UKRAINIAN MINISTRY OF PUBLIC HEALTH
Dnepropetrovsk State Medical Academy
«APPROVED»
At the methodological meeting of
the internal medicine propedeutics
department
Chief of the department
____________prof. Khomazuk T.A.
«
»
2013 y.
Guidelines
For Second-year Students of the Dentist Department
Subgect
Module №
Enclosure module №
Topic №11
Propedeutics of the internal medicine
Course
Faculty
2
General and special nursing the seriously sick and dying
patients.
Dnepropetrovsk- 2013
General purpose. To be able to observe and to care for seriously ill,
ahonuyuchymy.
Specific purpose:
1. To know main principles nursing the seriously sick and dying patients.
2. To study methods of assessment main vital indexes in the seriously sick
and dying patients.
3. To learn deontological questions of behavior with the seriously sick and
dying patients.
Topic content:
In the case of a terminal illness, the physician is usually responsible for
deciding what and how much the client should be told. These decisions are
usually made after consulting with the client's family and assessing the client. The
nurse, social worker, clergyman, or others in the service professions may also be
involved with this decision and in discussing the client's condition with him or
her.
Most clients want to know their prognosis as soon as possible so that they
can both come to grips with it and take care of business and personal affairs. It is
important for all involved with the client's care to known exactly what the client
and the family have been told, and it is also important for members of the client's
health team to communicate among themselves.
A dying client has a variety of options concerning death, and the clients
wishes should, if possible, be followed. Clients may choose to die at home, in a
hospital or nursing, or in a hospice.
The stages of dying, much like the stages of grief, may overlap, and the
duration of any stage may vary from as little as a few hours to as a period of
months. The process varies from individual to individual. Some individuals may
be in one stage for such a short time it seems a stage was skipped. Sometimes an
individual returns to a previous stage.
According to Kubler-Ross, the stages of dying are:
1. denial and isolation
2. anger
3. bargaining
4. depression
5. acceptance
Denial and isolation. In the denial and isolation stage, the client denies that he
or she will die, may repress what is discussed, and may isolate self from reality. The
client may think, "They made a mistake in the diagnosis. May be they mixed my records
with someone else's.
Anger. The client expresses rage and hostility in the anger -tage and adopts a
"why me" attitude. "Why me? I quit smoking and 1 watched what I eat. Why did this
happen to me?"
Bargaining. The client tries to barter for more time. "If I can lust make it to my
son's graduation 1 will be satisfied. Just let me live dll then." Many clients will put their
personal affairs in order, make wills, and fulfill last wishes such as trips, visiting
relatives, and so forth. It is important to meet these wishes, if possible, because
bargaining helps clients move into later stage of dying.
Depression. In the depression stage, the client goes though ;i period of grief
before death. The grief is characterized by crying ;ind not speaking much. "I waited all
these years to see my daughter get married. And now I may not be here to see her walk
down the aisle. I can't bear the thought of not being there for the wedding — and to see
my grandchildren".
Acceptance. When the stage of acccptance is reached, the client feels state of
tranquility and peace. The client has accepted death and rs'prepared to die. The client
may think, "I've tied up all those ends — made the will, made arrangements for my
daughter to live with her grandparents. Now I can go in peace knowing everyone will be
fine.
Nursing assessment of the critically, ill patient begins with a thorough assessment
of all the major body systems. Although the critically ill patient is often connected to
numerous lines and monitoring devices, physical assessment findings continue to
provide valuable and often early information regarding patient progress or the
development of complications. The critical care nurse then integrates the assessment
findings with data obtained from the numerous monitoring devices. Numbers and
assessment findings are only part of the picture; the patient is viewed as a whole, not as a
collection of bits and pieces, of information.
Central nervous system .
Level of consciousness- (LOC) and orientation are frequently assessed in the
patient to grossly monitor CNS function and cerebral perfusion. Assessing LOC is more
difficult in the intubated patient, since verbal responses are not possible. The use of
picture boards and the ability to follow commands giye evidence of the patient's LOC.
Restlessness and agitation are also noted, since they often signify decreased cerebral
perfusion, pain, or neurologic impairment.
Cardiovascular system
Heart rale and blood pressure are often measured hourly in many critical care
units
Respiratory system
The chest is auscultated bilaterally to assess for bilateral breath sounds and proper
artificial airway placement. Any crackles or wheezes are also noted.
