BASIC NURSING III�Mr. David

Preparation for Rectal Examination

Definition of Rectal Examination

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Inspecting the rectum and anal canal by way of inserting the finger or by instrumentation to visualise the rectum.

TYPES OF RECTAL EXAMINATIONS

• Digital Rectal Examination (DRE)

Rectal examination performed by means of inserting a gloved, lubricated finger into the rectum and palpating (feeling) for lumps.

• Proctoscopy

This is where a proctoscope is inserted into the anus to aid examination of the lower rectum and anal canal.

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Sigmoidoscopy

• A procedure where a sipmoidoscope is inserted into the anus to allow visualization of the distal sigmoid colon and rectum

DIGITAL RECTAL EXAMINATION

Purpose/Indication

• DRE is used as a screening tool to locate rectal cancer and prostate cancer.
• It is also used as a diagnostic test to find non-cancerous abnormalities within the rectum like hemorrhoids, anal fissures, or congenital deformities that can cause chronic constipation.

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Preparation

Explain procedure to patient

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Requirements

• A screen to provide privacy
• Sterile gloves
• Sterile lubricant
• A fenestrated drape
• Gauze swabs
• Paper bag for used swabs

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Steps

• Reassure patient and provide privacy
• Put patient in the required position i.e. genupectoral or left lateral
• Drape patient with the fenestrated sheet
• Assist doctor to perform the examination
• Make patient comfortable after the procedure
• Remove privacy

Preparation for Protoscopy

Explain procedure to patient

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Requirements

• An illuminated protoscope
• Gauze swabs
• Paper bag for used swabs
• Lubricated, gloves
• A fenestrated drape

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Steps

• Reassure patient and provide privacy
• Put patient in the required position i.e. genupectoral or left lateral
• Drape patient with the fenestrated sheet
• Assist doctor to perform the examination
• Label specimen if any
• Make patient comfortable after the procedure
• Remove equipment decontaminate, sterilize and store

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CATHETERIZATION

Def

Urinary catheterization is the process of inserting a fine plastic rubber catheter into the urinary bladder in order to remove urine or keep the urethra open

Indications for Catheterization

• Incontinence of urine (Paralysis, unconscious patients etc)
• Urine retention (Urethral stricture, etc)
• For proper monitoring of intake and output
• For collection of urine specimen
• Surgical operations e.g. laparotomy, S/C etc

Types of Urethral Catheters

There are several types of urethral catheters but the most commonly used one in our hospitals in Ghana is the two way foley’s catheter.

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Two way foley’s Catheter

Types of Foley’s Catheter

With the two way Foley’s catheter, the main lumen is for urinary drainage and the second fine lumen is for inflating the balloon with sterile water

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Requirements for catheterization

• Trolley

Top Shelf

A sterile tray or pack containing:

• Towel
• Gloves
• Dressing towels
• Receiver
• Gallipot
• Swabs
• Cotton wool balls
• Artery forceps
• 20 mls syringe

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Lower Shelf

• Various catheters of different sizes are used:

(14” and 16” for female)

(18” and 20” for male)

(8” and 10” for children)

• Sterile K.Y Jelly or Lubricant
• Savlon
• Receiver for used swabs
• Mackintosh and towel

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• Spigot
• Drainage bag
• Sterile water or Saline
• Specimen bottles
• Hypo-allergic tape or plaster
• A pair of scissors
• Hand lamp if necessary

Steps for Female Catheterization

• Explain procedure to patient
• Provide privacy
• Vulva and surrounding areas should be washed before the procedure
• Close all windows
• Send trolley to bedside
• Put patient in dorsal position and bed clothes turned down as far as patient’s knees, leaving her covered with only a blanket or a single sheet

• Place mackintosh/waterproof sheet under the patient’s thighs and buttocks
• Adjust the hand lamp so that it gives a good light
• Wash and dry hands
• Cover the waterproof sheet under the buttocks with a sterile towel and place sterile receiver between her legs ready to receive urine.

