FIRST SEMESTER

DEFIBRILLATION
Introduction
Defibrillation is a treatment for life-threatening cardiac dysrhythmias,
specifically ventricular fibrillation (VF) and non-perfusing ventricular
tachycardia (VT).
A defibrillator delivers a dose of electric current (often called a counter-
shock) to the heart. Although not fully understood, this
process depolarizes a large amount of the heart muscle, ending the
dysrhythmia. Subsequently, the body's natural pacemaker in
the sinoatrial node of the heart is able to re-establish normal sinus
rhythm.
A heart which is in asystole (flat line) cannot be restarted by a
defibrillator, but would be treated by cardiopulmonary
resuscitation (CPR).
In contrast to defibrillation, synchronized electrical cardioversion is an
electrical shock delivered in synchrony to the cardiac cycle. Although
the person may still be critically ill, cardioversion normally aims to end
poorly perfusing cardiac dysrhythmias, such as supraventricular
tachycardia.
Classifications of defibrillators
1. External
2. Internal (Trans venous) or implanted (implantable cardioverter-
defibrillator),
Indications
1. Cardiopulmonary resuscitation (CPR). This is an algorithm-based
intervention aimed to restore cardiac and pulmonary
function. Defibrillation is often an important step in CPR.
2. cardiac dysrhythmias, specifically ventricular fibrillation (VF)
3. pulseless ventricular tachycardia.
Contraindications
 1. If the heart has completely stopped, as in asystole or pulseless
electrical activity (PEA), defibrillation is not indicated.
2. Defibrillation is also not indicated if the patient is conscious or has
a pulse.
N/B Improperly given electrical shocks can cause dangerous
dysrhythmias, such as ventricular fibrillation.

Prognosis
Survival rates for out-of-hospital cardiac arrests are poor, often less than
10%. Outcome for in-hospital cardiac arrests are higher at 20%. Within
the group of people presenting with cardiac arrest, the specific cardiac
rhythm can significantly impact survival rates. Compared to people
presenting with a non-shockable rhythm (such as asystole or PEA),
people with a shockable rhythm (such as VF or pulseless ventricular
tachycardia) have improved survival rates, ranging between 21-50%.
Types
1. Manual external defibrillator
Manual external defibrillators require the expertise of a healthcare
professional. They are used in conjunction with an electrocardiogram,
which can be separate or built-in. A healthcare provider first diagnoses
the cardiac rhythm and then manually determine the voltage and timing
for the electrical shock. These units are primarily found in hospitals and
on some ambulances.
2. Manual internal defibrillator
Manual internal defibrillators deliver the shock through paddles placed
directly on the heart. They are mostly used in the operating room and, in
rare circumstances, in the emergency room during an open heart
procedure.
 3. Automated external defibrillator (AED)

An AED installed outside a Vets in a rural village. Positioned for public

use
The automated external defibrillator (AED) is a device that recognizes
ventricular fibrillation and other dysrhythmias and delivers an electric
shock at the right time. Automated external defibrillators are designed
for use by untrained or briefly trained laypersons. They contain
technology for analysis of heart rhythms. As a result, it does not require
a trained health provider to determine whether or not a rhythm is
shockable. By making these units publicly available, AEDs have
improved outcomes for sudden out-of-hospital cardiac arrests. Using the
team approach, one rescuer should coordinate all available rescuers so
that one rescuer performs chest compressions while the second rescuer
prepares the AED for use.
If the person has an implanted device, such as a pacemaker, you will see
a bulge over their chest. Place the defibrillator pads as close to the
correct position as possible without being directly over the device. For
persons with medication patches, remove the patch, wipe the skin dry,
and apply the AED pad.
AED STEPS

1. Retrieve the AED

o Open the case
o Turn on the AED
2. Expose the person’s chest
o If wet, dry chest.
o Remove medication patches.
3. Open the AED pads.
o Peel off backing.
 o Check for pacemaker or internal defibrillator
4. Apply the pads
o Apply one pad on the upper right chest above the breast.
o Apply the second pad on the lower left chest below the
armpit.
5. Ensure the wires are attached to the AED box
6. Move away from the person
o Stop CPR.
o Clear the person. Tell others not to touch the person.
7. Let AED analyze the rhythm.
8. If the AED message reads “Check Electrodes,” then:
o Ensure electrodes make good contact.
o If the chest is hairy, pull off the pad and replace it.
9. If the AED message reads “Shock,”
o Be sure the person is “clear” by making sure no one is
touching them.
o Press and hold the “shock” button until the AED delivers the
shock
10. Resume CPR for two minutes starting with chest
compressions
11. Repeat steps 1 to 10.
Short falls of AEDs
 Trained health professionals have more limited use for AEDs than
manual external defibrillators.
 AEDs do not improve outcome in patients with in-hospital cardiac
arrests.
 They have set voltages and does not allow the operator to vary
voltage according to need.
 They may also delay delivery of effective CPR.
 For diagnosis of rhythm, AEDs often require the stopping of chest
compressions and rescue breathing.
 For these reasons, using manual external defibrillators are
recommended over AEDs if manual external defibrillators are readily
available.
As early defibrillation can significantly improve VF outcomes, AEDs
have become publicly available in many easily accessible areas. They
have been incorporated into the algorithm for basic life support (BLS).
Many first responders, such as firefighters, policemen, and security
guards, are equipped with them.
How to use AEDs
AEDs can be fully automatic or semi-automatic. A semi-automatic AED
automatically diagnoses heart rhythms and determines if a shock is
necessary. If a shock is advised, the user must then push a button to
administer the shock. A fully automated AED automatically diagnoses
the heart rhythm and advises the user to stand back while the shock is
automatically given. Some types of AEDs come with advanced features,
such as a manual override or an ECG display.
4. Implantable cardioverter-defibrillator
Also known as automatic internal cardiac defibrillator (AICD).
These devices are implants, similar to pacemakers (and many can also
perform the pace making function). They constantly monitor the
patient's heart rhythm, and automatically administer shocks for various
life-threatening arrhythmias, according to the device's programming.
Many modern devices can distinguish between ventricular
fibrillation, ventricular tachycardia, and more benign arrhythmias
like supraventricular tachycardia and atrial fibrillation. Some devices
may attempt overdrive pacing prior to synchronised cardioversion.
When the life-threatening arrhythmia is ventricular fibrillation, the
device is programmed to proceed immediately to an unsynchronized
shock.
Possible risks with ICD
There are cases where the patient's ICD may fire constantly or
inappropriately. This is considered a medical emergency, as it depletes
the device's battery life, causes significant discomfort and anxiety to the
patient, and in some cases may actually trigger life-threatening
arrhythmias.
Some emergency medical services personnel are now equipped with a
ring magnet to place over the device, which effectively disables the
shock function of the device while still allowing the pacemaker to
function. If the device is shocking frequently, but appropriately, EMS
personnel may administer sedation.

5. Wearable cardioverter defibrillator

A wearable cardioverter defibrillator is a portable external defibrillator
that can be worn by at-risk patients. The unit monitors the patient 24
hours a day and can automatically deliver a biphasic shock if VF or VT
is detected. This device is mainly indicated in patients who are not
immediate candidates for ICDs.
6. Internal defibrillator
This is often used to defibrillate the heart during or after cardiac surgery
such as a heart bypass. The electrodes consist of round metal plates that
come in direct contact with the myocardium.

The connection between the defibrillator and the patient consists of a

pair of electrodes, each provided with electrically conductive gel in
order to ensure a good connection and to minimize electrical resistance,
also called chest impedance which would burn the patient. Gel may be
either wet (similar in consistency to surgical lubricant) or solid (similar
to gummi candy). Solid-gel is more convenient, because there is no need
to clean the used gel off the person's skin after defibrillation. However,
the use of solid-gel presents a higher risk of burns during defibrillation,
since wet-gel electrodes more evenly conduct electricity into the body.
Each type of electrode has its merits and demerits.
Paddle electrodes
Are the most well-known type of electrode. It is the traditional metal
paddle with an insulated (usually plastic) handle. This type must be held
in place on the patient's skin with approximately 25 lbs (11.3 kg) of
force while a shock or a series of shocks is delivered. Paddles offer a
few advantages over self-adhesive pads. Modern paddles allow for
monitoring (electrocardiography), though in hospital situations, separate
monitoring leads are often already in place.
Paddles are reusable, being cleaned after use and stored for the next
patient. Gel is therefore not pre applied, and must be added before these
paddles are used on the patient. Paddles are generally only found on
manual external units.
Self-adhesive electrodes
Newer types of resuscitation electrodes are designed as an adhesive pad,
which includes either solid or wet gel. These are peeled off their backing
and applied to the patient's chest when deemed necessary, much the
same as any other sticker. The electrodes are then connected to a
defibrillator, much as the paddles would be. If defibrillation is required,
the machine is charged, and the shock is delivered, without any need to
apply any additional gel or to retrieve and place any paddles.
In hospital, for cases where cardiac arrest is likely to occur (but has not
yet), self-adhesive pads may be placed prophylactically.
Placement

Anterior-apex placement of electrodes for defibrillation

Resuscitation electrodes are placed according to one of two schemes.
A. The anterior-posterior scheme is the preferred scheme for long-
term electrode placement. One electrode is placed over the left
precordium (the lower part of the chest, in front of the heart). The
other electrode is placed on the back, behind the heart in the region
between the scapula. This placement is preferred because it is best
for non-invasive pacing.
B. The anterior-apex scheme (anterior-lateral position) can be used
when the anterior-posterior scheme is inconvenient or unnecessary.
In this scheme, the anterior electrode is placed on the right, below
the clavicle. The apex electrode is applied to the left side of the
patient, just below and to the left of the pectoral muscle. This
scheme works well for defibrillation and cardioversion, as well as
for monitoring an ECG.
 Defibrillator with pad positions shown.

Mechanism of action
A defibrillator delivers a dose of electric current (often called a counter-
shock) to the heart. Although not fully understood, this
process depolarizes a large amount of the heart muscle, ending the
dysrhythmia. Subsequently, the body's natural pacemaker in
the sinoatrial node of the heart is able to re-establish normal sinus
rhythm.

Ventricular fibrillation, caused by disorganized electrical activity in the

main pumping chambers of the heart, is a common cause of cardiac
arrest. The treatment for ventricular fibrillation is defibrillation or the
delivery of an electric shock to the heart through the person’s chest wall.

This shock attempts to stop the disorganized electrical activity and allow
the heart’s normal rhythm to resume. They are used to prevent or correct
an arrhythmia, a heartbeat that is uneven or that is too slow or too fast.
Defibrillators can also restore the heart’s beating if the heart suddenly
stops.
Cardiac Dysrhythmias
A. Normal sinus rhythm

Normal sinus rhythm. Both atrial and ventricular rhythms are

essentially regular (a slight variation in rhythm is normal). Atrial
and ventricular rates are both 83 beats/minute. There is one P wave
before each QRS complex, and all P waves are of a consistent
morphology, or shape. The PR interval measures 0.18 seconds and is
constant; the QRS complex measures 0.06 seconds and is constant.

1. Rhythm originates from the SA node.

a. Atrial and ventricular rhythms are regular.
b. Atrial and ventricular rates are 60 to 100 beats/minute.
c. PR interval and QRS width are within normal limits.
Determination of heart rate for regular and irregular rhythms:
1. To determine atrial rate, count the number of P waves in 6 seconds
and multiply by 10 to obtain a full minute rate.
2. To determine ventricular rate, count the number of R waves or
QRS complexes in 6 seconds and multiply by10 to obtain a full
minute rate.
3. For accuracy, timing should begin on the P wave or the QRS
complex and end exactly at 30 large blocks later.

B. Sinus bradycardia
a. Atrial and ventricular rhythms are regular.
b. Atrial and ventricular rates are less than 60 beats/minute.
c. PR interval and QRS width are within normal limits.
d. Treatment may be necessary if the client is symptomatic (signs of
decreased cardiac output).
e. Note that a low heart rate may be normal for some individuals, such as
in athletes.
Interventions
a. Attempt to determine the cause of sinus bradycardia; if a medication is
suspected of causing the bradycardia, withhold the medication and
notify the HCP.
b. Administer oxygen as prescribed for symptomatic client.
c. Administer atropine sulfate as prescribed to increase the heart rate to
60 beats/minute.
d. Be prepared to apply a noninvasive (transcutaneous) pacemaker
initially if the atropine sulfate does not increase the heart rate
sufficiently.
Avoid additional doses of atropine sulfate because this will induce
tachycardia.
f. Monitor for hypotension and administer fluids intravenously as
prescribed.
g. Depending on the cause of the bradycardia, the client may need a
permanent pacemaker.

C. Sinus tachycardia
a. Atrial and ventricular rates are 100 to 180
beats/minute.
b. Atrial and ventricular rhythms are regular.
c. PR interval and QRS width are within normal
limits.
2. Interventions
a. Identify the cause of the tachycardia.
b. Decrease the heart rate to normal by treating the underlying cause.

D. Atrial fibrillation
a. Multiple rapid impulses from many foci depolarize in the atria in a
totally disorganized manner at a rate of 350 to 600 times/minute.
b. The atria quiver, which can lead to the formation of thrombi.
c. Usually no definitive P wave can be observed, only fibrillating waves
before each QRS.

Atrial dysrhythmias—atrial fibrillation

+++++++
Interventions
a. Administer oxygen.
b. Administer anticoagulants as prescribed because of the risk of emboli.
c. Administer cardiac medications as prescribed to control the
ventricular rhythm and assist in the maintenance of cardiac output.
d. Prepare the client for cardioversion as prescribed.
e. Instruct the client in the use of medications as prescribed to control
the dysrhythmia.

