1. Understanding the dying process and needs of the resident nearing the end of life. Nursing Fundamentals 7243 1 2.04 Unit A Nurse Aide Workplace Fundamentals Essential Standard NA2.00 Apply communication and interpersonal skills and physical care that promote mental health and meet the social and special needs of residents in long-term care. Indicator 2.04 Understand the Dying Process and Needs of the Resident Nearing the End of Life.

2. Nursing Fundamentals 72432 2.04 Introduction Death is defined as the final stage of life.  The nurse aide will need to develop a realistic attitude toward the topic of death to meet the physical and psychological needs of the resident and the family as they experience the dying process.  This indicator also includes care of the body following death. 2.04

3. Nursing Fundamentals 7243 3 2.04 The sun setting is no less beautiful than the sun rising. is no less beautiful than the sun rising.

4. PSYCHOLOGICAL CHANGES OF THE GRIEVING RESIDENT Nursing Fundamentals 7243 4 2.04 Five stages of grieving have been identified by Elizabeth Kubler-Ross

5. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 5 2.04 Not all residents go through all the stages Not all residents go through all the stages Some residents may stay in one stage until death occurs Some residents may stay in one stage until death occurs Residents may move back and forth between grieving stages Residents may move back and forth between grieving stages Family and friends of the resident will experience the grief stages Family and friends of the resident will experience the grief stages

6. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 6 2.04 Understanding the stages of grief helps the Nurse Aide apply psychological support to resident, family, and friends

7. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 7 2.04 DENIAL Defense mechanismDefense mechanism Buffer against realityBuffer against reality Emotional escape hatchEmotional escape hatch Resident may request another opinionResident may request another opinion

8. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 8 2.04 DENIAL (continued) Resident may avoid discussion of deathResident may avoid discussion of death Feeling of, “This can’t be happening to me.”Feeling of, “This can’t be happening to me.”

9. Care Point Nursing Fundamentals 7243 9 2.04 Nurse Aides must be ready to listen if the resident expresses their feelings

10. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 10 2.04 ANGER Bitterness and turmoilBitterness and turmoil Sense of unfairnessSense of unfairness Blame of others such as health care workersBlame of others such as health care workers Feeling of, “Why me?”Feeling of, “Why me?”

11. Care Point Nursing Fundamentals 7243 11 2.04 Nurse Aide must not take the accusations personally Nurse Aide must not take the accusations personally Do not follow the urge to leave the angry resident Do not follow the urge to leave the angry resident Listen empathetically Listen empathetically

12. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 12 2.04 BARGAINING Turn to religious and spiritual beliefsTurn to religious and spiritual beliefs Promises to God and othersPromises to God and others Comfort and hope when all seems lostComfort and hope when all seems lost

13. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 13 2.04 BARGAINING (continued) Generally know this won’t workGenerally know this won’t work Frustration and anger dissolve into depressionFrustration and anger dissolve into depression “If only...I will”“If only...I will”

14. Care Point Nursing Fundamentals 7243 14 2.04 Listen and reflect what is said, express understanding Listen and reflect what is said, express understanding Be aware of when silence is helpful and words are not Be aware of when silence is helpful and words are not

15. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 15 2.04 DEPRESSION Belief that hope is lost Belief that hope is lost Overwhelming despair Overwhelming despair Introverted and withdrawn Introverted and withdrawn Reminiscing and reviewing life Reminiscing and reviewing life Sleeplessness Sleeplessness “I always wanted to” “I always wanted to”

16. Care Point Nursing Fundamentals 7243 16 2.04 Your touch, if accepted, can be very helpful Your touch, if accepted, can be very helpful Understand the resident’s feeling of loss Understand the resident’s feeling of loss Do not deny death is approaching Do not deny death is approaching

17. ELIZABETH KUBLER-ROSS FIVE STAGES Nursing Fundamentals 7243 17 2.04 ACCEPTANCE Calm and subdued interest in lifeCalm and subdued interest in life Strives to complete unfinished businessStrives to complete unfinished business Helps loved ones accept deathHelps loved ones accept death Needs others to validate worth of lifeNeeds others to validate worth of life “I’ve had a good life.”“I’ve had a good life.”

