CARDIO PULMONARY RESUSCITATION

AND END OF LIFE CARE

DEFINITION
Cardiopulmonary resuscitation (CPR) is an emergency procedure which is attempted in an
effort to return life to a person in cardiac arrest.
It is indicated in those who are unresponsive with no breathing or only gasps. It
may be attempted both in and outside of a hospital.

INDICATIONS

Unconscious
No breathing, or extremely irregular or agonal breathing, Cheyne-Stokes respiration, etc.
No circulation
Obstructed airway and the victim is an infant, pregnant or obese (i.e. too large to get your
hands around to perform a Heimlich manuver).
Many indications exist for CPR, these include

Dead cases, where no pulse and no breathing can be detected

Drug over dosage
Drowning
Poisoning
Non-fatal cardiac arrhythmia
Shocks and seizures

PURPOSES

Preserve life
To restore airway, breathing and circulation.
To prevent complication
To make the victim as comfortable as possible to conserve the strength.

CPR TRAINING OBJECTIVES

Recognizing an Emergency
The first objective of a CPR course, according to the American Red Cross, is to train
participants to recognize an emergency and activate the emergency response
system. This involves learning the main life-threatening conditions that occur, the
signs of a heart attack and the steps to take during an emergency, such as calling

911.
The CPR instructor will also teach the cardiac chain of survival, a process that helps
maximize a victim's chance of survival.
Assessing the Victim
After the participants learn to recognize an emergency, they are trained to assess a
victim. Participants learn how to check an unconscious individual for signs of life,
and have to demonstrate that they know how to properly check for breathing and
feel for a pulse. CPR training participants will learn to determine whether CPR or
some other first aid measure is appropriate, and identify any other life-threatening
conditions.
Providing Basic Care
Finally, the participants will learn to how to provide basic care to a victim, which
involves demonstrating how to take basic precautions during cardiac and breathing
emergencies, how to care for a conscious and unconscious choking individual and
how to give compressions and breaths during CPR. Many CPR courses also train
participants to use an automatic external defibrillator (AED), which delivers a shock
to the heart to help it resume a normal rhythm.

Signs of cardio pulmonary arrest

Immediate loss of consciousness

Absence of pulse
Cessation of perceptible respirations and after 45 seconds arrest dilatation of pupils.

Resuscitation/ ABCDs of basic CPR

When the victim appears unconscious or lifeless the ABCDs of resuscitation needs to
be performed in order to assess his/her most urgent needs. This should be done as quickly
as possible by following 4 steps
1. Open the airway(A): By removing blockage and lifting chin
2. Check the breathing: by looking for chest movements, listening for sounds of
breathing and feeling or breath for 5 seconds
3. Check for circulation: By feeling for the carotid pulse for five seconds.
4. Defibrillation: if witnessed arrest use automatic external defibrillator. If un
witnessed arrest deliver 5 cycles of CPR before using automatic external
defibrillator.
LOOK LISTEN AND FEEL-- When you LLF, you are checking to see if the victim is
breathing on their own. After performing the Head tilt-chin lift, lean down and place your ear
close to the victim's mouth and nose. LOOK for a rise in the chest; LISTEN for air passing
through the mouth and nose; FEEL any air passing over your face.
Open the airway

To clear the airways remove obstructing substances from the mouth with finger.

Use first finger as a hook to dislodge any material causing obstruction.