E. Premature ventricular contractions (PVCs)

a. Early ventricular contractions result from increased irritability of the
ventricles.
b. PVCs frequently occur in repetitive patterns such as bigeminy,
trigeminy, and quadrigeminy.
c. The QRS complexes may be unifocal or multifocal.

Interventions
a. Identify the cause and treat on the basis of the cause.
b. Evaluate oxygen saturation to assess for hypoxemia, which can cause
PVCs.
c. Evaluate electrolytes, particularly the potassium level, because
hypokalemia can cause PVCs.
d. Oxygen and medication may be prescribed in the case of acute
myocardial ischemia or MI.

F. Ventricular tachycardia (VT)

Ventricular dysrhythmias—sustained ventricular tachycardia at a

rate of 166 beats/minute.

a. VT occurs because of a repetitive firing of an irritable ventricular

ectopic focus at a rate of 140 to 250 beats/minute or more.
b. VT may present as a paroxysm of 3 self-limiting beats or more, or
may be a sustained rhythm.
c. VT can lead to cardiac arrest.

2. Stable client with sustained VT (with pulse and no signs or symptoms

of decreased cardiac output)
a. Administer oxygen as prescribed.
b. Administer anti dysrhythmics as prescribed.

3. Unstable client with VT (with pulse and signs and symptoms of

decreased cardiac output)
a. Administer oxygen and antidysrhythmic therapy as prescribed.
b. Prepare for synchronized cardioversion if the client is unstable.
c. The HCP may attempt cough cardiopulmonary resuscitation (CPR) by
asking the client to cough hard every 1 to 3 seconds.
4. Pulseless client with VT: Defibrillation and CPR

G. Ventricular fibrillation (VF)

Ventricular dysrhythmias—coarse ventricular fibrillation.
a. Impulses from many irritable foci in the ventricles fire in a totally
disorganized manner.
b. VF is a chaotic rapid rhythm in which the ventricles quiver and there
is no cardiac output.
c. VF is fatal if not successfully terminated within 3 to 5 minutes.
d. Client lacks a pulse, BP, respirations, and heart sounds, and is
unconscious.

Interventions
a. Initiate CPR until a defibrillator is available.
b. The client is defibrillated immediately with 120 to 200 joules
(biphasic defibrillator) or 360 joules (monophasic defibrillator); check
the entire length of the client 3 times to make sure no one is touching the
client or the bed; when clear, proceed with defibrillation.
c. CPR is continued for 2 minutes and the cardiac rhythm is reassessed
to determine need for further counter shock.
d. Administer oxygen as prescribed.
e. Administer anti dysrhythmic therapy as prescribed.

Management of Dysrhythmias
A. Vagal maneuvers
1. Vagal maneuvers induce vagal stimulation of the cardiac conduction
system
and are used to terminate supraventricular tachydysrhythmias.

2. Carotid sinus massage

a. The HCP instructs the client to turn the head away from the side to be
massaged.
b. The HCP massages over 1 carotid artery for a few seconds to
determine whether a change in cardiac rhythm occurs.
c. The client must be on a cardiac monitor; an electrocardiographic
rhythm strip before, during, and after the procedure should be
documented on the chart.
d. Have a defibrillator and resuscitative equipment available.
e. Monitor vital signs, cardiac rhythm, and level of consciousness
following the procedure.

3. Valsalva maneuver
a. The HCP instructs the client to bear down or induces a gag reflex in
the client to stimulate a vagal response.
b. Monitor the heart rate, rhythm, and BP.
c. Observe the cardiac monitor for a change in rhythm.
d. Record an electrocardiographic rhythm strip before, during, and after
the procedure.
e. Provide an emesis basin if the gag reflex is stimulated, and initiate
precautions to prevent aspiration.
f. Have a defibrillator and resuscitative equipment available.

B. Cardioversion
a. Cardioversion is synchronized counter shock to convert an
undesirable rhythm to a stable rhythm.
b. Cardioversion can be an elective procedure performed by the HCP for
stable tachy-dysrhythmias resistant to medical therapies or an emergent
procedure for hemodynamically unstable ventricular or supraventricular
tachy-dysrhythmias.
c. A lower amount of energy is used than with defibrillation.
d. The defibrillator is synchronized to the client’s R wave to avoid
discharging the
shock during the vulnerable period (T wave).
e. If the defibrillator is not synchronized, it could discharge on the T
wave and cause VF.
2. Pre-procedure interventions
a. If an elective procedure, ensure that informed consent is obtained.
b. Administer sedation as prescribed.
c. If an elective procedure, hold digoxin for 48 hours pre-procedure as
prescribed to prevent post-cardioversion ventricular irritability.
d. If an elective procedure for atrial fibrillation or atrial flutter, the client
should receive anticoagulant therapy for 4 to 6 weeks pre-procedure
and a trans-esophageal echocardiogram (TEE) should be performed to
rule out clots in the atria prior to the procedure.

3. During the procedure

a. Ensure that the skin is clean and dry in the area where the electrode
pads/hands-off pads will be placed.
b. Stop the oxygen during the procedure to avoid the hazard of fire.
c. Be sure that no one is touching the bed or the client when delivering
the counter shock (check the entire length of the client 3 times).

4. Post-procedure interventions
a. Priority assessment includes ability of the client to maintain the
airway and breathing.
b. Resume oxygen administration as prescribed.
c. Assess vital signs.
d. Assess level of consciousness.
e. Monitor cardiac rhythm.
f. Monitor for indications of successful response, such as conversion to
sinus
rhythm, strong peripheral pulses, an adequate BP, and adequate urine
output.
g. Assess the skin on the chest for evidence of burns from the edges of
the pads.

C. Defibrillation
1. Defibrillation is an asynchronous counter shock used to terminate
pulseless VT or VF.
2. The defibrillator is charged to 120 to 200 joules (biphasic) or 360
joules (monophasic) for 1 counter shock from the defibrillator, and then
CPR is resumed immediately and continued for 5 cycles or about 2
minutes.
3. Reassess the rhythm after 2 minutes, and if VF or pulseless VT
continues, the defibrillator is charged to give a second shock at the same
energy level previously used.
4. Resume CPR after the shock, and continue with the life support
protocol.
Before defibrillating a client, be sure that the oxygen is shut off to avoid
the hazard of fire and be sure that no one is touching the bed or the
client.

D. Use of pad electrodes

1. One pad is placed at the third intercostal space to the right of the
sternum; the other is placed at the fifth intercostal space on the left mid
axillary line.
2. Apply firm pressure of at least 25 lb to each of the pads.
3. Be sure that no one is touching the bed or the client when delivering
the counter shock.
4. Pads for hands-off biphasic defibrillation may be applied in an
anterior-posterior position or apex-posterior position, and placement
directly over breast tissue should be avoided.

E. Automated external defibrillator (AED)

1. An AED is used by laypersons and emergency medical technicians for
prehospital cardiac arrest.
2. Place the client on a firm, dry surface.
3. Stop CPR.
4. Ensure that no one is touching the client to avoid motion artifact
during rhythm analysis.
5. Place the electrode patches in the correct position on the client’s
chest.
6. Press the analyzer button to identify the rhythm, which may take 30
seconds; the machine will advise whether a shock is necessary.
7. Shocks are recommended for pulseless VT or VF only (usually 3
shocks are delivered).
8. If unsuccessful, CPR is continued for 1 minute and then another series
of shocks
is delivered.
F. Automated implantable cardioverter-defibrillator (AICD)
a. An AICD monitors cardiac rhythm and detects and terminates
episodes of VT and VF by delivering 25 to 30 joules up to 4 times, if
necessary.
b. An AICD is used in clients with episodes of spontaneous sustained
VT or VF unrelated to an MI or in clients whose medication therapy has
been unsuccessful in controlling life-threatening dysrhythmias.
c. Transvenous electrode leads are placed in the right atrium and
ventricle in contact with the endocardium; leads are used for sensing,
pacing, and delivery of cardioversion or defibrillation.
d. The generator is most commonly implanted in the left pectoral region.

CPR
Introduction
To provide CPR first make sure the scene is safe. Approach the victim
and assess their responsiveness by tapping them and asking them loudly,
“are you okay?” Yell for help. Use a cellphone to call 911 and send a
bystander to get an AED. Check the victim’s breathing and pulse. If they
are not responding, breathing, or only gasping, start CPR with
compressions. It is essential to minimize interruptions in chest
compressions to 10 seconds. Perform 30 chest compressions at a rate of
100-120 compressions per minute. Proper CPR can be tiring, so make
sure to ask to switch positions when exhausted if another rescuer is
available to help.
To deliver high-quality CPR,
1. Begin with high-quality chest compressions.
  To begin, position the individual on their back on a firm, flat
surface.
 Feel for the end of the breastbone (sternum).
 Place the heel of one hand on the lower half of the breastbone.
Avoid pressing down on the very end of the breastbone as the
xiphoid process, may break off and cause damage.
 Put the other hand on top of the first hand.
 Press straight down. Let the chest rise completely between
compressions.
Your hands should remain in contact with the individual, without
bouncing or leaning on them.
2. Perform the head-tilt/chin-lift maneuver for breath.
 Most masks have a pointed end, which should go over the
bridge of the nose.
 First, place the mask over the victim’s mouth and nose then
open the airway by performing the head-tilt/chin-lift
maneuver.
 Open the individual’s airway by first placing one hand on
their forehead.
 Place your fingers on the bony part of their chin.
 Gently tilt the head back while lifting the chin. If there is no
good seal between the mask and the individual’s face it will
be ineffective.
 Give a breath for over one second and watch the chest rise.
 Deliver the second breath.
 If the chest doesn’t rise, reposition the airway. Let the head
go back to a normal position and then repeat the head-tilt-
chin/lift maneuver.
 Then, give another breath and watch for the chest to rise.
 If you suspect the victim has experienced head or neck
trauma, the jaw-thrust maneuver should be performed to
open the airway instead of the head-tilt-chin/lift maneuver.
  To perform the jaw-thrust maneuver, place the index and
middle fingers on the lower jaw to physically push the lower
jaw upwards while the thumb is used to push down on the
chin to open the mouth.
 When the AED arrives at the scene, turn the device on,
remove any clothing from the victim, and apply the AED
pads.
 Place one below the right collarbone and the other to the side
of the left nipple below the armpit. Plugin the connector and
clear the victim while the AED analyzes the rhythm. If no
shock is advised, resume CPR, beginning with chest
compressions. If shock is advised, clear the victim again
before delivering a shock. Once the AED has charged, hit the
shock button.
 After delivering the shock, resume CPR, beginning with 30
chest compressions. Open the airway and give two breaths.
 Continue at this ratio of 30 compressions to 2 breaths until
the AED prompts you to stop or further help arrives.
3. Circulation
Once the rescue breaths have been given attention should be turned to
the circulation and rapid assessment to see if there is a pulse present. In
children the carotid, brachial or femoral artery can be palpated. If there
are no ‘signs of life’ then cardiac compressions should be the next step.

Guidelines for performing adult CPR

1. If a victim is noted not breathing or only gasping, activate the
emergency response system and obtain an automated external
defibrillator (AED) or
monophasic or biphasic defibrillator depending on the setting and
equipment available.
2. Check the carotid pulse for a maximum of 10 seconds.
3. If no pulse is felt, begin chest compressions (100 to 120 per minute) at
a depth of 2 inches (5 cm) for 2 minutes or 5 cycles of 30 compressions
to 2 ventilations using a barrier device.
4. Check rhythm and for presence of a pulse every 2 minutes or after 5
cycles (depending on the setting and equipment available, deliver a
shock if indicated).
5. Switch compression and ventilation roles if another rescuer is
available, to avoid fatigue.
6. Continue this process until the victim gains consciousness, starts
breathing, or has a pulse.
7. If the victim has a pulse but is not breathing, continue with rescue
breathing until help arrives and advanced cardiovascular life support
measures
are instituted.
8. For updated information, refer to American Heart Association:
Guidelines for CPR and ECC, 2015. Retrieved from
https://eccguidelines.heart.org/
index.php/circulation/cpr-ecc-guidelines-2/

CPR for infants

CPR for infants is almost identical as it is for children.
If an infant is not responding and not breathing or only gasping, give
five sets of 30 compressions and two breaths.
In infants, push hard and fast as you would in a child or adult receiving
CPR. Move any clothing away from the chest and place two fingers of
one hand on the breastbone right below the nipple line.
Push straight down approximately 1.5 inches (that is 4 cm) at a rate of
100 to 120 beats per minute.
Allow the chest recoil to its regular position after every compression.

(1) Advanced Life Support Algorithim

Initial approach
‘The 3 S’s- SAFETY, STIMULATE, SHOUT:

Check for Safety– is it safe to approach?

In an out of hospital environment it is particularly important that the

rescuer does not himself and become a second victim.

Stimulate– asking the child ‘are you ok, can you hear me?’ and gently
applying stimulation in the form of shaking an arm or gentle stimulation
by rubbing the chest.

Shout– shout for help- to other passersby!

Airway opening manoeuvres:

Injuries can be caused to the soft tissue so ensure you use the bony
mandible. If there is a suspected neck injury the head tilt chin lift
should be avoided and a jaw thrust implemented. This can be done by
using two or three fingers on each side under the angle of the jaw and
push up on both sides- to raise jaw. If all of the measures above fail to
open the airway- even in the event of a C-spine injury maintaining the
airway would be the priority.

(2) Jaw thrust

Then you can assess the patency of the airway by ‘LOOKING,
LISTENING AND FEELING’

Look: for any obvious obstruction- blood, vomit, trauma and look for
any signs of abdominal or chest wall movement

Listen: for breath sounds

Feel: for breath on your cheek

This sequence of ‘Look, listen and feel’ should take a total of 10

seconds.

