_ Respiratory Failure is a broad, non specific clinical diagnosis indicating that the respiratory system is unable to supply the Oz necessary to maintain metabolism or cannot eliminate sufficient CO2. _ The group has chosen the case due to the urge to learn more and be familiar with said disease. After caring for said patient we have chosen to present it because carries with it a colossal amount of new learning and along with it the experiences faced by the two members of the group who handled the client. It is beneficial to study the case because of the complications that arose and thus it provokes critical thinking. This study also help us to develop our skills when it comes to palliative care. _ This study includes the three-days we handled the patient.Definition _ Respiratory failure is asyndrome in which the respiratory system fails in one or both of its gas exchange functions. That is oxygenation and carbon Rclfenaco(cnabbisyioretaie)n In practice, respiratory failure is defined as: -PaQz value of less than 60 mmHg while breathing air -PaCO2 of more than 50 mmHgETIOLOGY _ Acute exacerbation of asthma _ Pulmonary embolism Be cae ronven erty vaccta canted Mp Nat eBay lie-lus luge scarey eels veya Be gicctintonni ty ea eticetapyti(elaelaly _ Cardiogenic pulmonary edema Be oti trstoyertyime vette] Beto lcreCo Win itty QiUls meen itn teers ciocmi tale Calnates ‘chlorine, smoke, carbon monoxide, hydrogen sulfide)_ Upper/lower airway obstruction (e.g., foreign bodies, retropharyngeal abscess, epiglottitis, and swelling as a result of acute allergy or anaphylaxis) Begttatinelaiteyche _ Chronic lung disease (e.g., chronic obstructive pulmonary disease, cystic fibrosis, pulmonary fibrosis, chronic interstitial lung disease) Bronchiectasis Alveolar abnormalities (e.g., emphysema, Goodpasture syndrome, Wegener granulomatosis) Chest wall abnormalities (e.g., kyphoscoliosis) _ Malignancy _ Decompensated congestive cardiac failure Bre) erro ea ime etanRespiratory failure is a'syndrome of inadequate gas exchange due to dysfunction of one or both essential fous keretarle-Kelmaa( va virco mS Lethe -Chest wall (including pleura and diaphragm) RUA h id -Alveolar- capillary units -Pulmonary circulation -Nerve supply to respiratory organs -CNS:or Brain StemClassification of Respiratory Failure _ Type | or Hypoxemic (PaOz <60 mmHg): Failure of gone inns _ Type Il or Hypercapnic (PaCOz >45 mmHG); Failure to exchange or remove carbon dioxide _ Type III Respiratory Failure: Perioperative Respiratory Failure _ ‘Type IV Respiratory Failure: ShockHypoxemic Respiratory Failure _ Itis:characterized bya PaO2 of <60 mmHg Most common form of respiratory failure, and it can be associated with virtually acute diseases of the lung which generally involve fluid filling or collapse of alveolar units. Examples: Pulmonary edema, PNEUMONIA, and pulmonary hemorrhageRespiratory ei Beever athresteH Internal Petiaery olor co) mate yyiciees an} _ The respiratory system is responsible for gaseous| exchange between the circulatory system and the outside world. It is situated in the thorax _ Division of Respirator Tract _ Upper Respiratory Tract _ Lower Respiratory TractStructures of Respiratory System BO Coes eta erel I elt uceevi bye ey conosco inte me ita Lelarets) _ Pharynx - receive the air from the external environment and filter, warm, and humidify it before it reaches the lungs. _ Larynx - regulates the opening into the lower respiratory system and produces speech sounds. _ Trachea and Bronchi - maintain an open airway to arom etaterdi es) PTT TCOl RS Cea} _ Lungs - occurs exchange of gases between alveolar sacs and the blood in pulmonary capillaries. _ Lobes of lungs : _ Left lung - 2 lobes Be seria tere me] preRv ecretnteta of Breathing Environment = a | A feyr Nasopharynx OropharynxAltered lung mechanism Decrease cough effectiveness: it etixes et isera) | ep aitiitae Shaler tine ecane] CTS Mata.Clinical Manifestation _ Tachycardia _ Impaired functioning of the heart and blood vessels _ Inadequate blood circulation to the parts of the body Reyer too