Head tilt chin lift maneuver:

The head tilt chin lift maneuver is used to open the victims airway to give mouth
to mouth resuscitation. A) rescuer places one head on the victims fore head and
applies firm, backward pressure with the palm to tilt the head back. The chin is
lifted and brought forward with the fingers of the other hand. B) Check if breathing
is restored. If not, start mouth to mouth breathing.
Heimlich maneuver (abdominal thrust method): for severe airway obstruction

Stand behind victim and wrap arms around waist

Make fist with one hand
Place thumb side of fist against victims abdomen. Position fist midline , slightly
above umbilicus and well below xiphoid process
Grasp fist with other hand
Press fist in to victims abdomen using quick upward thrust. It will enhance the
coughing reflex
Repeat thrust un till object is expelled

3) Jaw thrust maneuver

Breathing
Act quickly and restore breathing by giving mouth to mouth resuscitation

Pinch and compress nose to close nostrils

Take deep breath

Place the mouth around victims mouth, make an airtight seal

Delivers a regular breath ( 4 times)
Allow patient to exhale
Assess for cessation of breathing
LOOK for chest rising and falling
LISTEN for air escaping during exhalation
FEEL for flow of air

Circulation
Act quickly and restore circulation by external cardiac compression

Place the victim on hard surface and kneel at victim side

Locate the xiphoid process, measuring 1 -2 above xiphoid process
Place heel of one hand at this point on sternum
Place the other hand on top of it.
Interlock fingers to keep them of the victims ribs
Keep elbows straight and lean forward
Make dull use of the body weight when delivering downward compression
Apply steady smooth pressure to depress victims sternum 3to 4
Then relax pressure completely but do not let the hand leave victim chest or may
lose correct hand position.
Repeat and perform CPR for one minute as follows
After 10 chest compression give 2 quick lung inflation by mouth to mouth breathing
(ambue bag) and then two more inflation it carotid pulse absent.
Resume CPR alternating lung inflation with chest depression.

NURSING ASSESSMENT AND CARE

A-AIRWAY
Unconscious patient
In the unconscious patient, the priority is airway management, to avoid a preventable
cause of hypoxia. Common problems with the airway of patient with a seriously reduced
level of consciousness involve blockage of the pharynx by the tongue, a foreign body,
or vomit.
At a basic level, opening of the airway is achieved through manual movement of the head
using various techniques, with the most widely taught and used being the "head tilt chin
lift", although other methods such as the "modified jaw thrust" can be used, especially
where spinal injury is suspected, although in some countries, its use is not recommended
for lay rescuers for safety reasons.
Higher level practitioners such as emergency medical service personnel may use more
advanced techniques, from oropharyngeal airways to intubation, as deemed necessary
Conscious patients
In the conscious patient, other signs of airway obstruction that may be considered by the
rescuer include paradoxical chest movements, use of accessory muscles for breathing,
tracheal deviation, noisy air entry or exit, and cyanosis.

Once oxygen can be delivered to the lungs by a clear airway and efficient breathing, there
needs to be a circulation to deliver it to the rest of the body.
B-BREATHING
Unconscious patients
In the unconscious patient, after the airway is opened the next area to assess is the
patient's breathing, primarily to find if the patient is making normal respiratory efforts.
Normal breathing rates are between 12 and 30 breaths per minute, and if a patient is
breathing below the minimum rate, then in current ILCOR basic life support protocols, CPR
should be considered, although professional rescuers may have their own protocols to
follow, such as artificial respiration.
Rescuers are often warned against mistaking agonal breathing, which is a series of noisy
gasps occurring in around 40% of cardiac arrest victims, for normal breathing.
If a patient is breathing, then the rescuer will continue with the treatment indicated for an
unconscious but breathing patient, which may include interventions such as the recovery
position and summoning an ambulance.

Conscious or breathing patients

In a conscious patient, or where a pulse and breathing are clearly present, the care
provider will initially be looking to diagnose immediately life-threatening conditions such
as severe asthma, pulmonary edema or haemothorax. Depending on skill level of the
rescuer, this may involve steps such as:

