OBSERVATION AND COLLECTION OF SPECIMENS: URINE,

STOOL, VOMITUS AND SPUTUM.

Observation and collection of urine, stool, vomitus and sputum.

The nurse is responsible for collecting urine specimens. The nurse collects clean voided
specimens for routine urine analysis, clean catch or midstream urine specimens for urine culture
and timed urine specimens for a variety of tests that depends on the clients specific health
problems.

Characteristics of normal urine

The nurse inspects the clients' urine for colour, clarity and odour.
Color: Normal colour of urine ranges from a pale, straw to amber depending on its
concentration.
Clarity: Normal urine appears transparent when freshly voided but becomes turbid
(cloudy) upon standing several minutes in a container.
Odour: Urine has a characteristic odour. The more concentrated the urine the stronger
the odour. Bacteria in the urine cause an ammonia odour. Fruity or sweet odour occurs from
acetone in patients with diabetics or starvation due to breakdown of fat
- Volume: Volume of urine varies from one to two liters in 24 hours. The urine output
depends upon the water intake.
PH: 4.6 and 8.0.Average 6.0 and is slightly acidic. 7 is neutral less than 7 is acidic and
greater than 7 is alkaline,
Specific gravity: 1.001 to 1.025.

Assessment and collection of urine specimens

Objectives

 To make the diagnosis and prescribe proper treatment.

 To observe the effect of special treatment and drugs.
 To ascertain the general health of the patient before surgery.

A. Clean voided Urine Specimen

It is collected for routine examination. Many clients are able to collect a clean voided
specimen and provide the specimen independently with minimal instructions. Male
clients generally are able to void directly into the specimen containers, and female clients
usually sit or squat over the toilet holding the container between their legs during
voiding. It is better to take first voided specimen in the morning because it tends to have a
higher, more uniform concentration and is more acidic P H. 10 ml of urine is sufficient
for a routine urine analysis. Instruct the client the following.
 The specimen must be free from fecal contamination.
  Close the container tightly to prevent spillage of urine and contamination of other objects.
 If the outside of the container has been contaminated by urine, clean it.
The nurse must make sure that the specimen label and the laboratory requisition carry the
correct information and attach them securely with the specimen.
B. Clean Catch or Midstream Urine Specimen for Culture
Clean catch or midstream urine specimen are collected when a urine culture is ordered to identify
microorganisms causing urinary tract infection. Clean catch specimens are collected in to a
sterile container with a lid. Disposable clean catch kits are also available.
Purpose
To determine the presence of microorganism, the type of organisms and the antibiotics to which
the organisms are sensitive.
Procedure

Steps Rationale
 Assessment
For proper planning.
Determine the ability of the client to provide the specimen.
Assess for clinical signs of Urinary Tract Infection (UTI).

•Proper planning saves time and

Planning energy
 Instruct client the correct process of obtaining
specimen.
Assemble the articles
• Clean gloves
• Sterile Specimen Container
• Specimen identification label
• Laboratory requisition form

Implementation
To reduce micro organisms.
Instruct client to clean the genital area
with soap and water, then rinse with plain
water

In case of female client spread the labia minora with one Cleaning from front to back is
hand and with the other hand cleanse the perineal area from to clean the area of least
front to back contamination to the area of
greatest contamination.
For male clients retract the foreskin using a circular motion, Cleaning from the area of least
clean the urinary meatus and the distal portion of the penis. contamination to the area of
greatest contamination.

Instruct the client to start voiding into the toilet or bed pan Bacteria in the distal urethra and
then stop the stream of urine for a moment. at the urinary meatus are cleared
by the first few milliliters of
urine expelled.
Place the specimen container into the midstream of urine and To avoid contaminating the
collect the specimen, taking care not to touch the container to interior of the specimen
the perineum or penis. Remove specimen container before container and the specimen
flow of urine stops and before releasing labia minora. itself.
Collect urine in the container and cap the container tightly This prevents contamination of
touching only the outside of the container and the cap the specimen and spilling of the
specimen.