meee Mee nnrett sae me Otero _ Drowsiness and malfunctioning of the brain and heart _ Lethargy and shortness of breath _ Impaired mental functioningLaboratory ae N51 G; _ Quantifies level of gas exchange abnormality _ Identifies type and chronicity of respiratory failure COMPLETE BLOOD COUNT _ Anemia may cause cardiogenic pulmonary edema _ Leukocytosis, or leukopenia suggestive of infection _ MICROBIOLOGY _ Respiratory cultures: sputum/tracheal aspirate _ Blood, urine, body fluid (e.g. pleural) culturesPULMONARY FUNCTION TEST/BEDSIDE DIMOY BoM Beg _ Identify obstruction, restriction eC ymcxctirctlacohauc lum marist! allt _ BRONCHOSCOPY _ Obtain biopsies _ Bronchoscopy may not be safe in the critically illCHEST RADIOGRAPHY _ Identify chest wall, pleural and lung parenchymal with opacities present - _ELECTROCARDIOGRAM Be onein alia it ec Cmca nic Ma ccnledaneclaen cain cadten| ~ ECHOCARDIOGRAM _ Identify right and left ventricular dysfunctionJanuary 24, 2013 Test ru NunetaelcS Interpretation Albumin Hemorrhage A/G ratio “ Over production of globulins in condition like multiple myeloma Total protein 6-4 Hemoconcentratio n Globulin NVABG (January 24, 2013) Noes piconet 7357-45 Uremia, DKA, hemorrhage, nephritis. Respiratory alkalosis Anemia, cardiac or pulmonary diseaseJanuary 22, 2013 45 mg/dl Excessive protein catabolism 1.3 mg/dl 142-1.09January 18, 2013 (CBC) a WBC Hemoglobin Hematoctit yee clic 410 120-160 0.37-0.47 Sy ses tecene ] Possible infection Decrease in various anemias, and with excessive fluid intake Severe anemiasCranial CT scan (January 7, 2013) Clinical history : Fall Impressions: chronic ischemic changes in the bilateral periventricular frontal white matter regions likely due to microvascular atherosclerosis as related diffuse cerebral atrophic changes. No evidence of skull fracture, intracerebral or extra axial hemorrhage.‘Treatment _ Mechanical Ventilator _ Emergency treatment follows the principles of cardiopulmonary resuscitation Endotracheal intubation may be required Respiratory stimulants such as doxapram may be used _ Bronchodilators _ Positive airway pressure, diuretics, vasodilators - Oz therapyIndications for Mechanical Ventilation BEG elle mesilate rae Bea Co igor momoeCeb ypu cc MIU LeI Cop ie celymecrale eS _ Acute respiratory acidosis _ Hypoxemia (when PaOz could not be maintained above 60 mmHG) _ Inability to:clear secretions with impaired gas le Teato ro cao h(i] ILE COON KOUCombive nt Omepro Generic name ol omepraz ole fa Ceara Etec) Anti- asthmati cand COPD prep Antacid, anti- reflux agent and anti- ulcerant Pitre em meen text) a) Manage ment of reversible bronchos pasm assoc with obstructi ve airway dse. Gastric ulcers, GERD, symptom atic GERD w/o esophage al lesions ndicatio n Hypertro phic obstructi ve cardiomy opathy, tachyarry thmia, hx. OF hypersen. sitivity to soya eC Woe a tele Petar mint Fine tremorof 2.5ml skeletal muscle, 6 hrs palpitatio ns, headache, dizziness, dryness of mouth Constipa Vial : 4o tion, mg flatulenc e, nausea, 4omgIV vomiting, OD acid regurgita tion, abdomin era ont patient alone >Given with meals >watch for the side effectsGeneric rama My eae Coc er eer name rf on ndicatio | reaction | ng testi ny pyitrsts Fluimucil Acetylcys Cough Acute Phenylke Rarely Tab >Monitor teine andcold and tonurius urticaria, 600mg _ respirato prep chronic bronchos ry rate, respirato pasm, pattern ry tract nausea, 600mgi and infection vomiting tab in3o rhythm, swith ccwater >Assess if abundant BID patient is mucus positive secretion in cough s and cold Aeknil Paraceta Analgesic Pyrexia Anemia, Hematol Amp: >monitor mol of cardiac _ogical, 150mg/m__temperat unknown and skinand | ure of the origin, hepatic other patient feverand disease allergic .ampq4 from pain reaction hours timeto associate prn for time dwith fever >check common for URTI chillingSolucorte f Hydrocor tisone Na succinate fa Petit Etec) Corticost eroid hormone Endocrin Se hematolo gic, rheumati cand collagen disorder Systemic fungal infection, lactation BN pverTsa C1) Fluid and electrolyt € disturban ce, impaired