Foundations of Nursing Signs of Impending Death & Care of Dying Patient

1. SIGNS & SYMPTOMS OF
IMPENDING DEATH
Ms.Lincy Thomas
Tutor
St.James’ College of Nursing,
Chalakudy

2. SIGNS & SYMPTOMS OF APPROACHING DEATH
1.CHANGES IN FACIAL APPEARANCE
 Facial muscles relax; cheeks become flabby, moving in and out with each breath.
 Facial structures may change, so the dentures cannot be worn; with the dentures removed
,mouth structure may collapse.
 lips become sink in; sides of the nose drawn in with each inspiration.
 Loss of muscle tone and anemia cause “facies hippocratica”, characterised by prominent
cheeks and chin, sharp nose, pale ashy skin, sunken glazed eye.
2.CHANGES IN THE SIGHT ,SPEECH & HEARING
 Sight gradually fails(Blurred vision). The pupils fails to react to light. Eyes are sunken and
half closed with a film like appearance over the eyes
 Speech becomes increasingly difficult, confused, unintelligent and finally impossible
 Hearing is thought to be retained longer

5. 3.RESPIRATORY SYSTEM CHANGES
Respiration becomes irregular, rapid and shallow or
very slow ; cheyne –stroke respirations; Stertorus or
noisy respirations due to the presence of secretions.
Mouth breathing leads to dry oral mucous
membrane
Feeling of “Lack of air” and breathlessness may
increase as death approaches
“DEATH RATTLE”-A rattling sound heard in throat
caused by secretions that the patient cannot cough
longer.

6. 4.CIRCULATORY SYSTEM CHANGES
Circulatory changes cause alterations in the
temperature, pulse and respirations.
Cardiac output decreases with a corresponding
decrease in peripheral & renal perfusion.
Pulse rate increases initially and then weakens and
becomes irregular. Radial pulse gradually
fails/nonpalpable; Once it stops, the apical pulse may
continue for some time. Usually the pulsations are
seen even after the patient has stopped breathing
BP decreases

8. 5. CHANGES IN GASTRO INTESTINAL SYSTEM
Hiccoughs, Nausea, Vomiting, impaired sense of
taste & smell, abdominal distension with flatus
The gag reflux disappears; the patient feels an
inability to swallow, loss of appetite
constipation/retention of feces due to decreased
food intake & reduced activity of the gut.

10. 6.GENITO URINARY SYSTEM CHANGES
Retention of urine, distention of the bladder,
incontinence of urine and stool due to loss of
sphincter control, fecal impaction

11. 7.CHANGES IN SKIN AND MUSCULO SKELETAL SYSTEM
The skin may become pale, cool and sweats lot (cold
sweats).Ears and nose are cold to touch. Skin is pale &
mottled due to congestion of blood in the veins as a result of
circulatory failure,
Increased perspiration.
 swelling in the feet and ankles, coolness in the tip of fingers
& toes
decreased ability to move, beginning in the legs and
progressing to arms; body becomes still and joints painful
when moved

12. 8.CHANGES IN CENTRAL NERVOUS SYSTEM
Reflexes and pain are gradually lost.
Patient may be restless due to lack of oxygen and
due to raised body temperature, although the body
surface is cool
Mental confusion or disorientation
Increased hallucination

13. CARE OF A DYING PATIENT
(CARE OF A TERMINALLY ILL PATIENT)

14. Introduction
Nurses has an important & major responsibility to provide care for a dying
patient & their family members. Even though death is an inevitable part of
everyone’s life, the individual needs care at the time of dying. So we should
have to make the long term goals like “ client will die with dignity “. For
achieving this goal, the nurses should help in alleviating the patient pain ,fear,
anxiety and maintain the basic physiological functions at the end of his life.
Care of dying patient include;
1.Psychological support
2.Symptomatic management
3.Pharmacological management
4.Spiritual care
5.Social care & supporting to the family members

15. 1.Psychological support
 The psychological needs of a dying person can be as follows:
- Relief from loneliness, fear and depression.
- Maintenance of security, self confidence and dignity.
- Maintenance of hope.
- Maintenance of a comfortable and peaceful environment
 The dying person who passes through the different stages of grief, so the
nurse should be supportive and understandable in these stages
 Nurse should be truthful but sensible in all their dealings with the patient
 The nurse should understand the physical & emotional pain that a dying
person suffers.

