careofterminallyill-201111095034.pdf nursing

Nursing notes

1. 1
CARE OF TERMINALLY ILL
PATIENT
Mr. Melvin Jacob
MSc Nursing
Mr. Melvin Jacob MSc (N)

2. CONCEPT OF LOSS, GRIEF
& GRIEVING PROCESS
2Mr. Melvin Jacob MSc (N)

3. CONCEPT OF LOSS
Thefactorprocessoflosingsomethingor
someone.
oxford dictionary
Lossisanactualorpotentialsituationin
whichsomethingthatisvaluedischanged,no
longeravailableorgone.
3Mr. Melvin Jacob MSc (N)

4. •Peoplecanexperiencelossofbodyimage,a
job,senseofselfetc.
•Deathisanfunctionalloss,bothfordying
personandforthosewhosurvive.
4Mr. Melvin Jacob MSc (N)

5. Types of loss
1.Actualloss–canberecognizedbyothers.
Eg–death
2.Perceivedloss–Itisexperiencedbyoneperson,
butcannotbeverifiedbyothers(psychologicloss)
Eg:-awomanwholeavesherjobtocareforchild
mayexperiencealossofindependenceand
freedom.
5Mr. Melvin Jacob MSc (N)

6. 3.Situationalloss-lossofone’sjob,deathofa
child,lossoffunctionalabilitybecauseof
injury.
4.Developmentalloss–lossoccurintheprocess
ofnormaldevelopment
Eg:departureofgrownchildrenfromhome,
retirement,deathofagedparents.
6Mr. Melvin Jacob MSc (N)

7. Sources of loss
1.Lossofanaspectofoneself
Eg:changeinbodyimage–burnintheface.
2.Lossofexternalobjects
-lossofinanimateobjects.eg:money,house
-lossofanimateobjects.eg:pets
3.Lossoffamiliarenvironment
Eg:4-yroldchildfeellosswhenleavingthehomeforthe
firsttimeforattendingtheschool
4.Lossoflovedones
Eg:lossbyillness,divorce,separation,death.
7Mr. Melvin Jacob MSc (N)

8. Concept of grief
•Griefisthetotalresponsetotheemotional
experiencerelatedtoloss
•Griefismanifestedinthoughts,feelingsand
behaviorsassociatedwithsorrows.
•Grievingisessentialformentalandphysical
health.
•Ithelpthepersontocopewiththeloss
graduallyandtoacceptitaspartofreality.
8Mr. Melvin Jacob MSc (N)

9. Factors influencing grief
Humandevelopment,
Personalrelationship,
Natureoftheloss,
Copingstrategies,
Socioeconomicstatus,
Cultureandethnicity,
Spiritualandreligiousbelief
9Mr. Melvin Jacob MSc (N)

10. STAGES OF GRIEVING /GRIEF
PROCESS
KUBLER-Ross's
10Mr. Melvin Jacob MSc (N)

11. 11Mr. Melvin Jacob MSc (N)

12. 1.Denial
Behavioralresponse:-refusestobelievetheloss.
eg:unreadytodealwithpracticalproblemssuch
asprosthesisafterthelossofleg.
Nursingimplications:-verballysupportthe
client
12Mr. Melvin Jacob MSc (N)

13. 2.Anger
Behavioralresponse:-client/familymaydirectangerat
nurse/staff.
Nursingimplications:
-Helpclienttounderstandthatangerisanormal
responsetofeelingsofloss/powerlessness.
--Donottakeangerpersonally
--Dealswithneedsunderlyinganyanger
13Mr. Melvin Jacob MSc (N)

14. 3.Bargaining
Behavioralresponse:-seekstobargaintoavoidloss
-Mayexpressfeelingsofguilt/fearof
punishmentforpastsins.
Nursingimplications:
-Listenattentivelyandencourageclienttotalk
torelieveguiltandfear
-Ifappropriate,providespiritualsupport.
14Mr. Melvin Jacob MSc (N)