Once the airway has been opened normal breathing ensues the rescuer
then turns the child onto their side (into the recovery position) and
maintains their airway until further help arrives. If the airway opening
manoeuvres do not result in spontaneous breathing, then rescue
breaths must be given.

Breathing
5 x initial rescue breaths must be given

The airway must be kept open during the rescue breaths. If the rescuer
is out of hospital without any equipment, then mouth to mouth can be
used to give the breaths. In older children this requires the nose to be
pinched closed. In infants the rescuer should attempt to cover both the
nose and mouth with their mouth.

The breaths given should be able to make the child/ infants chest rise as
normal. Slow exhalation is required (around 1-1.5 seconds) – too
vigorous can cause the stomach to inflate and contents to be
regurgitated.

A breath should be taken in between by the rescuer to increase the

oxygen concentration, ensuring you move your mouth away from the
patients so as not to breathe in their exhaled air.
If the chest does not rise- it implies the airway is not clear. Try to re-
position the airway– if there are two rescuers this can be done by a 2-
person jaw thrust– one maintaining the airway whilst the other
provides the breaths.

If this occurs in hospital a bag and mask device can be used to provide
the rescue breaths rather than a mouth.

Circulation
Once the rescue breaths have been given attention should be turned to
the circulation and rapid assessment to see if there is a pulse present. If
there are no ‘signs of life’ i.e. spontaneous breathing or movement after
the rescue breaths AND there is no central pulse present after 10 seconds
of palpation, or heart rate <60 then cardiac compressions should be the
next step.

In children the carotid, brachial or femoral artery can be palpated. In

infants who have a short neck- it is difficult to palpate the carotid artery-
the brachial artery should be used (medial aspect of antecubital fossa).

Chest compressions should be at the lower half of the sternum by around

1/3 of its depth. It is important that the chest fully recoils prior to the
next compression.

For infants, the most effective position with two BLS providers present
is the hand encircling technique. The rescuers hands are placed around
the lower half of the infant’s sternum and compressions are carried out
with the thumbs. If only one provider two finger technique should be
used with the other hand stabilising the infants head.
 ````

(3) Example of encircling technique

```

(4) Example of a 2 finger technique

For children, the rescuer should use the heel of their hand over
the lower half of the sternum. The arm should remain straight and
chest should be compressed to 1/3 of the depth. For larger children or
small rescuers two hands can be used one on top of the other with
fingers interlocked to perform the compressions.

Ratio: 15 compressions to 2 ventilations. Compression rate 100-120

per minute. If it is a single rescuer and no help has arrived emergency
services should be contacted 1 minute after commencing compressions.

Pediatric Basic and Advanced Life Support: Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care
Top 10 Take-Home Messages
1. High-quality cardiopulmonary resuscitation (CPR) is the
foundation of resuscitation. High-quality CPR generates blood
flow to vital organs and increases the likelihood of return of
spontaneous circulation (ROSC).

The 5 main components of high-quality CPR are

1. adequate chest compression depth 2inches in adults and

1.5inches in children/infants.

2. optimal chest compression rate,

3. minimize interruptions in CPR (i.e. maximizing chest

compression fraction or the proportion of time that chest
compressions are provided for cardiac arrest),

4. allow full chest recoil between compressions

5. avoid excessive ventilation.

Compressions of inadequate depth and rate, incomplete chest recoil, and

high ventilation rates are common during pediatric resuscitation
2. A respiratory rate of 20 to 30 breaths per minute is normal for
infants and children who are:

(a) receiving CPR with an advanced airway in place or

(b) receiving rescue breathing and have a pulse.

3. For patients with non-shockable rhythms, the earlier epinephrine is

administered after CPR initiation, the more likely the patient is to
survive.

4. Using a cuffed endotracheal tube decreases the need for

endotracheal tube changes.

5. The routine use of cricoid pressure does not reduce the risk of
regurgitation during bag-mask ventilation and may impede
intubation success.

6. For out-of-hospital cardiac arrest, bag-mask ventilation results in

the same resuscitation outcomes as advanced airway interventions
such as endotracheal intubation.

7. Resuscitation does not end with return of spontaneous circulation

(ROSC). Excellent post–cardiac arrest care is critically important
to achieving the best patient outcomes. For children who do not
regain consciousness after ROSC, this care includes targeted
temperature management and continuous electroencephalography
monitoring. The prevention and/or treatment of hypotension,
hyperoxia or hypoxia, and hypercapnia or hypocapnia is important.

8. After discharge from the hospital, cardiac arrest survivors can have
physical, cognitive, and emotional challenges and may need
ongoing therapies and interventions.

9. Naloxone can reverse respiratory arrest due to opioid overdose, but

there is no evidence that it benefits patients in cardiac arrest.
 10. Fluid resuscitation in sepsis is based on patient response and
requires frequent reassessment.

RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR
RRRRRRR

SECOND SEMESTER

Essential nursing care of the critically ill patient

Introduction

The high-technology–driven critical care environment is fast paced and

directed toward monitoring and treating life-threatening changes in
patient conditions. For this reason, attention is often focused on the
technology and treatments necessary for maintaining stability in the
physiological functioning of the patient. Great emphasis is placed on
technical skills, professional competence, and responsiveness to critical
emergencies.

The critical care nurse must be able to deliver high-quality care

skillfully, using all applicable technologies, while incorporating
psychosocial and other holistic approaches as appropriate to the time and
the patient’s condition.

The caring aspect is fundamental to the nurse-patient relationship and to

the health care experience. Holistic care focuses on human integrity and
stresses that the body, mind, and spirit are interdependent and
inseparable. Thus all aspects need to be considered in planning and
delivering care.
Health care providers clearly understand that a patient’s physical
condition progresses in fairly predictable stages, depending on the
presence or absence of comorbid conditions. Less clearly understood is
the effect of psychosocial issues on the healing process. For this reason,
special consideration must be given to determining the unique
interventions that will positively impact each individual patient and help
the patient progress toward desired outcomes.
An important aspect in the care delivery to—and recovery of—critically
ill patients is the personal support of family members and significant
others. The value of both patient-centered and family-centered care
should not be underestimated. It is important for families to be included
in care decisions and to be encouraged to participate in the care of the
patient as appropriate for the patient’s level of needs and the family’s
level of ability.

Cultural diversity in health care is not a new topic but is gaining

emphasis and importance as the world becomes more accessible to all as
the result of increasing technologies and interfaces with places and
peoples.

Nurses provide and contribute to the care of critically ill patients in a

variety of roles. The most prominent role for the professional registered
nurse (RN) is that of direct care provider through:

• Clinical grasp and clinical inquiry: problem identification and clinical

problem solving

• Clinical forethought: anticipating and preventing potential problems

Direct cares include:

1.Personal hygiene is important for minimising bacterial colonisation
and subsequent infection Personal hygiene is also closely related to a
person’s esteem and sense of Wellbeing.
These influence perceptions around quality of care and will often
increase family/visitor confidence in staff.
It is important to put the need for personal hygiene in context of the
bigger picture – other competing interests may take priority.
Determining what to do when as always – if possible negotiate with the
patient and involve them as much as possible in the decision making
around provision of cares.
Assess your patient:
 Are they diaphoretic/excessively sweaty?
 Do they have large amounts of ooze from wounds/drains/surgical
incisions?
 When was the last time they were washed?
 What method is most suitable for the patient?
  Think about length of time and potential cooling effects on the
patient like vasoconstriction or shivering and the systemic effects
this may cause.
Remember – bathing the patient is a great opportunity for an updated
physical assessment.
Some of the activities under Hygiene include: scrub the ward every shift.
Damp dust patient's bedframe, bedtable etc. bath Patient daily.
Relations/friends to observe standard precautions on visit. Clean
perineum when bathing is not possible.
Involve Patient in the cleaning if he can.
2. Eye Care
The eye is protected from dryness from frequent lubrication by blinking.
Complications from poor eye care in patients who are unable to blink
include: keratopathy, corneal ulceration, viral or bacterial conjunctivitis
Corneal abrasions develop in 40-60% of ICU patients
Goals of eye care are to provide comfort and protect from injury &
Infection.
Eye Care procedure:
Different requirements for each patient.
May just require a morning clean
May need drops/gel to maintain eye lubrication
Watch for proptosis, chemosis or abnormal discharge
Basic eye care consists of cleaning the sclera and surrounding tissue and
lubricating the eye with artificial tears.
Encourage Patient to be blinking the eye regularly. Observe sterility
when cleaning the eye, use different equipment for cleaning both eyes.
 3. Oral Care
Poor oral hygiene can cause halitosis and discomfort. It also increases
the risk of ventilator associated pneumonia
Absence of mastication decreases the amount of saliva produced –
which decreases the amount of protective enzymes located in the oral
cavity
Specific oral care may be required in addition to basic oral care if
conditions such as thrush or oral pressure areas are present
Assessment is required to determine the quantity and type of oral care
required
Remember: a normal healthy mouth is pink, moist, has no coating or
cracking, redness, ulcers or bleeding. When providing oral care, these
are what we aim to achieve.
Perform oral care daily, twice daily if there's oral thrush. Clean mouth
makes Patient feel good.
4.Patient positioning
 This is important for patient comfort.
 Reduces complications associated with pressure areas
 Aids in maintaining joint mobility
 Whilst modern technology has allowed the development of beds
that assist in patient positioning – they do not remove the need to
position patients
 Factors such as cardiovascular stability, respiratory function &
cerebral/spinal function all need to be considered when positioning
a patient
Goals of patient positioning: Positioning the patient comfortably
enhances
 therapeutic benefits
  epidural Oxygenation
 pulmonary drainage
 not inhibiting venous return
 Aiding feeding
To p r e v e n t p r e s s u r e s o r e s
Ensure that the limbs are supported appropriately and to maintain
flexible joints
General guidelines
If you have one available – use a tool to help determine the risk to your
patient. Use it to develop a care plan for your shift
There are very few patients’ who cannot be moved for prolonged periods
due to haemodynamic instability.
Completely immobile patients should have their position completely
changed 2/24
Patient’s should not be nursed supine – unless there is a specific reason
for doing so.
Even prone patients or spinal patients can usually have the bed tilt
function applied. Turn Patient every 4hrs. Treat pressure points with
each turning. Encourage Patient to perform passive exercise if possible
eg flexing of elbow and knee joints. Maintain Patient position while
turning him.
Remember – 7 days of bed rest will reduce muscle mass by 30%.
Passive exercises (shoulders, hands, hips & ankles are most at risk) are
essential!
5. Spirituality

Spirituality can become more important as people search for meaning

and guidance in critical, emergent, and unexpected tragic
 circumstances. Likewise, many health care practitioners turn to their
own spirituality to manage stress and find answers to the health care
issues that they face on a daily basis. Spiritual practices consist of
meditation, prayer, and spiritual materials and are based on personal
values and beliefs. Holt-Ashley describes how to incorporate prayer
into the critical care unit, concentrating on patients and families and
the nurse. The author also offers strategies for creating an
environment that is conducive to spiritual well-being for both patients
and staff.

Supply Patient with spiritual books eg bible according to his faith.

Invite his spiritual director/ priest to pray for him. Pray with your
patients when you take over duty & ask if they need any spiritual
help.
Address their spiritual needs individually.

6. Nutrition: Encourage patient to eat adequate diet if conscious with

more fruits and vegetables. If unconscious, serve fluid and soft dies
using nasogastric tube. Ensure to flush tube with fluid after eating.

7. Medication: Administer prescribed medications as and when due.

Summary
There are lots of risks posed to critically ill patients associated with
inadequate physical care and hygiene
Patients in critical care areas are often the most vulnerable of patients,
and as such, we have a duty of care to provide physical care and hygiene
in-line with what the individual requires.
AAAAAAAAAAAAAAAAAA

THE DYING PROCESS : Kübler-Ross Model

Introduction

The five stages of coping with dying (DABDA), were first described by
Elisabeth Kübler-Ross in her classic book, "On Death and Dying," in
1969. They describe the stages people go through when they learn that
they (or a loved one) are dying, beginning with the shock (or denial) of
the moment, and up to the point of acceptance.

The five stages of the Kübler-Ross stage model are the best-known
description of the emotional and psychological responses that many
people experience when faced with a life-threatening illness or life-
changing situation.

The stages do not only apply to death but any life-changing event for
which a loss is deeply felt, such as a divorce, the loss of a job, or the loss
of a home.

These stages are not meant to be complete or chronological. Not

everyone who experiences a life-threatening or life-changing event feels
all five of the responses nor will everyone who does experience them do
so in the order that is written. Reactions to illness, death, and loss are as
unique as the person experiencing them.

In her book, Kübler-Ross discusses this theory of coping in a linear

fashion, meaning a person moves through one stage to reach the next.

It's important to remember that some people will experience all of the
stages, some in order and some not, and other people may only
experience a few of the stages or even get stuck in one. These stages are
unique for each person facing illness, death, or loss, and most people do
not follow these in a linear pattern, they are helpful in describing some
of the emotions that accompany these life-changing events.

It's also interesting to note that the way a person has handled adversity in
the past will affect how a diagnosis of terminal illness is handled.

For example, a woman who always avoided adversity and used denial to
cope with tragedy in the past may find herself stuck in the denial stage
of coping for a long time. Similarly, a man who uses anger to deal with
difficult situations may find himself unable to move out of the anger
stage of coping.

The DABDA stages stand for the following:

 Denial
 Anger
 Bargaining
 Depression
 Acceptance

Denial

We all want to believe that nothing bad can happen to us.

Subconsciously, we might even believe we are immortal.

When a person is given the diagnosis of a terminal illness, it's natural to

enter a stage of denial and isolation.

They may demand a new set of tests, believing the results of the first
ones to be false. Some people may even isolate themselves from their
doctors and refuse to undergo any further medical treatment for a time.

