NURSING FOUNDATION

CARE OF TERMINALLY ILL SET 2

 Anorexia, nausea, and vomiting are commonly seen in dying patient person .
 The patient is unable to swallow even the sips of water poured in the mouth.
 Most of them may require I.V fluids.
 If they can tolerate the oral fluids, sips of water is given with teaspoon.
 That will help the patient to keep the mouth moist.
 Give frequent oral hygiene.
 Apply emollients to the dry lips.
 The denture are removed and kept safely.
 Problem associated with elimination:
 Constipation, retention of urine and incontinence of urine and stool are some of problem
faced by the patient.
 Catheterization has to be done .
 Through skin and Perineal care is to be given, to keep the patient clean and to prevent skin
breakdown.
 Problem associated with immobility:
 Frequent skin care should be given with particular attention to the pressure point.
 Patient should be comfortably placed and their position frequently changed in the bed.
 Problem associated with sense organ:

 Since the patient loses sight, before given any care to the patient, the nurse should
touch the patient and say what she is going to do.
 Since the hearing is retained longer, speak only what is appropriate.
 Avoid whispering any think in patient room.
 Speak distinctly so that patient may understand what is done for him.
 Since the eyes are opened, protect the eyes from corneal ulceration with protective
ointment.
 Problem associated with rest and
sleep:

Patient may distressing symptoms in these patients.
 Patient should not be disturbed while sleeping.
 The visitors should be instructed not to disturbed the patient during his
resting.
 Maintain calm and quit environment.
 Problem associated with cleanliness and grooming:
 Cleanliness and appearance are important until the end.
 Cleanliness of the skin, hair, mouth, and cloth has to be maintained.
 MANAGEMENT OF DYING
PATIENT :
 Cassen (1991) suggests seven essential features in the management of the
dying patient:
 Concern: Empathy, compassion, and involvement are essential.
 Competence: Skill and knowledge can be as reassuring as warmth and
concern.
 Communication: Allow patients to speak their minds and get to know
them.
 Children: If children want to visit the dying, it is generally advisable; they
bring consolation to dying patients .
 Cohesion: Family cohesion reassures both the patient and family.
 Cheerfulness: A gentle, appropriate sense of humor can be palliative; a
somber or anxious demeanor should be avoided.
 Consistency: Continuing, persistent attention is highly valued by
patients who often fear that they are a burden and will be abandoned;
consistent physician involvement mitigates these fears.
 NURSING CARE OF A DYING
INDIVIDUAL :
 The person who deals with the dying patient must commit (Schwartz and Karasu,
1997) to:
 Deal with mental anguish and fear of death,
 Try to respond appropriately to patient’s needs by listening carefully to the
complaints and
 Be fully prepared to accept their own counter transferences, as doubts, guilt and
damage to their narcissism are encountered.
 Management of the dying patient often elicits anxiety in nursing staff. Education and
role playing can improve perspective taking and empathetic skills, respect each
other’s point of view as well as appreciate the situation of patient and their families.

Developing a sense of control and efficacy.
 Encouraging peer groups for families coping with bereavement.
 Developing increased resourcefulness in dealing with death related
situations.
 Recognizing that a moderate level of death anxiety is acceptable.
 Improving our understanding of pain and suffering will also improve
communication and effective interactions.
 CARE FOR THE BODY AFTER
DEATH :
 After the physician has pronounced death legally documented the death in the medical
record, care of the body is usually performed by the nurse.
 An autopsy consent may be requested & obtained if required.
 If the patient is to be an organ donor arrangements will be made immediately.
 The family often wishes to view the body before final preparations are made, they
may be allowed.
 If the patient had any valuables, they are handed over to the relatives
 PURPOSES :
 Make body look as natural & beautiful as possible.
 Perform his last duty tenderly.
 Protect other patients from unpleasant sights and sounds which could frighten them
 ARTICLES REQUIRED
 Articles for bath
 Extra bandages and cotton swabs
 Perineal pads
 Sheets
 Restraints for jaw, hands and legs.
 Pair of gloves
 Thumb forceps

