Nursing Assignments

Care of Unconsciousness Patient

2012-05-28T00:26:00.001-07:00

CARE OF UNCONSCIOUSNESS PATIENT

Loss of Consciousness is apparent in patient who is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. A person who is unconscious and unable to respond to the spoken words can often hear what is spoken.

Consciousness is a state of being wakeful and aware of self, environment and time

Unconsciousness is an abnormal state resulting from disturbance of sensory perception to the extent that the patient is not aware of what is happening around him.

Levels of Unconsciousness

1. Alert :

- Normal consciousness

2. Automatism :

Aware of surroundings
May be unable to remember actions later
Possible abnormal mood, may show defects of memory and judgement

3. Confusion :

Loss of ability to speak and think in a logical coherent fashion
Responds to simple orders
May be disorientated for time and space

4. Delirium/Acute confusion with agitation :

Characterised by restlessness and possible violence
Not capable to rational thought
May be troublesome and not comply with simple orders

5. Stupor :

Quite and uncommunicative
Remains conscious but sits or lies with a glazed expression
Does not respond to orders
Bladder and rectal incontinence occur
More serious than the previous wild stage

6. Semi-coma :

A twilight stage
Patients often pass fitfully into unconsciousness
May be aroused to the stuporosed state by vigorous stimulation

7. Coma :

Patient deeply unconscious
Can not be roused and does not wake up with vigorous stimulation

Causes of Unconsciousness :

Head Injury
Skull Fracture
Asphyxia
Fainting
Extremes of Body Temperature
Cardiac Arrest
Blood Loss
Cerebro vascular Accident
Epilepsy
Infantile Convulsions
Hypoglycemia
Hyperglycemia
Drug Overdose
Hypothermia
Poisonous Substances and Fumes

Assessment of unconscious patients:

History

Physical assessment

Glasgow coma scale

Eye opening

spontaneous -4

to speech -3

to pain -2

no response -1

Verbal response

oriented -5

confused -4

inappropriate words -3

incomprehensible sounds-2

no response -1

Motor response

Obeys commands -6

Localizes -5

Withdraws -4

Flexes -3

Extends -2

No response -1

TOTAL SCORE: 3-15

Assessment of LOC

Evaluation of mental status.
Cranial nerve functioning.
Reflexes.
Motor and sensory functioning.
Scanning, imaging, tomography, EEG.
Glasgow coma scale.

Nursing Diagnosis

Ineffective airway clearance related to altered level of consciousness
Risk for injury related to decreased level of consciousness.
Risk for impaired skin integrity related to immobility
Impaired urinary elimination related to impairment in sensing and control.
Disturbed sensory perception related to neurologic impairment.
Interrupted family process related to health crisis.
Risk for impaired nutritional status.

Management

1. Maintaining patent airway

Elevating the head end of the bed to 30 degree prevents aspiration.
Positioning the patient in lateral or semi prone position.
Suctioning.
Chest physiotherapy.
Auscultate in every 8 hours.
Endo tracheal tube or tracheostomy.

2. Protecting the client

Padded side rails
Restrains.
Take care to avoid any injury.
Talk with the client in-between the procedures.
Speak positively to enhance the self esteem and confidence of the patient.

3.Maintaining fluid balance and managing nutritional needs

Assess the hydration status.
More amount of liquid.
Start IV line.
Liquid diet.
NG tube.

4.Maintaining skin integrity

Regular changing in position.
Passive exercises.
Back massage.
Use splints or foam boots to prevent foot drop.
Special beds to prevent pressure on bony prominences.

5.Preventing urinary retention

Palpate for a full bladder.
Insert an indwelling catheter.
Condom catheter for male and absorbent pads for females in case of incontinence.
Inducing stimulation to urinate.

6. Providing sensory stimulation

Provided at proper time to avoid sensory deprivation.
Effort are made to maintain the sense of daily rhythm by keeping the usual day and night patterns for activity and sleep.
Maintain the same schedule each day.
Orient the client to the day, date, and time accordingly.
Touch and talk.
Proper communication.
Always address the client by name, and explain the procedure each time.

7. Family needs

Family support.
Educate the needs of client.
Care to be provided.

8. Potential complications

Respiratory distress
Pneumonia
Aspiration
Pressure ulcer

Nursing Care of Physically Challenged

2012-05-28T00:06:00.002-07:00

NURSING CARE OF PHYSICALLY CHALLENGED

FRACTURES

A fracture is a discontinuity or break in a bone. The five major fracture classifications as follow:

1. Incomplete: Fracture involves only a portion of the cross-section of the bone. One side breaks; the other usually just bends (greenstick).

2. Complete: Fracture line involves entire cross-section of the bone, and bone fragments are usually displaced.

3. Closed: The fracture does not extend through the skin.

4. Open: Bone fragments extend through the muscle and skin, which is potentially infected.

5. Pathological: Fracture occurs in diseased bone (such as cancer, osteoporosis), with no or only minimal trauma.

Stable fractures are usually treated with casting. Unstable fractures that are unlikely to reduce may require surgical fixation.

NURSING CARE OF THE PATIENT WITH A PLASTER CAST

Although a patient with an arm or leg cast is much more self-reliant than a patient in a body or spice cast, it is a nursing responsibility to monitor all patients and assist as needed. Nursing management includes the following actions to assess the effectiveness of the cast.

Check the edges of the cast and all skin areas where the cast edges may cause pressure. If there are signs of edema or circulatory impairment, notify the charge nurse or physician immediately.
Slip your fingers under the cast edges to detect any plaster crumbs or other foreign material.
Move the skin back and forth gently to stimulate circulation
Lean down and smell the cast to detect odors indicating tissue damage. A musty or moldy odor at the surface of the cast may be the first indication that necrosis from pressure has developed underneath.
Check the integrity of the cast by looking for cracks, breaks, and soft spots.
The casted body part must be examined and assessed frequently in order to prevent complications.
Assess the casted part by checking the following.

Assess circulation by performing the blanching test and comparing the skin temperature and blanching reaction of the affected limb to that of the unaffected limb.
Assess the presence of sensation in the affected limb by touching exposed areas of skin and instructing the patient to describe what he felt.
Assess the motor ability of the affected limb by having the patient wiggle his fingers or toes.

Patient education will do much to prevent complications. Instruct the patient to do the following.

Avoid resting cast on hard surfaces or sharp edges that may dent the cast and cause pressure areas.
Never use a pen or other foreign object to "scratch" inside the cast. This may cause skin damage and infection.
Report any danger signs like pale, cold fingers or toes, tingling, numbness, increased pain, pressure spots, odor, or feeling that the cast has become too tight to the nursing staff immediately
Report any damage to the cast such as cracks, breaks, or soft spots.
Never attempt to remove or alter the cast.

