Post Mortem Care Aseron

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LOSS, GRIEVING

AND DEATH
PREPARED BY:
MARY ANTOINETTE B. ASERON, RN, MAN
COPING WITH LOSS,
GRIEVING AND
DEATH
LOSS – is an actual or potential situation in which
something that is valued is changed, no longer
available or gone.

TYPES OF LOSS
1. Actual Loss
• Can be identified by others and can arise
either in response to or in anticipation of a
situation
• Ex. A man whose wife is dying may
experience actual loss in anticipation of her
death.
2. Perceived Loss
• Is experienced by one person but cannot
be verified by others (psychological)
• Ex. A woman who leaves her
employment to care for her children at
home may perceived loss of
independence

SOURCES OF LOSS
1. Loss of an aspect of oneself
2. Loss of an external object
3. Loss of accustomed environment
4. Loss of loved ones
GRIEF AND
BEREAVEMENT
• GRIEF – is the total response to the
emotional experience related to loss
It is manifested in feelings and
behaviors thoughts associated with
overwhelming distress or sorrow

• BEREAVEMENT – is the subjective


response experienced by the
surviving loved ones after a death of
a person with whom they have
shared a significant relationship.
• MOURNING
– is the behavioral process through
which grief is eventually resolved or
altered.
It is often influenced by culture,
religious experience and custom.
TYPES OF GRIEF

A.NORMAL GRIEF

1. Abbreviated Grief – is brief but


genuinely felt. The lost object may
not have been sufficiently important
to the grieving person.

2. Anticipatory Grief – experience In


advance of the event.
TYPES OF GRIEF
B. UNHEALTHY GRIEF (Pathologic
or Dysfunctional)

1. Unresolved Grief – extended in length


and severity.

2. Inhibited Grief - many of the normal


symptoms of grief are suppressed and
other effects including somatic are
experienced.
C. COMPLICATED GRIEF
- Occurs if the pain of the loss is so
constant and severe that it keeps you
from resuming you life.

- It’s like being stuck in an intense state


of mourning.

- Trouble accepting the death long after it


has occurred or be so preoccupied with
the person who died that it disrupts your
daily routine and undermines your other
relationships.
SYMPTOMS OF
COMPLICATED GRIEF
• Intense longing and yearning for the
deceased
• Intrusive thoughts or images of your
loved one
• Denial of the death or sense of disbelief
• Imagining that your loved one is alive
• Searching for the person in familiar
places
• Avoiding things that remind you of your
loved one
• Extreme anger or bitterness over the loss
DEVELOPMENT OF THE
CONCEPT OF DEATH
• Infancy to 5 years – does not understand
the concept of death, believes death is
reversible, a temporary departure or sleep.
• 5-9 years – understands that death is final,
believes own death can be avoided.
Associates death with aggression or
violence.
• 9-12 years – understands death as the
inevitable end of life, begins to understand
own mortality.
• 12-18 years – fear of lingering death, may
fantasize that he/she can defy death.
• 18-45 years – has attitude towards
death
influenced by religious
and cultural beliefs.
• 45-65 years – accepts own mortality,
encounters death of parents and some
peers, experiences peaks of death
anxiety.
• 65 years and above – fears
prolonged illness, encounters death of
family and peers, sees death as having
multiple meanings.
STAGES OF GRIEVING

ELISABETH KUBLER-ROSS 5
stages of grieving

1. DENIAL – refuses to believe that loss


is happening.
- is unready to deal with
practical problems, may assume
artificial
cheerfulness.
Example: “ This can’t be happening to
me.”
2. ANGER – client or family may direct
anger at nurse or hospital about
matters that normally would not bother
them.
Example: “ Why is this happening? Who is
to blame?”
3. BARGAINING – seeks to bargain to
avoid loss, express feeling of guilt or
fear of punishment for past sins, real, or
imagined.
Example: “ Make this not happen, and in
return I will___.”
4. DEPRESSION – grieves over what has
happened and what cannot be, may talk
freely or may withdraw.
Example: “ I’m too sad to do anything.”
5. ACCEPTANCE – comes in terms with loss,
may have decrease interest in surroundings
and support persons, may wish to begin
making plans.
Example: “I’m at peace with what happened.”
MARTOCCHIO’S 5
CLUSTERS OF GRIEF
1. SHOCK AND DISBELIEF – a feeling of
numbness following the death of a loved one.
2. YEARNING and PROTEST – the anger that
the bereaved feel may be directed at the
deceased for having died, at God, others
whose
love ones are still alive or the caregiver.
3.ANGUISH, DISORIENTATION and
DESPAIR
- when the reality of the loss is genuinely
admitted, depression can set in, weeping
is common.
MARTOCCHIO’S 5
CLUSTERS OF GRIEF
4. IDENTIFICATION OF BEREAVEMENT
- the bereaved may take on the
behavior, personal traits, habits and
ambitions of the deceased.