• Open the packs of sterile dressing and catheter and place the contents onto the sterile area
• Turn back sheet covering the patient or ask assistant to do this if available or necessary
• Wash hands and wear sterile gloves

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• Swab external genital region with mild antiseptic e.g. savlon beginning with the labia majora then the labia minora and lastly the vestibule. Using each swab once only, from the vulva towards the back.
• Ask the assistant to fix the light for the clear view of the urethral orifice.

• Separate labia minora using the first finger and the thumb of the left hand and pass the catheter using either a gloved right hand or a pair of dressing forceps.
• If possible place a cotton wool swab on the vaginal orifice to help locate the urethra and to avoid contamination of the urethral catheter.

• Pass the tip of the catheter into the urethral orifice and then gently push it in an upward and backward direction for about 5cm (2 inches) leaving the open end in the receiver between the patient’s thighs
• Collect catheter specimen, label and send to the lab
• If it is a retaining catheter (indwelling catheter), then draw sterile aqua and inflate the balloon.

• Connect the end of the catheter to a urine bag and hang it on the edge of the bed
• Remove gloves and discard
• Tidy patient and make him/her comfortable in bed
• Clean all equipment thoroughly immediately after use if not disposable
• Decontaminate, wash, sterilize and store equipment
• Wash and dry hands and thank patient.

Note

Observations

• Observe the colour, transparency, and the odour of the urine
• Amount of urine is measured and recorded on patient’s fluid chart
• Record and report any unusual discomfort experienced by the patient

CATHETER HYGIENE/CARE

This is usually carried out whenever a self-retained catheter is in situ. Usually done during or after the patient’s personal hygiene.

REQUIREMENTS

• Sterile tray containing:-
• Sterile wool or gauze swabs
• Sterile towel
• Sterile water/saline
• Disposable bag for dirty dressing
• Pair of sterile gloves
• Mackintosh and towel
• Receiver for used swabs

STEPS

• Explain procedure to the patient
• Ensure privacy
• Place the mackintosh and towel under the patient’s buttocks
• Turn back bed clothes
• Wash hands and put on gloves
• Place sterile towel beneath the catheter
• Swab the urethral orifice if male, if female do vulva toileting/swabbing before
• Swab the exterior of the catheter carefully at its insertion and the entire catheter
• Remove and discard gloves

• Make patient comfortable in bed
• Decontaminate and sterilize all equipment immediately after use if not disposable

Passing a Naso-gastric Tube

This is a rubber tube that is passed through the nostrils down the oesophagus into the stomach. For the purpose of artificially feeding the patient or emptying the stomach of gastric content

Indications

• Paralysis of the soft palate
• Unconsciousness
• Acute abdomen

Requirements

A tray with the following:

• A receiver with a sinus forceps for cleaning the nostril
• Ryle’s tube
• Disposable syringe barrel 20 – 50 ccs or extra rubber tubing, glass connection and a glass funnel.
• Mouth wash to rinse after the feed

• A gallipot containing lubricant e.g.. Liquid paraffin
• A gallipot with cotton wool swabs
• A graduated jug containing feed
• Graduated glass with 30mls of water
• Receiver for used swabs
• Litmus paper to test aspirate in order to ascertain position of the tip of the tube

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• Adhesive strapping
• A pair of scissors
• Jaconet cape and cover

Steps

• Explain procedure to patient
• Provide privacy
• Send prepared tray to the bedside and place it on the patient’s locker
• Wash and dry hands
• Make patient comfortable in a suitable position e.g. upright, or lateral position
• Place jaconet cape across the patient’s chest

• Clean patient’s nostrils to provide clean passage
• Note marking on the tube to determine the approximate distance of 50 – 60cm from the stomach end of the tube (or measure the distance from the tip of the nose to the lobe of the ear, to the xiphisternum and mark the point with a pencil on the tube

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• Lubricate the tip of the tube with liquid paraffin
• Insert tube gently but quickly, passing it backwards and downwards.
• Look into patient’s mouth to make sure tube has not coiled up in the mouth
• Ask patient to swallow if conscious

• Check if gastric tube is in the stomach by the following:
• Aspirating a small amount of gastric juice and checking acidity with litmus paper
• Observing if patient is cyanosed
• Note if he is coughing

Note

If the purpose of the NG tube is to empty the stomach of gastric content in cases of acute abdomen prior to operations/surgery, you connect the NG tube to a drainage bag.