When client finishes voiding into bed pan or in the toilet Promotes client's comfort.
assists him to a comfortable
position.

Wash hands. Reduces transmission of

microorganisms.
Label the specimen and attach laboratory requisition and
transport to laboratory within 15 minutes. Prevents inaccurate
identification that could lead to
errors in diagnosis or therapy.

Bacteria grow quickly in urine

and specimen should be
analyzed immediately to obtain
correct results.
Recording and Reporting For proper documentation and
Record the characteristics of urine and date to take interventions if any.
and time urine specimen was obtained in
nurses' notes.

Evaluation For appropriate follow up.

Evaluate and report laboratory results to the
physician.
C. Timed urine specimen or 24 hours urine specimen
Some urine examinations require collection of all urine produced and voided over a specific
period of time ranging from 1 hour to 24 hours. Timed urine specimens generally either
refrigerated or contain a preservative to prevent bacterial growth or decomposition of urine
components. Each voiding of urine is collected in a small, clean container and then emptied
immediately into a large refrigerated bottle or carton.
Purposes
1. To assess the ability of the kidney to concentrate and dilute urine.
2. To determine disorders of glucose metabolism e.g. diabetes mellitus.
3. To determine level of specific constituents e.g. Albumin, Creatinine, Hormone like
Corticosteroids.
Steps of procedure

 Obtain specimen container with preservative (if indicated) from the laboratory.
 Label the container with identification information for the client, the test to be performed,
time started and the time of completion.
 Provide client a clean receptacle to collect urine e.g. bed pan
 Post signs in the clients' chart, room and bathroom alerting personnel to save all urine
during the specified time.
 At the start of the collection period, tell client to void and discard this urine.
 Save all urine produced during the collection period. Avoid contaminating the urine with
toilet paper or faeces
 At the end of the collection period, instruct the client to completely empty the bladder
and save voiding as a part of the specimen.
 Take the entire amount of urine collected to the laboratory with the filled requisition
 Record collection of the specimen, time starting and completed and any pertinent
observation of the urine.
Alert
If the client or staff forgets and discards the client's urine during a timed collection, the
procedure must be restarted from the beginning,
D. Collecting sterile specimen from an indwelling catheter
Sterile urine specimens can be obtained from closed drainage systems by inserting a sterile
needle attached to a syringe through a drainage port in the tubing. Aspiration of urine from
catheters can be done only with self sealing rubber catheters.
Steps of procedure

 Put on disposable gloves.