 POST MORTEM CARE :
 Rigor mortis is the stiffening of the body that occurs about 2
to 4 hours after death. Rigor mortis starts in the involuntary
muscles (heart, bladder, and so on), then progresses to the
head, neck, and trunk, and finally reaches the extremities.
 Algor mortis is the gradual decrease of the body’s temperature after death. When blood
circulation terminates and the hypothalamus ceases to function, body temperature falls
about 1°C (1.8°F) per hour until it reaches room temperature. Simultaneously, the skin
loses its elasticity and can easily be broken when removing dressings and adhesive tape.
 After blood circulation has ceased, the red blood cells break down, releasing
hemoglobin, which discolors the surrounding tissues. This discoloration, referred to as
livor mortis, appears in the lowermost or dependent areas of the body. 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 this process.
 CHANGES IN BODY AFTER DEATH :

 Rigor Mortis: body becomes stiff within 4 hours after death as a result
of decreased ATP production. ATP keeps muscles soft and supple.
 Algor Mortis: Temperature decreases by a few degrees each hour. The
skin loses its elasticity and will tear easily.
 Livor Mortis: Dependant parts of body become discolored. The patient
will likely be lying on their back, their backside being the 'dependant'
body part. The discoloration is a result of blood pooling, as the
hemoglobin breaks down.
 WILL / DYING DECLARATION :
 A will is a document by which a person regulates the rights of others over
his property or family after death.
 A statement by a person who is conscious and knows that death is imminent
concerning what he or
 she believes to be the cause or circumstances of
death that can be introduced into evidence during a trial in certain cases
 A person who makes a dying declaration must,
however, be competent at the time he or she makes a statement, otherwise, i
t is inadmissible.
 ORGAN DONATION:
 A person 18 years or older and of sound mind can donate all or any part of their own body for the following
purposes:
 For medical or dental education
 Research
 Advancement of medical or dental science
 Therapy
 Transplantation
 The request for organ donation should be done by patent in the presence of a physician or a nurse  Organs
removed from the body following the death cannot be sold.
 All organ donation are voluntary and there should not be any compulsion for the patient / family members
 Organs usually donated :- kidney, heart, lungs, liver, bone, cornea
 COUNSELLING FOR ORGAN
DONATION :
 Organ transplantation is truly one of the miracles of modern medicine, saving the lives of
many patients and improving the quality of life for many more.
 Given the ever-increasing gap between the number of organs needed and the supply, nurses
have an ethical obligation to help ensure that the desires of people who want to donate organs
are respected.
 Nurses have to ensure that the consent process is informed and voluntary.
 Information to the patient should consist of a balanced discussion of the available options and
counseling to help patients or their families reach the choice that is best for them, including the
provision of information about the urgent need for organs and the consolation that many
families derive from knowing that their loved one was able to help others
 MEDICO LEGAL ISSUES :
 Abuse of children, elderly, and spouse
 Drug-related injury
 Unknown cause of death
 Suicide
 Violent death
 Poisoning
 Accidents
 Suspicion of criminal action
 Obtain death reports
 Do investigation -the natural death and infant/child death
 Conduct post mortem , sexual assault/child abuse examinations
 Collaborate with organ/tissue procurement agencies
 Provide link between pathologists and lay investigative staff
 Normally, only uniformed officers attend the natural death scene
 Understand subtle signs of abuse and neglect
 Collaborate with pathologist to determine the appropriate medical records
 Review medical records once received
 Obtain follow-up information
 CARE OF UNIT AFTER DEATH :