NG Tube for the Purpose of Feeding

• Check the temperature of the feed on the back of your hand using a spoon
• Push 10-15mls of water through the tube just before the feed is introduced to check whether the feeding will be distressful to the patient
• Fill the funnel/barrel of 20cc syringe and allow the feed to run slowly.

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• Use the remaining water (10m-15mls) to clear the tube at the end of the feed.
• Pinch the tube and spigot the end, strap it to the patient’s check
• Congratulate the patient
• Document on the fluids intake and output chart accordingly

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• Make patient comfortable
• Remove screen
• Discard tray
• Wash hands

Administration of Oxygen and Precautions for Use

• Oxygen is given in conditions where there is hypoxia/anoxia

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• Oxygen may be delivered either piped through tubes in the wall or from the oxygen cylinder

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Precautions

When oxygen is given in the ward, the following precautions should be observed:

• Avoid naked flames or fire
• Put up a NO SMOKING sign at the entrance or ward and near patient
• Do not use electric gadgets or any article which can cause sparks
• Do not use oil on the oxygen cylinder

• Keep cylinder in a cool place
• Mark oxygen cylinders to indicate whether full or empty
• Use only carrier with wheels to transport oxygen cylinders do not roll them
• Do not apply alcohol to patient’s skin

Administration of Oxygen by Mask

Requirements

• Oxygen in a cylinder with a key, gauge and flow meter or an oxygen wall point
• Oxygen tubing
• A bowl containing water
• Oxygen Mask
• Nelson’s catheter

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• Glass connection
• Woulfe’s bottle containing water
• Elastoplast

Steps

• Observe precautions in giving oxygen
• Explain procedure and rational to patient
• Let patient, other patient and visitors know the dangers involved
• Prepare equipment
• Wheel cylinder to the bedside
• Connect tubing to cylinder or wall pipe point

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• Make patient comfortable and reassure him
• Turn key anticlockwise for 3 full turns to open cylinder
• Turn flow meter end of tubing into bowl of water for bubbles to test for flow of oxygen
• Connect oxygen mask to tubing and allow a little oxygen to flow through

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• Apply oxygen mask over patient’s nose and mouth and use elastic string attached to mask to hold it in position
• Regulate flow meter as prescribed e.g. 2-4 litres per minute in an adult. Children ½-2 litres/minute
• Stand by to observe flow of oxygen for sometime before leaving patient

• Fix tubing to pillow with a safety pin to keep the tube in position
• Record and report time of starting
• Wash and dry hands
• Keep patient under constant observation
• Regularly watch flow meter and gauge for the amount of oxygen in cylinder
• Remove oxygen mask from patient when he is better

• Turn off oxygen
• Make patient comfortable
• Clear away equipment
• Wash and dry hands
• Record and report observations

Administration of Oxygen by Catheters

Requirement

A tray with:

• Catheter in a receiver
• Gallipot with cotton wool swabs
• Orange sticks
• Receiver for soiled swabs
• Lubricant
• Safety pin and elastoplast

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• Y- connection
• A small bowl containing water

Steps

Same as for using mask with the following additions.

