Carr of terminal illness Fundamentals of nursing

Fundamentals of Nursing

1. Care of terminally ill

2. DEFINITION
•Terminal illness is a medical term used to describe a
disease that cannot be cured or adequately treated
and that is reasonably expected to result in the
death of the patient within a short period of time

3. IMPACT ON PATIENT
•Many patients realize that they are suffering from a terminal
illness, from nonverbal communication by their families
and by their health care professionals.
•Patients must be allowed to go through the stage of grieving
process and to make decisions about their care; they must
be supported in their decision making
•Competent patients have the right to consent and refuse
medical treatment, even life-sustaining treatmentand
should be made aware of this right.

4. IMPACT ON FAMILY
•The family and significant others of terminally ill patients
should be encouraged to participate in planning the
patient's care
•
•. Health care personnel should discuss the patient's
condition with the family members and support as the
family begins the grieving process
•
•The family may want to make arrangements with the patient
for funeral or memorial services

5. STAGES OF DYING ACCORDING TO KUBLER-
ROSS
•Denial: In denial and isolation stage, the patient denies that
he or she will die,and may isolate himself or herself from
reality
•Patient may think the doctor made a mistake in the
diagnosis or may be his/her records got mixed with someone
•Anger: In anger stage, patient expresses rage and hostility
and adopts ‘a why meattitude’

6. •Bargaining: In the bargaining stage, the patient tries to
barter for more time
•, many patients put their own personal affairs in order,make
wills and fulfill last wishes
•.Bargaining helps people to move into later stages of dying
•“Let me live untill my daughter s marriage”

7. •Depression: The patient goes through a period of grief
before death,the grief is characterized by crying and not
speaking much.
•“I dont know how my wife will get along after I am gone”
•.Acceptance: The patient feels tranquil. He or she has
accepted death and is ready to die, have no regrets
•. “I have done everything I wanted to”.

8. AIMS OF CARE OF TERMINALLY ILL PATIENT
•To improve the patient's and family's quality of life
•To provide prioritized careand symptom management
•To provide care of the multiple dimensionsof the illness
experience for both patients and families
•Promoting self care and self esteem
•Meeting client's needs
•manage life closure and the dying process
•Coping with loss and grief

9. THREE ESSENTIAL COMPONENTS FOR CARE OF
TERMINALLY ILL CLIENT
•1. Team work and partnership
•2. care for the needs
•3. Psychosocial support

10. Team Work and Partnership
•.Physician
•: The terminally ill patient comes in contact with many
different doctors during their illness
•. It might be their general practitioner, a hospital physician,
surgeon or oncologists.

11. •Nurses: Nurses working in medical, surgical or oncology
section are a part of the multiprofessional team andhave
specific post registration training in palliativecare
•
•.Physiotherapists, occupational therapists and speech
therapists
•.physiotherapists involved inrestoring musculoskeletal
function, prevention of deformity and prevention of
complications such as chestinfections.

12. •Occupational therapists
•maximizing patient's safety, independent living potential.
•Occupational therapists perform detailed assessment of
person's ability to carry out daily living tasks such as
feeding, dressing and mobilizing and helps to maintain and
use the skills

13. Social worker
•help the patient, family and care giversto deal effectively,
with the personal and social problems
•They provide the patient and family with advice on financial
matters and benefits
•. counseling and bereavement support for families.

14. Dieticians
•: The dietician's make a detailed assessment of patient's
individual needs
•. They can provide individual meal choices ,supplements
according to the patient's taste.

15. Pharmacists
•: The clinical pharmacist's roles
•provision of medicines
•
•they can advise on possible side effects
•Advice on drug interactions and best combinations to
avoid the side effects

16. Chaplains
•: Chaplains are excellent talkersand are also trained to listen.
•Many patients experience a huge range of emotions and
many people turn to be religiousduring this period.
•the chaplain can be relied on to comfort and care for the
bereaved family

17. Assessing and to Care for the Needs
•Physiological Needs
•Assessment
•Pain
•In a noresponsive client, agitation, restlessness, tense
muscles moaning, frowning of face can be assessed
for pain.
•Other measures are Wong Baker scale visual
analogue scale (VAS) used for measuring pain.

