RLE 9

Post mortem careAnd

Discharging a patient

BSN3K

Dinsay, BeaGalarse, KristinaRafanan, Andrea

Suficiencia, RutchieTabasa, Apple

Villamonte Jenny

POST MORTEM CARE

Objectives

After 3 hours of varied learning activities, the level III students will be able

to:

1. define the following terms:

1.1. post mortem care

1.2. autopsy

1.3. Cheyne-stokes respiration

1.4. coroner

1.5. deceased

1.6. death

1.7. embalming

1.8. expired

1.9. forensic medicine

1.10. grief

1.11. inquest

1.12. medical examiner

1.13. morgue

1.14. mourning

1.15. mortician

1.16. shroud

2. state the purposes of post mortem care

3. enumerate the clinical signs of impending death

4. cite the physical signs of impending death

5. identify the physiologic changes after death

6. differentiate the stages of grieving

7. explain the procedures occurring after death

8. discuss the guidelines of post mortem care

9. give the nursing responsibilities before, during, and after post mortem

care

10. demonstrate beginning skills in performing post mortem care

DEFINITION OF TERMS1. 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

2. Autopsy – an examination of the body after death by a pathologist to determine the cause of death and to learn more about a disease process

3. Cheyne-Stokes Respiration – rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure, increased intracranial pressure, or brain damage

4. Coroner – is a public official, not necessarily a physician, appointed or elected to inquire into the causes of death, when appropriate

5. Deceased – term given to a person who is dead6. Death – irreversible cessation of life7. Embalming – to treat a corpse with preservatives in order to prevent

decomposition; the act of preserving a body8. Expired – to emit the last breath; die9. Forensic Medicine – branch of medical science that is concerned with

establishing evidence for legal proceedings; application of medical knowledge to law

10. Grief – total response to the emotional experience related to loss which is manifested in thoughts, feelings, and behaviors associated with overwhelming distress or sorrow

11. Inquest – a legal inquiry into the cause or manner of death12. Medical Examiner – a physician and usually have advanced

education in pathology or forensic medicine who investigates the causes of death

13. Morgue – a room or building usually run by a state or municipal government in which bodies are kept until they are autopsied or identified

14. Mourning – the behavioral process through which grief is eventually resolved or altered

15. Mortician – a person trained in the care and disposal of the dead; also referred to as undertaker

16. Shroud – a large piece of plastic or cotton material used to enclose a body after death

PURPOSES OF POST MORTEM CARE to aid in preserving the physical appearance of the deceased to prevent discoloration and damage of the corpse skin to safeguard all the belongings of the deceased

to support family members during the initial hours of their bereavement

to show respect for the deceased

CLINICAL SIGNS OF IMPENDING DEATH Loss of Muscle Tone

o Relaxation of the facial muscles (e.g., the jaw may sag)o Difficulty in speakingo Difficulty of swallowing and gradual loss of the gag reflexo Decreased activity of the gastrointestinal tract, with subsequent

nausea, accumulation of flatus, abdominal distention, and retention of feces, especially if narcotics or tranquilizers are being administered

o Possible urinary and rectal incontinence due to decreased sphincter control

o Diminished body movement Slowing of the Circulation

o Diminished sensationo Mottling and cyanosis of the extremitieso Cold skin, first in the feet and later in the hand, ears, and nose (the

client, however, may feel warm because of elevated temperature)o Slower and weaker pulseo Decreased blood pressure

Changes in Respirationso Rapid, shallow, irregular, or abnormally slow respirationso Noisy breathing, referred to as the death rattle, due to collecting of

mucus in the throato Dry oral mucous membranes

Sensory Impairmento Blurred visiono Impaired sense of taste and smell

PHYSICAL SIGNS OF IMPENDING DEATH Musculoskeletal System

o Generalized weakness and fatigueo Loss of overall muscle toneo Relaxed facial muscles resulting in sagging jawo Bowel and bladder incontinenceo Decreased gag reflex and difficulty swallowing

