NCM 103A: FUNDAMENTALS OF NURSING (RLE)

Topic: Post Mortem

Acquire New Knowledge

At the end of the module, the student will be able to:
1. Identify and define post mortem changes.
2. Learn the different purposes of post mortem care.
3. Identify different nursing care and responsibilities on patient’s death

Overview:
 Nurses help client’s deal with all kind of losses, including loss of body
image, loss of loved one, loss of well-being and loss of a job.
 Nurses attitude about death and dying directly affect their ability to
provide care.
 Dying clients require open communications, physical help, emotional and
spiritual support to ensure a peaceful and dignified death.
Definition of Terms
 Loss is an actual or potential situation in which something that is valued is
changed or no longer available. People can experience the loss of body image, a
significant other, a sense of well-being, a job, personal possessions, or beliefs.
Illness and hospitalization often produce losses.
 Death is a loss both for the dying person and for those who survive. Although
death is inevitable, it can stimulate people to grow in their understanding of
themselves and others.
-irreversible cessation of life
 Grief is the total response to the emotional experience related to loss. Grief is
manifested in thoughts, feelings, and behaviors associated with overwhelming
distress or sorrow.
 Bereavement is the subjective response experienced by the surviving loved
ones.
 Mourning is the behavioral process through which grief is eventually resolved or
altered; it is often influenced by culture, spiritual beliefs, and custom.
 Autopsy/ Post Mortem Examination-examination of body after death
 DNR (Do Not Resuscitate)- “no code”, generally written when the client or proxy
has expressed the wish for no resuscitation in the event of a respiratory or
cardiac arrest.
 Euthanasia- aka “mercy killing” act of painlessly putting to death persons
suffering from incurable or distressing disease.
 Post Mortem Care – care of the body after death, aimed to provide dignity to
the dead and sensitivity to the personal, religious, and cultural needs of the
family

Helping Clients Die with Dignity

 Nurses need to ensure that the client is treated with dignity.
 Involves maintaining humanity, consistent with their values beliefs and culture.
 Nurses can restore and support feelings of control by introducing options available to
the client and significant others
 Attention to pain and symptom control
  Support and education during the decision-making process, including the benefits and
burdens of treatment
Preparation of the patient and family for death
Hospice & Palliative Care
 Hospice Care
 Focuses on support and care of the dying person’s family, with the goal of
facilitating a peaceful and dignified death
 Supports the client and family through the dying process and supports the family
through bereavement.
 Emphasizes care to improve quality of life rather than cure
 Palliative Care
 Focuses on symptom care of clients whom disease no longer respond to cure-
focused treatment
 Client is not necessarily believed to be imminently dying.
 provided to older patients who have: - acute, serious, life-threatening illness
(stroke, trauma, MI, cancer) - progressive chronic illness (end stage dementia,
CHF, renal or liver failure)
 may take place in the hospitals, in outpatient clinics, in long term care facilities
or in home

Physiologic Needs of a Dying Person

 This includes, personal hygiene measures, controlling pain and providing measures
related to sensory changes
 Pain control is essential to enable clients to maintain some quality in their life and their
daily activities. e.g eating, moving sleeping

PROBLEM NURSING CARE

Airway clearance Conscious client: fowler’s position, throat
suctioning
Unconscious client: Lateral position
Oxygen inhalation for hypoxic client

Bathing/ hygiene Frequent baths, change linens for

diaphoretic, mouth care as needed for dry
mouth, moisturizing cream and lotions for
dry skin
Physical mobility If Client is able: assist client out of bed
periodically
Log rolling
Support client’s position with pillows,
blanket rolls, towels as needed
Implement pressure ulcer prevention
program
Nutrition Antiemetic, encourage liquid food as
tolerated
Constipation Dietary fiber as tolerated
Stool softeners, laxative as needed
Urinary Elimination Skin care in response to incontinence of
urine or feces
Bedpan, urinal, or commode chair within
easy reach
 Catheterization if necessary

Sensory/ perceptual changes Check preference of a light room, hearing

is not diminished, speak clearly do not
whisper
Touch is diminished, but client will feel
pressure touch
Pain management protocol if indicated.