During depression, it is not uncommon to isolate oneself from family

and friends or to actively avoid discussing the trauma or event. It is a
self-protective mechanism by which a problem "ceases to exist" if you
don't acknowledge it.
This stage of denial is usually short-lived. Soon after entering it, many
begin to accept their diagnosis as reality. The patient may come out of
isolation and resume medical treatment.

Some people, however, will use denial as a coping mechanism long into
their illness and even to their death. Extended denial isn't always a bad
thing; it doesn't always bring increased distress.

Sometimes we mistakenly believe that people need to find a way to

accept their death to be able to die peacefully. Those of us who have
seen people maintain denial until the end know this isn't always true.

Anger

As a person accepts the reality of a terminal diagnosis, they may start to

ask, "Why me?" The realization that all of their hopes, dreams, and well-
laid plans aren't going to come about brings anger and frustration.
Unfortunately, this anger is often directed out at the world and at
random.

Anger is the stage where the bottled-up feelings of the previous stages
are released in a huge outpouring of grief and directed at anyone who
happens to be in the way.

Doctors and nurses are yelled at in the hospital; family members are
greeted with little enthusiasm and often face random fits of rage. Even
strangers aren't immune to the actions anger may bring about.

It is important to understand where this anger is coming from. A dying

person may watch TV and see people laughing and dancing—a cruel
reminder that he can't walk anymore, let alone dance.

In the book "On Death and Dying," Kübler-Ross astutely describes this
anger: "He will raise his voice, he will make demands, he will complain
and ask to be given attention, perhaps as the last loud cry, 'I am alive,
don't forget that. You can hear my voice. I am not dead yet!'"
For most people, this stage of coping is also short-lived. Again,
however, some people will continue in anger for much of the illness.
Some will even die angry.

Bargaining

When denial and anger don't have the intended outcome, in this case, a
mistaken diagnosis or miracle cure, many people will move on to
bargaining. Most of us have already tried bargaining at some point in our
lives.

Children learn from an early age that getting angry with Mom when she
says "no" doesn't work, but trying a different approach might. Just like
the child who has time to rethink his anger and begin the process of
bargaining with a parent, so do many people with a terminal illness.

Most people who enter the bargaining stage do so with their God. They
may agree to live a good life, help the needy, never lie again, or any
number of "good" things if their higher power will only cure them of
their illness.

Other people may bargain with doctors or with the illness itself. They
may try to negotiate more time saying things like, "If I can just live long
enough to see my daughter get married..." or "If only I could ride my
motorcycle one more time..."

Bargaining is the stage where one clings to an irrational hope even when
the facts say otherwise. It may be expressed overtly as panic or manifest
with an inner dialogue or prayer unseen by others.

The implied return favor is that they would not ask for anything more if
only their wish was granted. People who enter this stage quickly learn
that bargaining doesn't work and inevitably move on, usually to the
depression stage.

Depression
When it becomes clear that the terminal illness is here to stay, many
people experience depression. The increased burden of surgeries,
treatments, and physical symptoms of illness, for example, make it
difficult for some people to remain angry or to force a stoic smile.
Depression, in turn, may creep in.

Kübler-Ross explains that there are really two types of depression in this
stage. The first depression, which she called "reactive depression,"
occurs as a reaction to current and past losses.

For example, a woman who is diagnosed with cervical cancer may first
lose her uterus to surgery and her hair to chemotherapy. Her husband is
left without help to care for their three children, while she is ill and has
to send the children to a family member out of town.

Because of the high cost of cancer treatment, this woman and her spouse
can't afford their mortgage and need to sell their home. The woman feels
a deep sense of loss with each one of these events and slips into
depression.

The second type of depression is dubbed "preparatory depression." This

is the stage where one has to deal with the impending future loss of
everything and everyone they love. Most people will spend this time of
grieving in quiet thought as they prepare themselves for such complete
loss.

Depression is considered the stage without which acceptance is unlikely.

With that being said, one can feel many different losses during the same
event. Weeding out those feelings may take time, during which a person
may rebound in and out of depression.

Acceptance

The stage of acceptance is where most people would like to be when

they die. It is a stage of peaceful resolution that death will occur and
quiet expectation of its arrival. If a person is lucky enough to reach this
stage, death is often very peaceful.

People who achieve acceptance have typically given themselves

permission to express grief, regret, anger, and depression. By doing so,
they are able to process their emotions and come to terms with a "new
reality."

They may have had time to make amends and say goodbye to loved
ones. The person has also had time to grieve the loss of so many
important people and things that mean so much to them.

Some people who are diagnosed late in their illness and don't have time
to work through these important stages may never experience true
acceptance. Others who can't move on from another stage—the man who
stays angry at the world until his death, for example—may also never
experience the peace of acceptance.

For the lucky person who does come to acceptance, the final stage
before death is often spent in quiet contemplation as they turn inward to
prepare for their final departure.
 Recognizing Terminal Restlessness at the End of Life

How to Certify Death

A junior doctor, will often be called to the ward to confirm death in a
patient. It is first important to recognise that dying is a process leading to
death. Where a delay to the confirmation of death exists, such as in the
pre-hospital or primary care setting, there is often no doubt that the
patient has died.

However, in a hospital setting, where such a delay should not exist, the
distinction is less clear.

There has been a simultaneous onset of apnoea and unconsciousness in

the absence of circulation that is irreversible…

 … following extensive attempts to treat any contributing factors

that may have led to cardiorespiratory arrest.

The Final Examination

To confirm the death of a patient, you should observe the patient for a
minimum of 5 minutes. To ensure that you perform all necessary steps,
you can use a systematic A to E approach:

 Airway / Breathing – Auscultate the lungs for >1min

o There will be no respiratory effort and no audible breath
sounds.
 Circulation – Palpate for a pulse for >1min and auscultate the
heart for >1min
o There will be no palpable central pulse and no audible heart
sounds*
o Make sure you check for any palpable cardiac pacemaker
 Disability – Check for a pupillary response and check for a motor
response to pain
o Following 5 minutes of continued cardio-respiratory arrest
the patient’s pupils will be fixed, dilated and unresponsive to
light.
 o There will be no response to a painful stimulus. This can be
tested by applying supra-orbital pressure and looking for any
motor response.
 Exposure – The patient may be peripherally cold (depending on
the timing of your assessment)

*In a patient who had been monitored, you may also notice continuous
asystole on the cardiac monitor. In a patient who has an arterial line
you can observe an absence of pulsatile flow.

Documentation

The above examination will often be documented in the notes as below:

DATE 02/12, TIME: 2310: DEATH CERTIFICATION

No audible breath or heart sounds for greater than 1 minute.

No palpable pulse for greater than 1 minute. No palpable cardiac

pacemaker.

Pupils are fixed, dilated and unreactive to light.

There is no response to painful stimulus.

The patient has died.

During the process of confirmation of death, you will need to make

yourself available to discuss any issues around the circumstances of
death or hospital admission with the patient’s next of kin. If the family is
not present at the time of death, it is your duty to ensure that they are
informed immediately.
Death certificate

A death certificate is either a legal document issued by a medical

practitioner which states when a person died, or a document issued by a
government civil registration office, that declares the date, location and
cause of a person's death, as entered in an official register of deaths.

An official death certificate is usually required to be provided when

applying for probate or administration of a deceased estate. They are
also sought for genealogical research. The government registration
office would usually be required to provide details of deaths, without
production of a death certificate, to enable government agencies to
update their records, such as electoral registers, government benefits
paid, passport records, transfer of inheritance, etc.

Nature of a certificate

Before issuing a death certificate, the authorities usually require a

certificate from a physician or coroner to validate the cause of death and
the identity of the deceased. In cases where it is not completely clear that
a person is dead (usually because their body is being sustained by life
support), a neurologist is often called in to verify brain death and to fill
out the appropriate documentation. The failure of a physician to
immediately submit the required form to the government (to trigger
issuance of the death certificate) is often both a crime and cause for loss
of one's license to practice. This is because of past cases in which dead
people continued to receive public benefits or voted in elections.

A full explanation of the cause of death includes any other diseases and
disorders the person had at the time of death, even though they did not
directly cause the death.
The funeral home, cremation organization, or other person in charge of
the deceased person's remains will prepare and file the death certificate.
Preparing the certificate involves gathering personal information from
family members and obtaining the signature of a doctor, medical
examiner, or coroner. The process must be completed quickly -- within
three to ten days, depending on state law.

Information Contained in the Death Certificate:

A death certificate contains important information about the person who

has died. Details vary from state to state, but often include:

 full name
 address
 birth date and birthplace
 father's name and birthplace
 mother's name and birthplace
 complete or partial Social Security number
 veteran's discharge or claim number
 education
 marital status and name of surviving spouse, if there was one
 date, place, and time of death, and
 the cause of death.

Copies of a Death Certificate

In many states, either informational or "certified" copies of a death

certificate is issued. Informational copies are for personal records and
are usually available to anyone who requests them.

Certified copies bear an official stamp, and are necessary to carry out
many tasks after a death -- from obtaining a permit for burial or
cremation to transferring the deceased person's property to inheritors. In
an increasing number of states, certified copies are available only to
members of the deceased person's immediate family, the executor of the
estate, or someone who can prove that they have a direct financial
interest in the estate.

Last Will & Testament

A Last Will and Testament is a document that specifies how a person's

assets, including real estate, personal property, and investments, are
distributed after the person dies. This document is commonly referred to
as a Last Will or Will. After the form is created and signed, in front of
two witnesses, the will should be shared with all beneficiaries.

Last offices

Introduction

The last offices, or laying out, is the procedures performed, usually by a

nurse, to the body of a dead person shortly after death has been
confirmed. They can vary between hospitals and between cultures.

The word "offices" is related to the original Latin, in which officium

means "service, duty, business". Hence these are the "last duties"
carried out on the body.

Washing the body of a dead person, sometimes as part of a religious

ritual, or is a customary funerary practice in several cultures. It was
delegated to professionals in ancient Egypt, ancient Rome, by well-off
Victorians, and continues so in modern America, but was traditionally
performed by "family, friends, and neighbors."

Aims

 To prepare the deceased for the mortuary (a funeral home or

morgue), respecting their cultural beliefs.
  To comply with legislation, in particular where the death of a
patient requires the involvement of a Procurator Fiscal aka.
Coroner.
 To minimise any risk of cross-infection to relative, health care
worker or persons who may need to handle the deceased.

Procedure part A: Immediate attention before rigor mortis take place.

Requirements: tray containing:

 Water in a gallipot
 Cotton wool in a gallipot
 Bandage and scissors in a receiver
 Gloves

Procedure:

1. Immediately the patient stops breathing & there is no heartbeat,

screen the bed completely.
2. Send for the doctor to certify death.
3. After the death has been certified by the doctor, discontinue all
resuscitative activities.
4. Prepare tray & set requirements.
5. Take tray to patient bed side & put on gloves
6. Remove patient’s cloths leaving him covered with top sheet.
7. Remove all pillows, air rings, in-dwelling catheters etc. &
straighten the body in recumbent position but without pillow under
his head.
8. Close the eyes by gently pressing on the eyelids with your fingers
for a few minutes.
9. Bandage the jaw to close the mouth if open.
10. Bandage the feet together using cotton wool to pad between
the ankles to prevent bruises.
11. Leave the body covered with top sheet.
 12. Remove all extra equipment e.g. tubes & apparatus except
operation sutures unless the relatives want them removed.
13. Elevate the head of the bed slightly to prevent discoloration
from blood settling in the face.
14. Leave the patient for about an hour.

Procedure part B: This is a trolley procedure

Top shelf

 cotton wool
 sinus forceps/straight artery forceps in a receiver
 scissors in a receiver
 a pair of dressing forceps in a receiver
 plaster & gauze bandage in a receiver
 comb or brush in a receiver
 bowel of water
 soap in a dish
 Wash cloths/flannels

Bottom shelf:

 Mortuary sheet
 Gloves, destructor bowl with lid
 2 identification bands on which are written clearly the
patient’s full name, date & time of death, the ward & hospital
registration number.

Extra requirement:

 Dirty & soiled linen bins

Procedure
 1. Prepare, set trolley & wheel to patient’s side
2. Give the patient a bed bath
3. Turn patient to the left lateral position & plug the anal canal with
cotton wool
4. Plug the other orifices with cotton wool but they should not be
noted externally.
5. Dress wound if any
6. Straighten the legs & tie the toes together with gauze bandage
using cotton wool to pad between the ankles.
7. Straighten the hands on the abdomen & tie the thumbs together
with gauze bandage using cotton wool to pad between the wrist.
8. Tie one identification band on the wrist.
9. Roll out the draw sheet, draw mackintosh & bottom sheet.
10. Roll in the mortuary sheet, make sure that the middle of the
mortuary sheet is central.
11. Remove the top sheet.
12. wrap the mortuary sheet round the body.
13. Attach the second identification band firmly on the sheet.
14. Screen the body until the porter arrives with the mortuary
trolley.
15. The nurse should accompany the porters & relatives to the
mortuary.
16. Dismantle trolley appropriately.
17. Sterilize articles that should be sterilized, dry others & keep
in the appropriate places.

Precautions

1. The effects of the patient are listed in duplicate & packed neatly no
matter how insignificant it may be & given to the nearest relative.
Valuables are separately wrapped & kept in a locked cupboard
until claimed. The relatives are to sign the list before claiming
items.
 2. The nurse should follow the instructions of the family regarding
items to remain on the patient, e.g. rings, artificial dentures, rosary
beads, metals etc.
3. Two nurses should perform this procedure if possible.
4. It’s part of the reverence due to a person who has died to leave the
body for an hour before commencing last office. Part A of this
office is done to prevent deformity due to rigor mortis.
5. If the diseased suffered a contagious disease, the appropriate
precautions should be taken.
6. The body of the patient should be removed in a quiet & non
upsetting manner to avoid disturbing other patients.
7. The senior nurse on duty at the time of the death is responsible for
the patient’s belonging, hospital records, and the bill. The death
certificate is filled in duplicate copies, original is collected by
relative. Encourage them to register the death.