Checking for general respiratory distress, such as use of accessory muscles to

breathe, abdominal breathing, position of the patient, sweating, or cyanosis
Checking the respiratory rate, depth and rhythm - Normal breathing is between 12
and 20 in a healthy patient, with a regular pattern and depth. If any of these deviate
from normal, this may indicate an underlying problem (such as with Cheyne-Stokes
respiration)
Chest deformity and movement - The chest should rise and fall equally on both sides,
and should be free of deformity. Clinicians may be able to get a working diagnosis from
abnormal
movement
or
shape
of
the
chest
in
cases
such
as pneumothorax or haemothorax
Listening to external breath sounds a short distance from the patient can reveal
dysfunction such as a rattling noise (indicative of secretions in the airway)
or stridor (which indicates airway obstruction)
Checking for surgical emphysema which is air in the subcutaneous layer which is
suggestive of a pneumothorax
Auscultation and percussion of the chest by using a stethoscope to listen for normal
chest sounds or any abnormalities
Pulse oximetry may be useful in assessing the amount of oxygen present in the blood,
and by inference the effectiveness of the breathing

C-CIRCULATION
Non-breathing patients
Circulation is the original meaning of the 'C' as laid down by Jude, Knickerbockers & Safar,
and was intended to suggest assessing the presence or absence of circulation, usually by
taking a carotid pulse, before taking any further treatment steps.
In modern protocols for lay persons, this step is omitted as it has been proven that lay
rescuers may have difficulty in accurately determining the presence or absence of a pulse,
and that, in any case, there is less risk of harm by performing chest compressions on a
beating heart than failing to perform them when the heart is not beating. For this reason,
lay rescuers proceed directly to cardiopulmonary resuscitation, starting with chest
compressions, which is effectively artificial circulation. In order to simplify the teaching of
this to some groups, especially at a basic first aid level, the C for 'Circulation' is changed
for meaning 'CPR' or 'Compressions'

It should be remembered, however, that health care professionals will often still include a
pulse check in their ABC check, and may involve additional steps such as an
immediate ECG when cardiac arrest is suspected, in order to assess heart rhythm.
Breathing patients
In patients who are breathing, there is the opportunity to undertake further diagnosis and,
depending on the skill level of the attending rescuer, a number of assessment options are
available, including:

Observation of colour and temperature of hands and fingers where cold, blue, pink,
pale, or mottled extremities can be indicative of poor circulation
Capillary refill is an assessment of the effective working of the capillaries, and involves
applying cutaneous pressure to an area of skin to force blood from the area, and
counting the time until return of blood. This can be performed peripherally, usually on a
fingernail bed, or centrally, usually on the sternum or forehead
Pulse checks, both centrally and peripherally, assessing rate (normally 60-80 beats per
minute in a resting adult), regularity, strength, and equality between different pulses
Blood pressure measurements can be taken to assess for signs of shock
Auscultation of the heart can be undertaken by medical professionals
Observation for secondary signs of circulatory failure such as edema or frothing
from the mouth (indicative of congestive heart failure)
ECG monitoring will allow the healthcare professional to help diagnose underlying
heart conditions, including myocardial infarctions

ABCD
There are several protocols taught which add a D to the end of the simpler ABC (or DR
ABC). This may stand for different things, depending on what the trainer is trying to teach,
and at what level. It can stand for:
Defibrillation The definitive treatment step for cardiac arrest
Disability or Dysfunction Disabilities caused by the injury, not pre-existing
conditions
Deadly Bleeding
(Differential) Diagnosis
Decompression
ABCDE

Additionally, some protocols call for an 'E' step to patient assessment. All protocols that use
'E' steps diverge from looking after basic life support at that point, and begin looking for
underlying causes. In some protocols, there can be up to 3 E's used. E can stand for:

Expose and Examine Predominantly for ambulance-level practitioners, where it is

important to remove clothing and other obstructions in order to assess wounds.
Environment only after assessing ABCD does the responder deal with
environmentally-related symptoms or conditions, such as cold and lightning.
Escaping Air checking for air escaping, such as through a sucking chest wound,
which could lead to a collapsed lung.
Elimination
Evaluate Is the patient "time-critical" and/or does the rescuer need further
assistance.