15. 4.Depression
Behavioralresponse:
-Grievesoverwhathashappenedandwhatcaanotbe
-Maytalkfreelyormaywithdraw.
Nursingimplications:
-Allowtoexpresssadness
-Communicatenonverballybysittingquietlywithout
conservation
-Conveycaringbytouch.
15Mr. Melvin Jacob MSc (N)

16. 5. Acceptance
Behavioralresponse:
-Comesintermswithloss
-Mayhavedecreasedinterestinsurroundingsand
supportpeople.
Nursingimplications:
-Encourageclienttoparticipatedasmuchasin
treatmentandprogress
16Mr. Melvin Jacob MSc (N)

17. SIGNS OF CLINICAL
DEATH
17Mr. Melvin Jacob MSc (N)

18. Death
Deathcanbedefinedasthecessationofall
vitalfunctionsofthebodyincludingthe
heartbeat,brainactivity(includingthebrain
stem)andbreathing.
18Mr. Melvin Jacob MSc (N)

19. Incidence
Morethan2.5millionpeopledieintheUnited
Stateseachyear.
25%ofalldeathstakeplaceathome,with
about50%occurringinhospitals.Remaining
25%occurinnursinghomes.
19Mr. Melvin Jacob MSc (N)

20. Indications of death
Total lack of response to external stimuli
No muscular movement, especially breathing
No reflexes
Flat encephalogram (brain waves)
20Mr. Melvin Jacob MSc (N)

21. Physical manifestations of approaching
death
SYSTEM MANIFESTATIONS
Sensory
Decreasedsensation,decreasedperception,blurring
ofvision,sinkingandglazingofeyes,blinkreflex
absent,eyelidsremainhalfopened
Integumentary
Mottlingonhands,feet,armsandlegs;cold,clammy
skin;cyanosisonnose,nailbeds,knees;waxlikeskin
whenveryneartodeath
Respiratory
Increasedrespiratoryrate;Cheyne-stokes
respiration;inabilitytocoughorclearsecretions
resultingingranting,gurgling;irregularbreathing
21Mr. Melvin Jacob MSc (N)

22. Urinary Decreasedurinaryoutput,urinaryincontinence,
unabletourinate
Gastrointestinal
Accumulationofgas,distensionandnausea,lossof
sphinctercontrol
Musculoskeletal
Inabilitytomove,saggingofjaw,difficulty
speaking,difficultyinswallowing,difficulty
maintainingbodypostureandallignment,lossof
gagreflex,jerking
Cardiovascular
Increasedheartrate,slowerandweakeningpulse,
irregularrhythm.Decreasedinbloodpressure,
delayedabsorptionofdrugs
22Mr. Melvin Jacob MSc (N)

23. PSYCHOSOCIAL MANIFESTATIONS OF
APPROACHING DEATH
•Altered decision making
•Anxiety about unfinished
business
•Withdrawal
•Decreased socialization
•Fear of loneliness
•Fear of meaninglessness of one’s
life
•Fear of pain
•Helplessness
•Life review
•Peacefulness
•Restlessness
•Saying goodbyes
•Unusual
communication
•Vision like experiences
23Mr. Melvin Jacob MSc (N)

24. CARE OF DYING
PATIENTS
24Mr. Melvin Jacob MSc (N)

25. Themajornursingresponsibilityforclients
whoaredyingistoassisttheclienttoa
peacefuldeath.
25Mr. Melvin Jacob MSc (N)

26. 1. Helping clients die with dignity
•Nursesneedtoensurethattheclientistreatedwith
honorandrespect.
•Helptheclienttoconsistentwiththeirvalues,
beliefsandculture.
•Allowtheclienttomakesomechoicesonthe
locationofcareeg:hospital,home.
•Canhelpclientstodeterminetheirownphysical,
psychologicandsocialpriorities.
26Mr. Melvin Jacob MSc (N)

27. 2.Hospice and palliative care
•Hospicecarefocuseson“supportandcareofthedying
personandfamily”,withthegoaloffacilitatingapeaceful
anddignifieddeath.
•Itisbasedon“holisticcare”.
•Itemphasizecaretoimprovequalityofliferatherthancure
•Supportstheclientsandfamilythroughthedyingprocess
andsupportsthefamilythroughbereavement
27Mr. Melvin Jacob MSc (N)