NB

1. Following removal of the corpse, the bed & locker should be

treated using TERMINAL DISINFECTION procedure.
2. All equipment used for last office as well as all equipment taken
from the bed-side should be cleaned & disinfected in the proper
manner & returned to their proper places ready for use.

CARBOLIZATION

Definition: This is a procedure by which a discharged patient’s

environment is disinfected.

After discharge of a patient, the nurse disinfects the patient’s

environment, the materials used by the patient (including instruments &
furniture), & bed corner under a procedure called carbolisation.
It is a type of terminal disinfection which is carried out after discharge or
death of a patient using Jik 1in 6.

Reasons for carbolization:

 To prevent cross-infection
 To prevent odour
 Keep the ward neat
 Destroy micro-organisms
 For the comfort of the next patient

Requirements: it is a trolley procedure

Top shelf:

 A bowl of soapy water

 2 dusters/flannels
 Big bowl with Jik 1 in 6
 Extra clean water in a jug

Bottom shelf:

 Kidney dish & brush for collecting rubbish

 Hand gloves
 Nurses apron
 Linen hamper

Procedure:

1. Perform hand hygiene, put on apron & hand glove

2. Set trolley & wheel to patient bedside
3. Strip linen into the hamper
4. If mattress/pillows are not covered with mackintosh, take them out
to the sun for 4hours i.e. 2 hours on each side
5. Brush off crumbs from the bed & bed table
6. Clean first with soapy followed by water with disinfectant
 7. Clean the bed bedtable & disinfect, then clean the pillow, disinfect
& place it on the bedtable
8. Clean the top part of the bed frame, followed by top part of the
mattress
9. Fold mattress from top & clean the head of the bed
10. Clean the exposed part of the mattress & return to the head of
the bed
11. Fold mattress from foot of the bed & clean the foot of the bed
12. Clean the exposed part of the mattress & return
13. Change water if necessary
14. Using kidney dish & brush, remove crumbs/debris from the
bed locker
15. Clean with soapy water & disinfect but if possible, take it
outside wash & dry under the sun.
16. If sputum mug was used, soak in jik 1 in 6 for 10 minutes
then wash & sterilize.
17. Take away equipment & wash hands.

Reasons for carbolisation

 To prevent cross-infection.
 To keep the environment clean.

12 Stages of the Grieving Process

These are not in a sequential order but rather in order of how many
mourners slowly come to terms with loss.

1.Shock is the prelude to the grieving process.

Shock is often your very first response. When you go into shock, you
feel numb. This is your body’s way of protecting you.
The depth and length of this stage can vary. The biggest factors are the
degree of the relationship, cause of death, and whether it was a sudden
or unexpected death.

2. Grief is universal yet distinctive.

Everyone feels grief at some point, yet everyone feels grief differently.
This is important to keep in mind. Don’t let anyone tell you how you
“should” be feeling. This is a personal journey.

3. Healing takes place over time.

You must allow yourself the time to heal. It is a long journey and one
that can’t be rushed. Giving yourself the time you need to helps in the
recovery process.

4. Grief can cause depression.

You will experience bouts of depression and sadness during the grieving
process. This is normal.

Reach out to your support group. Often this is friends and family, but it
can even be a chat room of strangers. Talking about your grief will help
you work through the depression stage.

5. Grief can cause health problems.

Grieving may cause you to neglect your own health. Watch out for this,
and do your best to avoid it.

Keep up a healthy lifestyle of exercise, good nutrition, and sleep

routines. If you are having serious health symptoms, it is imperative to
seek medical attention.
6. You might panic.

Panic is another completely normal part of the grief process. Don’t let it
overtake your day to day routine.

Panic may include worrying over bills, your future, or facing the
unknown. Learning to accept help from others is a good way for you to
begin work on this stage.

7. Grief can cause guilt.

You and your loved ones may have had unresolved issues, or perhaps
you blame yourself for the death. We all have regrets in life but
shouldn’t allow them to grow out of proportion.

Talking with someone can be a great way to ease your feelings of guilt.
Start by talking to friends and family, and if necessary see a professional
counselor. They are trained and ready to provide help for this exact
situation.

8. Grief can cause anger.

You want to blame someone for your loss. The questions of: “Why
him?” “Why me?” “How can this be happening?” may never be
answered.

These unanswered questions can be so frustrating. Instead of continually

returning to these unanswerable questions, the way forward is to learn to
accept what has happened and grow through it.

9. Grief causes intense emotions.

Your emotions will be in turmoil after the death of a loved one. Feelings
can be overwhelming and will come in waves. You will suffer highs and
lows throughout this journey. You need to figure out constructive ways
to vent.
10. Grief causes a lack of direction and purpose.

You may find that normal activities are impossible to accomplish.

Daydreaming may become a favorite pastime. You can find yourself
thinking about the past and about the future that will never be.

Practice being grateful for your memories and understand that they are a
treasured and valued part of your story. At the same time, you will find
comfort in discovering a renewed purpose for your future.

11. Hope brings healing And vice versa.

It will take time and resolution, but eventually, you will see
improvement. Your life will take on new meaning. You will begin to
establish new relationships and treasure old relationships. Memories will
bring comfort and not sorrow.

For encouragement, remember examples from others grief and how they
survived.

12. Acceptance means that your loss has changed you, but you have not
been defeated by it.

As you learn to cope with the loss and come to terms with your grief,
you will discover new strengths within yourself. This experience has
changed you, and you’ve grown stronger through it.

You can begin to visualize the future with confidence. Be proud of

yourself; you are overcoming the hardest thing in life!

Others who can't move on from another stage—the man who stays angry
at the world until his death, for example—may also never experience the
peace of acceptance.

Common Questions About the Grieving Process

You’ll still have a lot of questions. Here are some of the most common.
How does grief affect your body?

Grief affects your body in various ways. It can:

 Worsen pre-existing health problems

 Increase blood pressure and the risk of blood clots
 Cause insomnia, or extreme fatigue
 Affect your eating habits through over- or under-eating
 It can also make pay less attention to your physical appearance
 It can make forget some of your healthy habits like daily exercise.
It is important to be mindful of your physical health.

How does grief affect your brain?

Your brain will go through changes during your grieving time. These
changes and disturbances are referred to as “grief brain.”

Your brain is experiencing a flood of information from overproduction

of neurochemicals and hormones. Symptoms might include:

 Panic attacks
 Fatigue
 Anxiety
 Sleep disturbances, nightmares, and vivid dreams.
 Memory loss
 Disorientation

All of these feelings are normal. If you find yourself not being able to
work through it, seek professional guidance.

The hardest stage of grief

Talk to a hundred different people and you will get a hundred different
answers. Each person’s grief journey is individual.
The loss of control you may feel is extremely hard to deal with. The
memories will wash over you. Your brain can’t seem to shut down and
let you rest.

However, most people find these as the hardest two stages of grief:

 Guilt: You may think there was some way you could have stopped
the death from occurring. Knowing that you could have done a
million and one things differently – but didn’t – you experience a
feeling of guilt. This feeling keeps you mired in that “stage” and
prevents you from pursuing further healing.
 Acceptance: Many people expect the acceptance phase to be a
miraculous cure. The grief doesn’t end upon acceptance. You will
always have feelings of grief pop up. This is considered the final
step in the grieving cycle. Accepting your loss doesn’t mean you
feel good about your loved one dying. Rather, it means you come
to terms with the reality of your loss and learn to live your life in a
new way. This stage is more about accepting that you can’t change
what has happened. Acceptance is still hard.

Length of grieving period

It is natural to wonder if there is an end to it. Grief doesn’t come to a

complete end, but that doesn’t mean you won’t feel better.

One day you will notice that you don’t hurt as badly. Things tend to get
better little by little. Your pain will become manageable, and you will
feel more “happy” times than “sad” times.

It’s important to give yourself time to work through this journey. It is

essential to permit yourself to be happy again.

Though you never forget the pain of losing your loved one, you have a
new reality of living. That reality will certainly include treasuring all the
memories you shared.
“Grief Without Denial.” by Constance Siegel

This model consists of 6 steps.

 Take your time when grieving: There’s no way around it; grief
takes time.
 Remember how they impacted your life: Focus on the positive.
 Have a funeral that speaks to their personality: Celebrate your
loved one’s life in a special, unique way.
 Continue their legacy: Carrying on in your loved one’s footsteps
is a great way to pay tribute to their life.
 Continue to talk to them and about them: You can’t see your
loved one, but that doesn’t mean you need to stop talking to them.
Their life was real, and it mattered. Talk about that.
 Know when to get help: It’s critical to give yourself time to
grieve. It is just as important to know when it’s time to get help. If
you need help, reach out to friends, family, or a professional.

Don’t avoid dealing with your grief. Working through grief is the
healthy way to start the process of recovery.

Supporting a Grieving Family Member or Friend: 6 Principles

The grieving process refers to the way the death of a loved one affects
an individual over time, and also the steps that person takes as they learn
to cope with the loss.

So the grieving process is both passive and active.

Grief is passive in that the loss is thrust upon you. You have no choice –
you will be emotionally affected by the death of a loved one. And grief
is active in how you choose to respond to this loss. There are steps you
can take to cope with the death of a loved one. That is what normal,
healthy mourning is all about.

1. Send something

Now if you get the sense that many people will send flowers, you may
want to think outside of the box. Some suggestions that people noted as
especially helpful include sending/dropping off:

 Home cooked meals

 Remembrance items
 Food and home staples
 Thoughtful cards and letters
 Items that belonged to the person
 Care box with self-care items

2. Offer practical support

People often need practical support after the death of a loved one for two
reasons:

(1) because their deceased loved one used to handle certain things and
fill certain roles

(2) because grief makes it hard to care about the minute day-to-day life.
Ask yourself, what might my loved one need help with and what unique
skills do I have to offer? If you find that you aren’t the best person to
help fill a potential need, you might also consider purchasing a gift
certificate so your loved one can hire someone at their own convenience
(i.e. a cleaning service or a landscaper).
A few examples of helpful practical support that were shared include…

 Help with little day-to-day tasks

 Help with children or pets
 Help the bereaved sort through a loved one’s belonging or helped
to clean out a house
 Help with yard work
 Help with odd jobs around the house
 Send meals
 Gave them a place to stay when they didn’t want to stay alone in
their home
 Accompany them on certain outings

3. Be there

Friends and family “being there”, physically and/or emotionally, was

one of the most helpful gifts a person could have given them after their
loved one died. To clarify, “being there” goes beyond a vague and non-
comital – “let me know if you need anything”.

Examples of how to “be there” in a real way vary, but include some of
the following: When a supportive friend or family member…

 Physically showed up during the bereaves time of need

 Continues to check in on a regular basis via text message or phone
 Regularly offers a simple “I love you” or “I’m thinking of you”
 Shares meals with the bereaved when they knew they
were struggling to eat alone
 Calls just to talk
 Offers a real hug
 Offers a hanky
 Offer sincere and simple words of support and encouragement
4. Help them take a break

One of the grief theories, the Dual Process Model, says that a
griever will oscillate between confronting their loss and avoiding the
loss. Under this model, seeking respite from grief is a healthy part of
coping. Sometimes a person needs a little time to feel normal or to
engage in activities that give them a boost of positive emotion. This
being the case, it may be helpful to offer or encourage distraction; with
the caveat that you should never push a person to minimize, move on, or
forget their loss and with the understanding that their grief could
overcome them at any moment (especially in the early days).

Some of the things that were noted as providing positive distraction

include….

 Laughter
 Sharing positive memories of their loved one
 Taking them out for a meal
 Taking them to the movies or on other recreational outings
 Accompanying them to parties or other social gatherings

5. Be willing to “go there” with them

Something people often express their appreciation for having friends and
family who are willing to be present for the sad and uncomfortable
moments without trying to fix them and without showing fear,
discomfort, or judgment. Being willing to “go there” with a bereaved
individual can mean many things such as…

When friends or family members were willing to…

 Be present for the tears, anger, and outbursts without judgment

 Sit in silence
 Talk about the person who died – say their name, share memories,
bring them up
 Just let the bereaved person cry
  Truly listen (without trying to offer advice)
 Accept the person’s grief months and even years later

6. Don’t forget

Part of being a supportive family member or friend is understanding that

grief is, in many ways, a forever thing. Your loved one doesn’t just need
your support in the immediate aftermath of loss, but also in the years to
come. Days like anniversaries, holidays, birthdays, Mother’s Day and
Father’s Day, weddings, and graduations may forever land somewhere
on the spectrum of sad to bittersweet.

