NURS 1510
Nancy Pares, RN, MSN
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Biologic—at risk
Nutrition
Physical activity
Sleep and rest
Lifestyle choices
Family
relationships
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Culture
Religion and
spirituality
Environment
Finances
Work that is
meaningful
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Physical disease
Injury
Mental illness
Loss
Impending death
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Competing
demands
The unknown
Imbalance
isolation
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Experiencing symptoms
Sick role behavior
Seeking professional care
Dependence on others
recovery
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Age
Family patterns
Culture
Nature of the illness
Hardiness
Intensity, duration, and complications of the
disruption
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Diagnosis (NANDA)
Planning outcomes
◦ Envision acceptable outcomes, set goals
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Planning interventions
◦ Envision strengths and potential in clients when
they are too overwhelmed to identify on their own
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Examine life’s uncertainties
Envision wellness for yourself and your client
Establish trust at your first client contact
Provide a healing presence.
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Prepare the room
◦ Neat, clean, well lit, temperature appropriate
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All equipment in the room
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Greet by name
Orient to room
Explain hospital
routine
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Provide privacy
Provide for safety
Initiate nurse/client
relationship
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Medical record
Nursing record
Physical
assessment
Clothing/personal
item inventory
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Items done at
registration
◦ Financial agreement
◦ Release of
information
◦ Advanced directives
 Pg 273
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Check for the order
Inform client and
family
Notify receiving unit
Gather client
belongings
Introduce client and
family to new nurse
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Provide complete
report to new nurse
Record condition and
means of transfer
Assure that other
depts know about
transfer.
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Written order
If no order, AMA
form
Notify ride home
Verify client
understands d/c
instructions
Check
clothing/valuable
list
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Transfer client per
w/chair to vehicle
Chart entire
procedure..
◦ ‘discharged per w/c
to home in stable
condition. Nurse and
wife in attendance’
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Arrange for
cleaning of room
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Client leaving without MD order
Client must sign form acknowledging
understanding and will not hold institution,
MD, personnel responsible
Unless held by court order or police hold,
CANNOT be physically detained.
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Legal pronouncement of death
◦ Usually by MD—some states allow RN
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May need autopsy
◦ Family must give consent unless death is unusual,
unexpected or violent—then body goes to coroner
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Organizations are required to have specific
policies related to referral for organ donation
◦ When family consents, nurse notifies donor team
◦ Time is essential
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Algor mortis
◦ When circulation stops
◦ Temp decreases to room
temp (1.8 degrees/hr)
◦ Skin is fragile—caution
removal of tape
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Liver mortis
◦ Occurs with algor mortis
◦ Discoloration due to RBC
breakdown
◦ Mostly in dependent
body parts
◦ Raise head slightly to
prevent pooling
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Occurs 2-4 hours after death
Body stiffens
◦ Involuntary muscles----then voluntary
◦ Disappears in 96 hours
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Nursing interventions
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Close eyelids
Insert dentures
Close mouth
Position body in natural postion
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Bath body
◦ ( Vol 2, technique 15.3 and 15.4.pg 168-170)
◦ Place supine covered with clean sheet
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Allow family to touch deceased
Allow privacy and time for family
Return deceased personal possessions to
family
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Obtain mortuary information
ID tag on toe and wrist
Shroud body and tag shroud
Follow facility policy for moving to morgue
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Sensitive, compassionate interpersonal skills
are required
Nurses provide invaluable support
Bring other disciplines as needed
◦ Clergy
◦ Social services
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Perfect your listening skills
Encourage and accept expression of feelings
Reassure that it is not wrong to feel anger,
relief, or other ‘unacceptable’ feelings
Increase your self awareness
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It is normal for the nurse to feel grief when a
client dies.
You must also take care of yourself.