Gastrointestinal systemo Anorexia and decreased oral intakeo Decreased or lack of swallow reflexo Dehydration

o Decreased peristalsiso Possible diarrhea

Cardiovascular systemo Alterations in vital signso Decreased peripheral circulationo Extremities begin to appear cyanotic and mottled and become coldo May perspire or run a fevero Poor skin turgoro Edemao Reduced rate of absorption of medications from tissueso Diminished kidney percussion with decreased urine output

Respiratory systemo Altered patterns or respiration such as labored breathingo Adventitious bubbling lung sounds "death rattle"o Irritation or tracheobronchial airway as evidenced by hiccupso Poor gas exchange

Neurological systemo Altered level of alertnesso Increased drowsiness, sleeping, unresponsiveo Periods of mental cloudinesso Possible agitation and restlessnesso Possible blurred visiono Intact sense of hearing

PHYSIOLOGIC CHANGES AFTER DEATHDeath 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. Rigor Mortis (Post Mortem Rigidity)

Rigor Mortis, or stiffening of the body after death, is due to the disappearance of adenosine triphosphate (ATP) from the muscle. ATP is the basic source of energy for muscle contraction. After death, the generation of ATP stops, though consumption continues. In the absence of ATP, actin and myosin filaments in the muscle become permanently complexed and rigor mortis sets in. It usually begins 2-4 hours after death, and fully develops in 6-12 hours. The full intensity of this process generally occurs within 48 hours. Eventually, and usually within 96 hours, there is complete exhaustion of chemical activity and the rigor passes. Rigor mortis is first evident in the muscles of the jaw, and then extends to involve all the muscles in the body. The body is fixed in the position in which it lies.

Algor Mortis (Post Mortem Cooling)Algor Mortis refers to post mortem cooling. After the circulation

stops and the hypothalamus ceases functioning, the internal body temperature begins to fall at approximately 1ºC per hour. Cooling of the brain tissues occurs at a slightly faster rate. The temperature continues to fall until it reaches or approximates room temperature, which is why the skin feels cold to the touch.

Livor Mortis (Post Mortem Lividity)Livor Mortis is a reddish purple discoloration in dependent areas of

the body due to accumulation of blood in the small vessels of the dependent areas secondary to gravity. It is first evident about 30 minutes after death and fully develops in 6-10 hours. Dependent areas resting against a firm surface will appear pale in contrast to the surrounding livor mortis due to compression of the vessels in this area, which prevents the accumulation of blood.

PutrefactionThe body decomposes as a result of bacterial and microorganism

action. In general, decomposition begins within 24 to 30 hours of death, and its start can be seen in the greenish discoloration of the right lower abdominal area. This is because the skin in this area is over the first part of the large colon (cecum) where large amounts of intestinal bacteria reside. The discoloration is followed by gaseous bloating and a greenish discoloration of the face, along with fluids being purged from the mouth. As decomposition continues, the tongue swells and protrudes from the mouth, and the eyes bulge. The discoloration of the face begins to spread to the chest and arms within about 48 hours. As decomposition progresses, the skin begins to slip, and after three days the body becomes bloated. The shedding of the skin of the hands, including the fingernails, is called gloving; the shedding of the skin around the feet and legs is called stocking.

STAGES OF GRIEVING Denial Stage

o It is the stage where there is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned.

o The individual is not ready to deal with the reality of the illness and act as though nothing has happened and may refuse to believe that a loss has occurred.

o He is unready to deal with practical problems, such as prosthesis after loss of leg and may assume artificial cheerfulness to prolong denial.

o The client may have feelings of isolation, may search for another health care professional who will give a more favorable opinion, and may seek unproven therapies.

o Some people can become locked in this stage when dealing with a traumatic change that can be ignored.

o Common statements: “This cannot be true.” “This can’t be happening, not to me!”