28. Palliative care
Palliativecareisanyformofcareor
treatmentthatfocusesonreducingtheseverityof
diseasesymptoms,ratherthantryingtodelayor
reversetheprogressionofthediseaseitselfor
provideacure.
28Mr. Melvin Jacob MSc (N)

29. 29Mr. Melvin Jacob MSc (N)

30. 3.Meeting the physiologic needs of
the dying client
-Personal hygiene measures
-Controlling pain
-Relieving respiratory difficulties
-Assisting with movement
-Nutrition , hydration and elimination
30Mr. Melvin Jacob MSc (N)

31. 4.Providing spiritual support
Expressionsoffeeling,prayer,meditation
,reading,discussionwithclergyorspiritual
advisor
31Mr. Melvin Jacob MSc (N)

32. 5. Supporting the family
-Providesupporttofamilymembersofadying
client,usingtherapeuticcommunication,to
facilitatetheirexpressionoffeelings.
-Encouragethemtoinvolveinpatientcare
32Mr. Melvin Jacob MSc (N)

33. ADVANCED DIRECTIVES
33Mr. Melvin Jacob MSc (N)

34. Euthanasia / mercy killing
-Itistheactofpainlesslyputtingtodeathpersons
sufferingfromincurableordistressingdisease.
-Asofnow,humaneuthanasiaislegalin
Netherlands,Belgium,Colombia,Luxembourgand
Canada,
-AssistedsuicideislegalinSwitzerland,Germany,
Japan,andintheUSstatesofWashington,Oregon,
Colorado,Vermont,Montana,WashingtonDC,and
California.
34Mr. Melvin Jacob MSc (N)

35. Living will
35Mr. Melvin Jacob MSc (N)

36. Specificinstructionsabout
whatmedicaltreatmenttheclient
choosetoomitorrefuse(eg:
ventilatorsupport)intheeventthat
theclientisunabletomakethose
decisions
36Mr. Melvin Jacob MSc (N)

37. Health care proxy / surrogate
Itisanotarizedorwitnesses
statementappointingsomeoneelse(e.g.a
relative/friend)tomanagehealthcare
treatmentdecisionswhentheclientisunable
todo.it.
37Mr. Melvin Jacob MSc (N)

38. 38Mr. Melvin Jacob MSc (N)

39. Declaration / certification of death
-Theformaldeterminationofdeathor
pronouncement,mustbeperformedby
physician.
-Theauthoritytopronouncethedeathforthe
nurse,maybelimitedinlongtermcare,home
healthandhospiceagenciesortoanadvanced
practicenurse.
39Mr. Melvin Jacob MSc (N)

40. -Thedeathcertificateissignedbythe
physicianandfiledwithalocalhealth
orgovernmentoffice.
-Acopyofcertificateisgiventothe
family
40Mr. Melvin Jacob MSc (N)

41. 41Mr. Melvin Jacob MSc (N)

42. Organ donation
-Aperson18yearsorolderandofsoundmindcan
donatealloranypartoftheirownbodyforthe
followingpurposes:
-Formedicalordentaleducation
-Research
-Advancementofmedicalordentalscience
-Therapy
-Transplantation
42Mr. Melvin Jacob MSc (N)

43. Itistheprocessofremovingtissuesor
organsfromalive,orrecentlydead,person
calledDonortobeusedinanotherliving
personcalledRecipient.
•Heart,liver,kidneys,lung,Pancreasand
tissuessuchascorneasandbonemarrow
•Organdonationshouldtakeplacewithin2-
6hrsafterthedeath.
43Mr. Melvin Jacob MSc (N)

44. 44Mr. Melvin Jacob MSc (N)

45. 45Mr. Melvin Jacob MSc (N)

46. •LiveDonations-Whenthepersonmakingthe
donationisalive
•Cadaver/DeceasedDonations-Afterthe
donordies
46Mr. Melvin Jacob MSc (N)

