Loss, Death, and Grieving

Introduction to Loss, Death, and Grieving

• Birth and death are universal and inevitable aspects of life.
• Dying and death are personal experiences, impacting both the individual and their loved ones.
• Death has multifaceted effects, including physical, psychological, emotional, spiritual, and financial dimensions.
• Death signifies the irreversible cessation of vital functions, particularly the heart, respiration, and higher brain function.
• "Death" refers to the end of biological functions sustaining a living organism.
• "Dying" indicates the process of approaching death.

Signs of Impending Death

• Impending death exhibits several signs, including loss of muscle tone, slowing circulation, changes in vital signs and sensory impairment.

Loss of Muscle Tone

• Relaxation of facial muscles, possibly causing the jaw to sag.
• Experiencing difficulty in speaking and swallowing.
• Gradual loss of gag reflex.
• Decreased activity of the gastrointestinal tract.
• Possible urinary and renal incontinence.
• Diminished body movement.

Slowing of Circulation

• Diminished circulation.
• Mottling and cyanosis of the extremities.
• Cold skin, initially in the feet, then in the hands, ears, and nose.

Changes in Vital Signs

• Decelerated and weaker pulse.
• Decreased blood pressure.
• Rapid, shallow, irregular, or abnormally slow respiration, potentially including Cheyne-Stokes respiration, noisy breathing (death rattle), and mouth breathing.

Sensory Impairment

• Blurred vision.
• Impaired sense of smell and taste.

Indications of Death

• Total lack of response to external stimuli.
• Absence of muscular movement.
• No reflexes.
• Flat electrocardiogram.
• A flat electrocardiogram is the most reliable indicator of death.

Nursing Interventions for the Dying Patient: Promoting Dignified and Peaceful Death

• Alleviate loneliness, fear, and depression to promote a dignified and peaceful passing.
• Maintain a sense of security, self-confidence, dignity, and self-worth.
• Instill hope.
• Provide physical comfort.

Maintain Physiologic and Psychologic Comfort

• Providing personal hygiene measures offers comfort
• Prioritize pain control for dying clients.
• Alleviate respiratory difficulties.
• Facilitate movement, nutrition, hydration, and elimination.

Providing Spiritual Support

• Help clients find a sense of forgiveness.
• Support the need for love.
• Foster a sense of hope.

Care of the Body After Death: Post-Mortem Changes and Care

• Changes to the body after death include categories like rigor mortis, algor mortis and livor mortis.

Rigor Mortis

• Rigor mortis is the stiffening of the body that occurs approximately 2-4 hours post-death.
• Position the body, insert dentures, and close the eyes and mouth before rigor mortis sets in.

Algor Mortis

• Algor mortis is the gradual decrease in body temperature after death.
• After blood circulation stops and the hypothalamus fails, the body temperature decreases by about 1 degree Celsius per hour until it matches room temperature.

Livor Mortis

• Livor mortis is the discoloration of the skin after death, after circulation has ceased.
• Red blood cells break down, releasing hemoglobin, which discolors the surrounding tissues.

Nursing Interventions for the Body After Death

• Maintain a clean, pleasant, natural, and comfortable environment.
• Remove all equipment and supplies from the bedside.
• Eliminate odors and remove soiled linens.
• Position the body in a supine position with arms at the sides and palms down.
• Place a pillow under the head and shoulders to prevent blood discoloration on the face.
• Close the eyelids, insert dentures, and close the mouth.
• Wash soiled areas of the body.
• Place absorbent pads under the buttocks to absorb any released feces and urine due to sphincter muscle relaxation.
• Provide a clean gown and comb the hair.
• Remove jewelry, document all valuables, and store them securely for the family.
• Allow the family to view the body.
• Apply identification tags to the ankle and wrist.
• Wrap the body in a shroud and attach another identification tag to the outside.
• Transport the body to the morgue for cooling.

Loss, Bereavement, and Grief

• Loss is an actual or potential situation where a valued object or person is inaccessible or no longer perceived as valuable.
• Bereavement is the subjective response to loss through the death of someone with whom a significant relationship existed.
• Grief is the total response to the emotional experience of loss, manifesting in thoughts, feelings, and behaviors.

Kubler-Ross Stages of Grieving

• The Kubler-Ross model outlines stages of grieving including are: denial, anger, bargaining, depression and acceptance.