STAGES OF GRIEVING
Client Responses and Nursing Implications in Kübler-Ross’s Stages of Grieving
STAGE BEHAVIORAL RESPONSE NURSING IMPLICATION
DENIAL Refuses to believe that loss is Verbally support client but do not
happening. Is unready to deal reinforce denial. Examine your own
with practical problems, such behavior to ensure that you do not
as prosthesis after the loss of share in client’s denial.
a leg. May assume artificial
cheerfulness to prolong
denial
ANGER Client or family may direct Help client understand that anger is a
anger at nurse or staff about normal response to feelings of loss
matters that normally would and powerlessness. Avoid withdrawal
not bother them or retaliation; do not take anger
personally. Deal with needs underlying
any angry reaction. Provide structure
and continuity to promote feelings of
security. Allow clients as much control
as possible over their lives.
BARGAINING Seeks to bargain to avoid loss Listen attentively, and encourage
(e.g., “let me just live until client to talk to relieve guilt and
and then I will be ready to irrational fear. If appropriate, offer
die”). spiritual support.
DEPRESSION Grieves over what has Allow client to express sadness.
happened and what cannot Communicate nonverbally by sitting
be. May talk freely (e.g., quietly without expecting
reviewing past losses such as conversation. Convey caring by touch.
money or job), or may
withdraw.
ACCEPTANCE Comes to terms with loss. Help family and friends understand
May have decreased interest client’s decreased need to socialize.
in surroundings and support Encourage client to participate as
people. May wish to begin much as possible in the treatment
making plans (e.g., will, program.
prosthesis, altered living
arrangements)

PHYSIOLOGIC CHANGES AFTER DEATH

Death is recognized when respiration and cardiac action ceases. The pupils of the eyes
become fixed and dilated and the skin on the face and extremities becomes cool to
touch.
 1. Rigor Mortis (Post Mortem Rigidity)
 Stiffening of the body that occurs about 2 to 4 hours after death due to lack of
Adenosine Triphosphate (ATP), which is not synthesized because of lack of
glycogen in the body.
 Starts in the involuntary muscles (heart, bladder, etc.) then progresses to the
head , neck trunk and finally reaches the extremities.
 Leaves the body about 96 hours after death.
2. Algor Mortis (Post Mortem Cooling)
 Gradual decrease of the body’s temperature after death.
 When the blood circulation terminates and the hypothalamus ceases to
function, body temperature falls about 1 degree Celsius per hour until it
reaches room temperature.
3. Livor Mortis (Post Mortem Lividity)
 Bluish discoloration of the skin after death.
 After blood circulation has ceased, skin becomes discolored.
 The RBC breakdown, releasing hemoglobin, which discolors the surrounding
tissues.
4. Putrefaction
 The destruction of a dead body by bacteria
 The rate at which changes develop depends on the environment. Hot, moist
conditions favor putrefaction, but cold, dry air delays or prevent it.
 The body of the deceased should be placed in refrigeration in the morgue as
soon as possible
 It is best not to keep the body on the nursing unit more than one hour
5. Embalming
 Embalming is used as a method of chemically preserving the body. A solution is
introduced
 into the body that kills the bacteria and prevents the rapid decomposition of
tissues.
 Tissues after death become soft and eventually liquefied by bacterial
fermentation.
 The hotter the temperature, the more rapid the change, therefore, bodies are
often stored in cool places to delay the process.
Mishandling- cause emotional distress to the survivors
Mislabeling- can create legal problems if inappropriately identified
PURPOSE OF POST MORTEM CARE
o to aid in preserving the physical appearance of the deceased
o to prevent discoloration and damage of the corpse skin
o to safeguard all the belongings of the deceased
o to support family members during the initial hours of their bereavement
o to show respect for the deceased

SIGNS OF IMPENDING CLINICAL DEATH

 Loss of Muscle Tone
- Relaxation of facial muscle
- Difficulty speaking
- Difficulty swallowing and gradual loss of gag reflex
- Decrease activity of gastrointestinal tract
- Possible urinary and rectal incontinence
 Slowing of the Circulation
 -Diminished sensation
-mottling and cyanosis of extremities
-cold skin, first in the feet and later in the hands, ears and nose
-slower and weaker pulse
-decreased blood pressure
 Changes in respiration
- Rapid, shallow, irregular, or abnormally slow respiration noisy
breathing,
 Sensory Impairment
- Blurred vision
- Impaired senses of taste and smell