Anger Stageo The client often generally expresses anger.o Anger can be manifested in different ways. People dealing with

emotional upset can be angry with themselves, and/or with others, especially those close to them.

o The client may have feelings of rage, resentment or envy directed at God, health care professionals, family, or others.

o He and his support persons may be uncharacteristically demanding and find faults with small matters.

o Common statements: “Why is this happening to me?” “How can this happen, I hate this world!”

Bargaining Stageo It is a way of trying to change the inevitable.o Bargaining rarely provides a sustainable solution, especially if it is a

matter of life or death.o The patient and/or family please for more time to reach an

important goal. The promises are sometimes made with God.o He seeks to bargain to avoid loss and may express feelings of guilt

or fear of punishment for past sins, real or imagined. o The individual attempts to make deals in a subtle or overt manner

to prevent the loss.o Common statements: “I promise I’ll be a better person if...” “I just

want to see my grandchild’s birth, then I’ll be ready...” “I will give my life savings if...”

Depression Stageo This stage occurs when the loss is realized and the full impact of its

significance is apparent. It is also known as preparatory grieving.o The individual experiences sadness, grief, and mourning for

impending losses; and feels overwhelming loneliness and withdrawal.

o He grieves over what has happened or what cannot be. He may talk freely or may withdraw.

o Common statements: “I don’t care anymore.” “I just don’t know how my kids are going to get along after I’m gone.” “I’m going to die... What’s the point?”

Acceptance Stageo This stage definitely varies according to the client’s situation,

although broadly it is an indication that there is some emotional detachment and objectivity.

o In this stage, the individual comes to terms with his or her reactions and makes plans.

o The patient and/or family are neither angry nor depressed.o He may have decreased interest in surroundings and support

people and may wish to begin making plans (e.g., will, altered living arrangements) and complete necessary business arrangements.

o Common statements: “I’m ready for whatever comes.” “I’ve lived a good life, and I have no regrets.”

PROCEDURES OCCURRING AFTER DEATH

Pronouncement of Death and Death Certificateo 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.

o Consent must be given by the closest surviving family members.o After an autopsy, hospitals cannot retain any tissues or organs

without the 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 Donationo 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.

GUIDELINES OF POST MORTEM CARE Show respect and preserve the client’s dignity by working quietly and

maintaining privacy.

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.

Ensure that none of the client’s property or personal belongings is lost. Dispose soiled dressings, linens, and other equipment properly. Observe standard precaution while performing post mortem care. Bathe and dress over leaking wounds. Clean up body thoroughly. Allow the family to say goodbye through touching and talking. Assure proper identification of the body by placing identification tags

on the hand and foot, or according to agency protocol. Do not cover the client’s face when the family is viewing the body. 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

Beforeo 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.

Duringo 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.

Aftero Do after care.o Transfer the body from the bed to a stretcher for transport to the

morgue.o Document the procedure.

BEGINNING SKILLS

1. Check the chart for the physician’s certification of the death of the patient.

2. Ask permission and explain to the significant others that you are going to perform post mortem care.

3. Prepare the necessary materials.4. Ask the family if they wish to remain inside the room during the

procedure.5. If in the ward, draw curtains to provide privacy.6. Pour lukewarm water into the basin.7. Put on clean gloves. Remove jewelry or any personal items of the

patient and give them to the significant others.8. Close patient’s eyes. Put on dentures, if any. Then close the patient’s

mouth.9. Remove all equipment, tubes, supplies, and dirty linens according to

hospital protocol.10. Dip wash cloth in basin with lukewarm water then wrap it around

your hand to form a mitten. Using circular strokes, wet patient’s forehead, eyes, cheeks, nose, mouth, and ears. Using the same technique, soap the areas mentioned. Then wash with lukewarm water, still using the same technique.

11. Get cotton balls and put them on patient’s closed eyes, in the nares, and in the outer ear. Then secure each with a tape lengthwise.