 If there is no urine in the catheter, clamp the drainage tubing at least 3 inches below the
sampling port for about 30 minutes. This allows fresh urine to collect in the catheter.
 Wipe the area where the needle will be inserted with a disinfectant swab to remove
microorganisms.
 Insert the needle at 30 to 45 degree angle to facilitate self sealing of the rubber
 Unclamp the catheter
 With draw the required amount of urine. E.g. 3ml for urine culture.
 Transfer urine to the specimen container.
 Discard the syringe and needle in an appropriate container.
 Cap the container.
 Remove gloves and discard appropriately.
 Label the container and send the urine to the laboratory immediately for analysis.
 Record collection of specimen and any pertinent observations of urine in the record.
Common Urine Tests
The laboratory performs a urinalysis on a specimen. The specimen should be examined as soon
as possible, preferably within 2 hours. Simple urine tests are often done by abnormal constituents
such as glucose, ketones, protein and occult blood.
Test for Specific gravity
The specific gravity is the weight or degree of concentration of a substance compared with an
equal volume of water. Urinometer is used for measuring the specific gravity of urine. Reliability
of the instrument should be assessed before testing urine for specific gravity. Allow the
urinometer to float in urine in a jar freely and read the specific gravity at eye level. Read
measurement at the base of the meniscus at the level of the urine . An elevated specific gravity
can indicate dehydration . The concentration of dissolved substances in the urine determines the
depth at which the urinometer will float.
Determining abnormal constituents in the urine
Nurses may perform test on urine specimens for known abnormalities. A nurse may test urine for
the presence of glucose, protein, bacteria and blood if laboratory facilities are not readily
available. The results are recorded in the client’s chart.
Test for albumin sugar and acetone
Articles required
A tray containing
 Test tube
 Test tube holder
 Acetic acid
 Nitric acid or sulpho salicylic acid 3%
  Benedicts Solution
 Ammonium sulphate crystals
 Sod. Nitroprusside crystals
 Liquor Ammonia
 Spirit lamp
 Match box
 Kidney tray
 Urine in a container
 Dropper
Test for albumin
Hot test
Fill three fourths of a test tube with urine. Heat the upper third of the urine and allow it to boil
over the spirit lamp flames. Keep the mouth of the test tube away from your face to prevent
scalding. Add one or two drops of acetic acid into the test tube of urine. If the urine still remains
cloudy it indicates presence of albumin and if it becomes clear it indicates that cloudy
appearance was due to phosphates. Normally no albumin is present in the urine.
Cold test
Pour small quantity of nitric acid or sulphosalicyclic acid 3% into clean test tube. Allow equal
quantity of urine to trickle steadily down through the sides of the test tube. If albumin is present
a white precipitate will be seen where the two fluids meet.
Test for sugar
Benedict's test: Take benedict's solution 5cc in a test tube, boil it over the spirit lamp to check the
purity of a solution, if no colour change, solution is pure. Add 8 drops of urine with a dropper
into the test tube and shake well. Boil it again 2 minutes and allow it to cool. The result may be
recorded according to the colour.

 Blue colour - Absence of sugar

 Green colour without deposit - Approximately 1% sugar.
 Green liquid with yellow deposit - Approximately 2% sugar
 Orange deposit with colourless liquid - Approximately 3% sugar
 Brick red - Sugar 5% and above
 Discard the urine, clean and replace articles
Test for acetone
Rothera's test: Take Ammonium sulphate crystals 2cm depth in a test tube and add equal
volume of urine and one crystal of sodium Nitroprusside and shake well. Add liquor ammonia to
the urine through the sides. If acetone is present a permanganate purple colour ring is formed at
the junction of urine and ammonia. Discard the urine, clean and replace articles.
Commercially prepared diagnostic kits are available for such tests. Although these tests are
economical and fast, laboratory analysis is recommended for precise results. Commercially
prepared diagnostic kits contain all needed equipment and the appropriate reagent. Reagents are
available as tablets, liquid, impregnated paper and plastic strips with a special coating. When the
reagent contacts urine, a chemical reaction occurs, causing a colour change. The colour is then
compared with the chart.
The amount of the specimen, the time allowed for the chemical reaction, and the interpretation of
the colour vary with the manufacturer. Hence always follow the directions given in the
diagnostic kit exactly.
Observation and collection of stool specimens.
Analysis of stool specimens can provide information about a client's health condition
Collection of stool specimen
Purpose
• To determine pathologic conditions e.g. hemorrhage, infection, mal absorption syndrome etc.
Procedure

