Tuesday, February 01, 2005

Physical Assessment for Dying Patients

I am shocked when I come onto shift and grab my patient’s chart to discover that the nurse before me didn’t chart a physical assessment on a dying patient. Do some nurses think there is nothing to assess, no need as the patient is dying? I just don’t understand what the rationale is for these nurses? Do they think the patients whom they are trying to cure of disease are more worthy of their time and attention? If that is the case, you need to get a job somewhere else. I hope that my blog has already illustrated why nursing care of dying patients is so crucial. But to illustrate the physical exam specifically, here is a very abbreviated version of my assessments:

Although many doctors will discontinue vital checks on dying patients, some of the vitals are still helpful and/or necessary. We wouldn’t want to walk into a dying patient’s room with a beeping pulse oximetry machine to check their oxygenation because what are we going to do different if their oxygen saturation is low? Their oxygen saturation is irrelevant – though managing their dyspnea (physical sensation of having difficulty breathing) is crucial. You should count respirations. For one, a declining respiratory rate may indicate they are getting closer to their end of life. For a patient who is no longer able to speak, a high respiratory rate may be our only indication that the patient is either in pain or is having difficulty breathing. You can also place your stethoscope against their chest without causing any discomfort and obtain a pulse. Their pulse can give you a clue as to how close to end of life they are (if it is either very high or very low), but also if they are febrile (have a fever). I also use obtaining the pulse as an excuse to make initial physical contact with the patient. I am very gentle with my stethoscope and always use my free hand to stabilize myself as well as provide another source of gentle, caring contact with the patient (usually on their shoulder). By having your hand on their body, you can also assess if their body is warm. If their body is warm and their pulse is high, check their temperature. Having a fever is uncomfortable. If they are febrile, we will want to treat that fever with Tylenol. You can use a suppository if the patient is unable to swallow pills.

All dying patients are at risk of developing bedsores. You don’t need to turn the patient over specifically to check their skin. Wait until you are doing a diaper change or until they need to be repositioned (which should be done every two to three hours on all dying patients). Then check all areas with bony prominences for signs of skin breakdown. As a reminder – a pink area that does not blanch when you press on it is a stage one bedsore (aka pressure ulcer or decubitus). This is the first sign of skin breakdown. Be sure to check their heels as well as their back.

Again, don’t turn the patient to specifically do this exam. Wait until you are turning them for other reasons. Minimally, chart the presence or absence of a death rattle. Chart whether their breathing pattern is irregular (which frequently happens as they get closer to death), if there are periods of apnea (when the patient stops breathing briefly), chart whether or not their breathing appears labored. Do you see them using abdominal muscles in order to get air in?

Again, you’ve already counted the pulse with your stethoscope. Also feel for peripheral pulses. Pulses frequently become diminished as people approach death. The carotid pulse in the neck may be the last pulse to be seen and/or felt. Sometimes getting a pulse is extremely difficult as a patient nears death. Check for warmth of skin. Not only will warmth tell you if they may have a fever, but coolness in the limbs may let you know that they are nearing death. Look for swelling in their limbs and abdomen.

Even if they can’t speak, chart whether or not they open their eyes, whether or not they respond at all to stimulation. Do they moan or grimace when you turn them? Not only does that inform you of possible pain, but it also provides information as to neurological status. Are they sleeping all of the time or do they come in and out of sleep.

GI & GU – The In’s & Out’s
I am always surprised when doctors discontinue I’s & O’s. For non-medical folk, this is tracking how much fluid goes into the patient (by mouth or IV) and how much fluid - urine, diarrhea, emesis (vomit), etc - comes out. A decrease in urine output is a good indication of how close to death they are. Even if the doctor doesn’t ask for I’s and O’s, I will track them, especially if the patient has a urinary catheter in place. It’s very easy, so why not? If they are incontinent and don’t have a catheter in, I will still chart whether or not they have wet their diaper. I always chart the last date that they took in any food and whether or not they have stooled during my shift as an assessment for constipation. If the patient is still alert, are they eating? What are they eating?

At the very end of life, most patients are bed bound. However, chart whether they are moving their body at all independently. If they are not moving, are their extremities flaccid or contracted? Are they cachectic (extremely thin and wasted)?

If the patient is awake and alert, chart their mood. If the family is present, chart whether or not they are coping well. Document any education you do with either the patient or the family. Care planning is very useful with dying patients and their families so that the next nurse who comes in knows where the family is at: what education needs to be reinforced, what resources might they need referrals to, etc. Has the patient become agitated during your shift?

Pain & Other Symptoms
Last, but certainly not least. Symptom management is the most crucial component of palliative care. Make sure you document symptoms well. If the patient is alert, are they reporting symptoms of pain, nausea, anxiety, dyspnea, itching, etc? If they are not alert, are they showing signs of any of these symptoms – moaning, grimacing, scratching at self, becoming agitated (which may be a sign of discomfort), pulling at tubes (may also be a sign of discomfort), etc?

I could write an entire book on assessing dying patients, but I guess I just wanted to make a point. Don’t leave assessment pages blank. There is always ample information to chart, even after you’ve just walked in and out of the room once, you should already have gathered some of this information at first glance. For information on symptomatology, see the numerous posts I have done on symptoms thus far.

1 comment:

Anonymous said...

Wonderful blogs!!
I just discovered your blog yesterday and love reading through these. I am a nurse in a cardiology ward and also help nurse a terminal patient (friend's father) at his home.