12. Secure the patient’s jaw with a cravat.13. Drape the patient with a blanket, then remove the top sheet

underneath.14. Remove patient’s clothes carefully as to not expose any body

part.15. Perform bed bath on the patient.

a. Expose farther arm. Place bath towel under it. Perform step # 10 on this body part. Then dry thoroughly.

b. Expose the other arm. Do the same procedure.c. Using the same technique, wet, soap, and rinse the chest,

abdomen, sides, and pubis.d. Turn patient towards you. Place the towel lengthwise under the

patient’s back, down to the buttocks. Wet, soap, and rise the back and the buttocks thoroughly.

e. Expose patient’s farther leg. Place towel under it. Wet, soap, and rinse thigh, leg, groin, and foot.

f. Do the same thing to the leg nearer you.g. Finish the bath doing the same to the patient’s genitalia

16. Put on the diaper, underwear, and patient’s new clothes.17. Remove bath blanket.18. Give the family option to view or not to view patient and

accompany them as they do so.19. Encourage the family to say goodbye through touching and

talking.

20. Do not rush this process. Once the family is more comfortable, ask if they would like to be left alone.

21. Apply nametags on the hand and foot.22. Cover and secure the patient with the shroud. Secure the shroud

with safety pins. Secure another nametag on the shroud.23. Transport patient to the morgue.

DISCHARGING A PATIENTObjectivesAfter 3 hours of varied learning activities, the level III students will be able to:1. enumerate the phases of the discharge process2. identify the elements of a written discharge3. state the purposes of discharging the patient4. cite the reasons for discharge5. enumerate the procedures to be performed before and on the day of

discharge6. identify nursing responsibilities of discharging a patient

PHASES OF THE DISCHARGE PROCESS1. Acute Phase – medical attention dominates discharge-planning efforts2. Transitional Phase – the need for acute care is still present, but its

urgency declines and clients begin to address and plan for their future health care needs

3. Continuing Care – the clients are able to participate in planning and implementing continuing care activities needed for discharge

ELEMENTS ON WRITTEN DISCHARGE Mode of Discharge – ambulatory, wheelchair, and stretcher Instructions for self-care activities – activities, diet, medication, special

treatment such as wound care, self-catheterization, and tracheostomy care

o Signs and symptoms of complications or drug reactions to be observant for.

o Signs and symptoms that is normal for the individual.o Correct setting for any equipment required.o Planned to follow-up appointment of physician's office/ clinic.o Explanation of pertinent emergency procedures.

Client’s signature showing understanding of instructions

PURPOSES OF DISCHARGING THE PATIENT to ensure that the client has the proper knowledge and skill to perform

self-care after discharge to return patient to a state of independent living to ensure adequate home health care support to minimize client’s anxiety after discharge to prepare a client to move from one level of care to another within or

outside the current healthcare facility to maintain a safe level of self-care

REASONS FOR DISCHARGE The patient has completed treatment and no longer needs the medical

care provided in that particular service The patient does not comply with the plan of care despite the efforts to

help him/her understand the steps in the treatment plan and the importance of the treatment

The patient has recovered The patient’s condition has stabilized Death

PROCEDURES TO BE PERFORMED BEFORE AND ON THE DAY OF DISCHARGE

Before the Day of Discharge1. Collaborate with the client, support persons and/or the home care

nurse regarding needs required in the home.

Adaptations in the home environment can often contribute to the independent functioning and to a client's safety.

2. Establish a teaching program for the client during hospitalization.The program may include on how to give injections, colostomy

care and diet. Provide written information when possible (people usually need time to practice new skills and ask questions). Written information can be referred to after discharge.

3. Provide the client and support persons with information about any community health resources that may be helpful.

Most communities have a variety of sources that can support client's and help meet their continued health needs e.g. meals on wheels and day care center for the elderly.

4. Complete referral form.Nurses make referrals for health care services in collaboration

with the physician. The nurse may be the first person to recognize the client's needs for a dietitian, home care nurse, nutritionist or social worker.