 Inform the nurse in charge and inform the medical staff of the patient’s death
 In the case of an expected adult death, a registered nurse deemed competent by
the Trust may confirm death
 Confirmation of death must be recorded in the patient’s healthcare record
 An unexpected death must be confirmed by the attending medical officer and
if confirmed the service manager should be contacted or duty manager out of
hours. Incident form to be completed
 Inform the patient’s relatives/next of kin of the patient’s death.
 Ensure that this is handled in a sensitive and appropriate manner
with as much privacy as possible.
 Ask if the relatives wish to see the chaplain or an appropriate
religious leader or other appropriate person to the person’s faith
or ethnic origins that need to be attended to immediately
 If relatives are in the hospital ask if they wish to assist with the
last offices and/or if they have any particular wishes regarding
the procedure
 If the relatives are not in the hospital ask if they wish to view the
body on the ward or at a later date
 Assemble required equipment
 Wash hands and put on disposable gloves and apron
 Any injuries sustained whilst carrying out the procedures on the deceased must be
reported through the Trust risk system and follow the Trust Sharps and Inoculation
Management Procedure
 Lay the patient on their back with one pillow in place (adhere to the Moving and
Handling Policy)
 Straighten the patient’s limbs (if possible) and place their arms by their sides
 Gently close the patient’s eyes if open by applying light pressure for 30 seconds. If
corneal or eye donation to take place, close the eye with gauze moistened with normal
saline
 Do not apply tape
 If syringe driver in situ, disconnect and remove battery In cases where there
is no referral to the coroner required infusions can be discontinued and
infusion lines, cannulae, drainage and other tubes can be removed If referred
to the coroner endo-tracheal tubes, catheters and infusion lines should
remain in situ. Discard all sharps into a sharps bin as per Trust Sharps and
Inoculation Management Procedure
 Place a receiver between the patient’s legs and drain the bladder
by pressing on the lower abdomen. Pads and pants can be used
to absorb any leakage
 Exuding wounds should be covered with absorbent gauze and
secured with an occlusive dressing
 Wash the patient if necessary, unless requested not to do so for
religious/cultural reasons or patient has died in suspicious
circumstances
 It may be important to the family and carrers to assist with washing,
thereby continuing the care given to the patient in the period before death
 Clean the patient’s teeth and gums using a moistened, soft small headed
nylon toothbrush and or suction to remove any debris and secretions
Clean any dentures and replace them in the mouth – a small pillow or
rolled up towel placed under the patient’s chin may help to keep the jaw
closed and teeth in situ
 Tidy the hair as soon as possible after death and arrange into the preferred style (if known)
 Patients should not be shaved; usually a funeral director will do this. Some faiths prohibit shaving
 Remove all jewellery, in the presence of another nurse, unless requested by the family to do otherwise.
 Any jewellery removed must be documented on a property form and placed in the hospital safe until
collected by the family. Wedding rings may be left in situ and taped in place.
 Any jewellery remaining on the body should be documented on the identification card accompanying
the patient to the mortuary or undertakers
 Record all property in the patient property book and pack in a labelled property bag, keeping secure until
collected by the family. Pack personal property showing consideration for the feelings of those receiving it.
Discuss the issues of soiled clothes sensitively with the family and ask whether they wish them to be disposed
of or returned
 Unless a specific request has been made by the family for alternative clothes the patient should be dressed in
a hospital gown
 If relatives are present at the time of death, or attend the hospital shortly after, staff should ensure that they
are given the Trust Bereavement information copies of which are available on the ward.
 Relatives should be told to contact the relevant Trust officer who supports bereavement or the patient’s GP to
collect the death certificate
 Label one wrist and one ankle with an identification band containing the following
information:
 Full name
 NHS Number
 Date of Birth
 Complete patient identification cards and notification of death book clearly in capitals
 If the patient has an implant device such as a pacemaker or an infectious disease is known or
suspected – record this fact on both patient identification cards
 Tape one identification card to clothing or hospital gown Wrap the body in a
sheet, ensuring that face to feet are covered and that all limbs are held securely
in position
 If the body may be infectious or there is a risk of leakage of body fluids place
the body in a body bag and put the second identification card into the pocket of
the body bag
 If the deceased person has a known infectious disease Category 3 & 4 they
must be placed in a heavy duty body bag and you must inform anyone else who
comes in contact with this patient e.g. funeral directors, porters.
 Remove gloves and aprons. Dispose of equipment according to local policy and wash hands
 If mortuary on site request porters to remove body from the ward to the mortuary
 If no on site mortuary, contact local funeral directors or the funeral directors according to
the relatives wishes Screen off the area where removal of the body will occur
 Screen off the area where removal of the body will occur
 Record all the details and actions in the nursing records Any property retained on the ward
out of hours must be stored in a secure area and any valuables stored in the ward or hospital
safe
continues…..