Grief: Denial

• Refusal to believe that the loss is happening.
• Unreadiness to address practical matters.
• Individuals may display artificial cheerfulness.

Grief: Anger

• Clients or family members may direct anger towards healthcare providers over matters that usually wouldn't bother them.

Grief: Bargaining

• Efforts to bargain to avoid the loss.
• Expressions of guilt or fear of punishment for past actions.

Grief: Depression

• Grieving over what has occurred.
• Openly discussing feelings or withdrawing.

Grief: Acceptance

• Coming to terms with the loss.
• Reduced interest in surroundings and support systems.
• Desire to start making future plans.

Rules and Guidelines in Charting

• Charting serves as a vital record of patient data, vital signs, and progress presented through graphs and charts.
• Charting in nursing offers documented medical records of provided services during patient care.
• Charting encompases; procedures performed, medications administered, diagnostic test results, and interactions between healthcare professionals and the patient.
• The patient's chart is a legal document.
• Chart information should be accurate and the chart should be considered as such.

Charting Qualities

• Qualities that are important are: accurancy, legibility, neatness, uniformity and completeness.
• Ensuring factual accuracy in record sheets or charts.
• Guaranteeing readability in record sheets or charts.
• Maintaining neatness in record sheets or charts and avoiding errors or white-outs.
• Ensuring uniformity in record sheets or charts.
• Completing, endorsing, and signing record sheets or charts correctly.

Charting Rules

• The rules for charting involve; accuracy, conciseness, the use of color and specific formats.
• Creating accurate, concise, and orderly charts, using factual statements while omitting unnecessary technicalities.
• Using standard ink for charting purposes.
• Using black ink for charting between 7:00 AM and 6:59 PM.
• Using black ink for chart numbers, patient names in headings, admission history, temperature, graphic sheet notations ("on Admission" term), weight, patient transfers, nurse's notes on sponge temperature, and blood pressure with B.I.D or Q.I.D. checks.
• Using red ink for charting between 7:00 PM and 6:59 AM.
• Using red ink for; medication, for the term "discontinued" on medication sheets, hospitalization days, pulse, and output on graphic sheets.
• Using pencil for information about the patient's bed or room number in the top left of the treatment and admission sheet; transfer patients should have their new number recorded instead of erasing the previous one.
• Admitting nurses/clerks are responsible for admission data and vital signs.
• All admission notes should include date and exact time, mode of admission (ambulatory, wheelchair, stretcher, etc.), consciousness, skin assessment, chief complaints (not diagnosis), and the physician's name.
• Print records in plain, legible characters and ensure spacing is appropriate, avoid crowding. The remark column to start each new statement with a capital letter, enabling clear reading.
• Unauthorized abbreviations should not be used.
• Dots of consistent size should be used to show test results, connecting the dots with a ruler for temperature and pulse rates.
• The frequency should be recorded in the "V" (urinate) column for voiding and the "S" (stool) column for loose stool.
• Amounts of voided stool should be written on the Intake & Output Sheet.
• Nurses on each shift are responsible for recording the results.
• Shift nurses should calculate the grand total (add) of all results for the entire 24 hours.
• The patient's diet should be recorded on the chart, including whether the patients are doing well or not.
• Attach laboratory results and X-ray results to the laboratory sheet.
• "DO NOT ERASE" charting or graphic errors; report errors and direction to the instructor.

Nurses Notes

• Nurses' notes are factual and encompass a patient's care, based on evaluation data and reflecting the patient's reactions to nursing interventions.

Purpose

• Nurses' notes serve to communicate patient information, maintain accurate records, inform healthcare teams, and document medication, treatment, and reactions.

Types of Charting (Nurses Notes)

• Charting Types consists of: narrative, APIE, SOAPIE, and Focus (DAR) or FDAR charting.

Narrative Charting

• Narrative charting is in statement form, covering events related to individual care while offering unstructured flexibility.
• Narrative charting could be time consuming, information retrieval and progress tracking can be difficult.

APIE Charting

• APIE charting includes; assessment upon admission (on a separate form), formation of a issue list, focused documentation of each client's care, interventions and and evaluation (based on issue)

APIE Process

• The APIE Process includes: assessment, problem identification, interventions and evaluation.

SOAPIE Charting

• SOAPIE charting records problem progress and contains narrative notes.
• Elements of progress notes include: flow sheets, and are utilized by all team members while specifically related to a numbered and titled problem list.