18. •Management
•regimen of analgesicsshould continue to receive those
medications as they approach the end of life.
•Assess the pain periodically and change the doses as
required.
•In case of opioids, a regimen to combat constipation should
be implemented.
•Patient controlled analgesia (PCA) pumps can provide the
patient with a sense of independence and manage the same
time.

19. •Dyspnea
•It is a subjective experience described as difficulty in
breathing or as an uncomfortable awareness of breathing
•the client's inability to carry out activities of daily living
(ADL), and perceived quality of life.
•To manage dyspnea, may be given:Anti anxiety agent,
bronchodilators, corticosteroids

20. •Maintain high Fowler's position
•Ensure drainage of secretions
•provide steam inhalation and chest physiotherapy
•Periodic suctioningis necessary
•Maintain adequate ventilation in the room
•Avoid overcrowdingaround the patient

21. •Skin and Mucous Membrane
•Patient should be comfortably placed and their position
should be frequently changed in the bed.
•The bedding should not be wrinkled
•Frequent skin care shouldbe given with particular attention
to the pressure points
•. Back massage is to be given
•Perineal care is to be given, to keep the patient clean and to
prevent skin breakdown.

22. •Catheterizationhas to be done in an incontinent patient
•Protect the eyes from corneal ulceration with protective
ointment
•Prevent drying of lips and skin breakdown
•Provide daily bath
•Assist in eliminationand keep the area clean
•Assist the patient in mobilization
•

23. •Nausea and Vomiting
•Provide small frequent meals
•Allow the patient to choose favorite foods and fluids
•Monitor the weight
•Provide Fowler's position and make the client to sit
upright after food intake for at least 15 minutes
•

24. •Provide anti-emeticshalf hour before the meals
•Provide adequate fluid intake
•Provide IV fluids if oral intake is inadequate
•
•Provide oral care after vomiting episodes
•Provide antacids

25. •Altered Nutrition
•Maintain a strict input and output chart
•Provide meals as per the taste of the client
•Provide a pleasant environment while meals are served
•. Serve the foodsas per the appropriate temperature
•Provide intravenous total (IV) fluids and parenteral nutrition
(TPN) in case the patient is not tolerating orally
•

26. •Maintain adequate hydration
•Provide a well-balanceddiet
•Do not force-feedthe patient
•Provide-home-cookedfood if allowed
•Prevent gas forming foods

27. •anorexia
•Offer small portions of food
•Avoid arguments at meal time
•Allow the patient to refusefoods and fluids.
•Cool foods may be better tolerated than hot foods

28. •Place nutritious foods at bedside(fruit juices, fruits, etc.)
•Schedule meals when family members are present to
provide company and stimulation
•Assist the patient to maintain a schedule of oral care.
•Rinse the mouth after each meal or snack.
•Use soft toothbrush, treat ulcers and lesions, and make sure
that dentures fit well

29. •Cachexia
•Cachexia is a complex syndrome associated with metabolism
offat causingmuscle wasting, loss of appetite and weight
loss.
•Ensuring good mouth care
•Maintaining pleasant surroundings
•Encouraging small and frequent meals
•Providing active and passive exercises
•Periodic weight checking
•Nutritional supplements.

30. •Bowel and Bladder Care
•Constipation
•Provide small frequent meals and increased fluid intake in
the diet
•Provide stool softeners
•Enemashould be given as per prescription
•Encourage mobilizationafter meals
•Establish a schedule for elimination

31. •Diarrhea
•Provide meticulous skin careduring diarrhea to prevent skin
breakdown
•Provide medicationsas prescribed to prevent diarrhea
•The food served should be properly cooked
•Proper hand-washing before meals should be ensured

32. •Keep the anal area dry and clean
•Change the linenand clothes when wet and soiled
•The hands of caregiver while feeding the patient should also
be clean
•Provide IV fluid in case of severe diarrhea and dehydration

33. •Bladder Care
•Maintain an intake and output chart
•Ensure adequate hydration
•Provide privacy
•Prescribe diureticsto be given
•Catheterizethe patient, if urinary incontinence prolongs
•Provide for skin care after urination

34. •Sleep Disturbances
•Impaired sleep
•Sleep is associated with tissue restoration.
•Sleep deprivation reducesimmune function.
•Excessive sleepiness is also disabling, resulting in an
inability to participate in treatment andsocial interactions.