• Clean nostrils with wool swabs on orange stick and water
• Lubricate the tips of the catheters
• Connect catheters with Y-connection
• Hold catheters to patient’s checks by a piece of elastoplast

• Continue with rest of steps till end

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Note

• The rate of flow is less than that of mask, about 2 litres per minute

Setting of Sterile Trays and Trolleys

Preparation of a tray or trolley for a sterile procedure:

• Put on mask, wash hands thoroughly and dry
• Clean the tray, if trolley clean the shelves and rails with soapy water, rinse, dry, clean with disinfectant e.g. habitane in spirit and dry
• Drape the tray, if trolley drape the upper shelve with a sterile towel

PRINCIPLES AND PRACTICES OF SURGICAL ASEPSIS

• All objects used in a sterile field must be sterile
• Sterile objects become unsterile when touched by unsterile objects
• Sterile items that are out of vision or below the waist level of the nurse are considered unsterile
• Sterile objects can become unsterile by prolonged exposure to airborne microorganisms
• Fluids flow in the direction of gravity

• Moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action
• The edges of the sterile field are considered unsterile (2.5cm margin at each edge of a sterile drape is considered unsterile)
• The skin cannot be sterilized and hence is unsterile
• Conscientiousness, alertness and honesty are essential qualities in maintaining surgical asepsis

Requirements for Wound Dressing

• A trolley

Top Shelf

• 3 gallipots for lotions
• 2 pairs of dressing forceps
• 2 pairs of dissecting forceps
• Sinus forceps
• Prone
• Stitch Scissors

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• Covered bowl for cotton wool and gauze swabs
• Covered receiver for dressing towel
• Clip remover

OR

A dressing pack containing:

• 2 dressing forceps
• 2 dissecting forceps

• Sinus forceps
• Stitch Scissors
• Probe
• Clip remover
• 3 gallipots
• Towels, Gauze and cotton wool swabs

Lower Shelf

• Bottles of lotions e.g.. Cetavlon. Eusol and methylated Spirit
• Adhesive plaster
• Scissors
• Bandages
• Covered receiver containing parazone 1:10 (0.5%) for soiled instruments
• Mackintosh with a cover
• Receptacle for soiled dressings

Steps for dressing of wound

• Explain procedure to patient
• Put on mask
• Ensure privacy
• Wash and dry hands
• Ask assistant to:
• Adjust bed clothes
• Pour out lotions into gallipots
• Remove plaster or bandage

• Remove soiled dressing with dissecting forceps and discard
• Clean wound with swabs soaked in antiseptic lotion, starting from the wound outward. Use one swab only once
• Clean wound with series of swabs
• Apply enough dressing and apply strapping or bandage

• Make patient comfortable and commend him for his co-operation
• Remove screen and discard the trolley
• Decontaminate, clean and sterilize instruments
• Wash and dry hands
• Record and report on the state of the wound

NOTE

• Carry out dressing an hour after bed making, sweeping and dusting. Visitors must not be allowed in the ward during dressing time

Removal of Stitches

Requirements

Same as requirement for wound dressing except that you add a sterile stitch scissors

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Steps

Refer to steps for dressing of wound up to step 8

• Pick the tooth dissecting forceps in the left hand with the stitch scissors in the right

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• Grasp the ends of the stitches with the dissecting forceps, pull it a bit to expose an area between the knot and the skin
• Insert one blade of the stitch scissors under the stitches and cut
• Cut it in a such a way that no piece of stitch is left in the tissue and remove the stitch without dragging the exposed area through the tissue.

• Place all removed stitches on a swab and examine
• Swab wound and dress with dry dressing
• Refer to dressing of wound and complete the dressing

Removal Of Clips

Requirements

Same as requirements for dressing of wounds (refer)

Add clip removing forceps

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Steps

Refer to dressing of wound up to step 8

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• Place sterile swab near the wound
• Take the clip removing forceps in the right hand and a pair of dissecting forceps in the left
• Steady the clip with the dissecting forceps insert one blade of the clip removers under the clip in the centre and the other blade on top of it.
• Ensure the blades are inserted for sufficient distance

• Press the blades together, this straightens the clips metal lifting it from the skin on either side
• Lift it on to a swab
• Repeat the above to all the clips or as required
• Swab the wound with spirit and apply dry dressing. Apply strips of plaster
• Refer to dressing of wound from step 10 to 14