ABCDEF
An 'F' in the protocol can stand for:

Fundus relating to pregnancy, it is a reminder for crews to check if a female is

pregnant, and if she is, how far progressed she is (the position of the fundus in relation
to the bellybutton gives a ready reckoning guide)
Family (in France) indicates that rescuers must also deal with the witnesses and the
family, who may be able to give precious information about the accident or the health of
the patient, or may present a problem for the rescuer.
Fluids A check for obvious fluids (blood, cerebro-spinal fluid (CSF) etc.)
Fluid resuscitation
Final Steps Consulting the nearest definitive care facility

ABCDEFG
A 'G' in the protocol can stand for

Go Quickly! A reminder to ensure all assessments and on-scene treatments are

completed with speed, in order to get the patient to hospital within the Golden Hour
Glucose The professional rescuer may choose to perform a blood glucose test, and
this can form the 'G' or alternately, the 'DEFG' can stand for "Don't Ever Forget
Glucose

PROCEDURE FOR RECOVERY POSITION

Any unconscious victim should be placed in the recovery position. This position prevents
the tongue from blocking the throat and because the head is slightly lower than the rest of
the body, it allow liquid to drain from the mouth, reducing the risk of casualty inhaling
stomach contents.

Kneeling besides the victim, open her/his airway by tilting the head or lifting the
chin. Straighten his or her leg. Place the arm nearest you out at right angles to her or
his body, elbow bent and with the hand palm uppermost.
Bring the arm from you across the chest, and hold the hand, palm outwards, against
the victims nearer cheek.
With the other hand grasp the thigh further from you and pull the knee up keeping
the foot flat on the ground
Keeping her or his hand pressed against her or his cheek, pull, at the thigh to roll the
victim towards you and on to her side.
Tilt the head back to make sure the airway remains open, adjust the hand under the
cheek, if necessary so that the head stays in this tilted position.
Adjust the upper leg if necessary, so that both the hip and the knee are bent at right
angles
Dial for an ambulance (108). Check breathing and pulse frequently while waiting for
help to arrive.

COMPLICATIONS
Broken Bones
Rib fractures are the most common complication of CPR. Chest compressions administered
during CPR are given quickly and with enough force to compress the chest about 1 inch in
depth. This provides pressure to the ribs, which can be strong enough to cause ribs to
fracture. Victims who are elderly, small in stature or children have the highest risk of
developing rib fracture during chest compressions. Additionally, the chest bone, or
sternum, also endures pressure and stress during chest compressions and can fracture as
well.
Internal Injuries
Internal organs lie within the area pressured by chest compressions. As the chest is
compressed during CPR, ribs and chest bones can break, puncturing the lungs and liver.
Additionally, internal bruising of the heart and liver can occur.
Vomiting and Aspiration
As chest compressions are administered, pressure builds inside the body, which can force
stomach contents up the esophagus and result in vomiting. This causes the risk of
aspiration, or absorbing the vomit into the respiratory system. Aspiration is a serious
complication which makes it difficult to provide the victim with adequate air and can
ultimately damage lung tissue or result in infection, like pneumonia.
Body Fluid Exposure
CPR presents the risk of exposure to body fluids. Providing mouth-to-mouth rescue
breathing to a victim without use of a mask results in saliva exposure between victim and
rescuer. Blood and vomit may also be present during CPR, which carries the risk of

communicable disease such as hepatitis and AIDS. The American Heart Association
encourages the use of a barrier mask when administering rescue breathing during CPR for
protection against contamination.
Gastric Distention
Rescue breathing during CPR provides air directly into the lungs of the victim. If air is
delivered too forcefully or for too long a time, the victim can accumulate air build-up in the
stomach, called gastric distention. Gastric distention causes the stomach to swell and places
pressure on the lungs