You can show your ongoing support for a grieving loved one by …

 Sending a card or checking in on the days you think may be

difficult
 Recognizing that certain times of year, like the time of year when
their loved one died, may be difficult
 Continuing to share memories and to talk about their loved one
 Continuing to randomly (or regularly) check in with the person
 Acknowledging that the person who died is always with them

FEVER
In health, body temperature is regulated around a set
point of 37 ± 1°C, and a circadian temperature rhythm
exists in which the highest temperature of each day
occurs around 6 P.M. The variance between the
highest and lowest core temperature in a given day is
usually no more than 1° to 1.5°C. This circadian
rhythm may differ among individuals but should be
consistent in each person. Relative to the core (blood)
temperature, oral temperature tends to be about 0.4°C
lower and axillary temperature up to 1°C lower, than
rectal temperature, probably because of fecal bacterial
metabolism, averages about 0.5°C higher.
Fever is a physiologic disorder in which the temperature
is elevated above one's normal temperature. An elevated
body temperature may accompany any condition in which
exogenous or endogenous heat gain exceeds mechanisms
of heat dissipation such as occurs with vigorous exercise,
exposure to a warm ambient temperature, or the use of
drugs that cause excess heat production or limit heat
dissipation. In these situations, the hypothalamic
"thermostat" remains "set" in the normal range. In true
fever, mechanisms to regulate the body temperature above
the normal set point are actively operating.
In most patients with fever lasting 1 to 2 weeks, the
etiology will be found or the fever will disappear.
Occasionally, despite the history, physical examination,
laboratory and radiologic procedures, fever (temperature
above 38.3°C) will continue beyond 2 to 3 weeks without
diagnosis.
5 Nursing Care Plans for Fever -Hyperthermia
Fever, also known as hyperthermia or pyrexia, is a
medical condition when there is an uncontrolled rise in
the body temperature, measured as above 37.5 degrees
Celsius.
It results from the failure of the body’s thermoregulatory
center, the hypothalamus to control the body temperature
between the normal range of 36 to 37.5 degrees Celsius.
There are several possible etiologies or causes of
hyperthermia, and the most common ones include an
ongoing infection, trauma, exposure to hot environment,
and increased metabolic rate due to extreme activity.
A fever can also be triggered by intake of some
medications, either as an adverse side effect (e.g.
antibiotics, sulfa drugs, and chemotherapy agents), or as
withdrawal symptom (e.g. fentanyl or heroin withdrawal).
Fever can be assessed by taking temperature from
different routes, including tympanic, axillary, oral, and
rectal.
Below are 5 nursing care plans that a nurse can consider
in the care of a patient who has hyperthermia.
Nursing Care Plan 1
Nursing Diagnosis: Hyperthermia related to upper
respiratory tract infection (URTI) as evidenced by
temperature of 38.5 degrees Celsius, rapid and shallow
breathing, flushed skin, profuse sweating, and weak pulse.

Desired Outcome: Within 4 hours of nursing interventions, the

patient will have a stabilized temperature within the normal
range.

Interventions Rationales

To assist in creating an accurate diagnosis

Assess the patient’s vital and monitor effectiveness of medical
signs at least every 4 treatment, particularly the antibiotics and
hours. fever-reducing drugs (e.g. Paracetamol)
administered.

Remove excessive
To regulate the temperature of the
clothing, blankets and
environment and make it more comfortable
linens. Adjust the room
for the patient.
temperature.

Use the antibiotic to treat bacterial infection,

Administer the which is the underlying cause of the patient’s
prescribed antibiotic and hyperthermia. Use the fever-reducing
anti-pyretic medications. medication to stimulate the hypothalamus
and normalize the body temperature.

Offer a tepid sponge To facilitate the body in cooling down and to

bath. provide comfort.

Head elevation helps improve the expansion

Elevate the head of the
of the lungs, enabling the patient to breathe
bed.
more effectively.
Nursing Care Plan 2
Nursing Diagnosis: Hyperthermia related to surgical wound
infection as evidenced by temperature of 38.0 degrees
Celsius, pus draining from the wound, shivering chills, and
profuse sweating.
Desired Outcome: Within 4 hours of nursing interventions, the
patient will have a stabilized temperature within the normal
range and no signs of surgical wound infection.
In addition to the nursing interventions mentioned previously,
here are some possible actions related to this particular nursing
diagnosis:
Interventions Rationales

To perform appropriate wound care

Perform a proper surgical
and aid in the healing process against
wound cleaning and dressing
the infection that has triggered the
change on a daily basis.
fever.
Inform the surgical doctor
regarding the signs of surgical
wound infection and inquire
about the need to use
antipyretic and antibiotic
drugs.
Use the antibiotic to treat bacterial
infection, which is the underlying
cause of the patient’s hyperthermia.
Use the fever-reducing medication to
stimulate the hypothalamus and
normalize the body temperature.

Start intravenous therapy as

prescribed. Encourage oral
Hyperthermia can lead to dehydration.
fluid intake if recommended
post-operatively.
Nursing Care Plan 3
Nursing Diagnosis: Alteration in comfort related to
hyperthermia.
Desired Outcome: Within 4 hours of nursing interventions, the
patient will have a stabilized temperature within the normal
range and will verbalize feeling more comfortable.

Interventions Rationales

Remove excessive To regulate the temperature of the environment

clothing, blankets and make it more comfortable for the patient.
and linens. Adjust
the room
temperature.

Use the antibiotic/antiviral/antiparasitic drug to

Administer the
treat the infection, which is the underlying cause
prescribed antibiotic/
of the patient’s hyperthermia. Use the fever-
antiviral or
reducing medication to stimulate the
antiparasitic and anti-
hypothalamus and normalize the body
pyretic medications.
temperature.

Offer a tepid sponge To facilitate the body in cooling down and to

bath. provide comfort.

Head elevation helps improve the expansion of

Elevate the head of
the lungs, enabling the patient to breathe more
the bed.
effectively.

Offer a cooling To facilitate the body in cooling down and to

blanket to the patient. provide comfort.
Nursing Care Plan 4
Nursing Diagnosis: Fluid Volume Deficit related to
dehydration due to fever as evidenced by temperature of
39.0 degrees Celsius, skin turgidity, dark yellow urine
output, profuse sweating, and blood pressure of
89/58mmHg.
Desired Outcome: Within 48 hours of nursing interventions,
the patient will have a stabilized temperature within the normal
range and will verbalize feeling more comfortable.
In addition to the nursing interventions mentioned previously,
here are some possible actions related to this particular nursing
diagnosis:
Interventions Rationales

Commence a fluid balance To monitor patient’s fluid volume

chart, monitoring the input and accurately and effectiveness of
output of the patient. actions to reverse dehydration.

To replenish the fluids lost from

Start intravenous therapy as
profuse sweating, and to promote
prescribed. Encourage oral
better blood circulation around the
fluid intake.
body.

To help the patient or the guardian

Educate the patient (or take ownership of the patient’s care,
guardian) on how to fill out a encouraging them to drink more
fluid balance chart at bedside. fluids as needed, or report any
changes to the nursing team.

Monitor patient’s serum Sodium is one of the important

electrolytes and recommend electrolytes that are lost when a
electrolyte replacement therapy person is sweating. Hyponatremia or
(oral or IV) to the physician as low serum sodium level may cause
needed. brain swelling.

Nursing Care Plan 5

Nursing Diagnosis: Hyperthermia related to possible
catheter-associated UTI as evidenced by temperature of 38.7
degrees Celsius, cloudy urine, pain in lower back, positive
urine dipstick, and profuse sweating.

In addition to the nursing interventions mentioned previously,

here are some possible actions related to this particular nursing
diagnosis:
Interventions Rationales

Collect a urine sample To confirm the medical diagnosis of urinary

and send to the lab for tract infection and determine the underlying
urinalysis and culture. bacteria that caused it.

To remove the contaminated catheter and

Change the urinary
replace with a new one that is fit for
catheter.
purpose.

0
Regular catheter care is required to ensure
that there is no recurrence of infection. This
involves proper documentation to show that
++6Perform regular it is done frequently.
catheter care properly.

With proper use of the nursing process, a patient can

benefit from various nursing interventions to eliminate
fever and promote client comfort and wellbeing.
PAIN
Introduction
Pain is one of the most common reasons why patients see
their doctors. The unpleasant feeling of pain is highly
subjective in nature that may be experienced by the
patient. And despite the advances in technology and
methods to relieve it, a lot of patients still experience
undertreatment. This makes it important for nurses to
have the skills not just in assessing the pain but managing
it as well.
And to help you out, here’s a guide to drafting the best
nursing care plan for pain management.

Definition of pain
1. The International Association for the Study of Pain
(IASP) defined pain as “an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage, or described in terms of such
damage.”
2. Another great definition of pain is from Margo
McCaffery, a nurse expert on pain, who defined it as
“pain is whatever the person says it is and exists
whenever the person says it does.” What your patient
 says about the pain he is experiencing is the best
indicator of that pain. We can’t prove or disprove
what the patient is feeling. We also can’t assume.

Classification of Pain
Pain can be classified into two types. You can distinguish
one from the other according to the cause, onset, and
duration.
Types of pain
There are 2 main types of pain:
 Acute pain – a normal response to an injury or

medical condition. It starts suddenly and is usually

short-lived.
 Chronic pain – continues beyond the time expected

for healing. It generally lasts for longer than 3

months.
Pain may be anything from a dull ache to a sharp stab and
can range from mild to extreme. You may feel pain in one
part of your body or it may be widespread
Causes of pain
The most common causes of pain in adults include:
 injury

 medical conditions (such as cancer, arthritis and back

problems)
 surgery.
Acute pain
Acute pain provides a protective purpose to make the
patient informed and knowledgeable about the presence
of an injury or illness. The unexpected onset of acute pain
reminds the patient to seek support, assistance, and relief.
The physiological signs that occur with acute pain emerge
from the body’s response to pain as a stressor. Acute pain
can have a sudden or slow onset with an intensity ranging
from mild to severe. It can happen after a medical
procedure, surgery, trauma or acute illness. It has a
duration of less than 6 months.

Acute Pain Nursing Assessment

Proper nursing assessment of Acute Pain is imperative for
the development of an effective pain management plan.
Nurses play a crucial role in the assessment of pain, use
these techniques on how to assess for Acute Pain:
1. Perform a comprehensive assessment of pain.
Determine via assessment the location, characteristics,
onset, duration, frequency, quality, and severity of
pain.
The patient experiencing pain is the most reliable source
of information about their pain, thus, assessment of pain
by conducting an interview helps the nurse in planning
optimal pain management strategies.
Alternatively, you can use the nursing mnemonic
“PQRST” to guide you during pain assessment:
 Provoking Factors: “What makes your pain better or

worse?”
 Quality (characteristic): “Tell me what it’s exactly

like. Is it a sharp pain, throbbing pain, dull pain,

stabbing, etc?”
 Region (location): “Show me where your pain is.”

 Severity: Ask your patient to rate pain by using

different pain rating methods (e.g., Pain scale of 1-

10, Wong-Baker Faces Scale).
 Temporal (onset, duration, frequency): “Does it
occur all the time or does it come and go?”
2. Assess for the location of the pain by asking to point
to the site that is discomforting.
Using charts or drawings of the body can both help the
patient and the nurse in determining specific pain
locations. For clients with a limited vocabulary, asking to
pinpoint the location helps in clarifying your pain
assessment – this is especially important when assessing
pain in children.

3. Perform history assessment of pain

Additionally, the nurse should ask the following questions
during pain assessment to determine its history:

(1) effectiveness of previous pain treatment or

management;
(2) what medications were taken and when;

(3) other medications being taken;

(4) allergies or known side effects to medications.

4. Determine the client’s perception of pain.

In taking a pain history, provide an opportunity for the
client to express in their own words how they view the
pain and the situation to gain an understanding of what
the pain means to the client. You can ask “What does
having this pain mean to you?”, “Can you describe
specifically how this pain is affecting you?”.

5. Pain should be screened every time vital signs are

evaluated.
Many health facilities set pain assessment as the “fifth
vital sign” and should be added to during routine vital
signs assessment.

6. Pain assessments must be initiated by the nurse.

Pain responses are unique from each person and some
clients may be reluctant to report or voice out their pain
unless asked about it.

7. Use the Wong-Baker FACES Rating Scale to

determine pain intensity.
Some clients (e.g., children, language constraints) may
not be able to relate to numerical pain scales may need to
use the Wong-Baker Faces Rating Scale.

8. Investigate signs and symptoms related to pain.

Bringing attention to associated signs and symptoms may
help the nurse in evaluating the pain. In some instances,
the existence of pain is disregarded by the patient.

9. Determine the patient’s anticipation for pain relief.

Some patients may be satisfied when pain is no longer
intense; others will demand complete elimination of pain.
This influences the perceptions of the effectiveness of the
treatment modality and their eagerness to engage in
further treatments.

10. Assess the patient’s willingness or ability to explore

a range of techniques aimed at controlling pain.
Some patients may be hesitant to try the effectiveness of
nonpharmacological methods and may be willing to try
traditional pharmacological methods (i.e., use of
analgesics). A combination of both therapies may be more
effective and the nurse has the duty to inform the patient
of the different methods to manage pain.

11. Determine factors that alleviate pain.

Ask clients to describe anything they have done to
alleviate the pain. These may include, for example,
meditation, deep breathing exercises, praying, etc.
Information on these alleviating activities can be
integrated into planning for optimal pain management.

12. Evaluate the patient’s response to pain and

management strategies.
It is essential to assist patients to express as factually as
possible (i.e., without the effect of mood, emotion,
or anxiety) the effect of pain relief measures.
Inconsistencies between behavior or appearance and what
the patient says about pain relief (or lack of it) may be
more a reflection of other methods the patient is using to
cope with the pain rather than pain relief itself.

13. Evaluate what the pain suggests to the patient.

The meaning of pain will directly determine the patient’s
response. Some patients, especially the dying, may
consider that the “act of suffering” meets a spiritual need.

Nursing Interventions for Acute Pain

Nurses are not to judge whether the acute pain is real or

not. As a nurse, we should spend more time treating
patients. The following are the therapeutic nursing
interventions for your acute pain care plan:
1. Provide measures to relieve pain before it
becomes severe.
It is preferable to provide an analgesic before the onset of
pain or before it becomes severe when a larger dose may
be required. An example would be preemptive analgesia
which is the administration of analgesics before surgery to
decrease or relieve pain after surgery. The preemptive
approach is also useful prior to painful procedures like
wound dressing changes, physical therapy, postural
drainage, etc.

2. Acknowledge and accept the client’s pain.

Nurses have the duty to ask their clients about their pain
and believe their reports of pain. Challenging or
undermining their pain reports results in an
unhealthy therapeutic relationship that may hinder pain
management and deteriorate rapport.