SOAPIE Process

• The SOAPIE charting process includes: subjective, objective, assessment, plan, internvention and evaluation.

FOCUS (DAR) FDAR Charting

• FOCUS (DAR) FDAR Charting addresses client needs/problems and has a column that highlights the entry's focus (not always a nursing diagnosis).

FOCUS (DAR) FDAR Process

• The FOCUS (DAR) FDAR charting process consists of: focus,data, action and response.

Documenting and Reporting

• Documentation forms a permanent record of individual data and care.
• Reporting occurs when two or more individuals exchange data about individual care through, in person or over the phone.

Purposes of Client's Record/Chart

• Key purposes include: communication; legal, research, statistical, education and audit/quality assurance documentation.
• Providing communication, which makes sharing data efficient and effective.
• Legal documentation is permitted as evidence in a court of law.
• Research contains health information for research.
• Statistics contain information to plan for future needs.
• Education is for health discipline students.
• Assurance to monitor client care and the competence of healthcare providers.
• Provides data for the health team and the client's care.
• Reimbursement offers help for care decisions and agency reimbursements.

Types of Records

• Key Records include source and problem oriented medical records.

Source Oriented Medical Record

• In traditional client charts, each department or individual records notations in separate sections.

Traditional Client Record: Basic Components

• Key areas include, the admission sheet, order sheet, medical history, nurses notes, and special records/reports.
• Special records can include: referrals, X-ray reports, lab findings, surgery reports, anesthesia records, I&O (intake and output), and medications.

Problem-Oriented Medical Record

• Individual data sorted by information source is used to record and arrange client details.
• All data gathered about the problem from team members are integrated into a single, comprehensive record.

Components of POMR/POR

• The four main components of POMR or POR are: the data base, problem list, initital list orders and progress notes.
• A data base contains all initial information.
• The problem list, encompasses all life aspects involved with care.
• An initial list include; orders and/or care plans.
• The progress notes include nurses' or narrative notes in SOAPIE format alongside subjective data, objective data, an assessment, planning and intervention.

Evaluation

• The evaluation and data are stored in flow sheets.
• Extra information includes discharge notes or referral summaries.

Kardex

• Kardex provides a concise method of organizing and recording client information for the health team.
• The tool can be a series of flip cards stored in a portable file.
• This tool ensure continuity of care from one shift and/or day to the next.
• Kardex is a tool used for shift reports instead of endorsement; the clients' healthcare needs still are the basis.

Kardex Inclusions

• Key area includes: information and basic medical data.
• Key data include: personal data, basic needs, allergies, diagnostic tests, daily procedures, medications, IV therapy, blood transfusions to oxygen therapy, suctioning and mechanical ventilation.

Characteristics of Good Reporting

• Qualities include: brevity, ink usage, and accuracy.

Clear Reporting Basics

• Entries are concise with short entries.
• Capital letters for entry, ending with a period.

Ink Usage

• Ink should be used in order to avoid pen and/or pencil erasures in chart.

Reporting Facts

• Information that is reported should be facts.
• The clients' complaints should be quoted.
• The document must be signed if the client refuses treatements and/or mediations.

Right Data

• Only list information that is correct and important.

Accurate Timing

• Continuous and/or accurate timing is must.
• Time/Date must be entered and/or noted on a new chart.

Chart Info

• Chart the times when the patient: leaves, returns, received medications and/or when treatements occur.

Terminologies

• All standardized terminology should be used.

Initials and/or Signature

• Each initial and/or complete signature should be noted on chart.

Correcting Errors

• In the event of an error, draw a line through error and sign/date next to it.

Privacy

• Protect privacy of charts from anyone who is unauthorized.

Following Procedure

• By only charting what you saw, heard and/or did.

No Chart Disposal

• Charts shouldn't be discarded unless for special circumstance.

Legibility & Patient

• Chart data should be written clearly; avoid using "patient and/or PT" within each chart.

Reporting Types

• Key reporting types: change of reports, telephone reports, telephone orders and transfer reports.

Shift Report

• Shift report should base health data on the clients needs.

Phone Report

• Should be concise and very clear.
• Recording calls within the chart and state each: date, caller, and why the calls were made.

Doctor Orders

• Only RNs are able to take doctors orders over the phone.
• Doctor order must be signed within 24 hours.

Transport Report

• Information being transported is very important to notate within the chart.