wound healing, thin fragile skin, muscle weakness. ierarer iy 4 Vial: 1oomg x aml 1oomg IV q6 hours i ont iblilities >Monitor BP >monitor electrolyt e levels >check patient's skin if there's woundCholiner Citicoline Anti- Cerebrov v Na convulsa ascular nt d/o including ischemic stroke, parkinso nism and head injury Heraclen Dibencoz Appetite Convales e ide enhancer cence from acute infection, faulty nutrition in older people Ress Tee ty pathetic hyperton. ja Hypersen sitivity to drug, children Check the VS Swatch for adverse reaction >monitor appetite of patientGeneric | Classifie | Indicatii | Contrai | Adverse | Packagi | Nsg. name Ets tral on | ndicatio | reaction | ng ptoy sre ny Lita DalacinC Clindamy Antibioti Infection Hypersen Diarrhea Cap: >check cin e scaused sitivityto occasion 150mg for by clindamy allywith 300mg _ hypersen susceptib cin or acute sitivity to le lincomyci colitis, drug anaerobi on abdomin 300mg1i >ask for corgram alpain, cap TID history of + GI upsets, Gl bacteria: skin disease upper reactions and lower respirato ry tract Asomex Amlodipi Calcium Forpt.at Active Flushing, Tab5mg >monitor ne antagonis increased liverdse, fatigue, VS esp. t CV risk edema, smgitab BP and due to dizziness OD HR the headache, >watch presence abdomin out for of HTN al pain knownTergecef Tazocin Generic Bent Cefixime Piperacill in Na Tazobact am fa Ceara Esc) Antibioti c Penicillin tite tel ora Acute bronchiti s, bronchio ectasis with infection, pneumon ia Tx. OF infection LRT eel tee ts ndicatio n Hypersen sitivity to cephalas phorins, penicillin s Hypersen sitivity to penicillin, cephalos phorin ec ae teler Petar Mint Hypersen Cap: sitivity 100mg reactions, 200mg, Gleffects, CNS ieap effects, 200mg hematolo gic d/o N/V, rash, Vial: 4.5 leukopen gm ia, neutrope 2.25gm nia, thrombo 4.5 gm IV cytopeni 8 hours a pruritus and hypotens ion ere ott >WOF Hypersen sitivity reaction >monitor results of blood test esp. Hgb level >monitor VS esp. temp preview result of (CBC esp. WBC levelesteem tetas) Address: Brgy. Bayanihan, Dolores Quezon PN oe som orb usr) (el Gender: Female BGs acest pies esiis _ Date of Admission: Jan. 7, 2013 2 Date of Discharge: Jan. 28, 2013 eben) ee ee clias Final Diagnosis: Cardiopulmonary Arrest secondary to Nata carta zs Sree tec lames a tino high risk and severe malnutrition Initial Vital Signs: BP: 90/60; CR: 106 bpm; RR: 22 bpm; T: cK . Physical Assessment: Patient is conscious but appears to be weak, immobile and with loss of appetite.eG Coa Gen ct vew il Ses itiay mem aust bic aci-mab mort atone Mer mag bathroom when she slipped and fell. Be era Cette O st tacela a _ Childhood illness: occasional fever and cold Br aetel (an bat crsse porn _ Immunization: incomplete. The relative couldn't ron eines MUN CMM cCeonnrcM ole Ced Coa ep Cnwmd aC er-taConte hadn't had all the vaccines. _ Allergies: no known allergySesriem areas Melecoun _ According to her caregiver when it comes to health the client isn’t very much concerned. She said that due to her old age the client rarely yerbalizes concerns other than physical symptoms such as occasional backache. - Nutrition/Metabolic Pattern The client’s meal on daily basis consist of rice, vegetables and soup because she had difficulty in mastication. A few months prior to confinement the pt. was only able to eat three spoons every meal. _ Elimination Pattern - Had regular bowel movement (at least once a'day) and urinated at least four times per day._ Activity/Exercise Pattern _ The patient doesn’t usually exercise. She sometimes roam around the yard or sit and watch the TV. _ Self-Perception Pattern _ (Could not be assessed because the patient cannot speak due to ET tube during interview) _ Sleep/Rest Pattern _ According to her caregiver the client only gets to sleep at ote eee sents Beer niga canal ceca) _ The client tends to be forgetful due to her age said the relative. She had diminished sense of hearing and Sats Ceh tyRole/Relationship aU ey vacate esate Meck tary oust oe Tre her sister’s family. Her brother-in-law, nephews and ; PVickeeie oman neem esd cL eee oe) mC a _ Coping/Stress MA Wdrsemtre(uavoctcen uote onme Wedel en OCn ont og sister about her problem, said her niece. BA ecrastsitad rs) eve tale) ierrtucReticeReeheneebar telcos k(n melelite cy for Mass. Doesn't consult any faith healers or albularyo.