DYING PERSON’S BILL OF RIGHTS

I have the right to be treated as a living human being until I die.
I have the right to maintain a sense of hopefulness however changing its focus may be.
I have the right to express my feelings and emotions about my approaching death in my own
way.
I have the right to participate in decisions concerning my care.
I have the right to expect continuing medical and nursing attention even though cure goals
must be changed to comfort goals.
I have the right not to die alone.
I have the right to be free from pain.
I have the right to have my questions answered honestly.
I have the right not to be deceived.
I have the right to have help from and for my family in accepting my death.
I have the right to die in peace and with dignity.
I have the right to retain my individuality and not be judged for my decisions which may be
contrary to the beliefs of others.
I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to
understand my needs and will be able to gain some satisfaction in helping me face my death.

GUIDELINES OF POST MORTEM CARE

o Show respect and preserve the client’s dignity by working quietly and maintaining
privacy.
o Maintain the normal position by having the client in a supine position and placing a
pillow under the head and shoulders to prevent distortion of the body and
discoloration of the face.
o Ensure that none of the client’s property or personal belongings is lost.
o Dispose soiled dressings, linens, and other equipment properly.
o Observe standard precaution while performing post mortem care.
o Bathe and dress over leaking wounds. • Clean up body thoroughly.
o Allow the family to say goodbye through touching and talking.
o Assure proper identification of the body by placing identification tags on the hand and
foot, or according to agency protocol.
o Do not cover the client’s face when the family is viewing the body.
o Do not remove engagement or wedding rings unless specified by an order or
according to the agency policy.

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER POST MORTEM CARE

• Before
o Check for the certification of death of the patient signed by the physician.
o Introduce yourself and explain to the significant others that you will perform post
mortem care.
o Gather and prepare the necessary materials.
o Provide privacy.
o Do medical handwashing and put on clean gloves.

• During
o Maintain the body in a supine position with head of bed raised at 30 degrees.
o Remove all supplies, dirty linens, and medical equipment or devices such as IV lines,
tubes, drains, and monitors according to the hospital protocol.
o Remove any jewelry and collect all other personal belongings to be sent to the family.
List each piece of jewelry as it is being removed.
o Bathe the body thoroughly.
o Give the family option to view or not to view the patient and accompany them as they do
so.
o Ensure that the identification tags are properly placed.
o Wrap the body with a shroud before it is taken to the morgue.
o
• After
o Do after care.
o Transfer the body from the bed to a stretcher for transport to the morgue.
o Document the procedure.

o PROCEDURES OCCURRING AFTER DEATH

o Pronouncement of Death and Death Certificate
o The formal determination of death, or pronouncement, must be performed by a
physician, a coroner, or a nurse (may be limited only to nurses in long-term care,
home health, and hospice agencies or to advanced practice nurses). o By law, a death
certificate must be made out when a person dies.
o The mortician assumes responsibility for handling and filling the death certificate with
proper authorities.
o A physician’s signature is required on the certificate, as well as that of the pathologist,
the coroner and other special case.
o The responsibility of the nurse is to ensure that the physician has signed the death
certificate.
o The family is usually given a copy to use for legal matters, such as insurance claims.

Autopsy
o An autopsy is an examination of the organs and tissues of a human body after death.
o The law describes under what circumstances an autopsy must be performed, for
example, when death is sudden or occurs within 48 hours of admission to a hospital.
o It is the responsibility of the physician or, in some cases, the designated person in the
hospital to obtain consent for an autopsy.

AUTOPSY OR POSTMORTEM EXAMINATION

❖ An examination of the body after death and is performed only in certain cases:
o When the death is sudden or occurs within 48 hours of admission to a hospital, the
organs and tissues of the body are examined to establish the exact cause of death.
o To learn more about the disease.
o To assist the accumulation of statistical data.
 ❖ Consent should be obtained by the physician from the decent (before death) or by the
next of kin (surviving spouse, adult children, parents, siblings).
❖ Hospitals cannot retain any tissues or organs without permission of the person who
consented to the autopsy.
• Inquest
o An inquest is a legal inquiry into the cause or manner of a death.
o It is conducted under the jurisdiction of a coroner or medical examiner.
o When a death is the result of an accident, for instance an inquest will be held into the
circumstances of the accident to determine any blame.
• Organ Donation
o People 18 years or older and of sound mind may make a gift of all or any part of their
own bodies for the following purposes: for medical or dental education, research,
advancement of medical or dental science, therapy, or transplantation.
o The donation can be made by a provision in a will or by signing a card-like form, which
must be carried at all times by the person who signed it.
o The details regarding the process of requesting donation from family members and other
legal aspects of organ donation vary from country to country.