After a leg cast is applied, prevent or alleviate swelling by elevating the extremity above the level of the heart.
If the patient has an arm cast, instruct him to make and release a tight fist.
Encourage the patient to wiggle his fingers and toes frequently

NURSING CARE OF PATIENT ON TRACTION

Traction permits pull on the long axis of the fractured bone and overcomes muscle tension/shortening to facilitate alignment and union.

Maintain position/integrity of traction (e.g., Buck, Russell)
Ascertain that all clamps are functional.
Lubricate pulleys and check ropes for fraying. Secure and wrap knots with
adhesive tape.
Keep ropes unobstructed with weights hanging free; avoid lifting/releasing weights.
Position patient so that appropriate pull is maintained on the long axis of the bone.
Review restrictions imposed by therapy, e.g., not bending at waist/sitting up with Buck traction or not turning below the waist with Russell traction.
Review follow-up/serial x-rays.
Administer analgesics as per physician orders.

Pain Management

2012-05-23T21:33:00.003-07:00

Pain is a normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus associated with surgery, trauma, and acute illness. It is generally time-limited and is responsive to Opioid therapy, among other therapies.

Definition

The international association for the study of pain (IASP) defined pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or it is described in terms of such damage.

Nature of pain

Clinical pain is subjective and no objective measures of it exists, the only people who can accurately define their own pain are experiencing that pain.
Pain is a protective physiological mechanism. E.g.: a person with a sprained ankle avoids bearing full weight on the foot to prevent further injury.
Pain is a warning that tissue damage has occurred.
Pain is a leading cause of disability.

Types of pain

There are different ways to define types of pain, which include according to onset, duration, severity, modes of transmission, location, causation and causative forces.

Onset or time of occurrence. e.g.: postoperative pain.
Duration. e.g.: chronic pain or acute pain
Severity or intensity. E.g.: severe, mild or scored (0 to 10 a scale )
Location or source. e.g.: superficial, deep or central pain
Causation. E.g.: pain due to receptor stimulation or nerve damage or psychophysiologic pain
Causative force or agent. E.g.: spontaneous, self inflicted or other pain.

Acute pain

Recent onset and is most commonly associated with a specific injury.
It is time limited and has a defined cause and purpose.
It may be mild, moderate or severe in nature and sudden in onset.
It occurs after an injury or disease, persists until healing occurs.

Chronic pain

Is a complex physiological and psychological phenomenon that causes varying degrees of disability in a larger portion.
It is constant or intermittent in nature that persist over a period of time.
It is often can not be attributed to a specific cause or injury.
It may lasts for six months or larger.
Classified as malignant or non malignant.

Superficial pain

It occurs when receptors in surface tissues are stimulated.
Classified into 2 types

Pain with an abrupt onset and a sharp or stinging quality.
Pain with a slower onset and burning quality.

It may be delineated by having the client point to the painful area.
It is relatively uncomplicated because it is readily localized , that is, which client can indicate exactly where it hurts.

Deep pain

Deep pain arises from deep tissues.
It is divided automatically into splanchnic which refers to pain in the viscera and deep somatic referring to pain in deep structures other than the viscera such as muscle, tendons, joints and periosteum.

Splanchnic pain:

Viscera pain tends to be diffuse, poorly localized, vague, dull pain.
Autonomic manifestations such as diarrhea, cramps, sweating, hypertension frequently accompany viscera pain.
It includes acute appendicitis, cholecystities, inflammation of the biliary and pancreatic tract, gastro duodenal disease, cardiovascular disease, renal and ureteral colic.

Deep somatic pain:

It is generally diffuse, less localizable than cutaneous pain. somatic structures vary in their sensitivity to pain.
Highly sensitive structure include tendons, deep fascia, ligaments, joints, bone periosteum, blood vessels and nerve.
Skeletal muscle is sensitive only in stretching and ischemia.

Localized pain

It arises directly from the site of the disturbance.

Referred pain

It is one which is felt in a part of the body which is remote from the actual point of stimulation.
The impulses usually arise in an organ, but the pain is projected to a surface area of the body.
E.g.: angina pectoris, the pain originates in the heart muscles, but it may be experienced in the mid-sternal region, the base of the neck and down to the left arm.

Intractable pain

Persistent, severe pain that cannot be effectively controlled by the usual medication.
It producing prolonged and intense bombardment of the central nervous system, are very difficult to bear.

Psychogenic pain

It is experienced when there is no detectable organic lesion.
It refers to pain that believed primarily due to emotional factors rather than physiologic dysfunction.
Clients experiencing psychogenic pain have a real pain expereince.

Factors influencing pain

Situation:

The situation associated with the pain influence the person’s response to it.
A person’s responses to pain experienced in a formal crowed situations may differ greatly from the responses were he or she alone or in a hospital.

Culture:

It influences how people learn to react to expressing pain.
People responds to pain in different ways.
A young girl may be allowed to cry because of pain whereas boys are not allowed to cry in some culture.

Age:

It is an important variable that influences pain particularly in children and older adults.
Young children have difficulty in understanding pain.
Older people may assign different meanings to that pain, it thought by the elderly as natural manifestation of aging.

Sex:

In most cultures boys are expected to show less expression of pain than girls.
As they grow older men are also expected to express less pain than women.

Meaning of pain:

The meaning of a person’s pain is a factor that influence his or her responses to pain.
For e.g.: pain caused by childbirth may be responded differently from pain caused by surgery.
A client copes differently with pain depending on its meaning.

Anxiety:

When anxiety is high pain is felt greater.
Emotionally healthy persons are usually able to tolerate moderate or even severe pain than those whole emotions are less stable.

Fatigue:

It heightens perceptions of pain.
This intensifies pain and decreases coping abilities.
Pain is often experienced less after a restful sleep than at the end of a long day.

Attention:

The degree at which a client focuses on pain can influence pain perception.
Increased attention has been associated with increased pain, whereas distraction has been associated with a diminished pain response.

Previous experience:

Each person learns from painful experiences.
Patient had repeated experience of pain may be better prepared to tolerate or take necessary actions to relieve pain to some extent.

Coping style
Family and social support

Assessment of Pain

Pain assessment is one of the most common and difficult activities a nurse performs.
Highly subjective.
Need a good rapport with the person in pain.

Factors to consider in a complete pain assessment are

The intensity.
Timing.
Location.
Quality.
Personal meaning.
Aggravating and alleviating factors.
Pain behaviors.

Pain Assessment Scales

Visual Analogue Scale (VAS).
Faces pain scale

Pain Management Strategies

Pharmacological
Non pharmacological measures

Pharmacological Methods

Main drug forms are

Balanced anesthesia/analgesia.
Analgesics.
Patient controlled analgesia.
Local anesthetic agents.
Opioid analgesic agents.