Removal of a Drainage Tube

Requirements

Same as requirements for dressing wound (Refer)

Add sterile sharp pair of scissors

Steps

• Refer dressing of the wound to step 8
• Grasp the protruding end of the drainage tube with an artery forceps and clip in position

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• Remove any stitch holding the drain in position
• Gently turn the drain within the wound to loosen it if is a tubular drain
• Remove the drain from the wound after swabbing around it
• Swab the wound with cleansing lotion
• Dress would with eusol and hold it down with strips of plaster

• Refer to dressing of the wound from 10-14

Care of Unconscious Patient

An unconscious patient is the one who is unaware of his surroundings and is incapable of responding to sensory stimuli. Mostly as a result of interruption of the normal activities of the brain.

LEVELS OF CONCIOUSNESS

There are different degrees of awareness or unawareness. The main ones are:

1. Full Consciousness: The person is alert, communicates well and can respond to questions normally.
2. Drowsiness: The person feels weak, can easily be aroused, but can get into unconsciousness again.

iii. Stupor: A partial or nearly complete unconsciousness. The is diminished response to stimuli making the patient aware of only painful stimuli. May therefore be aroused with difficulty.

iv. Coma: A state of profound unconsciousness from which the casualty/patient can not be aroused by stimuli or what so ever.

V. Coma Vigil: Not very different from coma except that, the patient’s eyes are wide open as if he/she is awake.

Causes of Unconsciousness

• Asphyxia
• Head injury (RTA)
• Shock
• Fainting
• Stroke/apoplexy/CVA
• Poisoning (alcohol, gases, drugs, etc)
• Heart attacks
• Epilepsy etc.

Objectives�

• To promote early return to consciousness
• To prevent pressure ulcer formation
• To prevent complication e.g. renal stones, embolism etc

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• To maintain the dignity of the patient (personal hygiene and avoiding unnecessary exposure)

Requirements

• Bed accessories e.g. side rails, sandbags, air-rings
• Bath trolley
• Urethral catheters, urine bags, bedpan
• A tray for vital signs

• Resuscitation tray
• Gloves
• Tray for oral hygiene
• Diagnostic set
• Tray for passing NG tube

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Steps

• Provide privacy
• Explain every procedure to patient and relatives
• Put patient in a lateral or semi prone with head turned to one side
• Establish and maintain airway for frequent suctioning
• Administer oxygen when necessary

• Remove dentures if any, wash, label and keep in a safe place
• Maintain patient’s safety by keeping up side rails
• Maintain good body alignment to prevent foot drop and other complications
• Check vital signs 4 hourly and record or as indicated

• Perform Glasgow coma scale assessment once or twice daily depending on patient’s condition
• Observe for twitching of any part of the body and document
• Maintain accurate intake and output chart
• Maintain personal hygiene
• Change position of patient every 2 hourly and inspect skin especially areas of bony prominence

• Observe bladder and bowls for retention of urine and faeces
• Maintain nutritional status by administering prescribed intravenous fluids and feed patient through NG tube
• Change linen when soiled to prevent pressure ulcers
• Administer prescribed drugs and observe and reaction and document

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• Give passive limb exercises at each turn
• Reassure patient and relatives
• Educate relatives on patient’s condition and involve them in his care

Precaution

• Unguarded statements by health staff and relatives must be avoided since patient may hear although he is unable to respond

GLASGOW COMA SCALE

GENERAL CARE OF UNCONSCIOUS PATIENT

• Explain every procedure to the patient even though he is unable to respond
• Maintenance of an adequate airway
• Establish patent airway
• Frequently suction if mucus collects in the oropharyngeal cavity
• Administer oxygen if prescribed or when necessary

Position and Rest

• Place patient in a lateral or semi prone position with head turned to one side and maintained bedside rails
• Maintain good body alignment to prevent foot and wrist drop etc by the use of sand bags, extra pillows etc
• Ensure quiet environment to promote rest & sleep

