DEATH OF A PATIENT
After a patient dies, nursing care should include the provision of support to family members and the preparation of the patient for family viewing. This preparation includes the removal of tubes and drains and bathing of the body. Arrangement of transportation to the morgue or funeral home may be done by the nursing supervisor. Identification and disposition of the patient’s belongings should be completed in accordance with the family’s wishes. Family members should be afforded privacy and given time to remain with their deceased loved one. Emotional support should be provided.
Postmortem care usually begins after the patient’s death is certified. If the patient died violently or under suspicious circumstances, postmortem care might be postponed until the medical examiner completes an examination. It is important to be aware of state laws related to notification of organ procurement organizations (OPOs).
Essential Documentation
The death of a patient is pronounced by a physician or nurse practitioner. In some states, registered nurses can pronounce a patient dead. The provider who pronounced the death of the patient should document the date and time of the patient’s death. If resuscitation was attempted, indicate the time it started and ended, and refer to the code sheet in the patient’s medical record. Note whether the case is being referred to the medical examiner. Include all postmortem care given, noting whether medical equipment was removed or left in place. List all belongings and valuables and the name of the family member who
accepted and signed the appropriate valuables or belongings list. Record any belongings left on the patient. If the patient has dentures, note whether they were left in the patient’s mouth or given to a family member. (If given to a family member, include the family member’s name.) There is a specific form provided by the facility that will be completed by the nurse or other provider regarding the disposition of the patient’s body; the name, telephone number, and address of the funeral home; medical examiner office contact; and OPO information. The names of the family members who were present at the time of death should be documented. If the family was not present at the time of death, note the name of the family member and the time notified. Be sure to document any care, emotional support, and education given to the family.
DEHYDRATION, ACUTE
Dehydration refers to the loss of water in the body resulting in a shift in fluid and electrolytes, which can lead to hypovolemic shock, organ failure, and death. Dehydration may be isotonic, hypertonic, or hypotonic. Common causes of dehydration are fever, diarrhea, and vomiting. Other causes include hemorrhage, excessive diaphoresis, burns, excessive wound or nasogastric drainage, and ketoacidosis. Prompt intervention is necessary to prevent complications, which can include death.
Essential Documentation
The nurse should record the date and time of the entry. The date and time are automatically recorded in electronic health records (EHRs).
An EHR and intake-output flow sheet are necessary to document dehydration. Record the results of the physical assessment and any subjective findings. Include laboratory values and the results of any diagnostic tests (e.g., stool culture to identify the cause of excessive diarrhea). Closely monitor and record intake and output on an intake-output flow sheet. (See “Intake and output,” pages 210 to 212.) Record the name of the health care provider notified, the time of notification, and any orders given. Document the nursing interventions, such as intravenous (IV) therapy, and the patient’s response. Record nursing actions to prevent complications, such as monitoring for IV infiltration and auscultating for breath sounds to detect fluid-volume overload. Also note the patient’s level of consciousness.
DEMENTIA
Dementia is considered a syndrome rather than a distinctive disease process. It is a progressive deterioration of cognitive ability characterized by memory loss, inability to perform abstract analysis, lack of judgment, and decline in language skills. Changes in personality and the inability to perform activities of daily living (ADLs) progress over time.
Nursing interventions are focused on helping the patient maintain an optimal level of cognitive performance, preventing physical injury, decreasing anxiety and agitation, increasing communication skills, and promoting the patient’s ability to perform ADLs.
Essential Documentation
The nurse should perform a neurologic assessment, as appropriate, including level of consciousness, appearance, behavior, speech, and cognitive function. Record the patient’s exact responses. Document measures taken to ensure patient safety, meet personal needs, and promote independence; also document the patient’s response. An EHR requires that the nurse document patient safety needs.
DIABETIC KETOACIDOSIS
Characterized by severe hyperglycemia, diabetic ketoacidosis (DKA) is a potentially life-threatening condition that occurs most commonly in people with type 1 diabetes. The clinical assessment of the patient with dementia is written on a standardized form, such as the mental-status examination form or other standardized record. An acute insulin deficiency precedes DKA, causing glucose to accumulate in the blood. At the same time, the liver responds to energy-starved cells by converting glycogen to glucose, further increasing blood glucose levels. Because the insulin-deprived cells can’t utilize glucose, they metabolize protein, which results in the loss of intracellular potassium and phosphorus and excessive release of amino acids. The liver converts these amino acids into urea and glucose. The result is grossly elevated blood glucose levels and osmotic diuresis, leading to fluid and electrolyte imbalances and profound dehydration. Moreover, the absolute insulin deficiency causes cells to convert fats to glycerol and fatty acids for energy. The fatty acids accumulate in the liver, where they are converted to ketones. The ketones accumulate in blood and urine. Acidosis leads to more tissue breakdown, more ketosis; and eventually, shock, coma, and death.
When caring for a patient with DKA, the nurse should document assessments and interventions in a time frame consistent with institutional policy. Avoid charting in blocks of time.