Most effective when a multi modal approach is used.
It refers to the use of more than one form of analgesia concurrently.
Three general categories of analgesia are

NSAID(non steroidal anti-inflammatory drugs)
Opioids
Local anesthetics

PCA allows the self administration of drugs for chronic pain.
Mainly used in cancer and POP cases.
This approach can be used with oral analgesic agents as well as continuous infusion of opioid drugs.
Local anesthetics work by blocking nerve conduction when applied directly to the fibers.
Topical application
Intraspinal administration

Non Pharmacological Methods

Cutaneous stimulation and massage.
Cold and heat therapies.
Trans Cutaneous Nerve Stimulation (TENS): It is a battery operated device with electrodes, applied to the skin to produce a tingling, vibrating or buzzing sensation in the area of pain. It decreases the pain by stimulating the non pain receptors of the site
Distraction
Relaxation techniques
Guided imagery
Hypnosis

Pender's Health Promotion Model

2012-05-21T00:18:00.002-07:00

The health promotion model (HPM) proposed by Nola J Pender (1982) was designed to be a “complementary counterpart to models of health protection.”

It defines health as a positive dynamic state not merely the absence of disease. Health promotion is directed at increasing a client’s level of well being.
The health promotion model describes the multi dimensional nature of persons as they interact within their environment to pursue health.

The model focuses on following three areas:

· · Individual characteristics and experiences

· · Behavior-specific cognitions and affect

· · Behavioral outcomes

The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral specific knowledge and affect have important motivational significance. These variables can be modified through nursing actions. Health promoting behavior is the desired behavioral outcome and is the end point in the HPM. Health promoting behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development. The final behavioral demand is also influenced by the immediate competing demand and preferences, which can derail an intended health promoting actions.

ASSUMPTIONS

The HPM is based on the following assumptions, which reflect both nursing and behavioral science perspectives:

1. Individuals seek to actively regulate their own behavior.

2. Individuals in all their biopsychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time.

3. Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their life span.

4. Self-initiated reconfiguration of person-environment interactive patterns is essential for behavior change

Henderson's Theory

2012-05-21T00:15:00.002-07:00

Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery".

· She emphasized the importance of increasing the patient’s independence so that progress after hospitalization would not be delayed.

· She described the nurse's role as substitutive (doing for the person), supplementary (helping the person), complementary (working with the person), with the goal of helping the person become as independent as possible.

· Her definition of nursing was "The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible"

· She categorized nursing activities into 14 components, based on human needs.

The 14 components

Breathe normally.
Eat and drink adequately.
Eliminate body wastes.
Move and maintain desirable postures.
Sleep and rest.
Select suitable clothes-dress and undress.
Maintain body temperature within normal range by adjusting clothing and modifying environment
Keep the body clean and well groomed and protect the integument
Avoid dangers in the environment and avoid injuring others.
Communicate with others in expressing emotions, needs, fears, or opinions.
Worship according to one’s faith.
Work in such a way that there is a sense of accomplishment.
Play or participate in various forms of recreation.
Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

Assumption

The major assumptions of the theory are:

"Nurses care for patients until patient can care for themselves once again.
Patients desire to return to health, but this assumption is not explicitly stated.
Nurses are willing to serve and that “nurses will devote themselves to the patient day and night”
A final assumption is that nurses should be educated at the university level in both nursing arts and sciences.

Roger's Theory

2012-05-21T00:14:00.001-07:00

Martha Elizabeth Rogers was an American nurse, researcher, theorist, and author. Rogers is best known for developing the Science of Unitary Human Beings.

Rogers' theory is known as the Science of Unitary Human Beings. Its primary tenants include the following:

· Nursing is both a science and art; the uniqueness of nursing, like that of any other science, lies in the phenomenon central to its focus.

· Nurses long established concern with the people and the world they live is in a natural forerunner of an organized abstract system encompassing people and the environments.

· The irreducible nature of individuals is different from the sum of the parts.

· The integralness of people and the environment that coordinate with a multidimensional universe of open systems points to a new paradigm: the identity of nursing as a science.

· The purpose of nurses is to promote health and wellbeing for all persons wherever they are.

Peplau's Theory of Interpersonal Relations

2012-05-21T00:13:00.000-07:00

Concepts

· Person :A developing organism that tries to reduce anxiety caused by needs

· Environment : Existing forces outside the organism and in the context of culture

· Health : A word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal and community living.

· Nursing: A significant therapeutic interpersonal process. It functions cooperatively with other human process that make health possible for individuals in communities

Roles of nurse

· Stranger: receives the client in the same way one meets a stranger in other life situations provides an accepting climate that builds trust.

· Teacher: who imparts knowledge in reference to a need or interest

· Resource Person : one who provides a specific needed information that aids in the understanding of a problem or new situation

· Counselors : helps to understand and integrate the meaning of current life circumstances ,provides guidance and encouragement to make changes

· Surrogate: helps to clarify domains of dependence interdependence and independence and acts on clients behalf as an advocate.

· Leader : helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way

Additional Roles include:

1.   Technical expert
2.   Consultant
3.   Health educator
4.   Tutor
5.   Socializing agent
6.   Safety agent
7.   Manager of environment
8.   Mediator
9.   Administrator
10. Recorder observer
11. Researcher

Theory of interpersonal relations

· Proposed by Dr. Hildagard E. Peplau in 1952.

· sequential and focus on therapeutic relationship

· uses problem solving techniques for the nurse and patient to collaborate on, with the end purpose of meeting the patients needs

· uses observation communication and recording as basic tools utilized by nursing

1. Orientation phase

· Problem defining phase

· Starts when client meets nurse as stranger

· Defining problem and deciding type of service needed

· Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past experiences

· Nurse responds, explains roles to client, helps to identify problems and to use available resources and services

2. Identification phase

· Selection of appropriate professional assistance

· Patient begins to have a feeling of belonging and a capability of dealing with the problem which decreases the feeling of helplessness and hopelessness

3. Exploitation phase

· Use of professional assistance for problem solving alternatives

· Advantages of services are used is based on the needs and interests of the patients

· Individual feels as an integral part of the helping environment

· They may make minor requests or attention getting techniques

· The principles of interview techniques must be used in order to explore, understand and adequately deal with the underlying problem

· Patient may fluctuates on independence

· Nurse must be aware about the various phases of communication

· Nurse aids the patient in exploiting all avenues of help and progress is made towards the final step

4. Resolution phase

· Termination of professional relationship

· The patients needs have already been met by the collaborative effect of patient and nurse

· Now they need to terminate their therapeutic relationship and dissolve the links between them.

· Sometimes may be difficult for both as psychological dependence persists

· Patient drifts away and breaks bond with nurse and healthier emotional balance is demonstrated and both becomes mature individuals.

Roy's Adaptation Theory

2012-05-21T00:09:00.005-07:00

Roy's Adaptation Theory

Every human life is purposeful in a universe that is creative and persons are inseparable from the environment - Dr. Callista Roy.

Concepts

-Person

o Humans are holistic, adaptive systems

o A whole with the parts that function in unity for some purpose

o Not limited to just the individual can include; groups, families, organizations, communities, and society as a whole

-Environment

o Includes all the conditions affecting the development and behaviours of the person.

o Stimuli include can be categorized as focal, contextual and residual.

