognize others' points of view
    • Reaching one's maximum potential
  • Role of the Nurse Aide (NA)
    • The NA is a vital link in assisting the resident to achieve individual levels of need
  • Context
    • Used within the NCDHHS/DHSR/HCPECINATI Curriculum (July 2024) for guiding resident care planning and prioritization

End-of-Life Care (Module W)

Definition List (Key Terms)

  • Acceptance: the final stage of grief when the person acknowledges death is imminent after working through feelings
  • Advance Directive: a living will written while competent or by a legal representative outlining choices about withdrawing/withholding life-sustaining procedures if terminally ill
  • Anger: second stage of grief; expressions of rage and resentment; may be triggered by small things; may lash out at others
  • Apnea: respiration stops
  • Bargaining: third stage of grief; seeking more time to live or finish business; may bargain with doctors or God
  • Cheyne-Stokes Breathing: alternating shallow breaths with periods of no breathing (5, 30, or 60 seconds); not typically causing discomfort
  • Death: end-of-life and cessation of bodily functions
  • Denial: first stage of grief; may refuse to accept diagnosis or discuss prognosis
  • Do Not Resuscitate (DNR): medical order not to perform CPR if the resident has no pulse or is not breathing; honors resident’s wishes to avoid extraordinary measures
  • Depression: fourth stage; mourning, crying, withdrawal
  • Dying: near end of life and nearing cessation of bodily functions
  • End-of-Life Care: support and care provided around the time of death
  • Extraordinary Measures: interventions to restore heartbeat or respiration (e.g., CPR)
  • Hospice Care: care program for people who are dying (usually with less than six months to live) focusing on comfort, dignity, respect, and support for resident and family
  • Mottling: changes in skin color near death (pale and bluish)
  • Obituary: description of a resident's life published posthumously
  • Postmortem Care: care of the body after death
  • Terminal Illness: an incurable illness that leads to death
  • Omnibus Budget Reconciliation Act (OBRA) & Patient Self-Determination Act (PSDA): legal framework giving rights to accept/refuse treatment and make advance directives, including living wills and durable powers of attorney
  • Living Will: outlines medical care desired if decision-making capacity is lost
  • Durable Health Care Power of Attorney: appoints someone to make healthcare decisions when the individual cannot

Module Structure (S-series Overview)

  • S-1 Title Slide
  • S-2 Objectives
    • Define death and end-of-life care
    • Describe stages of grief
    • Explore cultural differences in dealing with death and dying
    • Examine own feelings about end of life
    • Describe the nurse aide's role in end-of-life care
  • S-3 Advance Care Planning
    • Planning for future decisions about medical care
    • Typically used when one becomes incapacitated or cannot speak for themselves
    • Based on personal values, preferences, and discussions with loved ones
  • S-4 Advance Directives
    • OBRA/PSDA rights; living wills and durable powers of attorney
    • Can be changed or cancelled at any time
    • Must be written while mentally competent or by a legal representative
    • Durable Health Care Power of Attorney details
    • Nurse aides must honor advance directives
  • S-5 Advance Directive – Do Not Resuscitate (DNR)
    • Medical order instructing not to perform CPR if no pulse or breathing
    • Indicates no extraordinary measures during cardiac/respiratory arrest
    • Nurse aide must honor DNR
  • S-12 End-of-Life Care – The Healthcare Team
    • Staff and family may be unprepared for death; may feel shocked
    • Recognize variety of feelings and respond empathetically
    • Demonstrate caring, interested attitude
    • Observe for changes in other residents; report and record information
  • S-13 Signs of Impending Death
    • Psychological and physical withdrawal
    • Decreased alertness, more sleep
    • Temperature changes (rise), cooling, pale appearance, perspiration
    • Circulatory decline; pulse irregularity; BP drop
    • Extremities cold and mottled; respiratory decline; Cheyne-Stokes breathing
    • Death rattle (airways with saliva/mucus); focus on preventing choking
    • Apnea; digestive slowdown; abdominal distention; fecal incontinence; nausea/vomiting
    • Urinary changes; decreased kidney perfusion; incontinence
    • Diminished muscle tone; limbs become limp; head/neck relaxation; sensory decline including hearing
    • Pain may decrease with loss of consciousness
  • S-14 Signs of Death
    • Notify nurse immediately
    • No pulse, no respirations, no blood pressure
    • Pupils fixed and dilated; no response to voice or touch; eyes may remain open
    • Mouth may remain open; possible incontinence
  • S-15 Exploring Responses to Death
    • Reactions vary by personal, cultural, religious beliefs
    • Nurse aide feelings impact care; caregiver closeness in long-term care
    • Understanding dying helps ensure care with dignity and respect
  • S-16 Stages of Grief (Kubler-Ross model)
    • Denial, Anger, Bargaining, Depression, Acceptance
    • Stages are experienced differently by individuals; rates vary; may not pass through all stages; can be non-linear
    • Anger is not personal—use active listening and support
  • S-17 Denial (1st Stage)
    • “No, not me” response; may refuse prognosis or discuss prognosis; may believe a mistake occurred
  • S-18 Anger (2nd Stage)
    • “Why me” stage; expressions of rage; may target nurse aides; do not take personally
  • S-19 Bargaining (3rd Stage)
    • “Yes me, but”; seeks more time or to complete unfinished business; usually private/spiritual
  • S-20 Depression (4th Stage)
    • Mourning, withdrawal; may become weaker or unable to perform tasks; emotional support needed
  • S-21 Acceptance (5th Stage)
    • Not a guarantee that death is imminent; may plan affairs; may or may not reach before death
  • S-22 Meaning (6th Stage, added by David Kessler in 2019)
    • Personal and evolving; takes time; does not require immediate understanding; involves saying goodbye to the life lived and embracing the future
  • S-23 Dealing with Grief – An Obituary
    • Obituaries can be part of the grieving process; honors the deceased; sharing with others aids processing
  • S-24 Postmortem Care
    • Follow facility policy; privacy; prepare postmortem kit; hand hygiene; gloves
    • Close eyes; bed bath; dress in clean gown; pad beneath perineal area; dentures as instructed; remove jewelry per policy
    • Rigour mortis develops 2–4 hours after death; position body to normal alignment before rigor
    • Movement of body and release of air/contents may cause sounds; these are normal
    • Position: supine, legs straight, arms folded across abdomen, pillow under head
  • S-25 Role of the Nurse Aide — Care of the Family
    • Provide private space for family; identify who should be contacted
    • Offer water or a beverage; respect privacy; close door as needed
    • Nurse aides should respond with sincerity and compassion; offer an empathetic statement such as “I’m sorry”

End-of-Life Care: Focus on the Resident and Team

  • The goal is to provide care that is as normal as possible and preserves dignity
  • Environment considerations: well-lit, well-ventilated room; position for comfort; consider favorite music; keep the patient in a comfortable position; use back rubs; facilitate mouth care and food/fluid intake as tolerated
  • Cultural sensitivity is essential
    • Do not impose beliefs; ask about practices
    • Questions the team may ask: who provides personal care; cultural post-mortem customs; any special practices the family expects
    • Cultural examples (from the module):
    • Chinese culture: herbal remedies; autopsy/disposal may be restricted
    • Japanese culture: the number four is associated with death, which can affect scheduling of medications
    • Vietnamese culture: belief in reincarnation; prioritizes quality of life
    • Hindu culture: acceptance of God’s will; prayer for anxiety management; transfusions/organ transplants/autopsies allowed; cremation often preferred; belief in reincarnation
  • The healthcare team’s emotional readiness
    • Staff and families may be unprepared for death; some may be