The ventilator setting should be double-checked against the ordered settings. The
rate, depth, and rhythm of respirations are noted, along with the use of accessory
muscles or diaphoresis. Arterial blood gases are frequently drawn to assess arterial
oxygenation and saturation and acid base balance. The color, consistency, and odor of
the sputum is described.
Renal system
Urine output is measured hourly using a urimeter to get accurate readings. The
voiume, color, and clarity of the urine are examined. Specific gravity may also be
measured. The urine is often tested for glucose, ketones, and protein with dipsticks
designed specifically for that purpose.
Gastrointestinal system
The abdomen is auscultated for bowel sounds every 4 to 8 hours. If abdominal
distention is noted, abdominal girth measurements are often taken each shift or each day.
The amount, color, and consistency of any stools are also recorded. The stool may also
be checked for occult blood. Because the patient is receiving IV antibiotics, the normal
flora of the gut becomes altered, and the patient may have an overgrowth of more
pathogenic species. The stool may also be checked for bacterial load.
Laboratory
Following completion of the physical assessment and hemodynamic monitoring,
laboratory specimen are usually sent, including electrolyte levels, complete blood
counts, glucose, , creatinine.
Psychosocial
Psychosocial assessment findings include feelings of powcrlessncss, helplessness,
fear, anxiety, alteration in self- concept and depersonalization. For the patient unable to
speak or answer questions, pertinent information can also be gathered from family and
significant others. Changes in vital signs such as increased heart rate, blood pressure,
and respiratory rate can also Mgnal emotional changes such as increased fear or anxiety.
When a client dies, the nurse's responsibilities include care of the client's body,
care of the family, and discharging specific legal responsibilities. The latter involve
ensuring that a death certificate is issued and signed by a physician, labeling the body,
and reviewing organ donation arrangements (if any).
Tests self-knowledge and skills that students acquire while exploring
themes.
1. When necessary is Discontinuing Cardiopulmonary Resuscitation?
A. a person begins breathing
B. *a person’s heart starts beating
C. the victim does not respond to resuscitation, remains unconscious
D. pupils that are dilated even in the presence of light for as long as 30
minutes
E. everything mentioned above
2. Which organ are irreversible changes developed in firstly when patient has died?
A. *Lungs
B. Heart
C. Liver
D. Brain
E. Kidney
F.
3. Fact of the death is esteblished by:
A. Nurse
B. Hospital attendan
C. *Doctor
D. Patient relatives
E. Other patients
4.If patient forgoes eating, what should you do?
A. Feed patient using force
B. *Try to persuade patient to eat
C. Administer cleansing enemas
D. Not feed patient
E. Northing mentioned above
5.What is a method of artificial feeding gravy-ill patient?
A. Feeding with spoon
B. Feeding with teat and bottle
C*. Tube feeding
D. All mentioned above
E. Northing mentioned above
6.Care of the patient with collapse?
A. *To ensure the patients horizontal position with the raised legs
B. To measure the arterial pressure
C. To ensure the patient sitting position
D. All mentioned above
E. Northing mentioned above
Recommended Reading:
1. Diseases and disorders : a nursing therapeutics manual / Marilyn Sawyer
Sommers, Susan A. Johnson, Theresa A. Beery.—3rd ed.
2. Учебное пособие для иностранных студентов медицинских вузов,
обучающихся на английском языке / Мостовой Ю.М, Демчук А.В.,
Константинович Т.В.-1-е издание. - Винница:, 2009.
3. Clinical Nursing Skills and Techniques: basic, intermediate and advanced.
The C.V. Mosby Company, 1986.-1296 p.
4. Clinical Skills and Assessment Techniques in Nursing Practice. Scott,
Foresman and Company, 1989.-1280 p.
5. Emergency Nursing: priciples and practice. The C.V. Mosby Company,
1985.-715p.
6. Instructor's Manual for Fundamentals of Nursing, J.B. Lippincott Company
Philadelphia, 1989.-120 p.
7. Nursing interventions and clinical Skills. Mosby — year Book, Inc., 1996.813p.
8. Nursing Procedures: Student Version. Springhouse Corporation,1992.-788
p.