-Health

o A state and a process of being and becoming integrated as a whole person

o Reflection of adaptation that is the interaction of the person and the environment

-Nursing

o A science and practice that expands adaptive abilities and enhances person and environmental transformation.

-Adaptation

o Process and outcome whereby thinking and feeling persons use conscious awareness and choice to create human environment integration

Roy Adaptation Model

System-

a set of parts connected to function as a whole for some purpose

Stimulus-

something that provokes a response, point of interaction for the human system and the environment

Focal Stimuli-internal or external stimulus most immediately affecting the system
Contextual Stimuli-all other stimulus present in the situation
Residual Stimuli-environmental factor, that effects on the situation that are unclear

Regulator Subsystem-

automatic response to stimulus (neural, chemical, and endocrine)

Cognator Subsystem-

responds through four cognitive-emotive channels (perceptual and information processing, learning, judgment, and emotion)

Behaviour-

internal or external actions and reactions under specific circumstances

Adaptive Responses-

promote the integrity of the human system

Ineffective Responses-

neither promote not contribute to the integrity of the human system

Copping Process-

innate or acquired ways of interacting with the changing environment
Innate-genetically determined, automatic process
Acquired-developed through learning, deliberate and conscious

4 Modes of Adaptation

Physiologic-Physical Mode

Behaviour pertaining to the physical aspect of the human system
Physical and chemical processes
Nurse must be knowledgeable about normal processes
5 needs (Oxygenation, Nutrition, Elimination, Activity & Rest, and Protection)

Self Concept-Group Identity Mode

o The composite of beliefs and feelings held about oneself at a given time

o Focus on the psychological and spiritual aspects of the human system

o Need to know who one is, so that one can exist with a state of unity, meaning, and purposefulness

o 2 modes (physical self, and personal self)

Role Function Mode

o Set of expectations about how a person occupying one position behaves toward a person occupying another position

o Basic need-social integrity, the need to know who one is in relation to others

Interdependance Mode

o Behaviour pertaining to interdependent relationships of individuals and groups

o Focus on the close relationships of people and their purpose

o Each relationship exists for some reason

o Involves the willingness and ability to give to others and accept from others

o Balance results in feelings of being valued and supported by others

o Basic need-feeling of security in relationships

Orem's Theory of Self Care

2012-05-21T00:06:00.001-07:00

Theory of Self Care

Self care – practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being

Self care agency – is a human ability which is "the ability for engaging in self care“
Conditioned by age developmental state, life experience sociocultural orientation health and available resources

Therapeutic self care demand – "totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions"

Self care requisites-action directed towards provision of self care.

3 categories of self care requisites are:-

-Universal Self Care Requisites

o Associated with life processes and the maintenance of the integrity of human structure and functioning

o Common to all , ADL

o Identifies these requisites as:
· Maintenance of sufficient intake of air ,water, food
· Provision of care assoc with elimination process
· Balance between activity and rest, between solitude and social interaction
· Prevention of hazards to human life well being and
· Promotion of human functioning

-Developmental Self Care Requisites

o Associated with developmental processes/ derived from a condition…. or associated with an event
· E.g. adjusting to a new job
· adjusting to body changes

-Health deviation Self Care Requisites

o Required in conditions of illness ,injury, or disease .these include:--

o   Seeking and securing appropriate medical assistance
   o     Being aware of and attending to the effects and results of pathologic conditions
   o     Effectively carrying out medically prescribed measures
   o     Modifying self concepts in accepting oneself as being in a particular state of health and in specific forms of health care
   o     Learning to live with effects of pathologic conditions

Self Care Deficit

• Specifies when nursing is needed

• Nursing is required when an adult is incapable or limited in the provision of continuous effective self care

•     Orem identifies 5 methods of helping:--
·           Acting for and doing for others
·           Guiding others
·           Supporting another
·           Providing an environment promoting personal development

· Teaching another

Nursing Systems

• Describes how the patient’s self care needs will be met by the nurse , the patient, or both

•    ions of nursing system to meet the self care requisites of the patient:-
·      Wholly compensatory system
·      Partly compensatory system
·      Supportive – educative system

Betty Neuman's Theory

2012-05-21T00:00:00.004-07:00

The Neuman’s system model

It has two major components i.e. stress and reaction to stress.

The client in the Neuman’s system model is viewed as an open system in which repeated cycles of input, process, out put and feed back constitute a dynamic organizational pattern.

Each layer, or concentric circle, of the Neuman model is made up of the five person variables.
1. Physiological - refers of the physicochemical structure and function of the body.
2. Psychological - refers to mental processes and emotions.
3. Sociocultural - refers to relationships; and social/cultural expectations and activities.
4. Spiritual - refers to the influence of spiritual beliefs.
5. Developmental - refers to those processes related to development over the lifespan.

The Central Core

The central core, is made up of the basic survival factors that include: system variables, genetic features, and the strengths and weaknesses of the system parts. Examples of these may include: body temperature regulation ability, functioning of body systems homeostatically, cognitive ability, physical strength
The person's system is an open system and therefore is dynamic and constantly changing and evolving.

Flexible Lines of Defence

It is the outer barrier to the normal line of defense, the line of resistance, and the core structure.
If the flexible line of defense fails to provide adequate protection to the normal line of defense, the lines of resistance become activated. The flexible line of defense acts as a cushion.

Normal Line of Defence

It is considered to be the usual level of stability in the system.
The normal line of defense can change over time in response to coping or responding to the environment.

Line of Resistance

It protects the basic structure and become activated when environmental stressors invade the normal line of defense. Eg:: activation of the immune response after invasion of microorganisms. If the lines of resistance are effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death.

Reconstitution

It is the increase in energy that occurs in relation to the degree of reaction to the stressor.
Reconstitution begins at any point following initiation of treatment for invasion of stressors.
Reconstitution may expand the normal line of defense beyond its previous level, stabilize the system at a lower level, or return it to the level that existed before the illness.

Stressor

The Neuman Systems Model looks at the impact of stressors on health and the reduction of stress.
Stressors are capable of having either a positive or negative effect on the client system.
A stressor is any environmental force which can potentially affect the stability of the system:
The person has a certain degree of reaction to any given stressor at any given time. The nature of the reaction depends in part on the strength of the lines of resistance and defense. By means of primary, secondary and tertiary interventions, the person (or the nurse) attempts to restore or maintain the stability of the system

Types of Stressors

Intrapersonal - occur within person, e.g. emotions and feelings
Interpersonal - occur between individuals, e.g. role expectations
Extra personal - occur outside the individual, e.g. job or finance pressures

Prevention

It focuses on keeping stressors and the stress response from having a detrimental effect on the body.

Primary prevention

o occurs before the system reacts to a stressor.

o On the one hand, it strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors, and on the other hand manipulates the environment to reduce or weaken stressors.

o Primary prevention includes health promotion and maintenance of wellness.