5. REORGANIZATION and RESTITUTION


- achieving stability and a sense of
reintegration can take a period of time that
ranges widely, from less than a year to
several years
ENGEL’S STAGES OF
GRIEVING
SHOCK and DISBELIEF – refusal to
accept loss.
DEVELOPING AWARENESS – reality
of loss begins to penetrate awareness,
crying and self blame.
RESTITUTION – rituals of mourning
(funeral)
RESOLVING THE LOSS – attempts to
deal with painful void, still unable to
accept new object to replace lost person,
talks about memories of dead person.
ENGEL’S STAGES OF
GRIEVING
IDEALIZATION – produces image of dead
persons that is almost devoid of undesirable
features, guilty about past inconsiderate
acts to deceased, admired qualities of
deceased.

OUTCOME – behavior influenced by the


importance of the lost object as source of
support, degree of dependence, degree of
ambivalence, number and nature of other
relationships and grief experiences.
SYMPTOMS OF GRIEF
• Repeated somatic distress
• Tightness of the chest
• Choking or shortness of breath
• Sighing, empty feeling in the abdomen
• Loss of muscular power
• Intensive subjective distress
• Guilt
• Sadness
• Shock and disbelief
• Anger
• Fear
ASSISTING CLIENTS
WITH THEIR GRIEF
• Provide opportunity for the persons to
tell the story
• Recognize and accept the varied
emotions that people express
• Include children in their grieving process
• Encouraged the bereaved to maintain
established relationships
• Encourage self-care by family members
• Encourage the usefulness of counseling
ASSISTING CLIENTS WITH
THEIR GRIEF
• Explore and respect the client’s and
family’ ethnic, cultural, religious and
personal values in their expression of
grief.
• Teach the client or family what to expect
in the grief process.
• Encourage the client to express and share
grief with support people.
• Teach family members to encourage the
clients expression of grief, not to push the
client to move on or enforce his or her
own expectation of appropriate.
ASSISTING CLIENTS WITH
THEIR GRIEF
• Reactions
• Encourage the client to resume normal
activities on a schedule that promotes
physical and psychological health.
• Provide emotional support
Use silence and personal presence along
with techniques of therapeutic
communication.
Acknowledge the grief of the client’s family
and significant others.
NURSING DIAGNOSIS
1.ANTICIPATORY GRIEVING
– related to perceived potential
loss of loved one, body part or
function, or of physio-
psychosocial well being, personal
possessions, social role and
impending death of self.

2. DYSFYNCTIONAL GRIEVING
- Related to multiple past or
current losses, lack of resolution,
IMPAIRED ADJUSTMENT
- related to disability requiring
change in life-style, unavailable
support systems, impaired
cognition, ineffective denial.

SOCIAL ISOLATION
- Related to inability to engage in
satisfying personal relationships,
alterations in physical appearance,
altered state of wellness.
CARE OF THE DYING
CLIENT
DEFINITION:
In 1968, the world medical assembly
adopted the following guidelines for
physicians as indications of death:
 Total lack of response to external stimuli

 No muscular movement, especially

breathing
 No reflexes, flat encephalogram in

instances of artificial support


 Absence of brain waves
SIGNS OF IMPENDING
CLINICAL DEATH
1. LOSS OF MUSCLE TONE
– relaxation of the facial muscles, difficulty
speaking and swallowing, gradual loss of the
gag reflex, decreased activity of the GIT,
possible urinary and rectal incontinence,
and diminished body movement.