18. Care Point Nursing Fundamentals 7243 18 2.04 Your presence lets them know you will not desert them Your presence lets them know you will not desert them Listen if they wish to discuss their death Listen if they wish to discuss their death

19. BRAIN STORM Think Recall the conversation of a friend who had a family member to die. Did you hear any of Kubler-Ross stages of death (grieving)? Act Raise your hand and share your thoughts. Unit A / Essential Standard NA2.00 / Indicator 2.01 / Letter B Nursing Fundamentals 7243 19 2.04

20. Kubler-Ross – Five stages of grief Have we got it? Let’s check and see 20 Stick diagnostics Student Name A Student Name B Nursing Fundamentals 72432.04

21. FACTORS INFLUENCING RESIDENTS/FAMILY ATTITUDES TOWARD DEATH Nursing Fundamentals 7243 21 2.04 Personal experiences Personal experiences Culture; some fear death others look forward to and accept death Culture; some fear death others look forward to and accept death

22. FACTORS INFLUENCING RESIDENTS/FAMILY ATTITUDES TOWARD DEATH Nursing Fundamentals 7243 22 2.04 Religion Belief in life after death Belief in life after death Reunion with loved ones Reunion with loved ones Reincarnation Reincarnation Punishment for sins Punishment for sins No afterlife No afterlife

23. FACTORS INFLUENCING RESIDENTS/FAMILY ATTITUDES TOWARD DEATH Nursing Fundamentals 7243 23 2.04 Age: Children view death at temporary Children view death at temporary Adults may develop fears of pain and suffering, dying alone, separation from loved ones Adults may develop fears of pain and suffering, dying alone, separation from loved ones Elderly generally have fewer fears Elderly generally have fewer fears

24. Individual resident’s reaction to death Nursing Fundamentals 7243 24 2.04 Accept or be resigned to death Accept or be resigned to death Open and receptive Open and receptive Communicate about uncertainties Communicate about uncertainties Fearful or angry Fearful or angry Despairing or anxious Despairing or anxious Hostile Hostile Thoughtful and meditative Thoughtful and meditative

25. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 25 2.04 SENSORY FUNCTION Changes in SENSORY FUNCTION and the ability to speak VISION Blurred and failing vision Increased secretions in corner of eye No eye movement / staring / unfocused eye

26. Nursing Fundamentals 7243 26 2.04 Reduce glarekeep room lightening low Reduce glare and keep room lightening low

27. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 27 2.04 SENSORY FUNCTION Changes in SENSORY FUNCTION and the ability to speakSPEECH becomes difficult becomes difficult hard to understand hard to understand may be unable to speak may be unable to speak

28. Nursing Fundamentals 7243 28 2.04 Do not expect an answer Do not expect an answer Observe body language of the resident Observe body language of the resident Anticipate needs Anticipate needs

29. SENSORY FUNCTION Changes in SENSORY FUNCTION and the ability to speakHEARING last sensory function to be lost… COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 29 2.04

30. Nursing Fundamentals 7243 30 2.04 Be careful what you say!

31. SENSORY FUNCTION Changes in SENSORY FUNCTION and the ability to speakTOUCH SENSE OF TOUCH IS DEMINISHED COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 31 2.04

32. Nursing Fundamentals 7243 32 2.04 Resident can no longer turn themselves, SKIN CARE IS PARAMOUNT

33. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 33 2.04 CIRCULATION AND MUSCLE TONE Changes in CIRCULATION AND MUSCLE TONE and the ability to speak LOSS OF MOVEMENT, MUSCLE TONE, AND FEELING Body is limp Body is limp Jaw may drop Jaw may drop Mouth may stay partly open Mouth may stay partly open

34. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 34 2.04 CIRCULATION AND MUSCLE TONE Changes in CIRCULATION AND MUSCLE TONE and the ability to speak CIRCULATION FAILS Heat is lost from the body’ Heat is lost from the body’ Mottling (bruised appearance), spotting, or blotching of skin caused by poor circulation Mottling (bruised appearance), spotting, or blotching of skin caused by poor circulation

35. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 35 2.04 CIRCULATION AND MUSCLE TONE Changes in CIRCULATION AND MUSCLE TONE and the ability to speak CIRCULATION FAILS Hands and feet cold to touch Hands and feet cold to touch Face becomes pale or gray and mottled Face becomes pale or gray and mottled Perspiration may increase (DIAPHORESIS) Perspiration may increase (DIAPHORESIS)

36. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 36 2.04 VITAL SIGNS Changes in VITAL SIGNS BLOOD PRESSURE DECREASES

37. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 37 2.04 VITAL SIGNS Changes in VITAL SIGNSPULSE: Abnormally slow, rapid, or irregular

38. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 38 2.04 VITAL SIGNS Changes in VITAL SIGNSTEMPERATURE: Rising or below- normal

39. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 39 2.04 VITAL SIGNS Changes in VITAL SIGNSRESPIRATIONS: Slow, irregular alternating with rapid, shallow aka Cheyne-Stokes

40. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 40 2.04 VITAL SIGNS Changes in VITAL SIGNSRESPIRATIONS: “fish out of water breathing” aka Agonal Breathing

41. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 41 2.04 VITAL SIGNS Changes in VITAL SIGNSRESPIRATIONS: Rattling or gurgling sound referred to as Death Rattle

42. Nursing Fundamentals 7243 42 2.04 Elevate HOB to facilitate breathing

43. BRAIN STORM Think Why do you think the vital signs change as they do when a resident is dying? Act Raise your hand and share your thoughts. Unit A / Essential Standard NA2.00 / Indicator 2.01 / Letter B Nursing Fundamentals 7243 43 2.04

44. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 44 2.04 BOWEL AND BLADDER ELIMINATION Changes in BOWEL AND BLADDER ELIMINATION URINARY AND ANAL INCONTINENCE

45. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 45 2.04 BOWEL AND BLADDER ELIMINATION Changes in BOWEL AND BLADDER ELIMINATION DECREASED PERISTALSIS DECREASED PERISTALSIS ABDOMINAL DISTENTION ABDOMINAL DISTENTION RELEASE OF FLATUS RELEASE OF FLATUS

46. BRAIN STORM Think Why do you think the changes in bowel and bladder elimination occur? Act Raise your hand and share your thoughts. Nursing Fundamentals 7243 46 2.04

47. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 47 2.04 DECREASED PAIN

48. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 48 2.04 DECREASED INTAKE OF FOOD AND FLUID

49. Nursing Fundamentals 7243 49 2.04 Modify diet.Modify diet. Do not force feed.Do not force feed. Fluids most important.Fluids most important.

50. COMMON PHYSICAL SIGNS OF IMPENDING DEATH Nursing Fundamentals 7243 50 2.04 Disorientation and confusion, loss of consciousness

51. Physical Signs of impending Death Have we got it? Let’s check and see 51 Stick diagnostics Student Name A Student Name B Nursing Fundamentals 72432.04

52. NURSE AIDE CARE FOR THE DYING RESIDENT Nursing Fundamentals 7243 52 2.04 Observe “Care Points” in previous slides related to sensory function

53. NURSE AIDE CARE FOR THE DYING RESIDENT Nursing Fundamentals 7243 53 2.04 Care of Nose and Mouth: Give mouth care often; if resident unconscious, every two hours Give mouth care often; if resident unconscious, every two hours Apply lubricant such as a lip balm, to lips and nose Apply lubricant such as a lip balm, to lips and nose Olive oil is a good lubricant for lips Olive oil is a good lubricant for lips

54. NURSE AIDE CARE FOR THE DYING RESIDENT Nursing Fundamentals 7243 54 2.04 Care of SKIN: Give bed baths and incontinence care as needed Bathe perspiring patients often Keep skin clean and dry Change sheets and clothes for comfort Keep sheet wrinkle free

55. NURSE AIDE CARE FOR THE DYING RESIDENT Nursing Fundamentals 7243 55 2.04 Care of SKIN: Reposition resident often, use supportive devices as needed Reposition resident often, use supportive devices as needed At least every 2 hours or prn At least every 2 hours or prn

56. NURSE AIDE CARE FOR THE DYING RESIDENT Nursing Fundamentals 7243 56 2.04 Promote COMFORT: Observe for signs of pain and report them! Observe for signs of pain and report them! Frequent changes of position, back massage, and body alignment Frequent changes of position, back massage, and body alignment Elevate head of bed (HOB) to facilitate breathing Elevate head of bed (HOB) to facilitate breathing

57. NURSE AIDE CARE FOR THE DYING RESIDENT Nursing Fundamentals 7243 57 2.04 Control ENVIRONMENT: Place resident’s favorite objects and photographs where resident can see them Place resident’s favorite objects and photographs where resident can see them Provide appropriately lit and well-ventilated room without odor Provide appropriately lit and well-ventilated room without odor Place call bell in reach, even if resident unresponsive Place call bell in reach, even if resident unresponsive

58. Nursing Fundamentals 724358 Control Environment Features of resident’s room: –Contains personal items which provide comfort and reassurance PicturesPictures MementosMementos CardsCards FlowersFlowers Religious objectsReligious objects 2.04