Observation

• Check temperature hourly, 2 hrly, 4 hrly as patient’s condition improves
• Check blood pressure ½ hourly, hourly, 2 hrly and then 4 hourly as his condition improves
• Assess level of consciousness e.g using Glasgow coma scale
• Observe for twitching of any part of the body
• Record intake and output of patient

Personal Hygiene

• Give bed bath twice daily or when ever necessary
• Give mouth care twice daily or PRN moisten lips with vaseline
• Treat pressure areas 4 hourly
• Change position of patient 4 houly and keep bed dry
• Remove dentures, wash label and keep at safe place
• Provide care for feet, hair, and nails

Nutrition

• Sustain nutrition by administering prescribed IV infusion then
• pass NG tube and feed patient with light and fluid diet e.g. tea, fruit drinks, porridge etc
• Initiate oral feeds when swallowing reflex is present and patient has gained consciousness
• Serve with fluid, light and normal diet as condition improves
• Give small mouth full at a time

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Elimination

• Catheterize patient using aseptic technique
• Provide catheter care as required
• Record accurately intake and output
• Change soiled linen as often as possible if soiled with faeces. Apply pampers on patient
• Observe the characteristic nature of urine and faeces e.g. colour, odour etc

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Prevention of Injury

• Raise and pad side rails of patient’s bed to prevent him from falling
• Move extremities passively twice daily to prevent joint disfunctioning

Etc

• If patient starts gaining consciousness assist him out of bed
• Mop any fluid/water on the floor
• Remove ropes and all wires that might be on the floor to prevent him from entangling himself and falling

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Psychological Support

• Reassure patient relatives continually by;
• Telling relatives that there are competent health/medical team to attend to their relative
• Explain every procedure to the patient and relatives before carrying it out
• Encourage patient relatives to ask questions freely to allay anxiety
• Answer all questions simply and correctly

Note: Do not reveal patient’s diagnoses to relatives

Grief and the Grieving Process

Definition of Grief

This refers to a natural subjective reaction towards the experience of suffering, loss or fear of the unknown that produces a psychological reaction.

Simply put it refers to sorrow or sadness at the death or anticipated death of a love one, possessions, a job, status or part of the body.

Types of Grieving

Uncomplicated Grief

• Many individuals use the term normal grief. Engle (1961) proposed use of the term uncomplicated grief to describe a grief reaction that normally follows a significant loss. Uncomplicated grief runs a fairly predictable course that ends with the relinquishing of the lost object and resumption of the previous life. Even though the bereaved person’s life is changed forever, the person is able to regain the ability to function.

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Dysfunctional Grief�

• Persons experiencing dysfunctional grief do not progress through the stages of overwhelming emotions associated with grief, or they may fail to demonstrate any behaviors commonly associated with grief. The person experiencing pathologic grief continues to have strong emotional reactions, does not return to a normal sleep pattern or work routine, usually remains isolated, and has altered eating habits.

Conventional Grief:- Occurs after a loss

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Anticipator Grief:- Occurs in anticipation of a loss/impending loss

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FACTORS AFFECTING GRIEF�

The experience of grief is individual and is influenced by various factors.

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Factors that influence grief includes:

• the person’s developmental level,
• religious and cultural beliefs,
• relationship to the lost object, and
• the cause of death.

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Responses/Manifestation of Grieving

• Helplessness
• Loneliness
• Hopelessness
• Guilt & anger
• Loss of appetite and strength
• Changes in body activities e.g. restlessness, aimless motions nervous speech

Causes of Grieving

• Death, especially a dependant person, or someone you are emotionally attached to
• Loss body function or part or job, home, status or a pet
• Care for the terminally ill e.g. an incurable disease or massive injury
• Separation e.g. Married person, anticipation of separation, say a relative in army posted to Middle East

Models of Grief

• Many researches and theories have attempted to describe the X’tics of normal grief and the grieving process.
• Some have proposed stage models of grieving.
• Models of grieving are useful in nursing care for people experiencing loss
• They are also used in in helping to identify grief reactions that outside the normal range

Stages/Phases of Grieving

Kubler – Ross’ Model (KÜBLER-ROSS’S STAGES OF GRIEF)

Kubler – Ross (1969) proposed five stages of grief:

• Denial: Behavioral response :- Refuses to believe that loss is happening.
• Nursing implications :- Verbally support the client but don’t reinforce denial. Examine your own behavior to ensure that you don’t share in client’s denial.

