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Cheyene Stokes - Dying pt

Posted

Specializes in Acute Care. Has 7 years experience.

I was always under the assumption a pt with cheyene stokes is considered to be entering the last phases of dying. I had a pt today who had a "large" brainstem hemorrhage, expected to pass. This is on a med surg/CVA floor. He was a DNR/comfort care, and after he was made comfort care, he was transferred from ICU to my unit.

He had labored breathing this morning along with the "death rattle", lungs sounded very very congested. I suctioned him as best I could, but didnt get much up - wife also requested we keep him as comfortable as possible , so I didnt want to harass him with suction too much.

Towards the end of my shift, he had cheyne stokes resp. Also on a morphine drip - could the morphine be causing this or is it death taking over?

I couldnt tell if he was mottling really b/c he has severe PVD and his legs are very dark anyway.

How long before death do you see cheyene stokes? My charge today said she had a pt who had cheyene stokes for 13 days before he passed! I never thought it would be that long

Edited by Joe V

It can take awhile. I sat with a patient once all night, thinking he had taken his last breath, and then 40 seconds later he would breathe a little, then stop.... I'd start timing them again....

Ginger's Mom, MSN, RN

Has 41 years experience.

Look for other signs of impending death, such as BP changes and Decreased urine output. My own dad age 92 last over a week in this state.

NurseyPoo7

Specializes in Acute Care. Has 7 years experience.

Alexk49 said:
Look for other signs of impending death, such as BP changes and Decreased urine output. My own dad age 92 last over a week in this state.

He actually had orders stating no VS, including BP b/c it interferred with his comfort.

The only thing I did VS-wise today was take his temp (tympanic) at his wife's request.

Lorie P.

Specializes in Med/Surge, Private Duty Peds.

I once had a pt that did this for 6 days, she would only take one breath about every 45 seconds. I would think she was on her last breath, but come the 45 seconds would have to start counting again. Some times she wouldn't even get out the full breath.

I would come in every night thinking she would have passed on, but nope, stayed that way.

I don't trust those cheyne stoke resps...

Had a pt who was doing these, along w/the doll eyes, only to have both completely reversed and at baseline a couple of hrs later.

I'm telling you, there will always be pts who defy textbook anything.

Indy, LPN, LVN

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

How true. Reminds me of the dying chf'er I had a couple of years ago. My shift started with "she just passed" in report, when she hadn't but her son certainly was freaking out. The night was rough on the whole family but I did enjoy being able to educate a bunch of people who impressed me by sticking by their mom during her time. After a few hours she only breathed twice a minute. Period. Which she proceeded to do for another two days before passing, and that was with adequate amounts of morphine to decrease the moaning and discomfort. She was also periodically awake but never for more than a few seconds.

So the funny part is, her daughter asked me during a set of VS (q4 hrs) to please listen to her lungs and give her an update. Ok so I put my steth on her chest and listened. Then looked up at her daughter who was watching my every move. I couldn't help it; I let out a giggle. I had to explain that it was silly of me to try to listen to her breathe when it took 30 seconds or so for her to have another breath; file that under "new nurse." Fortunately no one took my sudden attack of the giggles as disrespectful.

Pedi-Gree, BSN, RN

Specializes in Peds.

I've seen children with Cheyne-Stokes respirations who have had at least partial recovery from whatever insult led them to the C-S breathing in the first place. They certainly don't always presage death.

I had a patient 2 weeks ago with Kussmaul AND cheyne stokes resps with doll eyes and was unresponsive to sternal rub, voice, etc with RR of 32 - 40...it occured all of a sudden and the physician said that her brain hemorrhage was getting worse and even said she wont live the night.

She is still with us 14 days later....she is eating now, able to speak (incohenrently but is able to speak at least) and she looks 1000 X better than she did that night)

Her vitals are stable now! I was SO surprised when I came back from vacation and saw her considering the condition she was in when I left

I also thought that CS resps basically meant you were gonna pass away soon but i guess not

mpccrn, BSN, RN

Specializes in ICU. Has 30 years experience.

are you sure it wasn't a neurologic breathing pattern you were seeing rather than cheyne-stokes considering the bleed was at the brain stem where the resp center (medulla) is located? just a thought

mpccrn said:
are you sure it wasn't a neurologic breathing pattern you were seeing rather than cheyne-stokes considering the bleed was at the brain stem where the resp center (medulla) is located? just a thought

The doctor was in the room and even said she was cheyne stoking + kussmauling

What is a neurological breathing pattern? Isn't that CS and Kussmaul?

thanks

lovingtheunloved, ASN, RN

Specializes in LTC, home health, critical care. Has 12 years experience.

I had a lady this weekend who I was sure wouldn't last the shift, and two days later she was up walking around cussing people out like she usually does.

CoffeeRTC, BSN, RN

Has 25 years experience.

Personal experience with this one. My dad went almost 2 days taking 1-3 breaths per minute. Mom and I (both nurses) knew what this meant and we were very okay with managing his pain levesl with the morphine. Stubborn man was waiting for my sister to come up from Tx.

Yes...it happens.

Pedi-Gree, BSN, RN

Specializes in Peds.

I think maybe we need some definitions here.

Kussmaul respirations have a regular rate and rhythm with a large tidal volume and pauses at end-inspiration and end-expiration. This pattern is seen most often in diabetic ketoacidosis and results in blowing off carbon dioxide to try to neutralize the acidosis.

Cheyne-Stokes respirations are regularly irregular. They follow a pattern of waxing and waning, that is to say that they start out very shallow and quickly become deeper and deeper, then begin to become shallower and shallower again, followed by a pause. Then the pattern starts again. Some references liken this to periodic breathing, but the oscillatory pattern is absent in periodic breathing, which is often seen in infants whose nervous systems are immature. This pattern is more one of irregular pauses in breathing with a normal rate and rhythm in between.

Central neurogenic hyperventilation is brainstem mediated and has no relation to oxygenation or gas exchange from a regulatory sense. The rate and rhythm are regular but very rapid and shallow, almost like panting.

Biot's respirations are also called cluster breathing. They're characterized by a cluster of rapid, shallow breaths followed by a variable period of apnea.

Apneustic respirations are irregular, gasping and include a full pause at end-inspiration.

Ataxic respirations are very irregular in rate, rhythm and volume, with irrgeular pauses and progressively longer periods of apnea. They often progress to agonal respirations: irregular and very infrequent breaths often seen just before death.

Most of these respiratory patterns can be related to brain injuries from taruma, stroke or some other mechanism and are often associated with other signs and symptoms of brain injury such as loss of airway protective reflexes. But some of these patterns may be related to metabolic conditions, which when treated, resolve.

This should eliminate some of the confusion.