Secondary prevention

o occurs after the system reacts to a stressor and is provided in terms of existing systems.

o It focuses on preventing damage to the central core by strengthening the internal lines of resistance and/or removing the stressor.

§ Tertiary prevention

o occurs after the system has been treated through secondary prevention strategies.

o offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.

Nursing Care of Wounds

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Purposes of Wound Care

To prevent infection
To prevent further tissue damage
To promote healing
To absorb inflammatory exudate
To convert the contaminated wound into clean wound
To prevent haemorrhage
To apply medications
To restore the functions of the part

Principles of Wound Care

1.      Microorganisms are present in the environment, on the articles and on the skin.
2.      Bacteria travel along with the dust partricles
3.      Cleaning an area where there are less no. of organisms, before cleaning an area where there are more organisms, minimize the spread of organisms to the clean area.
4.      A break in the skin and mucus membrane acts as a portal of entry for the pathogenic organisms.
5.      Respiratory tract harbours micro organisms that can enter the wound
6.      Nutrients and oxygen are carried to the wound via blood stream and are essential for collagen formation
7.      Moisture facilitates growth and movement of microorganisms
8.      Fluid moves downwards as a result of gravitational pull
9.      Fluid move through materials by capillary action.
10. Unfamiliar situations produce anxeity.
11. Systematic ways of working saves time, energy and material.

Dressing materials

Topical agents for cleansing wounds
Mercurochrome 1-2.5%
Tincture Iodine
Savlon 5%
Betadine solution
Normal saline
Hydrogen peroxide 1.5- 3%
Acetone/ Ether –Used to remove the adhesive marks from the skin

Types of dressings

Guaze dressings
Nonantiseptic dressings
Antiseptic dressings
Wet dressings
Pressure dressings
Nonadherent guaze dressings
Self adhesive transparent film
Hydrocolloid and hydrogen dressing

General instructions for the wound dressing

Practice strict aseptic technique
Use sterile articles
Wash hands
Use masks, gloves and gown
Dressings are not changed for at least 15min. after the room have been swept or cleaned
Use individually wrapped sterile dressings
Create a sterile field around the wound by spreading sterile towels
Avoid talking, coughing and sneezing when the wound is opened
All the soiled dressings and contaminated instruments should be carefully collected and disposed
Cleaning the wound should be done from the cleanest area to the less clean area
If the dressings are adherent to the wound due to the drying of the secretions, wet it with physiologic saline before it is removed from the wound
When drains are in place anticipate the drainage and reinforce the dressing accordingly
The amount of discharge from the wound is accurately measured by recording the number and size of dressing changed
Before doing the dressing inspect wound for any complications
Avoid meal timings
Give an analgesic prior to the painful dressings
Check the diagnosis and general condition of the patient
Check the condition of the wound, physicians order, patients name, abilities and limitations of the patient and articles available in the unit

Preparation of the articles

A sterile tray containing

Artery forceps-1
Dissecting forceps-2
Scissors
Small bowl
Gloves, mask and gown
Cotton balls, guaze pieces, cotton pads
Slit or dressing towel

Unsterile tray containing

Cleaning solutions as necessary
Ointments and powders as ordered
Vaseline gauze, ribbon guaze, swab stick in sterile containers
Transfer forceps in a sterile container
Bandages, binders, adhesive plaster and scissors
A large bowl with disinfectant solution
Kidney tray and paper bag
Mackintosh and towel

Preparation of the patient and the environment

Identify patient
Apply restrains in case of children
Shave the area if necessary
Comfortable position to the patient
Put off fan
Untie the bandage or adhesive or remove them

Procedure

Wear mask and wash hands, put on gown & gloves as necessary
Open the sterile tray and spread the sterile towel around the wound
Control the haemorrhage
Prepare to anaesthetise the wound edges
Clean the wound thoroughly with normal Saline
Using a sharp scissors cut off the dead tissues
Put on fresh sterile gloves
Pick up the dissecting forceps and remove the dressings and put it in the paper bag and discard the forceps in the bowl of lotion
Ask the assistant to pour small amount of cleansing solution into the bowl
Clean the wound from the center to periphery
After cleaning dry the wound with dry swabs
Apply medications and sterile dressings
Remove the gloves and secure the dressings with bandage
After care of the patient and the articles
Remove the mackintosh and towels
Replace all articles
Wash hands
Record the procedure on the nurses record

Factors influencing Wound Healing

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Factors influencing healing process

Favorable factors:

Young age
An adequate blood supply to the area
Good general health and stamina
Adequate nutritional intake especially of protein and Vit.C.
Minimal tissue destruction
Presence of tissues that are capable of regeneration
Absence of infection
Use of anti infective agents
Immobilization and rest to the part.

Unfavorable factors:

Old age
Poor health
Inadequate blood supply to the affected area
Presence of diabetes mellitus
Excess use of corticosteroids
Absence of tissues that can be regenerated
Presence of infection
Presence of foreign bodies and traumatized tissues
Excessive movements of the injured area.

Complications of Wound Healing

There are various complications during the process of wound healing. Impaired wound healing requires observation and ongoing interventions. One must be able to recognize the seriousness of the signs and symptoms that can arise before complications can turn vital.

Haemorrhage

Bleeding may indicate a dislodged clot, slipped sutures, coagulation problems, and trauma to blood vessels or tissues.
This type of bleeding could show up on the wounds dressing
Internal hemorrhaging can occur inside the cavity of the body while the dressing stays dry and shows no signs of collecting blood.

Dehiscence:

this is the medical term for when the wound layers separate.
Most people may experience this after coughing, sneezing or vomiting.
Immediately place a sterile dressing over the area until a physician can evaluate the area.

Evisceration:

this happens when the abdominal organs protrude through the opening of an incision.
a medical emergency.
The wound contents are to be covered in warm, sterile saline dressings.
This type of complication will require surgical repair.

Wound infection:

Most common form of complication of wound healing. A wound is "infected" when it contains purulent drainage.
The client may display fever, tenderness or pain at the site of the wound, edema and an elevated WBC.
Purulent drainage will have an odour and depending on the pathogen causing the infection it can be green or yellow in color.

Pain

Recurrence of pain at the site of injury should be interpretted as a sign of inflammation and infection.

Abcess formation

It is a localized collection of pus.
It complicates the healing process by enlarging the dead space which must be filled in.

Cellulitis

If the inflammation is localized, but extends to the surrounding cells with an edematous appearance of the parts it is called cellulitis.
Necrosis or Gangrene
If the blood supply is not restored to the area, the death of the tissues may take place. Its called as gangrene.

Keloids

These are huge ugly, tumour like over growths of scar tissues seen in certain individuals.

Contractures

Disability and severe deformity occurs when severe injuries are located over a joint and are healed by secondary union.

Types of Wound and Healing process

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Definition of Wound

A wound is a cut or break in the continuity of any tissue.