35. •Interventions
•Promote a regular fixed sleeping pattern
•Staying out of bed during the day
•Minimizingnight time disruptions
•Keeping active, mentally or physically during the day
•Avoid stimulantslike coffee at night
•.Treat potential causescontributing to impaired sleep such
as nausea and vomiting, itching and respiratory problems
•A sedativecan be given, as prescribed by the physician

36. •Psychological Needs
•Delirium
•Characterized by concurrent disturbances of level of
consciousness, attention, thinking, perception, memory,
psychomotor behavior, emotion and the sleep wake cycle.
•It is often identified as a sudden and significant decline in
level of functioning

37. •Intervention
•Haloperidolmay reduce hallucinations and agitations
Benzodiazepinesreduce anxiety
•Treat the underlying cause such as hypoxia, dehydration,
hypercalcemia, hyponatremia, sepsis, etc.
•Teach the family how to interact with the client

38. •Provide safetyof the patient
•Spiritual intervention
•music therapy
•gentle massage and therapeutic touchmay provide some
relief
•Avoiding harsh lighting or very dim lighting.
•The presence of familiar faceshelps ingentle reorientation

39. •Depression
•weight loss or gain, insomnia or hypersomnia, agitation
•motor retardation, fatigue or loss of energy, guilt feelings
and concentration difficulties.
•, unrecognizedas many of the .clinical manifestations of
depression likefatigue, anorexia ,weight loss, can be dueto
the disease process

40. •Interventions
•Emotional and spiritual support
•Control of physical distressing symptoms
•antidepressants
•.Presence of relatives
•Provide space and time for family to experience sadness and
to grieve
•Pharmacological intervention with psychostimulants,

41. •Spiritual Needs.
•Spiritual coping strategies enhance self empowerment
•spiritual counseling and support
•Obtain information regarding significant religious rituals,
beliefs and practices
•Encourage their practice to the maximum extent possible.

42. Need ofthe Family Members
•. Support the expression of feelings
•Encourage the telling their feelingsusing open-ended
questions or statements, e.g., tell me about your husband
•Assist to find an outlet for his or her feelingsby talking,
attending a support group or writing letters that will not be
mailed.
•Assess coping skills and social support

43. PALLIATIVE CARE
•Palliative care focuses on care of the whole person: body,
mind and spirit and heart and soul.
•The goal is to give patients the best quality of life they can
have by management of symptoms.
•is a type of care that focuses on alleviation of a client's
symptoms and not to cure.

44. Principles of Palliative Care
•• Palliative care looks after the medical, emotional, social,
and spiritual needs of the dying person,
•Palliative care supports the needs of the family members
helping them forcare giving and even supporting them as
they grieve.
•Palliative care look after the complete needs of the patient.

45. HOSPICE CARE
•Hospice is a coordinated program of interdisciplinary
services provided by professional caregivers to patients
with serious illness.
•In hospice setting, the patient and family together are a
unit of care
•Hospice care can take placeAt homeor At a hospice center
•A hospice care team typically includes: doctors. Nurses,
home health aides spiritual counselors

46. DEATH
•Definition
•Death is defined as: "cessation of heart-lung function, orof
whole brain function, or of higher brain function.
•“ irreversible cessation of circulatory and respiratory
functions or irreversible cessation of all functions of the
entire brain, including the brain stem.”

47. •Clinical Death
•Clinical death is the medical term for cessation of blood
circulation and breathing,
•This is called cardiopulmonary arrest,a period when a
person's heartbeat and breathing stop, but can still be
revived if early medical attention is given

48. •Biological Death
•it occurs four-six minutes after clinical death.
•without the blood coming from the heart, the brain
gradually ceases to function until it achieves irreversible
damage.