• Anger :- Behavioral response :- Client or family may direct anger at nurse or staff about matters that normally would not bothered them.
• Nursing implications Help client understand that anger is a normal response to feelings of loss & powerlessness. Avoid withdrawal or retaliation, do not take anger personally.

Bargaining :- Behavioral response :- Seeks to bargain to avoid loss. May express feeling of guilt or fear of punishment for past sins, real or imaginary.

Nursing implications :- Listen attentively & encourage client to talk to relieve guilt and irrational fear. If appropriate offer spiritual support

Depression :- Behavioral response :- Grieves over what has happened & what can not be. May talk freely or withdraw. Here the client acknowledges the reality, inevitability of his impending death

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Nursing implications :- Allow client to express sadness. Communicate nonverbally by sitting quietly without expecting conversation. Convey caring by touching.

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Acceptance :- Behavioral response :- Comes to term with loss. May have decreased interest in surrounding and support people. Loses interest in worldly activities. May wish to begin making plans.

Nursing implications :- Help family and friends. Understand client’s decreased need to socialize. Encourage client to participate as much as possible in the treatment program.

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Engel’s Model

Engel (1954) one of the first to study grief, proposed six phases of the grief process

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• Shock & disbelief - Behavioral responses - Refuse to accept loss. Has stunned feelings. Accepts the situation intellectually, but denies it emotionally.

Developing awareness – Behavioral responses – Reality and meaning of the loss begin to penetrate the person’s consciousness. The numbness of the first phase is replaced with feeling of intense psychological pain, often expressed through crying and anger. Anger may be directed at agency, nurses or others.

Restitution – Behavioral responses - Conducts rituals of mourning( e.g. Funeral) attempts to deal with painful void.

Resolving the loss:- Still unable to accept new love object to replace lost person or object. The grieving person focuses energy on thoughts of the deceased

Idealization - Behavioral responses – Produces image of lost object that is almost devoid of undesirable features. Represses all negative & hostile feelings towards lost object. May feel guilty about past inconsiderate or unkind acts to lost person. Unconsciously internalizes admired qualities of lost object. Reinvest feelings into others.

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Outcome:- Gradually the grieving person psychological dependence on the deceased diminishes and his or her interest in new relationship returns.

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Engel say the resolution of grief takes 1 year or more.

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Nursing Objectives of Grieving

• To educate the relatives on the process of grieving
• To support the relatives during the grieving process to adjust to the loss
• To assist relatives to go through the necessary procedures before burial
• To encourage the family to reinvest their energy into new relationships

Steps

• Inform relatives of the death in a supportive manner
• Allow them time to express their emotions
• Explain to relatives the procedures they need to go through before burial (Payment of bills, autopsy, certification and registration)
• Show empathy

• Return all possession of patient to relatives and let them sign for them
• Document all information

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Precaution

Educate relatives on how to handle the body and clothes if the patient died from an infectious disease.

