NUR 426 EXAM 1B
•Requires frequent assessment
•Not always present at end of life
•May not be able to rate pain & must rely on behavior cues
•Rule out / think about other causes of distress
•Use of oral/transdermal medications - answerPain at end of life
•Adult sudden death (i.e. accidents, heart attacks)
•Advanced illnesses, six months to live (i.e.
cancer)
•Chronic illness (i.e. diabetes, heart disease, COPD, etc),
•Childhood accidents, acute or chronic illnesses, Neonatal/infant deaths (i.e. congenital
defects, SIDS, etc) - answerNurse Exposures to Death
• Provide support to patients, families and each other
• Interpersonal competence: Empathy, Unconditional Positive Regard, Genuineness,
Attention to Detail
• Being present
• Interdisciplinary team - answerHealthcare Provider Role in death
-Appreciate unique roles of patient and family
-Avoid giving specific times
-Some patients want family present, some prefer to be alone
-Assess their understanding
-Echo their language
-Assess their willingness and ability to provide care
-Use simple terms, explain care being provided, provide reassurance
-Provide guidance / "what to expect" at/after death - answerCommunication with
Patient/Family in death
-Death Rattle: 56%
- Pain: 51%
- Agitation: 42%
- Urinary Incontinence: 32%
- Dyspnea: 22%
- N/V: 14%
- Myoclonus: 12% (brief, involuntary twitching of a muscle or group of muscles) -
answerFrequency of Sxs Last 48 hrs prior to death
• Requires frequent assessment
• Not always present at end of life
• May not be able to rate pain & must rely on behavior cues
,• Rule out / think about other causes of distress
• Use of oral/transdermal medications - answerPain in dying
-Is a distressing symptom for patients and families
• Be proactive
• Oxygen
• Positioning
• Fan/cool environment
• Calming environment/provide reassurance
• Use of opioids
• Benzodiazepines - answerDyspnea in dying
-pain
-dyspnea
-respiratory secretions
-restlessness
-delerium
-Cardiovascular - cold extremities/mottling, change is vital signs
-Respiratory - change in breathing pattern (apnea, panting, cheyne-stokes, mandibular
breathing), audible secretions
-Metabolic - fatigue, surge of energy, temperature changes/diaphoresis
-Gastrointestinal- decreased intake, nausea, vomiting, diarrhea, constipation,
incontinence
-Urinary - decreased urine output
-Communication - decrease interaction with others (i.e. withdrawn, using metaphors,
expressing emotional and/or fears) - answersymptoms of near death
-Be proactive
-Oxygen
-Positioning-(head elevated or side lying)
-Fan/cool environment-
-Calming environment/provide reassurance
-Use of opioids
-Benzodiazepines - answermanagement of Dyspnea in death
death rattle - answer-noisy wet-sounding respirations caused by mouth breathing and
accumulation of mucus in the airways
-distressing and frightening symptom for those involved in the patient's terminal care.
-For patients who are alert, their noisy respirations can cause them to become agitated
and fearful of suffocating
-primary lung cancer
-cerebral metastases
-pneumonia
-dysphagia
-those in the last days of life. - answerThose with increased risk for death rattle
,-Pulmonary embolism or myocardial infarction if the death rattle occurs suddenly
-Fluid overload as is found in congestive heart failure may benefit from a trial of diuretic
therapy
-Pneumonia may benefit from antibiotic therapy - answerPotential causes for the death
rattle may include:
*Begin anticholinergic drugs to dry secretions such as:
-Scopolamine patch, starting with one (1.5 mg) and increasing by one patch daily. If at
three patches the patient is without relief, begin an infusion of 50 mg/hr and titrate
hourly to a maximum of 200 mg/hr.
-Atropine (0.4 mg), either IV or SQ can be used, but this may cause excitation.
-Other agents include glycopyrrolate, oxybutynin, or hyoscine.
-Finally, reduce (to <500ml/24 hrs) or withhold parenteral fluids or enteral feeding, as
the fluids may be contributing to the rattling secretions. (Harlos, 2010). - answerdrugs
for death rattle
-Attempt to reposition the patient
-Keep head of bed elevated.
-Suctioning is generally not recommended, as it can increase agitation and distress in
the patient. - answernonpharm for death rattle
-Using the term "death rattle" can be a frightening term to hear. Some have suggested
using the term "respiratory congestion" or "terminal secretions" to describe this
phenomena to patients/family.