~ Personal/Social History _ Vices: doesn’t drink/ smoke _ Travel: She was from Visayas and came to Quezon to TNMs ue Be Olea Cen Heyer aos Srcrolat | @.vsalitteCol bmn teyet~ Day 1 (Jan. 23, 2013) Received patient on bed-awake, hooked toa mechanical ventilator and pulse oxymeter. _ Vital signs: BP: 120/70; PR: 104; RR: 20; T: 36; O, sat: 100% ~ With IVF: PNSS IL x 24Physical Assessment _ General status: Conscious but weak in appearance _ Skin: with dry, scaly and sagging skin; poor skin turgor; no wound or irritation noted _ Hair: evenly distributed but thinning gray-white hair, lay _ Head: normocephalic, no lesions noted. _ Eyes: opens spontaneously, white and clear sclera, pale conjunctiva, (+) PERRLA, no discharge seenPhysical Assessment _ Ears: no discharges noted, symmetrical, witha few outa _ Nose: with NGT on _ Mouth and Pharynx: with ET tube on; dry lips, with greenish-yellowish dried secretions on tongue _ Neck: with palpable lymph nodes _ Thorax and Lungs: symmetrical lung expansion, with crackles on both lung fields upon auscultation, RR: 20; no tenderness noted upon palpation. With blood fateexcte Vai Ceyns omen cutestPhysical Assessment _ Cardiovascular: BP: 120/70, PR: 104 bpm; no murmurs Litereaxal _ Abdomen: flat, with bourborygmi sound heard, no tenderness noted, with patent NGT upon auscultation - Genitals/Rectum and Anus: patent, urinary meatus slightly lower than normal; with foley catheterGordon's Functional Health Pattern _ Nutrition/Metabolic: receives food via NGT: 210 cc + 30 cc with medication + 30 cc of water with fluimucil + ORCC y haha en need ie elena _ Elimination: Defecated @ 12:00nn (brown soft consistency of stool) Foley catheter inserted; Urine Celta tia ome Ms Heeler ee _ Activity/Exercise: confined to bed; turned every 2 hoursGordon's Functional Health Pattern _ Sleep/rest: 3-4 hours of sleep at night; in the morning gets a few minutes of sleep (at least 15-30 minutes), easily awaken Bey sp ni oh reds) versy Hate ECL Orso (sy (ao) elon noe PD Cel Coy response: 5 verbal response:1) Nods when asked Colts aCoya} _ Role/Relationship: her niece is the one constantly present in the room with her - Coping/Stress: ET tube puts a stress on her and she tries to remove it that’s why safety straps were tied on her fingersAssessment Parra Objective; >With ET tube swith blood tinged yellowish secretions >Hooked to MV >RR: 20 >PR: 104 >Decrease PO2 >Increase PCO2 >With crackles on both lung fields Impaired spontaneous ventilation related to hypermetabo lic state After a series of nursing intervention the patient's respiratory pattern will be reestablished and maintained via respirator with absence of signs of hypoxia such as normal level of oxygen, saturation and no cyanosis Assess patient: >spontaneou srespiratory pattern, noting rate, depth, rhythm, symmetry of chest movement, use of accessory muscles >Auscultate breath sounds noting for adventitious breath sounds » To measure work of breathing >To determine presence and degree of hypoxemia and hypercapnia resulting in impaired ventilation Goal met Patient didn't exhibit signs of hypoxia and respiratory rate maintained in normal levels RR: 20 2 sat: 100%saath es ny Objective; Impaired >WithET spontaneous After a series of nursing tube ventilation intervention swith blood — related to the patient's tinged hypermetabo respiratory yellowish _ lic state patter will be secretions reestablished >Hooked to and MV maintained >RR: 20 via respirator >PR: 104 with absence >Decrease of signs of PO2 hypoxia such >increase as normal PCO level of With oxygen. crackles on. saturation both lung and no fields cyanosis >Review results >to assess of ABG presence and Other degree of diagnosticand _respiratory laboratory tests insufficiency >Assist with >to support implementation compromised. of ventilatory