Steps Rationale
Assessment
Determine the purpose of stool specimen Reveals clients ability and willingness to
collection and clients understanding of it. cooperate in collection of specimen.
Assess ability of client in collection of Because defecation is a private matter, most
specimen. patients prefer to be as independent in
collection as possible.
Nursing diagnosis Helps to plan interventions appropriately.
Develop appropriate nursing diagnosis.e.g.
knowledge deficit regarding stool specimen
collection
Planning Proper planning saves time and energy
Assemble the articles
 Clean disposable gloves
 Sterile test tube with swab for culture
 Specimen container
 Filled lab requisition form
 Bed pan
Implementation Allows patient to relax and it promotes
If patient is unable to use bathroom close room defecation.
door or put bed side curtain
Wash hands Reduce spread of infection
Assist client as needed to bathroom or to bed Client's physical mobility influence the
pan. amount of assistance needed
Instruct client to void into toilet before Faeces should not be mixed with urine or
defecating toilet tissue. Urine inhibits bacterial growth.
Toilet tissue contains bismuth which
interferes with test results
Provide client with clean dry bed pan and Faeces should not be mixed with water.
specimen container
Assist client if needed in washing after toileting Promotes comfort and sense of wellbeing.
and leave in safe comfortable position after
defecation
Take covered bed pan to bathroom. Covering bedpan and removing it from
patients room reduces odour and patient's
embarrassment
Put on clean gloves To prevent transfer of bacteria to nurse's
skin
Obtain specimen Stool is touched only by sterile swab to
For culture: Remove swab from sterile test tube, prevent introduction of bacteria.
gather bean size piece of stool, and return swab
in to test tube. If stool is liquid, soak cotton swab
in it and return to test tube.
For other tests: Obtain specimen by using Use of spatula prevents transfer of bacteria to
spatula to transfer portion of stool in to hands.
container
Wrap used spatula in paper towels and dispose Reduces spread of microorganisms.
of in waste. Remove disposable gloves and
discard.
Empty and clean bedpan and return it to its Makes them ready for next use.
place

Wash hands Reduces spread of microorganisms.

Attach specimen identification label and Inappropriate identification of specimen can

requisition with date, time and test name on it. lead to errors in diagnosis and therapy.

Send specimen to laboratory immediately Fresh specimen provides most accurate

results
Evaluation
Reveals deviation from normal.
Compare client's laboratory results with normal
values and discuss with physician.

Recording and reporting Laboratory values may allows for prompt

Record date and time specimen collected and interventions
characteristics of stool
Abnormality of stools
• Blood in stool - Different forms are:
1. Altered blood or melena.
2. Invisible blood or occult blood
Melena: characteristics are:
1. Black tarry (sticky) stool.
2. Offensive
3. Semisolid in consistency.
• Observation of Vomitus
Relationship to food intake
Relationship to pain i.e. relieves or increases.
The number and amount of vomitus in 24 hours
Type of Ejections
Projectile: Significant of pyloric stenosis and cerebral conditions.
Effortless: Significant of intestinal obstruction.
Consistency of Vomitus
Mucus: seen in gastritis.
Undigested food: seen in pyloric spasm, stenosis and obstruction.
• Bile: Present in abnormal functioning of pylorus.
Blood: presence of blood seen in gastritis, peptic ulcer, esophageal varices.

Sputum
Sputum is the mucous secretion from the lungs, bronchi, and trachea. It is important to
differentiate it from saliva, the clear liquid secreted by the salivary glands in the mouth. Thirty
ounces of mucus produced/ day.
Healthy Individuals do not produce sputum.
Clients need to cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in
order to expectorate into a collecting container.
• Document amount of sputum collected, color, odour, consistency (thick, tenacious, watery) and
presence of blood.
Amount : No sputum or very little is expectorated, It is colour less & translucent Amount may
vary according to the diseases. E.g. Asthma, Bronchitis
Yellowish colour indicates bacterial infection.
Blakish colour indicates carbon pigment E.g. Smoking
Bright red Dark red, tarry colour indicates blood.
Greenish colour indicates bronchiectasis.
Brown colour indicates gangrenous condition of lung.
Odour: Odourless
Unpleasant odour indicates lung abscess, lung cancer.
Consistency: Frothy, watery tenacious and thick depending on the type of condition.
Collection of sputum specimen
Purposes
• For culture and sensitivity to identify a specific microorganism and its drug sensitivities.
• For cytology to identify the origin, structure and pathology of cells.
• For acid fast bacillus (AFB) requires serial collection for three consecutive days to identify the
organism. Sputum specimens are collected in the morning. Upon awakening the client can cough
up the secretions that have accumulated during the night. When a client cannot cough the nurse
must use pharyngeal suctioning to obtain the specimen
Steps of procedure

 Explain client the method and purposes of sputum collection.

