1st signs of passing.

webblarsk · Dec 14, 2005

Yes, the time finally comes.
I'm a first time nurse. During my shift yesterday (11-7) I have gotten report from previous shift of change in condition in a pt of ours who's on Hospice care.
I tried to sat her and I got inaccurate readings of 71. Poor peripheal circulation, poor cap refill. O s/sx of cyanosis, 0 distress. Pt has been poor with appitite eating bites and sips. (Very fragile elderly). I know she's definitely dehydrated. If a pt is on hospice, could the doctor still order IV NS for hydration?
I called the supervisor b/c I wanted to know the protocol or the question "What do I do?" I was told to put her on 02 (nursing judgement) and get order in am. Respiratory therapist who was on the unit came to assess. She administered 02. I think she's at her first stages of dying. Her pulse was 100 and rr 32 shallow. Alittle deeper with the 02.
Is there any pointers that I should've done besides comfort care? I know that maybe tonight or tomorrow, I might be administering morphine, but I'm afraid to do it. I guess being 1st time nurse I'm just afraid of the unknown.
Just me,
Just wondering

For any needs you can always call the on call hospice nurse. That is what we are here for. Hospice needs to be aware of changes with the patient, and come to assess if needed. The patient sounds like she was comfortable and not struggling, so there isn't probably much more you could do. Besides contacting the family and making sure she remained symptom free. But I definitley encourage you to get the hospice involved and allow them to help you with this patient.

Mazzi · Dec 15, 2005

It is very hard to change the mind set that Nursing School teaches you about how to take care of the patient. While in school, all thought is about keeping the patient alive. But with hospice it is allowing the patient to die comfortablely. That is why we have hospice nurses. We have made that change in mind set. I agree with last post. CALL THE HOSPICE NURSE. Use us!!! Get our support and allow us to assist you in caring for your patient to the best of you ability. Good luck. Sounds like you are a caring nurse.

leslie :-D · Dec 15, 2005

it sounds like she's already receiving hospice care, according to the op's first statement.

giving good mouth care, repositioning, and ensuring comfort...w/rr in low 30's, hospice should be starting her on some mso4 to get her rr down.

some signs of impending death are mottled extremities, cheyne-stoking and dramatic changes in loc.

if there's a communication book for the hospice nurses, report your findings for continuity of care.

and if she is actively dying, there would be no need for iv hydration; if anything, it would make her more uncomfortable.

you'll do just fine, i'm sure.

leslie

Just wondering · Dec 15, 2005

I did mention to my supervisor do I need to contact Hospice (2am), "It was not needed until the morning," he said. We did what we can do. 7-3 "regular" staff told me they'll follow through with everything. And yes when I opened the chart, hospice was the first page with all the contact info. So, tonight, if I have any concerns or questions I won't hesitate to use my resources.

There was no distress as resident was also assessed by a respiratory therapist. This is an LTC with vent pts. The other thing I mentioned on the other post was morphine. I think by today they should have the order. Lastly, can anyone give me some of your experience on assessing the need for morphine and what is the patch for med to help ease congestion. As I recall there is a topical patch that can be used. I feel so incompetent being this is my first actual case. But I'm willing to grasp all info. Thanks again all.

Just me, Just wondering

leslie :-D · Dec 15, 2005

I did mention to my supervisor do I need to contact Hospice (2am), "It was not needed until the morning," he said. We did what we can do. 7-3 "regular" staff told me they'll follow through with everything. And yes when I opened the chart, hospice was the first page with all the contact info. So, tonight, if I have any concerns or questions I won't hesitate to use my resources.
There was no distress as resident was also assessed by a respiratory therapist. This is an LTC with vent pts. The other thing I mentioned on the other post was morphine. I think by today they should have the order. Lastly, can anyone give me some of your experience on assessing the need for morphine and what is the patch for med to help ease congestion. As I recall there is a topical patch that can be used. I feel so incompetent being this is my first actual case. But I'm willing to grasp all info. Thanks again all.
Just me, Just wondering

with a hr of 130 and respirations in low 30's, the pt needs morphine. her body is trying to compensate as it fails, and vital signs are indicative of these stressors. just because a pt isn't grimacing or moaning does not mean that they're comfortable. your goal is to lower her respirations to wnl so she doesn't get alkalosis.

the patch you're asking about is scopalamine and works quite well.

leslie

CANRN, MSN, RN · Dec 15, 2005

It sounds like you should have called the Hospice nurse on call. She could have instructed you on what to do from there and a visit may not have been necessary. But I will say, if one of the facilities that has one of our Hospice patient's in it had NOT called Hospice with these changes in condition, there would have been some educating (nice way of letting someone know they messed up). Hospice is usually brought in to administer end of life care (obviously) and many of these paitents are in LTC. We write orders on admission and one of them is "Notify Hospice of ANY condition changes in patient. NOtify Hospice if any medications change. "

You really should have called the Hosice nurse on call and allowed her/him to make a decision regarding comfort measures, visits etc. Also, I always write an order to D/C B/P's and SPo2's because, what are you going to do about a low/high reading anyway? Provide comfort!

As far as IV therapy for dehydration. Dehydration is part of the dying process. The body is shutting down, no intake, bowel sounds decreasing, urine production decreasing. Adding fluids to a dying patient is not advised. Where is the fluid going to go if the kidnyes don't work? You'll get edema and the lungs will fill with fluid and cause much more harm than good.

Next time this happens, call the Hospice nurse!

MMARN, BSN, RN · Jan 10, 2006

it sounds like she's already receiving hospice care, according to the op's first statement.
giving good mouth care, repositioning, and ensuring comfort...w/rr in low 30's, hospice should be starting her on some mso4 to get her rr down.
some signs of impending death are mottled extremities, cheyne-stoking and dramatic changes in loc.
if there's a communication book for the hospice nurses, report your findings for continuity of care.
and if she is actively dying, there would be no need for iv hydration; if anything, it would make her more uncomfortable.
you'll do just fine, i'm sure.
leslie

Great advice.

rosemadder · Jan 18, 2006

Just a note about first signs of passing...sometimes there aren't any! Some people don't fit any mold and one moment they'll be breathing and the next they'll be gone!

For hospice patients... oxygen is only provided as a comfort. If a patient who is actively dying is not short of breath at a 74% oxygen level than they don't have to have oxygen. I had one COPD® that had an 02 sat of 36% and was sitting up in bed talking and laughing...talk about compensation. WOW! The thing to remember mainly with Hospice patients is comfort, comfort, comfort. IV fluids do not provide comfort, O2 face masks normally don't provide comfort (as they're uncomfortable), Q2hour turns can often provide much discomfort...and at this point you're not worrying about skin breakdown...just remember COMFORT! You sound like a great nurse, good luck in your career!