-Be honest with families and let them know that this can occur before death, so that
families caring for their loved one at home will know what may be available to relieve
this symptom - answerfamily support for death rattle
-Elevate head of bed
-Begin anticholinergic drug(s)
-Reduce or stop IV fluids/enteral feedings
-Provide reassurance and education
-Provide peaceful, calming environment
-Role model comforting - answerInterventions/Management for respiratory
secretions/death rattle
HYPERactive -restlessness, calling out, agitated, disoriented, crawling out of bed,
delusions
HYPOactive -lethargic, somnolent, appear to be in a stupor
-Can have both - hypo and hyper active delirium - answerDelirium and death
• Assess for reversible causes (i.e. constipation, distended bladder)
• Provided a calm, comforting environment
• Use medications as ordered - answerRestlessness in death
, -changes in the sleep/wake cycle/ICU psychosis/restraints - answercauses of delirium in
death
-environmental
-use of antipsychotics (if indicated)
-Benzodiazepines may worsen delirium (especially in the elderly) - answertreatment of
delirium in death
*Absent
-pulse
-blood pressure
-respirations
-response to stimuli blinking/corneal reflex
*May see
-bowel/bladder incontinence
-eyes slightly open
-jaw relaxed
-mouth open
-waxy, pasty appearance to skin - answerSigns Death has Occurred
• Cardiovascular - cold extremities/mottling, change is vital signs
• Respiratory - change in breathing pattern (apnea, panting, cheyne-stokes, mandibular
breathing), audible secretions
• Metabolic - fatigue, surge of energy, temperature changes/diaphoresis
• Gastrointestinal- decreased intake, nausea, vomiting, diarrhea, constipation,
incontinence
• Urinary - decreased urine output
• Communication - decrease interaction with others (i.e. withdrawn, using metaphors,
expressing emotional and/or fears) - answerOther Signs of Imminent Death
1) Normal
2) Sleepy
3) Lethargic
4) Obtunded
5) Semicomatose
6) Comatose
7) DEAD - answerThe Usual Road to death
1) Normal
2) Restless
3) Confused
4) Tremulous
5) Hallucination
6) Mumbling/Delirium
7) Myoclonic Jerks
•Requires frequent assessment
•Not always present at end of life
•May not be able to rate pain & must rely on behavior cues
•Rule out / think about other causes of distress
•Use of oral/transdermal medications - answerPain at end of life
•Adult sudden death (i.e. accidents, heart attacks)
•Advanced illnesses, six months to live (i.e.
cancer)
•Chronic illness (i.e. diabetes, heart disease, COPD, etc),
•Childhood accidents, acute or chronic illnesses, Neonatal/infant deaths (i.e. congenital
defects, SIDS, etc) - answerNurse Exposures to Death
• Provide support to patients, families and each other
• Interpersonal competence: Empathy, Unconditional Positive Regard, Genuineness,
Attention to Detail
• Being present
• Interdisciplinary team - answerHealthcare Provider Role in death
-Appreciate unique roles of patient and family
-Avoid giving specific times
-Some patients want family present, some prefer to be alone
-Assess their understanding
-Echo their language
-Assess their willingness and ability to provide care
-Use simple terms, explain care being provided, provide reassurance
-Provide guidance / "what to expect" at/after death - answerCommunication with
Patient/Family in death
-Death Rattle: 56%
- Pain: 51%
- Agitation: 42%
- Urinary Incontinence: 32%
- Dyspnea: 22%
- N/V: 14%
- Myoclonus: 12% (brief, involuntary twitching of a muscle or group of muscles) -
answerFrequency of Sxs Last 48 hrs prior to death
• Requires frequent assessment
• Not always present at end of life
• May not be able to rate pain & must rely on behavior cues
,• Rule out / think about other causes of distress
• Use of oral/transdermal medications - answerPain in dying
-Is a distressing symptom for patients and families
• Be proactive
• Oxygen
• Positioning
• Fan/cool environment
• Calming environment/provide reassurance
• Use of opioids
• Benzodiazepines - answerDyspnea in dying
-pain
-dyspnea
-respiratory secretions
-restlessness
-delerium
-Cardiovascular - cold extremities/mottling, change is vital signs
-Respiratory - change in breathing pattern (apnea, panting, cheyne-stokes, mandibular
breathing), audible secretions
-Metabolic - fatigue, surge of energy, temperature changes/diaphoresis
-Gastrointestinal- decreased intake, nausea, vomiting, diarrhea, constipation,
incontinence
-Urinary - decreased urine output
-Communication - decrease interaction with others (i.e. withdrawn, using metaphors,
expressing emotional and/or fears) - answersymptoms of near death
-Be proactive
-Oxygen
-Positioning-(head elevated or side lying)
-Fan/cool environment-
-Calming environment/provide reassurance
-Use of opioids
-Benzodiazepines - answermanagement of Dyspnea in death
death rattle - answer-noisy wet-sounding respirations caused by mouth breathing and
accumulation of mucus in the airways
-distressing and frightening symptom for those involved in the patient's terminal care.
