End of Life care for beginners

[jeyre1847]

I'm a fairly new nurse, and just starting out at an SNF. First off, I love my job, I love my residents and my coworkers :)

Today was my first personal experience with a patient death. I've had patients I've cared for die, but they've always managed to hang on til my day off. So I've had a few dying patients I've cared for, but none that have gone. But today was that big nursing milestone, and I think it went okay.

I just have a few end of life questions. I can't seem to find answers (there's not too much info about end of life care, but that's another discussion). I almost feel silly asking my coworkers because the way they discuss symptoms it seems like I should have heard of them already. I have two I'm most curious about.

1. Fever. My patient today ran a low grade fever. I can't seem to find any physiology on why that's normal for end of life. Is it a last inflammation kick? Or maybe the body knows something's wrong and it's trying to fix it? Or is it more in the brain and hypothalamus, hormones, etc?

2. Mottling. I've heard of this happening with patients within a few days of death. It's a lack of circulation, particularly in the extremities, and I can figure that much out. His legs almost looked stringy and blue, not just discolored like I would expect? And why are the knees the place to look for it?

Thanks for your help! I'm pretty new to this. I was really nervous at first because he was having a lot of trouble breathing, but he was resting comfortably when he passed away. I felt like a good nurse today for taking care of him. I'd like any tips you can offer on this aspect of nursing so I have that much more I can offer the next time I'm in the position.

Also, I've had so many fantastic experiences with hospice nurses. You guys are fantastic :)

[Daisy_08, BSN, RN]

Fever - The maintenance of our bodies temperature is a very delicate mechanism. When someone is dying their body is shutting down and things are not working like they should. The negative feedback mechanism is so delicate to regulate temperature that the body cannot always maintain it. A fever is very common. (There is probably more patho to it but this what I understand)

Mottling _ your correct, this is a lack of circulation. I find it usually starts in the feet though. The farthest away from the vital organs.

The other cardinal sign is congestion. The lungs begin to fill with fluid and you can hear it without a stethoscope. If I think a person is getting close, I put my hand on their chest and I can feel the congestion before you can hear it. Typically the pt is unaware when this starts to develop. But it is very upsetting to the family. Scopolamine and glycopyrrolate can help. I also will give dilaudid to for dyspnea.

My other advise to you is there is no such thing as too much medication in late stage end of life care. So what if they have low resps, or become sedated. It’s all about symptom control. As well educate the family. You may notice A and B , C is normal, if you notice D let me know as I have a medication that can help ect.

I thought of another one. At the very end, when they are unconscious. Some pts heads will hyperextend back, and their mouths open. There is really nothing that can be done, families hate it. Same story for open eyes. You just have to let the family know that closing your eyes and mouth is a muscle contraction, a forced movement, the pt has lost that, but they it is not causing them any pain.

All the best at your new job. It sounds like they are lucky to have you.

[~MIA~, ASN, RN]

Great explanation ~ Hospice nursing is the best! I LOVE IT!

[Daisy_08, BSN, RN]

I always feel like a nut when I tell people how much I love end-of-life-care. But it really is the best!

I also looked into the hyperextension a bit more. In CNS pts it can be due to the nerves not being able to interpret, or send out messages.