END OF LIFE CARE

End-of-life care requires a range of decisions, including questions of palliative care,
patients' right to self-determination (of treatment, life), medical experimentation, the
ethics and efficacy of extraordinary or hazardous medical interventions, and the ethics and
efficacy even of continued routine medical interventions. In addition, end-of-life often
touches upon rationing and the allocation of resources in hospitals and national medical
systems. Such decisions are informed both by technical, medical considerations, economic
factors as well as bioethics. In addition, end-of-life treatments are subject to considerations
of patient autonomy.
Caring for dying patients is inseparable from our efforts as physicians to improve our
patients lives. The increasingly large numbers of patients who are part of our aging
population along with technologic advancements make it vitally important to improve and
refine our teaching of end-of-life care. One of medicines most important missions is to
allow terminally ill patients to die with as much dignity, comfort and control as possible. In
patients for whom a cure is not possible, there is still an enormous amount of care and
support that can and should be provided for patients and their families. Many of the tenets
embodied in family medicine are very important in the care of the dying. A holistic
approach to the patients physical and psychosocial well-being, a focus on the family,
continuity of care and an emphasis on quality of life are four important principles that
make the family physician uniquely suited to care for the terminally ill. The end of life is
one of the most critical times in the doctor-patient relationship. A family physician
providing and coordinating hospice or other team care for a dying patient can ease physical
symptoms and provide social, emotional and spiritual support. The care and support
provided can set the stage for some of the most meaningful experiences in which human
beings participate. The time and care surrounding a loved ones death are not just
remembered for days or weeks but often lifetimes. Appropriate teaching and experiences
in end-of-life care during residency training will not only provide necessary information to
help ease pain and suffering, but it will also inspire family physicians to participate in the
ultimate continuity of care: that of the terminally ill.

COMPETENCIES
At the completion of residency training, a family medicine resident should:

 Be able to identify a plan of care for terminally ill patients, which is based upon a
comprehensive interdisciplinary assessment of the patient and familys expressed values,
goals and needs, and communicate the plan to the patient and family.(Patient Care, Medical
Knowledge, Interpersonal Communications)
Optimize treatment plans for terminally ill patients via integrating knowledge of local
palliative and hospice care resources, as well as state and federal resources.(Practice-based
Learning, Systems-based Practice)
Recognize the signs and symptoms of the imminently dying patient. (Medical Knowledge)
Demonstrate systematic recognition, assessment and management of pain syndromes
utilizing evidence-based medicine. This should include both pharmacologic (opiate and
non-opiate) and nonpharmacologic treatments as well as possible side effects. (Patient
Care, Medical Knowledge, Practice-based Learning)
Be aware of the ethical and legal issues from which the terminally ill patients preferences
and choices may be based upon and/or limited within. Further, skilfully negotiate
treatment decisions with terminally ill patients and his or her family within this context.
(Professionalism, Interpersonal Communications) Attitudes
The resident should demonstrate attitudes that encompass:
The process of breaking bad news, including choice of setting, talking with the patient
and family members, summarizing, using appropriate wording and questioning and the
impact of this process on the patient and family.
An understanding of the psychosocial issues and family dynamics affecting the terminally
ill patient.
An understanding of the spiritual and religious issues affecting the terminally ill patient.
An understanding of the family cultural issues and particular customs in the context of
death and dying.
An understanding of the dying patients need for palliative care, pain relief, control and
dignity.
An understanding of the special issues associated with children, either as terminally ill
patients or as family members of a terminally ill patient.
An understanding of the impact of attitudes and experiences about death and dying in
relation to caring for terminally ill patients.