16.  Nurse should use therapeutic communication with patient and relatives
 During this period, they may ask many doubts regarding his condition,
we should clarify these by using their own words/language.
 One of the simplest way of providing support by physical contact such as
holding hands, a touch on their arms or wrist or a gentle massage or a
hug, can make a person feel comfortable. it can be very soothing and
may psychologically heal them.

17.  Being present with the patient and listen the client actively. Show
genuine attitude of interest in dealing with his problems.
 Some health care providers suggest that a low volume music or soft
lighting are comforting for a dying patient. It is proven that music
therapy is able to improve a patient’s mood by increasing relaxation &
reducing their pain.
 Dying client might believe that, health care members will make their
remaining life will be meaningful by using any treatments or
comfortable measures and make/allow them to approach a dignified
death.

18. Problem associated with breathing:
The dying person who is restless, apprehensive and short of breath may
be given-
 Oxygen inhalation to remove his discomfort.
 Elevation of the patient’s head and shoulders may make breathing
easier.
 Keep the room well ventilated and keep the crowds away.
 Periodic suctioning is necessary in order to maintain patency of airway
 Change the position frequently at least 2 hourly

19. Problem associated with eating and drinking:
 Anorexia, nausea, and vomiting are commonly seen in dying patient
person. They are unable to take any form of food and if they taken,
they are unable to retain the food in the mouth
 The patient is unable to swallow even the sips of water poured in the
mouth. Most of them may require I.V fluids. If they can tolerate the
oral fluids, sips of water is given with teaspoon. That will help the
patient to keep the mouth moist.
 Give frequent oral hygiene.
 Apply emollients to the dry lips.
 The denture are removed and kept safely.

22. Problem associated with rest and sleep:
 Patients may have distressing symptoms, so the patient should not be
disturbed while sleeping.
 The visitors should be instructed not to disturbed the patient during he
is resting.
 Maintain calm and quiet environment.
Problem associated with cleanliness and grooming:
 Cleanliness and appearance are important until the end.
 Cleanliness of the skin, hair, mouth, and cloth has to be maintained.

24. SPIRITUAL CARE
 Religion is a prime source of strength to many people when they are
dealing with death. So meet the spiritual needs of the client
according to their religious customs.
 Some patients may not wish to access such support & these wishes
should be respected
 It is a good practice to check with the patient what they would like or
to family members if the patient is not able.
 Since an unconscious patient is still able to hear, nurses may suggest
that family members invite religious person/s to come & perform
certain prayers as it will help the patient to meet their spiritual needs.

25. SOCIAL CARE & SUPPORTING TO THE
FAMILY MEMBERS
 Dying persons want to maintain relationships with the special people
in their lives. They may be concerned about their roles within the
family, in the work place &in community.
 The family members also passes through the same stages of emotion
as the patient is nearing death. So the nurses attitude towards the
relatives should be sympathetic, considerate and meaningful.
 Allow the relatives to see the patient & give enough time to be with
the dying person
 Nurses can encourage the family members to share their memories of
good times with the patient.

26.  Nurses see that the family members have a place to take rest & to have
their meals.
 Whenever possible, communicate the news of a patient’s declining
condition or impending death when they are together. So they can
provide support to one another
 The dying person may be shifted to private room or privacy is
maintained by putting the screen, so that other patients may not be
disturbed by the unpleasant sight, the cries and other disturbances.
 Assist the client & family members in decision making at the end of the
client’s life, because they may not have enough knowledge or prior
experience.