2. SLOWING OF THE CIRCULATION


– diminished sensation, mottling and cyanosis
of the extremities, cold skin, first in the feet
and later in the hands, ears and nose.
3.CHANGES IN VITAL SIGNS
– decelerated and weaker pulse, decreased pulse
pressure, rapid, shallow, irregular or abnormally
slow respirations, Cheyne-Stokes respirations,
noisy breathing ( death rattle); mouth
breathing.

4.SENSORY IMPAIRMENT
– blurred vision, impaired senses of taste and
smell.

5.INDICATIONS OF DEATH
- total lack of response to external stimuli, no
muscular movement, especially breathing, no
reflexes, flat encephalogram.
THE DYING PERSON’S BILL
OF RIGHTS
I HAVE RIGHT :
1. To be treated as a living human being until I
die
2. To maintain a sense of hopefulness however
changing its focus may be
3. To express my feelings and emotions about my
approaching death in my own way
4. To participate in decisions concerning my care
5. To expect continuing medical and nursing
attention even though cure goals must be
changed to comfort goals
6. Not to die alone.
7. To be free from pain.
9. Not to be deceived
10. To have help from and for my family
in accepting my death.
11. To die in peace and with dignity.
12. To retain my individuality & not be
judged for my decisions which may be
contrary to the beliefs of others.
13. To be cared for by caring, sensitive,
knowledgeable people who will attempt
to understand my needs & will be able
to gain some satisfaction in helping me
face my death.
NURSING INTERVENTIONS
FOR DYING CLIENT
1. Assist the client achieve a dignified and
peaceful death : provide relief from
loneliness, fear and depression, maintain
the client’s sense of security, self
confidence, dignity, and self-worth,
maintain hope.
2. Maintain physiologic and psychologic
comfort:
personal hygiene measures, relief of
respiratory difficulties, assistance with
movement, nutrition, hydration and
elimination.
NURSING DIAGNOSIS:
FOR THE DYING CLIENT
FEAR related to:
 Knowledge deficit
 Lack of social support in threatening
situation

HOPELESSNESS related to:


 Prolonged restrictions of activity resulting

in isolation
 Deteriorating physiologic condition,

terminal illness, institutional environment,


interpersonal behavior of others
POSTMORTEM CARE
• POSTMORTEM CARE (CARE OF THE BODY AFTER
DEATH)
• MORTICIAN(undertaker) -is a person trained in
the care of the dead.
• EMBALMER -is a person who apply antiseptic
and preservative to a corpse to retard the
natural decomposition of tissues.

BODY CHANGES DURING DEATH:


1. Pallor mortis - The main change that occurs
is increased paleness because of the
suspension of blood circulation. This is the
first sign and occurs quickly, within 15-30
minutes of death.
POSTMORTEM CARE
2. Algor mortis
• Is the gradual decrease of the body’s
temperature after death 1C (1.8F) per hour.
• Skin loses its elasticity

3. Rigor mortis
• Is the stiffening of the body that occurs
about 2 to 4 hours after death
• It start in the involuntary muscles
• Usually leaves the body about 96 hours
after death
4. Livor mortis
• This is the last phase of death. When the
heart stops pumping, the blood is pulled
by gravity and begins to collect in certain
areas depending on the position of the
body. Lividity begins with the skin where
the blood has settled, giving it a bright
red tone. After a few hours, the color
changes from red to blue or purple. This
can take about 6-8 hours.
• Blood circulation ceases, RBC break
down, release hemoglobin which discolor
surrounding tissue.
DECOMPOSITION
Two distinct cycles: Autolysis and Putrefaction.
Autolysis - starts when the cells start to
release enzymes and goes on for about 2 hours
after cells starved of oxygen die and lose their
structure.
Putrefaction – it is when the dead body
becomes bloated and decays, and dry phases
of decomposition begin. Bacteria inside the
body produce gases that the non-breathing
corpse can't diffuse. The eyes and tongue
might protrude and begin to smell of death.
Bloating normally starts around the second day
of postmortem and proceeds to last for 5-6
POSTMORTEM CARE
PROCEDURE IN CARING FOR THE BODY:

ASSESSMENT:
1. Verify that vital function have ceased and
pronounce patient dead if permitted to do so.
Otherwise, notify physician and record time
of death and time pronounced dead.