KNOWLEDGE
In the appropriate setting, the resident should demonstrate the ability to apply knowledge
of:
1. The philosophy of palliative care

a. Home-based approach
b. Family-as-care unit
c. Pain control
d. Symptom control
2. Hospice team roles
a. Physician
I. Identification of appropriate patients for hospice care
1). Cancer-related
2). Non-cancer-related
a). Pulmonary
b). Cardiovascular
c). Neurologic
d). Infectious
ii. Referral process and criteria
iii. Insurance and medical care coverage
iv. Cost of care for terminally ill in various settings
b. Nurses c. Social worker
d. Pharmacists
e. Home health care aides
f. Volunteers
g. Family
3. Prognosis of terminal illness
a. Accuracy of prognosis
b. Clinical indicators of time until death
c. Value of medical therapies
d. Psychosocial stages of the dying process for patient and family
4. Major pain syndromes

a. Neuropathic
b. Bone pain
c. Visceral pain
d. Non-physiologic pain
5. Pain control
a. Opiates (long- and short-acting)
b. Non-opiates
c. Addiction, habituation and dependence
d. Baseline dosing and rescue
e. Complementary and alternative medicines
f. Nonpharmacologic pain control measures
g. Side effects of pain control measures
6. Causes and treatment of non pain symptoms
a. Nausea
b. Shortness of breath
c. Loss of appetite
d. Vomiting
e. Sleeplessness
f. Depression
g. Anxiety
h. Cough
i. Constipation
j. Diarrhea
k. Xerostomia
7. Nutrition and hydration in the terminally ill
a. Artificial feeding
b. Intravenous fluids

c. Withholding feeding and fluids

8. Care locations
a. Emergency department
b. Inpatient
c. Outpatient
d. Extended-care facilities
e. Home
9. Data related to end-of-life care in the United States
a. Aging population
b. Most common chronic illnesses
c. Most common causes of death by age
d. Cost of care for the terminally ill in various settings
e. Where people die (home vs. in hospital)
10. The bereavement process
a. Normal grief reaction
b. Differentiate grief reaction from depression
11. Legal issues
a. Patient competency
b. Advance directives
c. Do-not-resuscitate (DNR) orders
d. Power of Attorney for health care
e. Living will
f. Estate planning for patient and family
g. Withholding and withdrawing life support
h. Pronouncement of death
i. Completion of death certificate Skills

In the appropriate setting, the resident should demonstrate the ability to independently
perform or appropriately refer:
1. Physical assessment with attention to common findings of the terminally ill patient
2. Correct compliance with regulations pertaining to use of controlled substances in the
terminally ill patient in and outside hospice care
3. Development of an initial and ongoing analgesic regimen to include the use of morphineequivalent dosages and other narcotic equivalents
4. Effective use of alternative routes of analgesia
a. Rectal
b. Topical (e.g., creams, gels, patches)
c. Nasal
d. Subcutaneous
5. Correct use of pain scales to adjust medication dosage
6. Effective referral of available social services for both patient and family
7. Effective counselling of family and others
a. The process of the death and dying of a loved one via direct communication, family
conferences and creation of a multidisciplinary team for resolution
b. Grief reaction
c. Continuing relationships with family members after a loss
8. Self-care and seeking support when patients die

IMPLEMENTATION
This curricular segment lends itself to a combination of longitudinal and blocks learning
experiences over the 3 years of residency training. The curricular content should be
integrated into the core conference schedule and should include exposure to hospice care,
home visits and bereavement counselling whenever possible. Relevant literature should be
available in the resident library. An attempt should be made to include patients who have
terminal illnesses in all resident-patient panels. The faculty should function as role models
for residents dealing with dying patients and their families. Active learning techniques such
as role playing, simulated patients, case discussions and topic presentations are useful
The Dying Persons Bill of Rights