49. •Immediate Signs of Death
•The respiration becomes labored, irregular, rapid or very slow,
•noisy breathing (death rattle) sound of secretions moving in the
airway
•.There is a weak thready pulse and falling blood pressure
•The heart rate decreases
•As the oxygen supply to the brain decreases, the patient may
become restless

50. •The skin becomes pale and cool, there is peripheral
cyanosis, the skin loses its turgor
•The extremities are cold to touch
•The sightgradually fails, the pupils fail to react to light, and
sunken eyes are present
•Mental confusionarises
•Urinary output may decrease
•There may be incontinence of urine
•Difficulty talkingor swallowing.

51. Changes in Body after Death
•Rigor mortis:
•Body becomesstiff within 4 hours after death as a result of
decreased adenosine triphosphate (ATP

52. •Algor mortis:
•Temperature decreasesby a few degrees each hour.The skin
loses its elasticity and will Tear easily
•
•Livor mortis:
•Bluish color of death also known as hypostasis.discoloration
of the skin due to the pooling of blood in the dependent
part of body following death.

53. Signs of Impending Death
•Physical Signs
•As death approaches, the patient grows physically weaker
and spend more time sleeping.
•appetite decreases and the patient may refuse even favorite
foods and later fluids also
•Moistening the patient's lips and mouth, and providing
oral hygiene, are more comfortable than “pushing” food or
fluids.

54. •Urine output decreases and urine becomes more
concentrated.
•There may be edema of the extremities or over the sacrum
•Incontinencemay occur as patient becomes less aware of
his surroundings.

55. •Vital signs change as death approaches
•. The pulse increases and becomes weaker and thready.
•Blood pressure declines, and the skin of the extremities
becomes cool and clamy.
•Respirationsbecome shallow and irregular.
•There may be pooling of secretions in the lungs and causes
respirations to sound moist “death rattle".
•Cheyne stoke respirations may be noted, i.e. periods of
apnea (no breathing) followed by shallow breathing.
•Body temperaturemay rise, and the patient may complain
of feeling hot or cold.

56. Psychosocial and Spiritual Aspects of Dying
•the patient reaches the stage of acceptance.
•the patient talks about making funeral arrangements.
•say good bye to those people and thingsthat are important.
•It may also involve saying “I am sorry, forgive me”, “I forgive
you,” and “I Love you”.
•the patient may give to family and friends special memories
or possessions

57. •their spiritual needs has greater importance.
•Religious practices and rituals have great significance
•It is important to be familiar with those beliefsand nurse
mudtnot impose own religious beliefs on dying patient
•family, but assist patients to find comfort and support in
their own belief systems

58. •the patient becomes less verbal and more withdrawn.
•Everyday activities and news are not of interest and
nonverbal communication becomes most important.
•Sitting with patient and holding his hand or stroking his hair,
are most meaningful.
•be aware of remarks made in presence of an unresponsive
patient asthey couldhear. Hearing is last senseto be lost
death

59. •Dying patient exhibit confusion
•He may report dreams or visions of seeing unrelated faces
and objects,this is comforting and he may speak of
preparing fora journey to join loved ones.
•At times patient may become restless and agitated.
•Adequate pain and anxiety medicationcan ease the distress

60. The procedure of care of dead
•according to the policy of the hospital, which is according
to the state laws
•Immediate notificationof the officials
•General consideration for other patients in the ward
•Preparation of the body for transfer to home/ morgue

61. •The nurse notifies the physician and the ward sister
•When the death occurs following certain communicable
diseases such as smallpox, the body requires special
attention to prevent the spread of the disease
•. if the patient has ceased breathingIt is the dutyof
physician to declare death of the client

62. •The personal care after death needs to be carried out within
2-4 hoursof the person dying to preserve their appearance,
•Pack personal property.
•Discuss theissue of soiled clothes sensitivelywith the family
and ask whether they wish them to be disposed off or
returned
•.