On the Day of Discharge1. Verify and implement the physician's discharge orders.

o Check out the physician's order for discharge has been written. Only the physician authorizes discharge.

o Verify orders for prescriptions, charge in therapies or need for special appliances. Checking the orders early enables the nurse to implement any procedure required in with relevance for discharge.

2. Review health care instructions and needs with the client.o Instruct client and/or support person about the dosage and

frequency of administration, precautions, and or any other relevant information of all prescriptions or medications ordered by the physician. Proper instruction about medication ensures correct drug administration and achieves the intended benefit for the client.

o Allow the client and/or support person to ask questions about medications, physical care and supplies. This relieves the anxiety about self-care and facilitates final classification of information and compliance with required care.

o Provide the client with necessary written instructions, pertinent pamphlets and supplies. Some agencies provide at discharge limited a supply of syringes, dressing materials and crutches.

3. Determine whether the client's transportation for home has been arranged.

o Note the time arranged for transport and the method of transport. The client's condition will determine the method of transportation.

o Usually client's and or support persons are responsible for making arrangements for their own transportation. If an ambulance is required at some agencies the nurse may telephone to make the arrangements.

4. Assist the client as required to perform any hygiene measures, dress and pack all personal belongings.o Check whether the client being discharged to a nursing home

may wear bed clothing.o Check all closets and drawers to ensure that all belongings are

packed.o If there are valuables in safekeeping, obtain the clients signature

on the release form and return all valuables listed.o Inspect and change all surgical dressings required.

5. Ensure that all required hospital departments are notified of the discharge.o Notify admitting, dietary housekeeping, business office and or

cashier. Usually the unit desk performs this function.o Notification enables these departments to prepare for the next

generation.o Confirm that the business office has completed its procedures. If

it has not, make arrangements for paying are usually made at the time of admission.

6. Escort the client from the nursing unit to the arranged mode of transport.o Contact the transport service or obtain a wheelchair if required

unless an ambulance will be used.o Obtain a utility cart to transport personal affects if the client

cannot hold them because of the danger of overexertion, some hospitals require that a wheelchair be used even though the client feels and is able to work. The ambulance crew will have a stretcher for the person who needs an ambulance. This ensures a safe exit from the agency.

o Lock the wheels of the chair. Raise the foot support. Then assist the client into the wheelchair and support the feet appropriately. Locking the wheels prevent the chair from moving and thus project the client's safety.

o Take the client and the personal belongings to meet the arranged transportation.

7. Report and document the client's dischargeo Report to the nurse in-charge and or the unit clerk that the client

has been discharged.

o Document on the client's chart the discharge time, mode of transport to the agency door and assessment data. Some agencies also suggest that the client’s destination be included in the discharge notes.

8. Write a discharge profiles as referral summary for specified institution or community health nurse.o Include any active health problems, current medication, current

treatments that are to be continued eating and sleeping habits, self-care abilities, support networks, lifestyle patterns and religious preferences.

NURSING RESPONSIBILITIES OF DISCHARGING A PATIENT Assess needs of client on the day of admission and continue

assessment during hospitalization. Involve the client / family in the discharge process. Provide written and verbal instructions at the client / family’s level of

understanding. Verbally explain instructions to client / family prior to discharge and

provide client / family a written copy. Ascertain that client has follow-up care arranged at discharge. Provide verbal and written information on what signs and symptoms to

observe and when to contact the physician. Assess if any community resources should be used and contact

appropriate personnel. Document all discharge teaching on Discharge Instruction Sheet and

Nursing notes. If the client is determined to leave against medical advice (AMA), ask

him or her to sign a special form which releases the physician and agency from future responsibility of any complication.

Ensure that all discharge instructions have been provided. Provide a written summary of discharge instructions.

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 applicableo who pronounced the death of the cliento who was called and who came to the hospitalo personal articles left on the body and taped to skin or tubes left ino personal items given to the familyo time of discharge and destination of the body

o location of name tags on the bodyo special requests by the familyo any other statements that might be needed to clarify the situation

Medical forms must be signed by a doctor or registered nurse.