1. I have the right to be treated as a living human being until I die.

2. I have a right to maintain a sense of hopefulness, however changing its focus may be.
3. I have the right to be cared for by those who can maintain a sense of hopefulness
however changing it might be.
4. I have the right to express my feelings and emotions about my approaching death in
my own way.
5. I have the right to participate in decision concerning my care.
6. I have the right to expect continuing medical nursing attention even though CURE
goals must have change to COMFORT goals
7. I have the right not to die alone.
8. I have the right to be free from pain.
9. I have the right to have my questions answered honestly.
10. I have the right not to deceive.
11. I have the right to have help from and for my family in accepting my death.
12. I have the right to die in peace and in dignity.
13. I have the right to retain my individuality not to be judged for my decisions which
may contrary to the beliefs of others.
14. I have the right to expect that the sanctity of the human body will be respected after
death.
15. I have the right to be cared for my caring, sensitive, knowledgeable people who will
attempt to understand my needs and will be able to gain some satisfaction in
helping me face my death.
Nursing Care of Dying Patient
Physiological Needs
According to Maslows Hierarchy of needs, physiological needs must be met before
others, because they are essential for existence.
Areas that are often problematic for the terminally ill client are respirations, fluids &
nutrition, mouth, eyes and nose, mobility, skin care and elimination.
Respiration: Oxygen is frequently ordered for the client experiencing laboured
breathing. Suctioning may be needed to remove secretions that the client is unable to
swallow.
Fluids & Nutrition:
The refusal of food and fluids is almost universal in dying clients. It is
believed that the client is not feeling thirst and hunger.
Although the issue of permitting dehydration in terminally ill clients is often
met with great resistance.
Artificial nutrition often increases the client agitation leads to increased use
of limb restraints and increases the risk of aspiration pneumonia.
Hospice nurses have indicated that withholding artificial nutrition is not
painful. Regardless, in every situation, the client the clients own wishes must
always take precedence.

 If the comatose client has not previously made his wishes known, family
members must be given accurate and truthful information.
For the person in irreversible coma, withholding artificial nutrition does not
causes death rather it allows life to take its natural course and it should be
discontinue to support nutritionally if the client request.
Mouth, Eyes & Nose:
MOUTH
Oral discomfort is the only documented side effect of dehydration in the terminally
ill client.
Both the administration of oxygen and mouth breathing increase the need for
meticulous oral care. Caregiver can use saliva substitutes and moisturizers to
alleviate discomfort.
Regular brushing of teeth should be encouraged and the tongue must also be given
the same attention as is the rest of the mouth.
Ice chips and sips of favourable beverages should be offered frequently and
petroleum jelly applied to the lips.
Oral care must be given every 2-3 hrs to maintain the clients comfort.
EYES

Due to the dryness the eyes may become irritated and artificial tears can alleviate
this discomfort
Therefore wiping off the tears from inner to outer cantus to remove the discharges.

NOSE
The nares may become dry and crusted. Oxygen given by the cannula can further
irritate the nares.
So, a thin layer of water soluble jelly applied to the nares will be helpful to alleviate
discomfort.
Mobility:

As the clients condition deteriorates, mobility decreases. Te client become less able
to move about in bed or to get out of the bed and requires more assistance.
Therefore physical dependence increases the risk of complication related to
immobility. E.g Atrophy &pressure ulcer.

Nursing Management:
Frequently re-positioning according to the patient and considering the underlining
condition of the patient such as arthritis & lung disease.
Passive range of motion exercise should be done 2 times (twice) a day to prevent
stiffness and aching of the joints.
Using a wheelchair can also increase the clients environmental space, giving the
client more mobility, control, and independence.

Skin Care
Prevention of pressure ulcer is the priority. These are painful and can cause
secondary complication such as sepsis and are costly to treat.
In addition to the care of the pressure point keeping the skin clean moisturized
promotes healthy tissue.
The skin should be inspected twice daily.
Gentle massages with soothing lotion are comforting.
Bed bath are adequate if the client cannot get into the tub or sit in the shower chair.
Elimination
Constipation may occur due to the side effects of the analgesics and the lack of
physical activities.
Fluids and foods with high fibre contained can be effective preventive measures for
the client with adequate oral intake.
It can also be alleviated by maintaining a scheduled time for bowel elimination and
administering suppositories if necessary
The client may have incontinence of bladder and bowel, so the nurse need to check
the client frequently, clean the skin the peri-wash, apply a moisture barrier after
each incontinence episode.
Comfort

Pain relief
Keep the patient clean and dry.
Provide a safe and non threatening environment
Provide a respectful, careful attitude to provide psychological comfort by
establishing good rapport.