Classification of wound

Wounds are classified according to the extent of injury, the causes ,the type of wounds and presence or absence of pathogens.

Open wound

· An open wound is one in which there is a cut or break in the continuity of skin or mucus membranes.
· caused by a sharp blow or object.
· allows the entry of foreign particles and organisms and loss of fluid from the body.

Closed wound

· A closed wound is one in which there is no break in the continuity of skin or mucus membrane.
· accompanied by the damage of tissues under the skin.
· caused by direct blow or by some blunt instruments or by crushing.
· Unusual straining or twisting can also cause closed wounds.
· Also called as ‘contused wound’
· The blood vessels may be damaged and bleeding may take place into the tissues.
· The discoloration caused by the extravasations of blood in the tissues is called as ‘echymosis’.
· A ‘haematoma’ may occur if the bleeding into the area is localized and significant.
· Exudate collection can lead to swelling, loss of function and pain may accompany both closed and open wounds.

Surgical and Traumatic wounds

· A surgical wound is an intentional type of wound, usually performed by the surgeons during the surgical procedures, under aseptic precautions. They are usually called ‘incisions’
· A traumatic wound is an unexpected wound usually caused by accidents. They occur in septic conditions.

Incised and Lacerated wounds

· When the wound is clean cut with a sharp, smooth and regular edges that can be readily approximated, it is called as incised wound.
· When the wound has torn and irregular edges, it is called lacerated wound. The incised wound bleed more profusely than the lacerated wound.

Abrasions and penetrating wounds

· An abrasion is a superficial wound caused by scraping or sliding of the skin surface over a firm and fixed surface.
· A penetrating wound is caused by an object or instrument passing through the skin and mucus membrane into the deeper tissues or organs. A penetrating wound can be a ‘perforating wound’ if the instrument or object cuts open the whole thickness of the wall of a cavity or organ.

Puncture Wound

· A ‘puncture wound' is produced by a sharp pointed object piercing the deep tissues, leaving a very small opening on the surface.
· These wounds are potentially dangerous because of the anaerobic organisms may enter into the injured area.

Clean, Contaminated and Infected wound

· A clean wound contains no pathogenic micro organisms. A surgical wound is considered to be a clean wound because it is made under aseptic conditions.
· A contaminated wound is one in which there is a great likelihood of pathogenic micro organisms invading the wound. A wound may become contaminated by the foreign bodies that have entered through the injured surfaces during the injury.
· An infected wound is one in which pathogens have invaded and overcome the body’s first line of defense, producing clinical signs of infection.
· The infected wound is also called ‘septic wound’.

Healing Process:

The healing process takes place in three ways:

· Healing by first intention (primary union)
· Healing by second intention (delayed union)
· Combination of above two processes (healing by third intention)

Healing buy first intention takes place when the wound heals without infection or separation of the wound edges. The clean surgical wounds are healed by this process.

When the wound edges are not approximated, granulation tissue or connective tissues fill in the gap and the wound is closed , it is described as healing by second intention or delayed union . Contaminated and infected wound are healed by this method. When there is combination of the above two processes ,namely, the wound edges initially left opened and later approximated or initially sutured and later break open, and healing takes place by filling in by granulation tissues, it is known as healing by third intention. The healing process takes place in different stages. Within few seconds after injury, the blood escapes into the injured area with the loss of function of the organ. There will be bacterial and foreign body contamination of the wound if it is open to the outside.

· Within few minutes the blood starts clotting
· Acute localized inflammatory response
· Local edema by collection of transudate
· The white blood cells(phagocytes) migrate into the injured site.
· The plasma cells produces specific antibodies against the particular organisms that have entered the wound.
· The phagocytes together with the specific antibodies attack the invading organisms and the infection is brought under control.
· If the bacteria is defeated, the phagocytes clear the bacteria and foreign bodies from the injured area and healing takes place.
· If bacteria are virulent, and the resistant of the host is poor, the infection may settle.
· Pus formation.
· If the infection is under control within 4-5 days, healing process starts (proliferate phase)
· a scab is formed over the wound which protects the underlying tissues from contamination.

Grief Counselling

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GRIEF COUNSELING

It refers to a specific form of therapy, or a focus in general counseling with the goal of helping the individual grieve and address personal loss in a healthy manner.

Specific tasks of grief counseling include emotional expression about the loss (which can include a wide range of feelings), accepting the loss, adjusting to life after the loss, and coping with the changes within oneself and the world after the loss.
Typical feelings experienced by individuals, and addressed in grief counseling, include sadness, anxiety, anger, loneliness, guilt, relief, isolation, confusion, or numbness.
Behavioral changes may also be noticed, such as being disorganized, feeling tired, having trouble concentrating, sleep problems, appetite changes, vivid dreams, or daydreaming about the deceased.

Purpose

The purpose of grief counseling is to help individuals work through the feelings, thoughts, and memories associated with the loss of a loved one.
Helps to achieve positive adjustment following loss after the death of a loved one.
Grief counseling helps the individual recognize normal aspects of the grieving or mourning process, cope with the pain associated with the loss, feel supported through the anxiety surrounding life changes that may follow the loss, and develop strategies for seeking support and self-care.

Description

Grieving is a normal life process—an adjustment reaction to a loss.
Grief counseling is meant to facilitate that normal process
Grief counseling helps the individual work through the feelings associated with the loss of another, accept that loss, determine how life can go on without that person, and consolidate memories in order to be able to move forward.
Grief counseling also provides information about the normal grieving process, to help individuals understand that many of the symptoms and changes they are experiencing are a normal, temporary reaction to loss.
Individuals who seek grief counseling may be experiencing an emotional numbness, or a residual shock in reaction to the loss, and need assistance to return to a normal life.
In those cases, grief counseling will focus on helping the individual get in touch with those feelings and become more active in the daily routine. This often requires accepting the loss as a reality.
For some people, grieving may initially be so extreme that physical and psychological symptoms may be experienced, while other people appear to experience no symptoms whatsoever, similar to the numbness described above.
Additional work in grief counseling may involve identifying ways to let go or say good-bye if the individual has not been able to do so successfully. Therapeutic letters may be a helpful mechanism to express thoughts that were not conveyed prior to the death.

Medico-Legal Issues in Death and Dying

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EUTHANASIA

It is the intentional killing by act or omission of a dependent human being for his or her alleged benefits.

Types

Voluntary euthanasia: When the person who is killed has requested to be killed.
Non-voluntary euthanasia: When the person who is killed made no request and gave no consent.
Involuntary euthanasia: When the person is killed made an expressed wish to the contrary.
Euthanasia by action: Intentionally causing a person’s death by persson’s death by performing an action such as by giving a lethal injection.
Euthanasia by omission: Intentionally causing death by not providing necessary and ordinary casual and customary care or food and water.

WILL

A will is a document by which a person regulates the rights of others over his property or family after death.