59. Nursing Fundamentals 724359 Nurse Aide Role - Respect Treat religious objects with care and respect:Treat religious objects with care and respect: –medals –pictures –statues –Bibles Encourage family and friends to be includedEncourage family and friends to be included 2.04

60. Nursing Fundamentals 724360 Nurse Aide’s Role - Support Source of strength and comfortSource of strength and comfort Open and receptiveOpen and receptive Know own feelings about death and do not project those feelings onto resident.Know own feelings about death and do not project those feelings onto resident. 2.04

61. Nursing Fundamentals 724361 Nurse Aide’s Role - Support EmpatheticEmpathetic Calm and efficientCalm and efficient Normal tone of voiceNormal tone of voice Good listening skillsGood listening skills Non-judgmentalNon-judgmental 2.04

62. Nursing Fundamentals 724362 Nurse Aide Role Support to Family & Friends Offer comfort measures such as drinks, food, chairs, blankets etc. within facility policy.Offer comfort measures such as drinks, food, chairs, blankets etc. within facility policy. Use good communication skills Use good communication skills Listen and provide understanding throughout the grief/loss stagesListen and provide understanding throughout the grief/loss stages Answer questions or refer to supervisorAnswer questions or refer to supervisor 2.04

63. Nursing Fundamentals 724363 Nurse Aide Role Support to Family & Friends Available for supportAvailable for support Use touch as appropriateUse touch as appropriate Courteous and considerateCourteous and considerate Respect right to privacyRespect right to privacy Let family assist with care, if they desire, where appropriateLet family assist with care, if they desire, where appropriate 2.04

64. Nursing Fundamentals 724364 Nurse Aide Role – Spiritual Support Priest, rabbi, minister or other clergy may be contacted at request of resident or familyPriest, rabbi, minister or other clergy may be contacted at request of resident or family Privacy to be provided when clergy with residentPrivacy to be provided when clergy with resident 2.04

65. Nursing Fundamentals 724365 Nurse Aide Role – Spiritual Support Support resident’s religious/spiritual practices even if different from that of nurse aideSupport resident’s religious/spiritual practices even if different from that of nurse aide Listen respectfully to religious/spiritual beliefsListen respectfully to religious/spiritual beliefs Participate in religious practices if asked and acceptableParticipate in religious practices if asked and acceptable 2.04

66. Nursing Fundamentals 7243662.04

67. Nursing Fundamentals 724367 Hospice Care Hospice Care offered:Hospice Care offered: –in hospitals and extended care facilities –by special facilities –usually in the individual’s home Continuing care provided by team of health professionalsContinuing care provided by team of health professionals Designed for residents with terminal illnessDesigned for residents with terminal illness 2.04

68. Nursing Fundamentals 724368 Hospice Care Acceptance of death as imminent (6 months or less)Acceptance of death as imminent (6 months or less) Assures that individual dies with dignity and comfortAssures that individual dies with dignity and comfort Not concerned with cure or life-saving proceduresNot concerned with cure or life-saving procedures Emphasis on pain reliefEmphasis on pain relief Trained volunteers and professionals make regular visits.Trained volunteers and professionals make regular visits. 2.04

69. Nursing Fundamentals 724369 Hospice Care Provides counseling for individual and family:Provides counseling for individual and family: –Emotional –Psychological –Spiritual –Financial –Bereavement Family included in all aspects of care as desiredFamily included in all aspects of care as desired 2.04

70. Nursing Fundamentals 7243702.04

71. Nursing Fundamentals 724371 Reasons for Postmortem Care Prevent discoloration and skin damagePrevent discoloration and skin damage Maintain good appearance of bodyMaintain good appearance of body Identify body and prepare for transportationIdentify body and prepare for transportation Position body in normal alignmentPosition body in normal alignment Arrange time family to view the bodyArrange time family to view the body 2.04

72. Nursing Fundamentals 724372 Postmortem Care – General Guidelines Begin care when instructed by supervisorBegin care when instructed by supervisor Treat body to privacy, respect and gentlenessTreat body to privacy, respect and gentleness Give care before rigor mortis sets inGive care before rigor mortis sets in 2.04

73. Nursing Fundamentals 724373 SKILL 2.04 SKILL 2.04 Postmortem Care Training Lab Assignment Engage in the Skill EXPLORATION Process for:

74. Understanding the dying process and needs of the resident near the end of life. 74  END  2.04 2.04Nursing Fundamentals 7243