-For patients who are alert, their noisy respirations can cause them to become agitated
and fearful of suffocating
-primary lung cancer
-cerebral metastases
-pneumonia
-dysphagia
-those in the last days of life. - answerThose with increased risk for death rattle
,-Pulmonary embolism or myocardial infarction if the death rattle occurs suddenly
-Fluid overload as is found in congestive heart failure may benefit from a trial of diuretic
therapy
-Pneumonia may benefit from antibiotic therapy - answerPotential causes for the death
rattle may include:
*Begin anticholinergic drugs to dry secretions such as:
-Scopolamine patch, starting with one (1.5 mg) and increasing by one patch daily. If at
three patches the patient is without relief, begin an infusion of 50 mg/hr and titrate
hourly to a maximum of 200 mg/hr.
-Atropine (0.4 mg), either IV or SQ can be used, but this may cause excitation.
-Other agents include glycopyrrolate, oxybutynin, or hyoscine.
-Finally, reduce (to <500ml/24 hrs) or withhold parenteral fluids or enteral feeding, as
the fluids may be contributing to the rattling secretions. (Harlos, 2010). - answerdrugs
for death rattle
-Attempt to reposition the patient
-Keep head of bed elevated.
-Suctioning is generally not recommended, as it can increase agitation and distress in
the patient. - answernonpharm for death rattle
-Using the term "death rattle" can be a frightening term to hear. Some have suggested
using the term "respiratory congestion" or "terminal secretions" to describe this
phenomena to patients/family.
-Be honest with families and let them know that this can occur before death, so that
families caring for their loved one at home will know what may be available to relieve
this symptom - answerfamily support for death rattle
-Elevate head of bed
-Begin anticholinergic drug(s)
-Reduce or stop IV fluids/enteral feedings
-Provide reassurance and education
-Provide peaceful, calming environment
-Role model comforting - answerInterventions/Management for respiratory
secretions/death rattle
HYPERactive -restlessness, calling out, agitated, disoriented, crawling out of bed,
delusions
HYPOactive -lethargic, somnolent, appear to be in a stupor
-Can have both - hypo and hyper active delirium - answerDelirium and death
• Assess for reversible causes (i.e. constipation, distended bladder)
• Provided a calm, comforting environment
• Use medications as ordered - answerRestlessness in death
, -changes in the sleep/wake cycle/ICU psychosis/restraints - answercauses of delirium in
death
-environmental
-use of antipsychotics (if indicated)
-Benzodiazepines may worsen delirium (especially in the elderly) - answertreatment of
delirium in death
*Absent
-pulse
-blood pressure
-respirations
-response to stimuli blinking/corneal reflex
*May see
-bowel/bladder incontinence
-eyes slightly open
-jaw relaxed
-mouth open
-waxy, pasty appearance to skin - answerSigns Death has Occurred
• Cardiovascular - cold extremities/mottling, change is vital signs
• Respiratory - change in breathing pattern (apnea, panting, cheyne-stokes, mandibular
breathing), audible secretions
• Metabolic - fatigue, surge of energy, temperature changes/diaphoresis
• Gastrointestinal- decreased intake, nausea, vomiting, diarrhea, constipation,
incontinence
• Urinary - decreased urine output
• Communication - decrease interaction with others (i.e. withdrawn, using metaphors,
expressing emotional and/or fears) - answerOther Signs of Imminent Death
1) Normal
2) Sleepy
3) Lethargic
4) Obtunded
5) Semicomatose
6) Comatose
7) DEAD - answerThe Usual Road to death
1) Normal
2) Restless
3) Confused
4) Tremulous
5) Hallucination
6) Mumbling/Delirium
7) Myoclonic Jerks