Physical environment
A soothing physical environment can significantly increase the clients comfort
Adequate lighting enhances vision without causing discomfort associated with
harsh, glaring light.
Provide night light if patient requires
As the client circulation slightly sluggish, the body temperature will fall, so
providing a light weight comforters will be helpful to warmth without adding
uncomfortable weight.
Provide quite and calm environment.( even the phone can be removed if patient find
it disturbing.

Psychosocial needs
Death presents a threat to not only ones physical existence but to ones psychological
integrity.

 Even though in the presence of the nurse, the family members should be encouraged
and invited to participated in the clients care, if they desire to do so and the client is
willing
Maintain a well groomed appearance is important. cutting the nails, shaving the
beard will help to promote patients dignity.
Combing and brushing the hair not only improves appearance but is also a
comforting and relaxing activity for many clients.
Spiritual needs
The nurses play a major role in promoting the dying clients spiritual comfort. Dying
persons are among the most vulnerable members of the human family

Communicate empathy
Play music
Use touch
Pray with the client
Contact clergy if requested by the client
Read religious literature aloud, at the patient request.

Support for the family

The family member needs to be involved in the care of their dying lived one.
Guilt may be increased by the feeling of powerlessness.
Involving the family members in the treatment is a helpful intervention
The families facing the impending death of the loved one require much support from
the nurses and the care givers.
o Being with the family members is extremely important
o Provide assistance and guidance if the family members have limited coping
skills and inadequate supporting system.
o She must be supportive and non judgmental

Legal consideration during death

The Patient Self Determination Act (PSDA) was incorporated into the Omnibus
budget reconciliation Act (OBRA) of 1990
The Act was intended to provide a legal means for individuals to determine the
circumstances under which life sustaining treatment should or should not be
provided to them. The individuals choice are validated by advanced directives
An advanced directive is any written instruction including a living will or durable
power of attorney for health care that is recognised under state law( Taylor 1995)
The act applied to hospitals, long term care facilities , home care agencies, hospice
programs, and certain health maintenance organisations (HMOS)
All the clients entering into the healthcare system through this organisation must be
given information regarding the complete care. It is necessary not only to inform
about the care but also the need to indicate the wishes in regarding to artificial
feeding, intubation, chemotherapy, surgery, blood transfusion etc.

Although the living will and durable power of attorney for health care are legal
documents, they do not preclude the need for resuscitation
The medical record must have a written DNR (Do-Not-Resuscitate) order from a
physician if this is in agreement with the client wishes and with the advanced
directives. In the absence of this order resuscitation is not initiated.

Ethical consideration during dying

Death is often fraught with ethical dilemmas that occur almost daily in health care
settings.
Many health care agencies have ethics committees to develop and implement
policies to deal with and to end-to-life issues
Ethical decision making is a complex issue. One of the most ethical dilemmas is
determining the difference between killing and allowing someone to die with
holding life-sustaining treatment methods.
The ANA distinguish reliving pain and mercy killing( euthanasia or assisted suicide)
Pain relief is a central value in nursing, where as euthanasia is viewed as unethical.
The ANAs position is that increasing dose of medication to control pain in
terminally ill client is ethically justified even at the expenses of maintaining life.
CONCLUSION
CPR is an emergency procedure which is attempted in an effort to return life to a person in
cardiac arrest. It is indicated in those who are unresponsive with no breathing or only
gasps. It may be attempted both in and outside of a hospital. CPR alone is unlikely to restart
the heart; its main purpose is to restore partial flow of oxygenated blood to the brain and
heart. It may delay tissue death and extend the brief window of opportunity for a successful
resuscitation without permanent brain damage