 Instruct client to rinse mouth with plain water and not with antiseptic mouth washes.
 Ask client to breathe deeply and then cough up 15 to 30ml of sputum.
 Wear gloves and mask to avoid direct contact with the sputum.
 Ask the client to expectorate or spit out the sputum into the specimen container.
 Make sure that sputum does not contact the outside of the container
 Following sputum collection, offer mouth wash to remove any unpleasant taste.
 Label and transport the specimen to laboratory with requisition immediately or it should
be refrigerated because microorganisms may grow and multiply and produce false results.
 Document the collection of sputum specimen on the clients' chart. Include the amount,
colour, consistency, odour and presence of blood and any discomfort experienced by the
client.
Conclusion
Prompt and accurate collection of specimens can directly affect a client's diagnosis, treatment
and recovery. Nurses play an important role for the collection of specimens.

PSYCHOLOGICAL ASSESSMENT
The mental status examination or mental state examination
It is abbreviated as MSE, and is an important part of the clinical assessment process in
psychiatric practice. It is a structured way of observing and describing a patient's current state of
mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought
process, thought content, perception, cognition, insight and judgment.
Purposes
• To obtain a comprehensive cross sectional description of the patient's mental state.
• To make an accurate diagnosis for treatment planning.
Assessment of Intelligence
Various types of standardized psychological tests are used during the assessment of intellectual
disabilities (ID, formerly mental retardation). These tests may assess intelligence (IQ), learning
abilities, and behavioral skills, A standardized test is uniformly designed and consistently
administered. This permits comparisons of individual scores against average scores for the same
group. This comparison provides vital information about a person's skills and abilities relative to
their peers. Comparisons between group and individual scores should be matched by age,
culture, education, and other factors know to affect IQ scores.
Tests of intellectual functioning (IQ)
Tests of intellectual functioning are designed to measure different mental abilities. These tests
are commonly called IQ tests. IQ tests measure the following mental abilities:

 Reasoning
 Problem solving
 Abstract thinking
 Judgment
 Academic learning
 Experiential learning
IQ Percentage of the population

IQ % Interpretation
121-130 6.4 Gifted
111-120 15.7 Above average intelligence
90-110 51.6 Average intelligence
80-89 15.7 Below average intelligence

< 80 10.6 Intellectual disabilities

Type of intelligence:
a) Analytical intelligence:- It is the academic problem solving skills.
b) Creative intelligence:- It involves insights, synthesis and the ability to react to new situations
and stimuli.
c) Practical intelligence:- It is the intelligence which operates in the real world.
► Behavior
Abnormalities of behavior also called abnormalities of activity. It includes observations of
specific abnormal movements, as well as more general observations of the client's level of
activity and observations of the client's eye contact and gait. A tremor may indicate a
neurological condition or the side effects of antipsychotic medication. Lack eye contact may
suggest depression or autism.
Mood
Mood is a person's predominant internal state at any one time. Mood is described as neutral,
euthymic, dysphoric, euphoric, angry and anxious. Alexithymic individuals may be unable to
describe their subjective mood state. An individual who is unable to experience any pleasure
may be suffering from depression.
Emotions or Affect
Emotions play a major role in influencing one's behavior. Life would be dreary without feelings
like joy and sorrow, excitement and disappointment, love, fear and hope. Emotions add colour
and spice to life. Emotions have both positive as well as negative effects. Emotions or affect may
be described as appropriate or inappropriate to the current situation, and as congruent or
incongruent with the thought content. For example, someone who shows a bland affect when
describing a very distressing experience would be described as showing incongruent affect,
which might suggest schizophrenia. The intensity of the affect may be described as normal,
blunted affect, exaggerated, flat, heightened or overly dramatic.
Normal and abnormal behaviour
Normality tends to be seen as good and desirable by society, while abnormality may be judged as
bad or undesirable. Therefore, someone being called normal or abnormal can have vast social
ramifications.
→ Definition of normal behaviour: - People who are capable of establishing an acceptable
relationship with other people and their emotional reactions are basically appropriate to different
situations is termed as normal behavior.
► Characteristics of Individual with normal behaviour