2. Notify the following people/departments


• a. attending physician
• b. nursing supervisor
POSTMORTEM CARE
c. next of kin/emergency contact person
d. admitting or census department
e. appropriate agency for organ
procurement.
f. medical examiner if appropriate
g. designated mortician, if not a medical
examiner’s case.

PLANNING:
3. Plan for any special religious/ cultural
practices desired by the family
POSTMORTEM CARE
4. Offer to transfer any other patients in
room to another location temporarily
5. Wash your hands
6. Gather equipment
- clean gloves , soap, washcloth, towel,
basin, clean gown, clean linen if the
patient is to be viewed, clean dressing if w/
wound, disposable pads, shroud or sheets,
identification tags and masking tape.
POSTMORTEM CARE
• IMPLEMENTATION:
• 7. Place ”No visitors-Check at Nurses
Station” sign on door.
• 8. Place body in supine position with bed
flat.
• 9. Place low pillow under the head
• 10. Close patients eyes
• 11. Remove watch and jewelry and make
list of all possessions.
• 12. Put on clean gloves
POSTMORTEM CARE

• 13. Replace patients dentures


• 14. Place small towel under chin
• 15. Remove IV’s and other tubes unless
autopsy is to take place
• 16. Remove soiled dressing and replace
• 17. Wash soiled areas of body
• 18. Place pad in perineal area
• 19. Remove and discard gloves
• 20. Put clean gown on patient
POSTMORTEM CARE

• 21. Leave wrist identification in place


• 22. Attach second identification tag
• 23. If body is to be viewed (replace top
linens).
• 24.Care for dentures and eyeglasses
• 25. Gather personal effects and give to
family or provide for safekeeping.
• 26. Wrap body and attach identification tag
on outside, if facility policy indicates.
• 27. Transport body to facility morgue or await
arrival of mortician.
POSTMORTEM CARE

• 28. Put away or dispose of equipment/ supplies


• 29. Wash your hands

• EVALUATION:
• 30. Evaluate using the following criteria
• Body cared for and transported appropriately
• All necessary notification carried out
• Family able to carry out rituals, viewing and
spend time with patient as desired
POSTMORTEM CARE
• Possessions should be handled appropriately.

• DOCUMENTATION:
• 31. Document postmortem activities including
• Time of cessation of vital signs.
• Persons notified and time of notification.
• List and disposition of valuables and personal
belongings.
• Time body removed from unit, destination and removed
by whom.
• Other information required by the facility.
• POSTMORTEM EXAMINATION
(AUTOPSY)

-Is the examination of the body after


death
-It is performed when death is sudden
or occurs within 48 hours of admission to a
hospital
Organs and tissues are examined to:
1. Establish exact cause of death
2. To learn more about a disease
3. To assist in the accumulation of
statistical data.
• ORGAN DONATION
• UNIFORM ANATOMICAL GIFT ACT (USA)
• HUMAN TISSUE ACT (CANADA)

• PURPOSES:
• Medical or Dental Education
• Research
• Advancement for Medical and Dental
Science
• Therapy
• Transplantation
• The donation can be made by a provision
in a will or by signing a card like form in
the presence of two witnesses.

• INQUEST
• Is a legal inquiry into the cause or
manner of a death.
• It is conducted under the jurisdiction of a
coroner or medical examiner.
• MORTICIAN(undertaker) - is a person
trained in the care of the dead.