Care of the Dead (Last Offices)

• Death is one of the universal and individually unique events of the human experience.
• It is the inevitable end that every living human being will experience when the time comes
• A person is clinically dead when there is total absence of activity in the brain and central nervous system, cardiovascular system and the respiratory system as observed and declared by a physician

SINGS OF IMPENDING CLINICAL DEATH

LOSS OF MUSCLE TONE

• Relaxation of facial muscles (jaw sagging)
• Difficulty speaking
• Difficulty swallowing and gradual loss of the gag reflex
• Decrease activity of the gastrointestinal tract, with subsequent nausea, accumulation of flatus, abdominal distension
• Bilateral incontinence
• Diminished body movement

SLOWING OF CIRCULATION

• Diminished sensation
• Mottling and cyanosis of the extremities
• Cold skin, 1^st in the feet and later in the hands, ears, and nose

CHANGES IN VITAL SIGNS

• Decelerated and weaker pulse
• Decreased BP
• Rapid, shallow, irregular or abnormally slow respiration, noisy respiration (death rattle)

SENSORY IMPAIRMENT

• Blurred vision
• Impaired senses of taste and smell

CHANGES IN THE BODY AFTER DEATH

Rigor Mortis: Stiffening of the body that occurs about 2 to 4 hours after death.

• It results from lack of adenosine triphosphate (ATP)
• Which is not synthesized because of lack of glycogen in the body
• Rigor mortis usually starts from the involuntary muscles

NOTE: Proper body alignment needs to be done before rigor mortis sets in. It usually wears off after 96 hours

Algor Mortis:

• The gradual decrease of body temperature after death
• When blood circulation terminates, the hypothalamus ceases to function hence body temperature falls until it reaches room temperature.

Olivor Mortis: Discolouration of a dead body due to haemoglobin which is released in to the body as a result of rapid break down of RBC’s after death, lowermost or dependent areas of the body are the most hit.

Objectives of Last Offices

• To maintain the dignity of the dead person
• To maintain a proper alignment of the deceased

Requirements

• Bath trolley and toiletries
• Dressing set and dressings
• Shroud/ Body or Cadaver bag/ two clean sheets and tape for securing the sheet
• Two name bands/ labels
• Receiver to express bladder
• Property book

Steps

• Inform the Medical Officer to confirm death
• Screen the bed as soon as death occurs remove other gadgets that are not in use.
• Clip all gadgets
• Inform relatives and give them opportunity to see the deceased
• Pay attention to the deceased patient’s and relative’s beliefs and wishes

• Wear protective clothing
• Remove any tubes, catheters and infusions unless otherwise indicated, e.g. post-mortem requirements
• Wash the body. Leave/ replace dentures if they fit
• Two nurses carry out last offices e,g. plugging orifices, closing the eyes, tying the jaw and the limbs

• Pack or pad wound or orifices
• With the second nurse as witness, remove all jewellery from the body document and hand over to relatives
• Place one identification label on the chest attached to the shroud with adhesive tape
• Place one name band on the wrist and another on the ankle or according to local hospital policy �

• Place the shroud on the body, with the fastening at the back. In the event that there is no shroud available, place underpants on body to maintain the patient’s dignity
• Place a clean sheet under the body, leaving enough sheets to fold over the head and feet
• Wrap the body in the sheet and secure with tape

• Place body in a cadaver or body bag and label with the appropriate tag
• Complete the property form. Both nurses must document and sign for any valuables

Precautions

• Last offices requires two nurses working together quietly
• Be familiar with hospital policy regarding last offices
• After death leave the body for an hour before last offices are commenced, during which time a doctor would have certified death

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• Remember to support jaw to prevent the mouth falling open, and the eyes closed with moist swabs if necessary
• Religious and cultural preferences must be ascertained prior to last offices, e.g. who can touch the body (Muslims), removal of religious objects or jewellery, etc
• Use a top sheet/ counterpane to cover body if the body is to be seen by the family after last offices

• It is important to prevent leakage from the body, as this is unpleasant and potentially dangerous for porters and mortuary technicians.

Post Procedure Care

• Remove protective clothing and wash hands
• Complete the care plan and other documentation according to hospital policy
• Pack the deceased’s belongings
• Store property according to hospital policy if relatives or next of kin are not in attendance
• Contact porters or mortuary technicians to remove the body

• Clear equipment and dispose of clinical waste safely
• Leave the area tidy, ready for cleaning/ disinfection.