 The common pattern of behavior found among the general majority is said to be the
normal behaviour.
 Normal people adjust to their social surroundings and manage their emotions.
 Their emotional experiences do not affect their personality adjustment even though they
experience occasional frustrations and conflict.
 People having average amount of intelligence, personality stability and social adaptability
are considered as normal.
Definition of abnormal behavior: -The unusual or mal adapted behavior of people who do not
fit in to our common forms of behavior is known as abnormal behavior or behavior that violates
norms of the society.
► Characteristics of Individual with abnormal behavior

 It is the simple exaggeration or perverted development of the normal psychological

behavior.
 Biological, social and psychological maladjustment affects the functioning of individual
in a society.
 It refers to maladjustment to one's society and culture.
 It is the deviation from the normal in an unfavourable and pathological way.
 Maladaptive behaviors are not only harmful to the society but also to individual.
Conclusions
Psychological assessment helps the nurse to assess the mental well being of patients.
Psychological assessment includes assessing the intelligence, mood, emotions and behavior.
MEETING THE PSYCHOLOGICAL AND SPIRITUAL NEEDS OF A PATIENT
Meeting psychological needs of patient is as equally important as any other physical
needs. The reticulo-endothelial system will be depressed in emotionally upset people. The
emotional / psychological wellbeing plays a major role in the recovery of illness.
In sickness or illness the patient is more attached to spirituality and he feels the need for
spirituality. He may or may not know it, but deep within himself he feels the need for a supreme
strength and power. He believes on the super natural power. He also feels great comfort and
consolation through trusting in God. The trust brings peace and relaxation to him.
A nurse should understand the cultural background of the patient and she should permit religious
leaders of patients to visit the patient and to provide spiritual help.
A nurse should respect one's beliefs. She should help the patient as far as it is possible
Many hospitals have a prayer hall for meeting the spiritual needs of the patient. The patient
needs to be informed of them, and encouraged to attend services if possible. Many will attend if
helped by nurse, especially those who need a wheel chair. It is a great advantage if nurse knows
something about other faiths, which will help nurse to understand the patient better.
Different ways to meet the Psychological needs of Patients are:

 Make a good rapport with the patient and family members.

 Talk to the patient and clarify his doubts,
 Maintain a therapeutic relationship with patients
 Gain their confidence
 Answer to their questions in simple language
 Include family members also in the care
 Include patient and family for planning the care
 Show sympathy and empathy as required
 Show the concern for the well being of the patient
 Engage the patient in activities like yoga, meditation, exercises (if condition permits)
 Engage in recreational and divertional activities
Recreational and divertional therapy: Recreation is an activity which relaxes the mind and
body. It diverts us from the routine stress and provides mental and physical relaxation. With the
help of recreation we can get the maximum level of benefits to reduce stress.
The types of recreation depend upon an individual's ability and field of interest. Recreation will
make the patient feel self contented.
The common forms of recreational activities that can be provided in the hospital surroundings
are as follows;