47. MEDICO LEGAL ISSUES
47Mr. Melvin Jacob MSc (N)

48. Itcanbedefinedasacaseofinjuryor
alimentetc..Inwhichinvestigationsbythe
lawenforcingagenciesareessentialtofixthe
responsibilityregardingthecausationofthe
saidinjuryoraliment
48Mr. Melvin Jacob MSc (N)

49. •Abuseofchildren,elderly,andspouse
•Drug-relatedinjury
•Unknowncauseofdeath
•Suicide
•Violentdeath
•Poisoning
•Accidents
•Suspicionofcriminalaction
49Mr. Melvin Jacob MSc (N)

50. •Obtaindeathreports
•Doinvestigation-thenaturaldeathandinfant/childdeath
•Conductpostmortem,sexualassault/childabuse
examinations
•Collaboratewithorgan/tissueprocurementagencies
•Normally,onlyuniformedofficersattendthenatural
deathscene
50Mr. Melvin Jacob MSc (N)

51. •Understandsubtlesignsofabuseandneglect
•Collaboratewithpathologisttodeterminethe
appropriatemedicalrecords
•Reviewmedicalrecordsoncereceived
•Obtainfollow-upinformation
•Organize interagency meetings as necessary
51Mr. Melvin Jacob MSc (N)

52. 52Mr. Melvin Jacob MSc (N)

53. Definition
Anautopsy(post-mortem)isthesurgical
dissectionofabodyafterdeathtodetermine
theexactcauseandcircumstancesofdeathor
discoverthepathwayofadisease.
53Mr. Melvin Jacob MSc (N)

54. •Itisperformedincertaincasessuchas:
-Whendeathissuddenoroccurswithin48hrsof
admissiontothehospital
-Committedsuicide
-Unknowncauseofdeath
-Unknowndeadbodies
-Homicide(Thekillingofonehumanbeingby
another)
54Mr. Melvin Jacob MSc (N)

55. 55Mr. Melvin Jacob MSc (N)

56. 56Mr. Melvin Jacob MSc (N)

57. EMBALMING
57Mr. Melvin Jacob MSc (N)

58. Definition
Embalmingistheartandscienceof
preservinghumanbodybytreatingthem
with chemicalsto prevent
decomposition.
•Itistemporaryinnature
58Mr. Melvin Jacob MSc (N)

59. Purpose
•Tokeepthebodysuitableforpublicdisplayat
afuneral.
•Formedicalandscientificpurposessuchas
theiruseasanatomicalspecimens
59Mr. Melvin Jacob MSc (N)

60. •Injectionofchemicalsintothebodytodestroy
thebacteria;therebypreventsrapid
decompositionoftissues.
•Embalmingfluidcontainsamixtureof
formaldehyde,methanol,ethanolandother
solvents
60Mr. Melvin Jacob MSc (N)

61. Process
Embalmingfluidisinjectedintothe
arteriesofthedeceasedduringembalming.
Manyotherbodilyfluidsmaybedrainedor
aspiratedandreplacedwiththefluidaswell.
61Mr. Melvin Jacob MSc (N)

62. 62Mr. Melvin Jacob MSc (N)

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64. 64Mr. Melvin Jacob MSc (N)

65. CARE OF DEAD BODY
65Mr. Melvin Jacob MSc (N)

66. Afterdeaththebodyundergoesmany
physicalchanges.socaremustbeprovided–as
early-topreventtissuedamage/disfigurement
ofbodyparts.
66Mr. Melvin Jacob MSc (N)

67. Physiological changes after death
1.Rigormortis
-Stiffeningofthebodythatoccursabout2-4hrsafter
death.
-ResultsfromalackofATP,whichcausesthe
musclestocontract,whichinturnimmobilizethe
joints
-Itstartsintheinvoluntarymuscles(heart,bladder)
thenprogresstohead,neck,trunk,extremities.
67Mr. Melvin Jacob MSc (N)

68. 68Mr. Melvin Jacob MSc (N)