• EMBALMER -is a person who apply


antiseptic and preservative to a corpse to
retard the natural decomposition of
tissues.
RELIGIOUS AND CULTURAL
BELIEFS AND PRACTICES AND
VIEWS ON DEATH AND DYING
• HINDUISM
• Each caste has a different view of death.
• This life is a transition between the
previous life and the next.
• Bodies are cremated, ashes cast in holy
river. During the first 10 days after death,
relatives must create a new ethereal
body.
• Good karma leads to good rebirth.
• Many elderly people withdraw into their
homes where they prepare for death
through prayer and meditation.
• A good death is timely, at the right place,
conscious and prepared, with the
thoughts on God.
• A bad death is untimely, violent and
unprepared. The worst death is suicide.
• Reincarnation after leading a perfect life
may join Brahma.
• Priest pours water into mouth of corpse ,
and ties string around wrist or neck as
sign of blessing.
• String must not be removed, family
washes body.
• No restriction to autopsy, organ donation
and prolonging of life.
• JUDAISM
• Human beings are mortal, and their
bodies belong to God.
• Although the physician has the authority
to determine the appropriate course of
treatment, ultimately the patient has the
right to choose.
• Disclosure is important.
• Jews are obligated to visit the sick.
• Traditional criteria for death are cessation
of breathing and heartbeat.
• Views on the use of artificial nutrition and
hydration vary depending on the
particular sect.
• Most rabbis maintain that jews may enroll
in hospice (a facility that provides
palliative and emotional care to the
terminally ill person).
• Death will be resurrected with coming of
Messiah.
• Body ritually washed by members of
Ritual Burial Society, burial as soon as
possible after death , dead not left
unattended, five stages of mourning
extended over a year.
• No embalming, no flowers at funeral.
• Orthodox prohibits autopsy while some
liberals permit it, but no body parts
should be removed.
• Cremation is strictly prohibited but beliefs
may vary.
• They generally oppose prolonging of life
after irreversible brain damage.
• BUDDHISM
• There is no central authority in the
Buddhism religion.
• Treatment by someone of the same
gender is preferable.
• Cremation is the most common way of
disposing of the dead.
• Some Buddhist may be unwilling to take
pain medication or strong sedatives. It is
believed that an unclouded mind can lead
to better rebirth.
• Believes that after death there is either
rebirth or Nirvana(state of great
happiness and peace).
• The person should be psychologically
prepared to accept impending death.
• It is often appropriate to decide when the
patient is beyond medical help and allow
events to take its course.
• Buddhism supports the use of hospice.
• Last rite, chanting at bedside is allowed.
• No restriction to autopsy and cremation.
• Organ donation is an act of mercy and is
also encouraged.
• They permit euthanasia in hopeless
illnesses.
• ISLAM
• Muslims believe in one God.
• God revealed the message of God to
Muhammad, the prophet, in the Qur’an. It
states that muslims should maintain
balance diet and exercise.
• Muslim patients may wish to engage in
ritual prayer, they practice it five times
during the day.
• Fasting during the month of Ramadan is a
pillar of Islam.
• Completion of the pilgrimage (hajj) to
Mecca (money and health permitting) is
also a pillar of Islam.
• Everyone will face death and the way a
person dies is of great individual
importance.
• The believe that death does not happen
without God’s permission.
• There is a belief that healthcare providers
must do everything possible to prevent
premature death.
• Pain is a cleansing instrument of God.
• Killing of terminally ill person is an act of
disobedience against God. However,
withdrawing of life support to untreatable
disease is permissible as long as there is
formal agreement among parties.
• May join Allah by being good Moslem and
observing rituals daily.
• A dying person must confess sins and ask
forgiveness in the presence of family.
• Family washes and prepares body and
turns body towards Mecca.
• May oppose autopsy.
• Organ donation and cremation are
prohibited.
• Prolonging life is prohibited.
• TRADITIONAL CHRISTIANS

• Christians believe in one God.


• The belief in eternal salvation sets
Christianity apart.
• Christian belief may vary. Some Christians
hope to attain eternal salvation and some
view religion more as a culture.
• Even within a family , religious view may
differ.
• Intentionally bringing about death by
either omission (failure to act)or
commission (crime) is prohibited.
• The appropriateness of analgesia and
sedation to avoid experiencing pain.
• Terminal suffering and despair is
acceptable.
• There is no obligation to postpone death.
The attempt to save life at all cost is
forbidden.
• Impending death offers a final chance to
become reconciled with those whom one
has harmed and to ask Gods forgiveness.
• Liturgical Christians generally regard last
rites as integral to the relationship with
God.
• Rites for anointing the sick is not
mandatory.
• Receiving Holy Communion is mandatory.
• Autopsy is permitted and all body parts
must be given appropriate burial.
• No restriction to organ donation and
cremation.
• Prolonging life is discouraged. ***
END
THANK YOU FOR LISTENING!

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