NURSING RESPONSIBILITIES OF DISCHARGING A DEAD PATIENT

• Evaluate the nursing care for the grieving and dying client through communication and
assessment.
• Evaluate the situation in clear and precise terms as stated by the choice of a applicable
nursing diagnosis based on accurate database that is evolving and realistic
• Document the ff:
o time of death and actions taken to prevent the death, if applicable
o who pronounced the death of the client
o who was called and who came to the hospital
o personal articles left on the body and taped to skin or tubes left in
o personal items given to the family o time of discharge and destination of the body
o location of name tags on the body
o special requests by the family
o any other statements that might be needed to clarify the situation
• Medical forms must be signed by a doctor or registered nurse.
DEATH CERTIFICATE
o Formal determination of death, or pronouncement, must be performed by a physician,
coroner, nurse
o The granting of the authority to nurse to pronounce death is regulated by the state or
province.
o This may be limited to nurses in long-term care, home health, hospice agencies,
advanced practice nurses.
o The family is given a copy to use for legal matters.
LABELING OF THE DECEASED
o If inappropriately identified and prepared incorrectly can create legal problems.
o Placed on the wrist, ankle, and on the shroud.
o Contains name of deceased, hospital number, and name of attending physician.

DOCUMENTATION
Documenting death confirmation in the notes
1. Document your reason for attending and who asked you to attend (e.g. asked to confirm
death of Mrs Jones by staff nurse Amanda Miles)
 2. Document who was present whilst you were confirming the death (staff/deceased patient’s
family and friends)

3. Document the circumstances of the death:

o Location of the patient
o The individual who first noted the patient to be dead
o Any individual present at the moment of death
o If resuscitation was attempted, indicate the time it started and ended, and refer to the
code sheet in the patient's medical record. Note whether the death is being referred to the
medical examiner and whether an autopsy is being performed. Include all postmortem
care given, noting whether medical equipment was removed or left in place. List all
belongings and valuables and the name of the family member who accepted and signed
the appropriate valuables or belongings list. Record any belongings left on the patient.

4. Document confirmation of death assessment:

o Identity confirmed by wrist band
o General inspection
o No signs of respiratory effort
o No response to verbal stimuli
o No response to painful stimuli
o No pupillary response to light
o No central pulse
o No heart sounds after 3 minutes of auscultation
o No respiratory sounds after 3 minutes
The recommended times for auscultation varies, so adhere to your local hospital policy.
The only official guidance on this matter can be found here¹ , which advises a minimum of five
minutes total (heart sounds and respiratory sounds) to establish that irreversible
cardiorespiratory arrest has occurred.

5. Document the outcome of the assessment, including date and time of the patient's death
and the name of the health care provider who pronounced the death (which should be
documented as the time at which you completed your assessment)

6. Document any discussions you had with staff members or relatives of the deceased in
relation to the death

7. Document any concerns of staff members or the relatives

8. Document the disposition of the patient's body and the name, telephone number, and
address of the funeral home. List the names of family members who were present at the time
of death. If they weren't present, note the name of the family member notified and who
viewed the body. Be sure to document any care, emotional support, and education given to the
family.

Part of a good note might look like this:

7/22/18 14:20-Called to room by pt.'s daughter, Mrs. Helen Jones, stating pt. not breathing. Pt.
found unresponsive in bed at 1345, no respirations, no pulse, no heart or breath sounds
auscultated. No code called per advance directive and signed DNR order in chart. Death
pronounced by Dr. Holmes at 1350. NG tube, indwelling urinary catheter, and I.V. access device
in L forearm removed and dressing applied. Postmortem care performed and dentures placed
in mouth. Belongings checked off on belongings list and signed by Mrs. Jones, who will take
them home with her. Body sent to morgue at 1415. Jeanne Ballinger, RN-----------------------