63. Organ donation:
•Organ Donation is donating a donor's organs like heart, liver,
kidneys, intestines, lungs, and pancreas, after the donor dies,
for the purpose of transplanting them into another person
who is in need of an organ

64. Once the brain death has been confirmed, the patient will
remain connected to the ventilator
•members of the medical team speak with the person's
family about donation.
•If the familysupports. The person will remain connected to
the ventilator during this time to keep blood and oxygen
circulating to the organs
•donation of eye, heart,lung,bone ,liver ,kidneys,pancreas,
skin tissues etc can be donates

65. •medical condition of the person at the time of death can
determine what organs and tissues can be donated
•Organs need to be removed as soon as the person is
declared brain-dead.
•Without the necessary oxygen supply, the organs stop
functioning

66. •The medicolegal case:
•If death is caused by accident, suicide, homicide, etc. it
should be brought to the notice of legal authorities
•the body should not be handed over to the relatives without
the permission of the legal authorities

67. Autopsy
•It is the examination of the body of a dead person.
•Autopsies are performed to determine the cause of death,
for legal purposes, for education and research
•the doctor gets the consent from relatives
•The concerned authority's signature should be obtained
while handing over the body in the death performa
•.

68. •The personal protective equipments should be worn while
handling the body
•The waste management protocol must be followed
•Disinfectionof the patient's room ,articles and equipments
used should be done
•Ifthe family members want to be involved in the care,it
has to be dealt as per the institutional policy.

69. •AUTOPSY
•Autopsy is defined as the medical procedure that consists of
a thorough examination of a corpse to determine the cause
and manner of death and to evaluate any disease or injury
that may be present.
•It is an examination of the organs and tissues of a human
body after death.
•Autopsy is usually performed by pathologist.

70. Purposes of Autopsy
•Autopsy is done mainly for two reasons
•1. Legal purpose
•2. Medical purpose
•Legal Purpose
•Included inforensic autopsy
•. Forensic autopsy is done in case the deceased is having the
clinicalor medicolegalbackground.to identify Cause and
evidence of death

71. •Medical Purpose
•It includes academical autopsy.
•It is done to find out the unknown cause of death.
•To identify the extend of diseasethat the patient had .or
the death is due to the medical or surgical cause

72. Types of Autopsy
•Internal Autopsy
•In this, the dead body is dissected and the internal organs
are examined.
•For this, consentfrom the relativeor spouse is taken.
•It is commonly the physician's responsibility to obtain
consent for autopsy.
•The nurse can assist by explaining reasons for autopsy.
•It is only done if it is required by law.

73. External Autopsy
•This does not require any consent.
•This is the external examination of dead body.
•Making an inspectionof the body to locate a cause of death

74. •Procedure
•The body is received in body bag
•. The body is then photographed from all anglesto look for
any external injury
•. , ultraviolet searchis done to look for any minute
abrasions, hairs, nails etc.
•radiographyof the body is done to rule out any bone
fracture.
•Then any external wound, if present, is examined.
•

75. •After that, the body is dissected.
•The actual part of internal dissection depends upon the
cause of death. The part that is involved is left intact
•After autopsy all the internal organs are replaced before
handing over the body to the relatives.

76. EMBALMING
•Embalming is the art and science of preserving human
remains by treating with chemicals to delay
decomposition.
•The intention is to keep them suitable for public display at a
funeral, for religious reasons, or for medical and scientific
purposes such as “anatomical specimens”.

77. Embalming Process
•The first stepin the embalming process is surgical, in which
bodily fluids are removed and are replaced with
formaldehyde-based chemical solutions.
•The second step is cosmetic, in which the body is prepared
for viewing by styling the hair and facial features.

78. Preparing the Body for Embalming
•the body is washed in a disinfectant solution and the limbs are
massaged and manipulatedto relieve rigor mortis
•Any facial hair is shavedoff, unless the person who died hadfacial
hair.
•Setting the Facial Features
•The eyes are closed, after using skin glue
•plastic flesh-colored oval-shaped “eyes caps” are fixed on the eye to
secure the eyelid
•The mouth is closed and the lower jaw is secured,by sewing or with
wires.

79. Arterial Embalming
•the blood is removedfrom the body
•the blood vessalsand replaced with an embalming solution
•The embalming solution is usually a combination of
formaldehyde, glutaraldehyde, methanol, ethanol, phenol,
and water,and may also contain dyes in order to stimulate a
life-like skin tone

80. Cavity Embalming
•a small incisionis made near the belly button
•a sharp surgical instrument called a trocar, is inserted into
the body cavity.
•organs in the chest cavity and abdomen are punctured .
•gas and fluid contentsare drained outand then filledwith
formaldehyde chemical mixture
•The incision is closed and at this point the body is fully
embalmed.