3. Provide nonpharmacologic pain management.

Nonpharmacologic methods in pain management may
include physical, cognitive-behavioral strategies, and
lifestyle pain management. See methods below:

3.1. Provide cognitive-behavioral therapy (CBT) for

pain management.
These methods are used to provide comfort by altering
psychological responses to pain. Cognitive-behavioral
interventions include:

 Distraction. This technique involves heightening

one’s concentration upon non-painful stimuli to
 decrease one’s awareness and experience of pain.
Drawing the person’s mind away from the pain
lessens the perception of pain. Examples include
reading, watching TV, playing video games, guided
imagery.
 Eliciting the Relaxation Response. Stress correlates

to an increase in pain perception by increasing

muscle tension and activating the SNS. Eliciting a
relaxation response decreases the effects of stress on
pain. Examples include directed meditation, music
therapy, deep breathing.
 Guided imagery. Involves the use of mental pictures

or guiding the patient to imagine an event to distract

from the pain.
 Repatterning Unhelpful Thinking. Involves
patients with strong self-doubts or unrealistic
expectations that may exacerbate pain and result in
failure in pain management.
 Other CBT techniques include Reiki, spiritually

directed approaches, emotional counseling, hypnosis,

biofeedback, meditation, relaxation techniques.
3.2. Provide cutaneous stimulation or physical
interventions
Cutaneous stimulation provides pain relief that is
effective albeit temporary. The way it works is by
distracting the client away from painful sensations
through tactile stimuli. Cutaneous stimulation techniques
include:
 Massage. When appropriate, massaging the affected
area interrupts the pain transmission, increases
endorphin levels, and decreases tissue oedema.
Massage aids in relaxation and decreases muscle
tension by increasing superficial circulation to the
area. Massage should not be done in areas of skin
breakdown, suspected clots, or infections. It is better
suited to soft tissue injuries and should be avoided if
the pain is in the joints, but it is not recommended as
a long-term therapy.
 Heat and cold applications. Cold works by reducing
pain, inflammation, and muscle spasticity by
decreasing the release of pain-inducing chemicals
and slowing the conduction of pain impulses. Cold is
best when applied within the first 24 hours of injury
while heat is used to treat the chronic phase of an
injury by improving blood flow to the area and
through reduction of pain reflexes. Use ice packs
immediately after an injury to reduce swelling. Heat
packs are better for relieving chronic muscle or joint
injuries.

 Acupressure. An ancient Chinese healing system of

acupuncture wherein the therapist applies finger
pressure points that correspond to many of the points
used in acupuncture.
  Contralateral stimulation. Involves stimulating the
skin in an area opposite to the painful area. This
technique is used when the painful area cannot be
touched.
 Transcutaneous Electrical Nerve Stimulation
(TENS). Is the application of low-voltage electrical
stimulation directly over the identified pain areas or
along with the areas that innervate pain.
 Immobilization. Restriction of movement of a
painful body part is another nonpharmacologic pain
management. To do this, you need splints or
supportive devices to hold joints in the position
optimal for function. Note that prolonged
immobilization can result in muscle atrophy, joint
contracture, and cardiovascular problems. Check with
the agency protocol.
 Other cutaneous stimulation interventions include
therapeutic exercises (tai-chi, yoga, low-intensity
exercises, ROM exercises), acupuncture may help
reduce pain, keep you mobile and improve your
mood. You may need to increase your exercise very
slowly to avoid over-doing it.
4. Provide pharmacologic pain management as
ordered.
Pain management using pharmacologic methods involves
the use of opioids (narcotics), nonopioids (NSAIDs), and
coanalgesic drugs.

The World Health Organization (WHO) in 1986

published guidelines in the logical usage of analgesics to
treat cancer using a three-step ladder approach – also
known as the analgesic ladder. The analgesic ladder
focuses on aligning the proper analgesics with the
intensity of pain.

 Step 1: For mild pain (1 to 3 pain rating), the WHO

analgesic ladder suggests the use of non-opioid
analgesics with or without co-analgesics. If pain
persists or increases despite providing full doses, then
proceed to the next step.
 Step 2: For moderate pain (4 to 6 pain rating),

opioid, or a combination of opioid and non-opioid is

administered with or without co analgesics.
 Step 3: For severe pain (7 to 10), the opioid is

administered and titrated in ATC scheduled doses

until the pain is relieved.
4.1. Provide non-opioids include acetaminophen and
nonsteroidal anti-inflammatory drugs (NSAIDs) such
as aspirin or ibuprofen, as ordered.
NSAIDs work in peripheral tissues. Some block the
synthesis of prostaglandins, which stimulate nociceptors.
They are effective in managing mild to moderate pain. All
NSAIDs have anti-inflammatory (with the exception of
acetaminophen), analgesic, and antipyretic effects. They
work by inhibiting the enzyme cyclooxygenase (COX), a
chemical that is activated during tissue damage, resulting
in decreased synthesis of prostaglandins. NSAIDs also
have a ceiling effect meaning that once the maximum
analgesic benefit is achieved, additional amounts of the
same drug will not produce more analgesia and may risk
the patient for toxicity.

Common side effects of NSAIDs include heartburn or

indigestion. There is also a possibility of forming a
small stomach ulcer due to platelet aggregation. To
prevent these side effects, clients should be taught to take
NSAIDs with food and a full glass of water.

Common NSAIDs include:

 Aspirin. It can prolong bleeding time and should be

stopped a week before a client undergoes any
surgical procedure. Should never be given to children
below 12 years of age due to the possibility of Reye’s
syndrome. May cause excessive anticoagulation if the
client is taking warfarin.
 Acetaminophen (Tylenol). May have serious
hepatotoxic side effects and possible renal toxicity
with high dosages or with long-term use. Limit
acetaminophen usage to 3 grams per day.
 Celecoxib (Celebrex). Is a COX-2 inhibitor that has
fewer GI side-effects than COX-1 NSAIDs.
4.2. Administer opioids, as ordered. Opioids are
indicated for severe pain and can be administered orally,
IV, PCA systems, or epidurally.

 Opioids for moderate pain. These include codeine,

hydrocodone, and tramadol (Ultram) which are
combinations of non-opioid and opioid.
 Opioids for severe pain. These include morphine,

hydromorphone, oxycodone, methadone, and

fentanyl. Most of these are controlled substances due
to potential misuse. These drugs are indicated for
severe pain, or when other medications fail to control
pain.
4.3. Administer coanalgesics (adjuvants), as ordered.
Coanalgesics are medications that are not classified as
pain medication but have the properties that may reduce
pain alone or in combination with other analgesics. They
may also relieve other discomforts, increase the
effectiveness of pain medications, or reduce the pain
medication’s side effects. Commonly used co-analgesics
include:

 Antidepressants. Is a common co-analgesic that

helps in increasing pain relief, improve mood, and
reduce excitability.
 Local Anesthetics. These drugs block the
transmission of pain signals and are used for pain in
specific areas of nerve distribution.
  Other co-analgesics. Include anxiolytics, sedatives,
antispasmodics to relieve other discomforts.
Stimulants, laxatives, and anti-emetics are other co-
analgesics that reduce the side effects of analgesics.
Mechanism of action of pain medications:
Pain medicines work in various ways. Aspirin and other
NSAIDs are pain medicines that help to reduce
inflammation and fever. They do this by stopping
chemicals called prostaglandins. Prostaglandins cause
inflammation, swelling and make nerve endings sensitive,
which can lead to pain.
Prostaglandins also help protect the stomach from
stomach acid, which is why these medicines can cause
irritation and bleeding in some people.
Opioid medicines work in a different way. They change
pain messages in the brain, which is why these medicines
can be addictive.
Choosing the right pain medicine
The right choice of medicine for pain will depend on:
 the location, intensity, duration and type of pain
 any activities that ease the pain or make it worse
 the impact your pain has on your lifestyle, such as
how it affects your appetite or quality of sleep
  your other medical conditions
 other medicines you take.
Side effects of pain medicines: Some of the side effects
of common pain medicines include:
 Paracetamol – side effects are rare when taken at the
recommended dose and for a short time. Paracetamol
can cause skin rash and liver damage if used in large
doses for a long time.
 Aspirin – the most common side effects are nausea,
vomiting, indigestion and stomach ulcer. Some
people may experience more serious side effects such
as an asthma attack, tinnitus (ringing in the ears),
kidney damage and bleeding.
 Non-steroidal anti-inflammatory drugs (NSAIDs) –
can cause headache, nausea, stomach upset,
heartburn, skin rash, tiredness, dizziness, ringing in
the ears and raised blood pressure. They can also
make heart failure or kidney failure worse, and
increase the risk of heart attack, angina, stroke and
bleeding. NSAIDs should always be used cautiously
and for the shortest time possible.
 Opioid pain medicines such as morphine, oxycodone
and codeine – commonly cause drowsiness,
confusion, falls, nausea, vomiting and constipation.
They can also reduce physical coordination and
balance. Importantly, these medicines can lead to
 dependence and slow down breathing, resulting in
accidental fatal overdose.
5. Manage acute pain using a multimodal approach.
Multimodal approach is based on the use of two or more
distinct methods or drugs to enhance pain relief (rather
than resorting to opioid use or other pain management
strategies alone). Using different combinations of
analgesic medications, adjuvants, and procedures can act
on different sites and pathways in an additive or
synergistic fashion. Combining medications and
techniques allows the lowest effective dose of each drug
to be administered, resulting in reduced side effects.

6. Administer analgesia before painful procedures

whenever possible.
Doing so will help prevent pain caused by relatively
painful procedures (e.g., wound care, venipunctures, chest
tube removal, endotracheal suctioning, etc.).

7. Perform nursing care during the peak effect of

analgesics.
Oral analgesics typically peak in 60 minutes, intravenous
analgesics in 20 minutes. Performing nursing tasks during
peak effect of analgesics optimizes client comfort and
compliance in care.

8. Evaluate the effectiveness of analgesics as ordered

and observe for any signs and symptoms of side
effects.
The effectiveness of pain medications must be evaluated
individually by the patient since they are absorbed and
metabolized differently.

The Nursing Care Plans

If you are caring for a patient who is in pain, it’s
important that you know the skills to assess and manage
his discomfort properly. As a guide, here are some
nursing care plans for pain management you can use.
Acute Pain may be related to
-Injuring agents (biological, chemical, physical,
psychological)
Possibly evidenced by
-Patient’s report of pain
-Guarded and protective behavior
-Loss of appetite
-Inability to perform Activities of Daily Living
-Narrowed focus
-Autonomic responses
-Changes in muscle tone
 -Expressive behavior (restlessness, crying, moaning)
-Facial mask of pain
-Sleep disturbance
Desired outcome
-Verbalizes pain relief methods
-Demonstrates the use of appropriate diversional activities
and relaxation skills
-Reports pain management methods relieve pain to a
satisfactory level
-Reports ability to get enough sleep and rest
-Displays improved vital signs and muscle tone
Nursing Interventions Rationale
Perform a comprehensive assessment. Assessment is the first step in
Assess location, characteristics, onset, managing pain. It helps ensure that
duration, frequency, quality and severity the patient receives effective pain
of pain. relief.
Some patients may deny the
Observe for nonverbal indicators of existence of pain. These behaviors
pain: moaning, guarding, crying, facial can help with proper evaluation of
grimace. pain.
Accept the patient’s description of pain. Pain is highly subjective.
Vital signs are usually affected
Obtain vital signs. when pain is present.
Assess the client’s current use of Aids in planning and in obtaining
medications. medication history.

Early and timely

intervention is the key to
effective pain
management. It can even
Anticipate the need for pain reduce the total amount of
management. analgesia required.
Additional stressors can
intensify the patient’s
perception and tolerance
Provide a quiet environment. of pain.
Use nonpharmacological Works by increasing the
pain relief methods release of endorphins,
(relaxation exercises, boosting the therapeutic
breathing exercises, music effects of pain relief
therapy). medications.
Provide optimal pain relief Various types of pain
by administering prescribed require different analgesic
pain relief medication. approaches. Some
respond well to non-
opioid pain relievers
while others demand a
combination of non-
 opioid and low dose
opioid.
It helps determine the
effectiveness of pain
control measures. If the
patient demands pain
medications more
Review patient’s medication frequently, a higher dose
records and flow sheet. may be needed.
It helps the entire
healthcare team evaluate
Document patient’s response their pain management
to pain management. strategy.

Chronic pain
For pain to be classified as chronic, the patient needs to be
experiencing it for more than 6 months. Its intensity can
range from mild to extremely incapacitating. In some
cases, chronic pain can restrict a patient’s ability to
perform his Activities of Daily Living and this usually
ends up with feelings of despair.
Chronic pain has two subcategories: malignant and non-
malignant.
1. Malignant refers to pain associated with cancer
2. and other progressive diseases. Non-malignant chronic
pain, on the other hand, refers to pain that persists beyond
the expected time of healing.
Chronic pain may be related to
-Chronic physical and psychological disability
-Injuring agents (biological, chemical, physical,
psychological)
Possibly evidenced by
-Patient’s report of pain
-Changes in sleep pattern
-Changes in appetite
-Irritability, restlessness, depression
-Weight changes
-Atrophy of involved muscles
-Less interaction with people
-Sympathetic mediated responses
-Facial mask
-Guarding behavior

Desired outcome
 -Verbalizes or demonstrates relief or control of pain
-Demonstrates use of both non-pharmacological and
pharmacological pain relief strategies
-Shows the ability to engage in activities
-Shows use of appropriate therapeutic interventions
Nursing Interventions Rationale

Perform a comprehensive
assessment. Assess
location, characteristics, Assessment is the first step in
onset, duration, frequency, managing pain. It helps ensure that
quality and severity of the patient receives effective pain
pain. relief.