ADVANCE DIRECTIVES

An advance directive tells the health care team what kind of care the patient would like to have if he is unable to make medical decisions (e.g., if in coma)
A good advance directive describes the kind of treatment the patient would want depending on the sickness.

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
Organ donation should take place with in 2-6hrs after the death.

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

o Obtain death reports

o Do investigation -the natural death and infant/child death

o Conduct post mortem , sexual assault/child abuse examinations

o Collaborate with organ/tissue procurement agencies

o Provide link between pathologists and lay investigative staff

o Normally, only uniformed officers attend the natural death scene

o Understand subtle signs of abuse and neglect

o Collaborate with pathologist to determine the appropriate medical records

o Review medical records once received

o Obtain follow-up information

AUTOPSY

An autopsy or postmortem examination is an examination of the body after death.

It is performed in certain cases such as:

o Committed suicide

o Unknown cause of death

o Unknown dead bodies

o Homicide (The killing of one human being by another )

· The organs and tissues of the body are examined to establish the exact cause of death , to learn more about a disease

· A consent should be obtain from the immediate relative :surviving spouse, adult children, parents, siblings.

· After an autopsy , hospitals cannot retain any tissues/ organs without the permission of the person who signed the consent form

EMBALMING

It is the process of preserving dead body from decay
Injection of chemicals into the body to destroy the bacteria ; thereby prevents rapid decomposition of tissues.
Embalming fluid contains a mixture of formaldehyde, methanol, ethanol and other solvents

Process of Embalming

Embalming fluid is injected into the arteries of the deceased during embalming. Many other body fluids may be drained or aspirated and replaced with the fluid as well. The process of embalming is designed to slow decomposition of the body.

The actual embalming process usually involves 4 parts:

Arterial embalming: which involves the injection of embalming chemicals into the blood vessels, usually via the right common carotid artery. Blood is drained from the right jugular vein.
Cavity embalming: The suction of the internal fluids of the corpse and the injection of embalming chemicals into the body cavities, using an aspirator and trocar.
Hypodermic embalming: The injection of embalming chemicals under the skin as needed.
Surface embalming: Which supplements the other methods especially for visible, injured body parts.

Stages of Grief

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End of Life Care (EOL)

It is the term currently used for issues related to death and dying. The institute of medicine defines “end of life” as the concluding phase of a normal life span, although life can end at any age. The time from diagnosis of a terminally illness to death varies considerably depending on the patient’s diagnosis and extent of disease. EOL care focuses on physical and psychological needs at the end of life for the patient and the patient’s family.

Goal for EOL care:

o Provide comfort and supportive care during the dying process.

o Improve the quality of the remaining life.

o Help ensure a dignified death.

Definition of Grief

It is emotional response to loss
Intense sorrow caused by loss of loved one (especially by death)
The physical and emotional responses to the death, separation or loss of a beloved person or thing.

“Grief is defined as an emotional response to an external and consciously recognized loss; self-limiting and gradually subsiding within a reasonable length of time.”

Types:

Normal grief:

Physical : hollowness in stomach, lightness in chest, heart palpitations.
Emotional : numbness, relief, sadness, fear, anger and gait.
Cognitive: disbelief, confusion, inability to concentrate.

Complicated grief:

Chronic grief: normal grief reactions over very long periods of time
Delayed grief: normal grief reactions are suppressed or postponed.
Exaggerated grief: self destructive behaviour.
Marked grief: unaware that behaviors are a result of the loss.

Stages of Grief

Stage 1: - Feeling emotionally numb is often the 1st reaction to a loss, and may last for a few hours, days or longer.If some ways, this numbness can help you get through the practical arrangements and family pressures that surround the funeral, but if this phase goes on for too long, it could be a problem.

Stage 2: - The numbness may be replaced by a deep yearning for the person who has died.You may feel agitated and angry, and find it difficult to concentrate, relax or sleep, may also feel guilty, dwelling on arguments you had with that person or on emotions and words you wished you had expressed.

Stage :3 - This period of strong emotion usually gives way to bouts of intense sadness, silence and withdrawal from family and friends. During this time, you may be prone to sudden outbursts of tears, set off by remainders and memories of the dead person.

Stage :4 - Overtime, the pain sadness and depression starts to lesson you begin to see your life in a more positive light again, although it is important to acknowledge that you may not completely overcome the feeling of loss.

Stage:5 - The final phase of grieving is to let go of the person who has died and more with your life. This helps sadness to dear, and energy levels to return to normal.

Coping with the Grieving Process

Ask for help and support from family, friends or a support group.
Encourage them to express whatever they are feeling, be it anger, guilt or sadness.
Accept that some things like death are beyond our control.
Avoid making major discussions on the event.
Ask the person to give their self the time and space to grieve.
Sometimes, the grieving process is especially difficult. Certain factors can make a difficult bereavement more likely:

Being male
Several previous bereavements
A history of mental illness.
A dependent relationship with the person who has died, or a relationship where you had troubled or negative feelings about the deceased.
Low self esteem
A lack of support from family and friends.

Nursing Care of Death & Dying

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Death

Death is a irreversible cessation of circulatory, respiratory function or the irreversible cessation of all functions of the entire brain, including the brainstem.

Signs of Dying

This includes the following changes:

Loss of appetite
Decreased oral fluid intake and decreased thirst.
Increasing weakness and/or fatique
Decreasing blood perfusion, including decreased urine output, peripheral cyanosis and cool extremities.
Neurologic dysfunction, including delirium, lethargy and coma and changes in respiratory patterns.
Loss of ability to close eyes.
Noisy breathing as pharyngeal muscle relax.
In particular, neurologic dysfunction can sometimes result in terminal delirium. Which can include a mounting syndrome of confusion, hallucinations, delirium, myocardial jerks and seizures prior to death.
Pitting edema develops, especially of the extremities and sacrum
Movement and sensation are gradually lost.
Temperature elevation will be there, but the skin feels cold and clammy.
Pulse becomes irregular, weak and fast.
BP falls as the peripheral circulation decreases.
The skin cyanosed as circulation decreases.
Respiration become noisy
Reflexes disappear
Urine decreases
Pain usually subsides
Mental alertness varies
Jaw and facial muscles relax with the expression becoming peaceful.

STAGES OF DYING

According to Kubler- Ross, the five stages of dying are:

1. Denial

On being told that one is dying, there is an initial reaction of shock. The patient may appear dazed at first and may then refuse to believe the diagnosis or deny that anything is wrong. Some patients never pass beyond this stage and may go from doctor to doctor until they find one who supports their position.

2. Anger

Patients become frustrated, irritable and angry that they are sick. A common response is “Why me? ” They may become angry at God, their fate, a friend, or a family member. The anger may be displaced onto the hospital staff or the doctors who are blamed for the illness.

3. Bargaining
The patient may attempt to negotiate with physicians, friends or even God, that in return for a cure, the person will fulfill one or many promises, such as giving to charity or reaffirm an earlier faith in God.