Essential Documentation
A standardized EHR or flow sheet is used for documentation of the changing condition of a patient experiencing DKA. The nurse should document the patient’s hourly blood glucose levels, intake and output, urine glucose levels, mental status, ketone levels, and vital signs. When using an electronic medication administration record (MAR), enter hourly blood glucose levels and treatment with insulin or titration of an insulin drip. Record the clinical manifestations of DKA assessed, such as polyuria, polydipsia, polyphagia, Kussmaul respirations, fruity breath odor, changes in level of consciousness, poor skin turgor, hypotension, hypothermia, warm and dry skin, and mucous membranes. Document all interventions, such as fluid and electrolyte replacement and insulin therapy, and record the patient’s response. Record any procedures, such as arterial blood gas analysis, blood samples sent to the laboratory, cardiac monitoring, or insertion of an indwelling urinary catheter. Record results, the names of persons notified, and the time of notification. Include emotional support provided and patient education in the notes.
DISCHARGE INSTRUCTIONS
Hospitals today commonly discharge patients earlier than they did in years past. As a result, the patient is discharged with acute care needs, and family and home health care nurses must change dressings; assess wounds; deal with medical equipment, tube feedings, and IV lines; and perform other functions.
To perform these functions properly, the patient and the caregiver must receive adequate instruction. The nurse is usually responsible for these instructions. If a patient receives improper instructions and injury results, the nurse could be held liable.
Many hospitals distribute printed instruction sheets that adequately describe treatments and home care procedures. The patient’s chart should indicate which materials were given and to whom. Generally, the patient or responsible person must sign that he or she received and understood the discharge instructions. EHRs have discharge instructions where documentation of patient teaching is required as well as evidence of teaching efficacy, the patient’s willingness to learn, and the patient’s ability to “teach back” the information to verify understanding.
Courts typically consider these teaching materials as evidence that instruction took place. However, to support testimony that instructions were given, the materials should be tailored to each patient’s specific needs and refer to any verbal or written instructions that were provided. If caregivers practice procedures with the patient and family in the hospital, this should be documented, too, along with the results.
Essential Documentation
Many facilities combine discharge summaries and patient instructions in one discharge summary form. This form contains sections for recording patient assessment, patient education, detailed special instructions, and the circumstances of discharge. (See
The discharge summary form, page 97.)
When writing a narrative note about discharge instructions, the nurse should include the following information:
date and time of discharge
family members or caregivers present for teaching
treatments, such as dressing changes, or the use of medical equipment
signs and symptoms to report to the health care provider
patient, family, or caregiver understanding of instructions or ability to give a return demonstration of procedures
whether a patient or caregiver requires further instruction
health care provider’s name and telephone number
date, time, and location of any follow-up appointments or the need to call the health care provider for a follow-up appointment
details of instructions given to the patient, including medications, activity, and diet (include any written instructions given to patient)
DO-NOT-RESUSCITATE ORDER
When a patient is terminally ill and death is expected, the patient’s health care provider and family (and the patient if appropriate) may agree that a do-not-resuscitate (DNR), or no-code, order is appropriate. The health care provider writes the order, and the staff carries it out if the patient goes into cardiac or respiratory arrest.
Because DNR orders are recognized legally, the nurse will incur no liability if he or she does not try to resuscitate a patient and that patient later dies. The nurse may, however, incur liability if he or she initiates resuscitation on a patient who has a DNR order.
Every patient with a DNR order should have a written order on file. Some facilities have specific forms that help define what care the patient or family doesn’t wish delivered in the case of a code, such as no CPR or no intubation. The order should be consistent with the facility’s policy, which commonly requires that such orders be reviewed every 48 to 72 hours.
Increasingly, patients are deciding in advance of a crisis whether they want to be resuscitated. Health care facilities must provide written information to patients concerning their rights under state law to make decisions regarding their care, including the right to refuse medical treatment and the right to formulate an advance directive.
This information must be provided to all patients upon admission. The nurse must also document that the patient received this
information and whether brought a written advance directive with him. (See
“Advance directive,” pages 8 to 10.) A photocopy of the directive should be placed in the patient’s record.
Essential Documentation
If a terminally ill patient without a DNR order tells the nurse that he or she does not want to be resuscitated in a crisis, the nurse should document this statement as well as the patient’s degree of awareness and orientation. The nurse should then contact the patient’s health care provider and the nursing supervisor and ask for assistance from administration, legal services, or social services.
The nurse has a responsibility to help the patient make an informed decision about continuing treatment. If the patient’s wishes differ from those of the patient’s family or the health care provider, make sure the discrepancies are thoroughly recorded in the chart. Then document that the charge nurse, nursing supervisor, or legal services staff was notified.
COMPUTERIZED PHYSICIAN ORDER ENTRY (FORMERLY CALLED DOCTOR’S ORDERS)
Computerized physician order entry (CPOE) is the process of a medical professional entering medication orders or other physician instructions electronically instead of on paper charts. A primary benefit of CPOE is that it can help reduce errors related to poor handwriting or the transcription of medication orders. Such forms are especially useful for commonly performed procedures such as cardiac catheterization. As with other standardized documents, blanks are used for information that must be individualized according to the patient’s needs.
ACCUCHART
ACCUCHART