Check current and past

analgesic/narcotic drug It helps obtain a medication
use. history.

It’s possible that pain may not be

Review the patient’s completely resolved but it can be
expectation of pain relief. lessened significantly.

Encourage patient to use This helps the patient achieve

breathing techniques and generalized relaxation which aids
positive affirmations. in reduced perception of pain.
Explore the patient’s need
for medications from the
three classes of analgesics:
NSAIDS, opioids, and Combinations of analgesics may
nonopioids. enhance pain relief.

As much as possible, use These medications promote

tranquilizers, narcotics, and addiction and can cause sleep
analgesics sparingly. disturbance.

Encourage the use of non-

pharmacological
interventions (massage,
guided imagery, breathing They help reinforce
techniques). pharmacological interventions.

Determine the patient’s

appetite, bowel
elimination, and the ability Side effects should be monitored
to rest and sleep. and managed accordingly.

Evaluate the effectiveness

of pain medications and Medications should be adjusted to
ask to decrease or increase achieve optimum pain relief
dose and frequency as without causing severe adverse
necessary. effects.
Effect of pain on the body
Pain is a complex protective mechanism. It is an essential
part of evolution that protects the body from danger and
harm.
The body has pain receptors that are attached to 2 main
types of nerves that detect danger. One nerve type relays
messages quickly, causing a sharp, sudden pain. The other
relays messages slowly, causing a dull, throbbing pain.
Some areas of the body have more pain receptors than
others. For example, the skin has lots of receptors so it is
easy to tell the exact location and type of pain. There are
far fewer receptors in the gut, so it is harder to pinpoint
the precise location of a stomach ache.
If pain receptors in the skin are activated by touching
something dangerous (for example something hot or
sharp), these nerves send alerts to the spinal cord and then
to part of the brain called the thalamus.
Sometimes the spinal cord sends an immediate signal
back to the muscles to make them contract. This moves
the affected body part away from the source of danger or
harm.
This is a reflex reaction that prevents further damage
occurring. It happens before you feel pain.
Once the ‘alert!’ message reaches the thalamus, it sorts
the information the nerves have sent, taking into account
your previous experience, beliefs, expectations, culture
and social norms. This explains why people have very
different responses to pain.
The thalamus then sends the information on to other parts
of the brain that are linked to physical response, thought
and emotion. This is when you may feel the sensation of
pain, think ‘That hurt! What was it?’, and feel annoyed.
The thalamus also contributes to mood and arousal, which
helps to explain why your interpretation of pain partly
depends on your state of mind.

Overview
A barium enema is an X-ray exam that can detect
changes or abnormalities in the large intestine (colon).
The procedure is also called a colon X-ray.
An enema is the injection of a liquid into your rectum
through a small tube. In this case, the liquid contains a
metallic substance (barium) that coats the lining of the
colon. Normally, an X-ray produces a poor image of soft
tissues, but the barium coating results in a relatively clear
silhouette of the colon.
Why it's done
In the past, doctors used barium enema to investigate the
cause of abdominal symptoms. But this test has mostly
been replaced by newer imaging tests that are more
accurate, such as CT scans.
In the past, your doctor may have recommended a barium
enema to determine the cause of signs and symptoms,
such as the following:
 Abdominal pain
 Rectal bleeding
 Changes in bowel habits
 Unexplained weight loss
 Chronic diarrhea
 Persistent constipation
Similarly, a barium enema X-ray previously may have
been ordered by your doctor to detect such conditions as:
 Abnormal growths (polyps) as part of colorectal
cancer screening
 Inflammatory bowel disease
Risks
A barium enema exam poses few risks. Rarely,
complications of a barium enema exam may include:
 Inflammation in tissues surrounding the colon
 Obstruction in the gastrointestinal tract
 Tear in the colon wall
 Allergic reaction to barium
Barium enema exams generally aren't done during
pregnancy because X-rays present a risk to the developing
fetus.
How you prepare
Before a barium enema exam, you'll be instructed to
empty your colon. Any residue in your colon may obscure
the X-ray images or be mistaken for an abnormality.
To empty your colon, you may be asked to:
 Follow a special diet the day before the exam. You
may be asked not to eat and to drink only clear
liquids — such as water, tea or coffee without milk or
cream, broth, and clear carbonated beverages.
 Fast after midnight. Usually, you'll be asked not to
drink or eat anything after midnight before the exam.
 Take a laxative the night before the exam. A
laxative, in a pill or liquid form, will help empty your
colon.
  Use an enema kit. In some cases, you may need to
use an over-the-counter enema kit — either the night
before the exam or a few hours before the exam —
that provides a cleansing solution to remove any
residue in your colon.
 Ask your doctor about your medications. At least a
week before your exam, talk with your doctor about
the medications you normally take. He or she may
ask you to stop taking them days or hours before the
exam.
What you can expect
During the exam
During your barium enema, you'll wear a gown and be
asked to remove eyewear, jewelry or removable dental
devices. The exam will be performed by a radiology
technician and a physician who specializes in diagnostic
imaging (radiologist).
You'll begin the exam lying on your side on a specially
designed table. An X-ray will be taken to make sure your
colon is clean. Then a lubricated enema tube will be
inserted into your rectum. A barium bag will be connected
to the tube to deliver the barium solution into your colon.
If you're having an air-contrast (double-contrast) barium
enema, air will flow through the same tube and into your
rectum.
The tube that's used to deliver the barium has a small
balloon near its tip. When positioned at the entrance of
your rectum, the balloon helps keep the barium inside
your body. As your colon fills with barium, you may feel
the urge to have a bowel movement. Abdominal cramping
may occur.
Do your best to hold the enema tube in place. To relax,
take long, deep breaths.
You may be asked to turn and hold various positions on
the exam table. This helps ensure that your entire colon is
coated with barium and enables the radiologist to view the
colon from various angles. You also may be asked to hold
your breath at times.
The radiologist may press firmly on your abdomen and
pelvis, manipulating your colon for better viewing on a
monitor attached to the X-ray machine. A number of X-
rays will likely be taken of your colon from various
angles.
A barium enema exam typically takes about 30 to 60
minutes.
After the exam
After the exam, most of the barium will be removed from
your colon through the enema tube. When the tube is
removed, you'll be able to use the toilet to expel
additional barium and air. Any abdominal cramping
usually ends quickly, and you should be able to return to
your usual diet and activities right away.
You may have white stools for a few days as your body
naturally removes any remaining barium from your colon.
Barium may cause constipation, so you may find you can
reduce your risk of constipation by drinking extra fluids
in the days following your exam. Your doctor may
recommend a laxative, if needed.
Check with your doctor if you're unable to have a bowel
movement or pass gas more than two days after the exam
or if your stool doesn't return to its normal color within a
few days.
Results
The radiologist prepares a report based on the results of
the examination and sends it to your doctor. Your doctor
will discuss the results with you, as well as subsequent
tests or treatments that may be required:
 Negative result. A barium enema exam is considered
negative if the radiologist detects no abnormalities in
the colon.
 Positive result. A barium enema exam is considered
positive if the radiologist detects abnormalities in the
colon. Depending on the findings, you may need
additional testing — such as a colonoscopy — so that
 any abnormalities can be examined more thoroughly,
biopsied or removed.
If your doctor is concerned about the quality of your X-
ray images, he or she may recommend a repeat barium
enema or another type of diagnostic test.

4.5 SPECIAL INVESTIGATIONS

In certain circumstances visual inspection

alone does not provide sufficient
information to formulate a treatment plan
and special investigations are required.
These may include radiographs, vitality
tests and checking for cracked teeth or
cusps.The outcomes should be recorded.

4.5.1 Radiographs
The use of radiographs for dental
applications is covered by the Ionising
Radiation Regulations 1999 and the
Ionising Radiation (Medical Exposure)
Regulations 2000 (IRMER).16,17 Although
there is no requirement for the explicit
recording of the justification it is
recommended that this should be done
unless the justification is obvious from the
records. There is however a regulatory
requirement for reporting of the
radiograph. A quality assurance
programme should be established to
optimise the quality of radiographs
produced. Full details are provided in the
Department of Health’s Guidance Notes
for Dental Practitioners on the Safe Use of
X-ray Equipment.18
Justification: No person shall carry out a
medical exposure unless it has been
justified by the practitioner as showing
sufficient net benefit. When referring a
patient, the referrer must supply details of
the patient’s radiographic history to the
receiving practitioner.

Optimisation: The practitioner and

operator shall ensure that doses arising
from the exposure are kept as low as
reasonably practicable, consistent with
the intended purpose.

Clinical evaluation (reporting): All

radiographs must be reported. Dates,
causes and repeat exposures should be
recorded for any whose quality renders it
of no diagnostic value.

Quality assurance: It is essential that a

quality assurance programme is set up,
and that every radiograph is assessed for
quality. Factors such as correct
positioning, contrast and processing are
assessed. This should be seen as a
feedback mechanism for improving the
quality of radiographs and as assisting in
the detection of deficiencies in the
current systems. A simple grading system
(1 = no faults, 2 = faults but still of
diagnostic value, 3 = of no diagnostic
value) is helpful.

The following sections give only a very

brief overview of guidelines published by
the FGDP(UK) in Selection Criteria for
Dental Radiography,15 and the reader is
encouraged to refer to this for more
detailed consideration.

4.5.1.1 Radiographs and caries diagnosis

Bitewings have been shown to be of

benefit for caries detection on both
approximaland occlusal surfaces.

Patients are assessed for caries risk (see

appendix 5) and placed into high,
moderateor low caries risk groups. For
patients with high caries risk, bitewings
are indicated at six-monthly intervals until
lesion progression has stopped and no
new lesions are detected. Yearly
bitewings are indicated for patients in a
moderate caries risk category. For adults
with a history of low risk, this period may
be extended and it is appropriate to
record if there has been a considered
deviation from the guidance. For example,
if a patient does not wish to have further
exposure to radiation, or if the clinician
considers there will be no diagnostic gain.
The extended period should not be beyond
two years unless there is ‘explicit clinical
evidence of continuing lowcaries risk.’15

It is recommended that children with a

low caries risk should have bitewings
taken at 12-18 month intervals in the
deciduous dentition, with this period
extending if there is evidence of
continuing low caries risk.15
4.5.1.2 Radiographs and periodontology

The use of radiographs should be regarded

as secondary to a clinical examination in
the diagnosis of periodontal disease, and
radiographs should only be taken after a
thorough clinical examination has
indicated their use as an adjunct.
Bitewings, periapical radiographs and
panoramic radiographs have all been
recommended for use in periodontology.
Horizontal bitewings are recommended if
pocketing is limited to less than 5mm and
there is little/no recession. For greater
depths of pocketing, vertical bitewings or
periapical radiographs are indicated.
Panoramic radiographs can be considered
an alternative to numerous intra-oral
radiographs. However, there are
limitations to the fine detail achievable
with many panoramic machines. This may
necessitate supplementary intra-oral
radiographs, thereby negating any dose
reductionbenefits of panoramic
radiographs. Digital radiographs may offer
improved measurement accuracy. Cone
beam computed tomography (CBCT) may
offer greater accuracy than conventional
two dimensional intra-oral images
compared with conventional radiographs,
however it is not indicated as a routine
method of imaging periodontal bone
support.15

4.5.1.3 Radiographs and endodontics

Radiographs are essential for endodontic

treatment to assist in diagnosis and
treatment planning, and also in surgical
and non-surgical endodontic care. The
preoperative radiograph will confirm the
diagnosis and reveal possible difficulties
to be encountered during root treatment.
A tooth should only be considered for root
treatment if it is restorable, and has
reasonable prognosis. Treatment planning
should consider dental care as part of the
patient’s overall health. Following
endodontic treatment, an immediate post-
treatment radiograph is required to assess
the qualityof obturation and surgical
treatment, and to act as a baseline for
review and follow-up radiographs. Some
clinicians recommend taking a follow-up
radiograph after one year, even if teeth
are asymptomatic, although ideal follow-
up remains controversial. Follow-up
clinical assessment is important and the
findings should be recorded. The healing
processes may take up to four years.
Teeth that remain symptomatic or had
large areas of pre-treatment pathology
may require more frequent radiographs.15

4.5.1.4 Radiographs and orthodontics

(management of the developing dentition)

If a routine dental examination indicates

that an orthodontic opinion may be
appropriate then radiographs, for
orthodontic purposes, should not be taken
at this stage. The appropriate radiographs
should be part of a full orthodontic
assessment and prescribed by the
clinician carrying out the assessment.19
However, any relevant radiographs that
have been taken should be forwarded,
with the clinical information, when a
referral is made.17

For orthodontic purposes, radiographic

examination in general dental practice
may be appropriate to investigate
abnormal delay in permanent tooth
eruption. When individual teeth are
involved, intra-oral periapical radiographs
are most appropriate. The inability to
palpate the upper canines in the buccal
sulcus from 10 years of age onwards may
be an indication for such radiographs.20

Study models

Study models provide valuable information

not readily obtained clinically. They are
essential in the analysis and planning of
many forms of treatment including
monitoring of tooth wear, and helpful
when teeth are to be replaced in a
partially dentate patient and when the
occlusion is to be changed. They are also
essential in assessment for orthodontic
treatment. Study models should be
mounted on an articulator. See chapter
2.5 for consideration of the storage of
study models.

Vitality tests

These may be taken to assist in making a

diagnosis. There are several methods of
vitality testing, and the method and
outcome should be noted, whether
positive or negative.

Test for cracked cusps

There are various methods of checking for

cracked cusps in teeth, including
transillumination, magnification,
tenderness to percussion, and various
biting devices. The type of test and the
outcome should be recorded, including
positive and negative for particular cusps.