4. Depression

The patient shows clinical signs of depression- withdrawal, psychomotor retardation, sleep disturbances, hopelessness and possibly suicidal ideation. The depression may be a reaction to the effects of the illness on his or her life or it may be in anticipation of the approaching death.

5. Acceptance

The patient realizes that death is inevitable and accepts the universality of the experience. Under ideal circumstances, the patient is courageous and is able to talk about his or her death as he or she faces the unknown.

Physical Signs of Dying

Confusion – about time, place, and identity of loved ones; visions of people and places that are not present
A decreased need for food and drink, as well as loss of appetite – this may be caused by the body’s need to conserve energy and its decreasing ability to use foods properly
Drowsiness – an increased need for sleep and unresponsiveness
Withdrawal and decreased socialization – can be caused by mentally preparing for dying, decreased oxygen to the brain and decreased blood flow
Loss of bowel or bladder control – caused by relaxing muscles in the pelvic area
Skin becomes cool to the touch – especially in the hands and feet, skin may become bluish in color caused by decreased circulation to the extremities
Rattling or gurgling sounds while breathing or breathing that is irregular and shallow, decreased number of breaths per minute, or breathing that switches between rapid and slow
Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms also mean that the end of life is near .

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. Patients benefit immeasurably from the reassurance that their providers will not allow them to live or die in pain.
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. The clinician who gets to know the family maximizes patient support and is prepared to help the family through bereavement.
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 DYING PATIENT

Creating a peaceful environment to the patient’s liking.
Preparing instructions about whom to call (usually not all) when death occurs.
Give the relatives time to witness what is happening.
Creating and using rituals that can help mark the occasion in the respectful way.
When death occurs, families should encouraged to take whatever time they need to feel what has happened, and say their goodbyes. There is no need to rush the body to a funeral home, and some families want to stay with the body for a period of time after death.

Meeting physical needs:

A patient in the terminal stages of a disease, is given all the nursing care possible to ensure the most comfort and freedom from pain. Physical comfort is important as well as emotional and spiritual comfort.

Meeting nutritional need:

Patients suffer discomfort due to decreased gastrointestinal activity.
Nutrients and fluids are given intravenously when they are not tolerated orally.
Sips of water is given as long the swallowing reflex is present.
When there is a problem gauze soaked with water may be placed in the patient’s mouth for him to suck and moisten the mouth.

Meeting special needs:

Mucus that collects in the throat is removed by placing the patient in a lateral position, wiping it way, or by suctioning.
Frequent oral hygiene is done to keep the mouth free of dried secretions, and feeling fresh to the patient.
Vaseline or cream is applied to the lips to keep them soft.
The nostrils are kept cleans and lubricated as necessary.
The eyes are cleaned with cotton balls miostened with normal saline.
Lubricating drops or ointment may be applied to the eyes.
The patient may perspire profusely even though the skin feels cool.
Bath the patient and change the linen needed.
Light weight bed covering should be used. Heavy covering seems to be uncomfortable to dying patients.
Urinary and fecal incontinence often occur due to relaxing of the sphincter muscles. Pads are used to keep the bed linen from being soiled. The patient is checked frequently and pads or linen changed as necessary. The patient’s skin is washed and dried each time it is soiled.
Frequent change of position (make sure the position permits each breathing)
§ Pain is a great problem in some diseases. The doctor orders sufficient medication to control pain. It must be given as frequently as permitted. If it does not adequately control the pain, inform the doctor.
Nursing measures for pain are used to make the patient comfortable on a minimum of medication.
Dimness and shadows are confusing and increase a sense of loneliness. So we have to provide adequate light facility to the patient.

Meeting Emotional Needs:

Touch is an important method of communication with a dying person. The patient appropriates some one holding his hand or playing a hand on an arm, his head or some other part of the body. It conveys a feeling of caring and concern. Quiet, encouraging conversation to the patient is helpful.
Speak in a normal voice to the patient or to others in his presence.
Do no speak in a whisper in the patient’s presence. It is very distressing to most sick people.
Hearing is believed to the last sense to disappear. Weeping is disclosed in the patient’s presence or nearby.

Signs of Death

Absence of heartbeat and respirations.
Fixed pupils
Skin color turns to a waxen pallor and extremities may darken.
Body temperatures drops
Muscles and sphincters relax, sometimes resulting in release of stool or urine

PHYSIOLOGICAL CHANGES AFTER DEATH

1. Rigor mortis

Stiffening of the body that occurs about 2-4hrs after death.
Results from a lack of ATP, which causes the muscles to contract, which in turn immobilize the joints
It starts in the involuntary muscles( heart, bladder) then progress to head, neck, trunk , extremities.

2.Algor mortis

Gradual decrease of the body temperature after death.
When blood circulation terminates and hypothalamus ceases to function , body temperature falls down.

3.Livor mortis

Discolouration of body after death.
After blood circulation has ceased , the RBC broken down , - leads to discolouration of surrounding tissues

4. Decomposition

Tissues after death become soft and eventually liquified by bacterial fermentation .
The hotter the temperature, the more rapid the change.
So bodies are stored in cool places / embalming

CARE AFTER DEATH

After death the body undergoes many physical changes. So care must be provided as early to prevent tissue damage /disfigurement of body parts.

Physician must certify the death
Consent form for autopsy
Provide options for organ donation
If death due to any accident, suicide , poisoning etc., it should be informed to legal authorities . The body should not be handed over without any legal written permission.
Care of dead body ,often depends upon the customs and religious beliefs
Nurses provide dignity and sensitivity to the client and family

1. Check orders for any specimens

2. Ask for special requests to family (eg: shaving , a special gown , Bible in hand , rosary at the bedside)

3. Remove al equipments , tubes , supplies and dirty linens.

4. Cleanse the body thoroughly , apply clean sheets

5. Brush and comb the hairs

6. The eyelids are closed and held in place for a few seconds , so they remain closed.

7. Dentures should be in the mouth to maintain facial alignment.

8. Mouth should be closed.

9. Remove all the ornaments , except wedding bands ( in some instances)

10. Absorbent pads are placed under the buttocks to take up any faces and urine released because of muscle sphincter relaxation

11. All the orifices should be closed.

12. Cover with a clean sheet up to the chin.

13. Spray a deodorizer to remove unpleasant odour.

14. Apply name tag ( wrist , right big toe)

15. Allow the family members to view the dead body

16. The body is wrapped in a “ shroud” a large piece or plastic or cotton material used to enclose a body after death. Identification is then applied outside of the shroud.

17. Hand over all the belongings to the relatives.

18. Do complete documentation in the nursing notes.

Time of death and actions taken to prevent the death.
Who pronounced the death.
Any organ donation
Personal articles left on the body
Personal items given to family
Time of discharge and destination of the body
Location of name tags on the body
Special request by family

19.Handed over the dead body to the relatives / sent to the mortuary.