69. 2.Algormortis
-Gradualdecreaseofthebodytemperatureafter
death.
-When bloodcirculationterminatesand
hypothalamusceasestofunction,bodytemperature
fallsdown.
69Mr. Melvin Jacob MSc (N)

70. 3.Livormortis
-Discolorationofbodyafterdeath.
-Afterbloodcirculationhasceased,theRBC
brokendown,-leadstodiscolorationof
surroundingtissues
70Mr. Melvin Jacob MSc (N)

71. 71Mr. Melvin Jacob MSc (N)

72. 4.Decomposition
-Tissuesafterdeathbecomesoftandeventually
liquefiedbybacterialfermentation.
-Thehotterthetemperature,themorerapidthe
change.
-Sobodiesarestoredincoolplaces/embalming
72Mr. Melvin Jacob MSc (N)

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74. 74Mr. Melvin Jacob MSc (N)

75. Care after death
•Physicianmustcertifythedeath
•Consentformforautopsy
•Provideoptionsfororgandonation
•Ifdeathduetoanyaccident,suicide,poisoning
etc.,itshouldbeinformedtolegalauthorities.
•Thebodyshouldnotbehandedoverwithoutany
legalwrittenpermission.
75Mr. Melvin Jacob MSc (N)

76. •Careofdeadbody,oftendependsuponthe
customsandreligiousbeliefs.Alsoconsider
anyinjuryorscaringoraccidentswhichcan
causethreattoothers.
•Nursesprovidedignityandsensitivitytothe
clientandfamily
•Checkordersforanyspecimens
76Mr. Melvin Jacob MSc (N)

77. •Askforspecialrequeststofamily(eg:shaving
,aspecialgown,Bibleinhand,rosaryatthe
bedside)
•Removealequipments,tubes,suppliesand
dirtylinens.
•Cleansethebodythoroughly,applyclean
sheets
•Brushandcombthehairs
77Mr. Melvin Jacob MSc (N)

78. •Theeyelidsareclosedandheldinplacefora
fewseconds,sotheyremainclosed.
•Denturesshouldbeinthemouthtomaintain
facialalignment.
•Mouthshouldbeclosed.
•Removealltheornaments,exceptwedding
bands(insomeinstances)
78Mr. Melvin Jacob MSc (N)

79. •Absorbentpadsareplacedunderthebuttocksto
takeupanyfecesandurinereleasedbecauseof
musclesphincterrelaxation
•Alltheorificesshouldbeclosed.
•Coverwithacleansheetuptothechin.
•Sprayadeodorizertoremoveunpleasantodor.
•Applynametag(wrist,rightbigtoe)
•Allowthefamilymemberstoviewthedeadbody
79Mr. Melvin Jacob MSc (N)

80. •Thebodyiswrappedina“shroud”alargepiece
orplasticorcottonmaterialusedtoenclosea
bodyafterdeath.Identificationisthenapplied
outsideoftheshroud.
•Handoverallthebelongingstotherelatives.
•Handedoverthedeadbodytotherelatives/sent
tothemortuary.
80Mr. Melvin Jacob MSc (N)

81. •Docompletedocumentationinthenursingnotes.
-Timeofdeathandactionstakentopreventthedeath.
-Whopronouncedthedeath.
-Anyorgandonation
-Personalarticlesleftonthebody
-Personalitemsgiventofamily
-Timeofdischargeanddestinationofthebody
-Locationofnametagsonthebody
-Specialrequestbyfamily
81Mr. Melvin Jacob MSc (N)

82. Conclusion
Thedyingpatienthasavarietyofneeds
rangingfromtheneedforopencommunicationto
physiologicalandspiritualneeds.Theyshould
maintainselfcareaslongaspossible.Familiesof
thedyingpatientmayliketoassistinproviding
care.Thenurseshouldprovideemotionalsupport
forthegrievingfamily.
82Mr. Melvin Jacob MSc (N)

83. 83
Before leaving let me ask
Do you need any clarification?
Mr. Melvin Jacob MSc (N)

84. Thank
you
84Mr. Melvin Jacob MSc (N)