ventilation support, as indicated >Observe overall breathing >For baseline pattern data >Count client's RR for 1 full minuteBera PCT eMC Ts Esty Objective; Impaire After a series With ET d of nursing tube spontan intervention >with blood — eous the patient's tinged ventilati__ respiratory yellowish on, patter will secretions related be >Hooked to to reestablishe MV hyperme dand >RR: 20 tabolic maintained >PR: 104 state via >Decrease respirator POQ2 with >lncrease absence of PCO signs of >With hypoxia crackles on such as. both lung normal level fields of oxygen saturation and no cyanosis acacia fsa >Check tubings for >To prevent obstruction, drain contamination tubings as and bacterial indicated and avoid growth draining towards client or back into the reservoir >Check ventilator alarms for proper functioning >Assess ventilator > To liquify setting routinely secretions facilitating >Note inspired removal humidity and temperature; maintain hydration >To clear secretion and >suction as needed maintain airwayAssessment Objective; >With ET tube >with blood tinged yellowish secretions >Hooked to MV >RR: 20 >PR: 104 >Decrease PO2 >increase PCO2 =With crackles on both lung fields Impaired spontaneous ventilation related to hypermetabo lic state get ird After a series of nursing intervention the patient's respiratory pattern will be reestablished and maintained via respirator with absence of signs of hypoxia such as normal level of oxygen saturation and no cyanosis Hite i >Monitor vital signs and record it >Place in high-fowler's position >Monitor IV fluids and regulate accordingly >Give NGT feeding >Change soiled linens and turn client every 2 hours >Administer medications as ordered >For baseline Goal met data and Patient didn't assessment exhibit signs >For of hypoxia maximal and lung respiratory expansion —_rate >Toprevent maintained fluid in normal overload levels RR: 20 Oz sat: 100% >To meet nutritional needs >To promote comfort to the client and protect skin integrityPhysical Assessment _ General status: Conscious but weak in appearance _ Skin: with dry, scaly and sagging skin; poor skin turgor; no wound or irritation noted _ Hair: evenly distributed but thinning gray-white hair, lay _ Head: normocephalic, no lesions noted. _ Eyes: opens spontaneously, white and clear sclera, pale conjunctiva, (+) PERRLA, no discharge seenPhysical Assessment _ Ears: no discharges noted, symmetrical, witha few outa _ Nose: with NGT on _ Mouth and Pharynx: with ET tube on; dry lips, with greenish-yellowish dried secretions on tongue _ Neck: with palpable lymph nodes _ Thorax and Lungs: symmetrical lung expansion, with crackles on both lung fields upon auscultation, RR: 22; no tenderness noted upon palpationPhysical Assessment _ Cardiovascular: BP: 120/80, PR: 95 bpm; no murmurs Litereaxal _ Abdomen: flat, with bourborygmi sound heard, no tenderness noted, with patent NGT upon auscultation _ Genitals/Rectum and Anus: patent, urinary meatus slightly lower than normal; with foley catheterGordon's Functional Health Pattern _ Nutrition/Metabolic: receives food via NGT: 210cc + 30 ce with medication + 30 ce of water with fluimucil + 30 ool dition Any en enw ieea eked _ Elimination: Defecated once during 6-2 shift; urine output the whole day: 610cc _ Activity/Exercise: confined to bed; turned every 2 hoursGordon's Functional Health Pattern Bes copyprateee ty W oieno as jerrmnicielest marta toutes gets a few minutes of sleep (at least 15-30 minutes), easily awaken _ Cognitive/Perceptual: GCS= 10 (eye opening: 4; motor response: 5 verbal response1) _ Role/Relationship: both nephew and niece were present in the room _ Coping/Stress: ET tube puts a’stress on her and she tries to remove it that’s why safety straps were tied on her fingershese | alee seo pen a a Objective: Riskfor — Aftera >Assess skin >Toidentify Goal Met sPhysical impaired seriesof routinely, note: particular _—Patient didn’t immobilizatio skin nursing moisture, color_—_vulnerability acquire any n integrity interventio and elasticity skin tear and >Poorskin relatedto nthe >Toprevent — skin integrity turgor immobilit patient's | >Handle patient injurysuch — was >Dry, scaly y skin gently as bruising or maintained and saggy integrity skin tearon will be client maintained and free >Inspect skin from skin surfaces and >To prevent tear pressure points development routinely of pressure sores >Observe for reddened or blanched areas or skin rashes and institute tx immediatelygoin en cl a Objective: Riskfor — Aftera >Maintain >To maintain >Physical impaired seriesof _meticulousskin skin integrity immobilizatio skin nursing hygiene, and keep n integrity interventio lubricate skin skin moist >Poorskin related to nthe with lotion or turgor immobilit patient’s emollient >Dry, scaly y skin (moisturizer) as and saggy integrity indicated >To prevent will be >Change bed sores maintained position in bed and free ona regular fromskin schedule tear >Massage bony prominences and use proper positioning, turning and lifting techniques when. moving client >Keep >To provide bedelothes dry protection to ae ra leePhysical Assessment _ General status: Lethargic _ Skin: with dry, scaly and sagging skin; poor skin turgor; no wound or irritation noted _ Hair: evenly distributed but thinning gray-white hair, lay _ Head: normocephalic, no lesions noted. _ Eyes: white and clear sclera, pale conjunctiva, no discharge seenPhysical Assessment _ Ears: no discharges noted, symmetrical, witha few outa _ Nose: with NGT on _ Mouth and Pharynx: with ET tube on; dry lips, with greenish-yellowish dried secretions on tongue _ Neck: with palpable lymph nodes _ Thorax and Lungs: symmetrical lung expansion, with crackles on both lung fields upon auscultation, RR: 21; no tenderness noted upon palpationPhysical Assessment _ Cardiovascular: BP: , PR: bpm; no murmurs heard _ Abdomen: flat, with bourborygmi sound heard, no tenderness noted _ Genitals/Rectum and Anus: patent, urinary meatus slightly lower than normal; with foley catheterGordon's Functional Health Pattern _ Nutrition/Metabolic: receives food via NGT. With intake of 510 total feeding with meds. _ Elimination: With no bowel movement within 6-2 shift, With 400 cc urine output. _ Activity/Exercise: confined to bed; turned every 2 hoursGordon's Functional Health Pattern _ Sleep/rest: 3-4 hours of sleep at night; in the morning gets a few minutes of sleep (at least 15-30 minutes), easily Earl can Beer itr Ii yacac yn ec KO Sy Keaton caer résponse=3, Motor Response=4, Verbal Response=1) _ Role/Relationship: both nephew and niece were present in the room, They reports of feeling of tired, frustrated, has family conflict, looks impatient and has insufficient ‘finances. _ Coping/Stress: ET tube puts a stress on her and she tries to remove it that’s why safety straps were tied on her fingersASSESSMENT | DIAGNOSI | PLANNING eee RATIONALE | EVALUATIO lf Ey ie) h wi SUBJECTIVE: Caregiver Afterseries © >Nurse >togaintrust After series “Walanapo Role of nursing _ patient and rapport of nursing talaga kmi Restrain r/t interventions interaction interventions, pagkukunan,” insufficient the client >Facilitate >To share goal met, the asverbalized finances along with family information client along by the her caregiver conference, anddevelop withthe caregiver will identify as plan for caregiver will resources appropriate involvement identify OBJECTIVE: within self to in care resources. >Caregiver deal with the activities within self to status: situation. >Provide >Toenhance deal with the -fatigue appropriate spiritual situation. -frustration references aspects -family and conflict encourage -looks discussion of impatient information >Never leave >To provide and stay with emotional the client support and the relativesASSESSMENT | DIAGNOSI fe PLANNING A ia ie) >Encourage verbalization of feelings >Provide the pros and cons for possible extubating the patient >provide the caregiver time to decide and sit silently with the client >Inform AP of decision RATIONALE | EVALUATIO >To acknowledge concerns and problems faced by the caregiver >To present reality and show options available >To provide some form of support