 Reading book and magazines of any field

 Listening the music and enjoying the music with the help of ear phones so as not to
disturb the acutely ill patient.
 Watching television and movies will divert the mind of patients.
  Arts in the form of pictures and sceneries provide peaceful and comfortable environment.
 Indoor games like puzzle games and Sudoku will relieve the patient from physical and
mental tension.
 Occupational therapy can also be provided which will not only divert the mind but also
helpful for handicapped patient to regain some activities.
CARE OF TERMINALLY ILL AND DYING
Introduction:
Many patients suffer unnecessarily when they do not receive adequate attention for the
symptoms accompanying serious illness. Careful evaluation of the patient should include the
physical, psychosocial and spiritual problems of the patients and their family.
Terminally ill: Terminal illness commonly causes fears of physical pain, isolation and dying.
When people experience periods of disease remission, they may become asymptomatic for long
periods of time and leave the idea of illness and any terminal outcome. Terminal illness creates
an uncertainty about what death means and this makes patients susceptible to spiritual distress.
The patients who have spiritual sense of peace are able to face death without fear.
Individuals experiencing terminal illness will often ask "why is this happening to me or "What
have I done” Family and friends can be affected just as much as the patient. Terminal illness
causes members of the family to ask important questions about it meaning and how it will affect
their relationship with the patient.
Domains of Health based on terminally ill Patients:

Spiritual
Belief in a higher power

Recognition of mortality

self actualization

Health

Mental Emotional Physical

Love Feeling good

Hope Health promotion

Control Relationship with physician

Loss: Throughout our lives, from birth to death, we suffer from losses. Losses such as death of
loved ones, divorce or loss of independence are significant and can have long term effects on our
physical and psychological health. Loss comes in many forms based on the values and priorities
including family, friends, society and culture. A person experience loss in the form of an object,
person, body part or function, emotion, or idea that was formerly present. Loss may be of various
types :
(a) Actual loss
(b) Perceived loss
(c) Maturational loss (d) Situational loss
(i) Actual loss: any loss of a person or object that was present, can no longer be felt heard,
known, or experienced by the individual.
(ii) Perceived loss: is any loss that is uniquely defined by the grieving patient. It may be less
obvious to others.
Eg.loss of prestige
Perceived losses are easily overlooked or misunderstood, but the process of grief follows the
same sequencing and progression as actual losses.
(iii) Maturational loss: includes any change in the developmental process that is normally
expected during a life time.
Eg. Feeling of loss as a child going to school
Events associated with maturational loss are part of normal life transitions, but the feelings of
loss persists as grieving.
v) Situational loss: includes any sudden, unpredictable external event .Often this type of loss
includes multiple losses rather than a single loss, such as an automobile accident that leaves the
driver paralyzed, unable to return to work, and grieving over the loss of passenger in the
accident.
GRIEF
Grief is the emotional response to a loss. It is manifested in a variety of ways that are unique to
an individual and is based on personal experience, cultural expectations and spiritual beliefs.
Bereavement includes grief and mourning - the inner feelings and outwards reactions of the
survivor.
Types of Grief:
(i) Normal grief
(ü) Anticipatory grief
(iii) Complicated grief.
(iv) Disenfranchised grief.
(i) Normal grief: Normal or uncomplicated grief consists of the normal feelings, behaviours, and
reactions to losses. These include resentment, sorrow, anger, crying, loneliness and temporary
withdrawal from activities. As people mature they develop ways of dealing with losses to
maintain and enhance their feelings of safety and security.
(ii) Anticipatory grief: The process of disengaging or "letting go” that occurs before an actual
loss or death has occurred is called anticipatory grief.
eg. Once a person or family receives a terminal diagnosis, they begin the process of saying good-
bye and completing life affairs. The process becomes more stressful when the patient is unable to
make decisions due to deterioration in health. There are risks in anticipatory grieving. The family
members may withdraw emotionally from the patient too soon, leaving the patient with no
emotional support as death approaches.
(ii) Complicated grief: when a person has difficulty progressing through the normal phases or
stages of grieving, bereavement becomes complicated. In these cases bereavement appears to "go
wrong" and loss never resolves. This can threaten a person's relationships with others.
(iv) Disenfranchised grief: Persons experience grief when a loss is experienced and cannot be
openly acknowledged, socially sanctioned, or publicly shared.
Eg; Includes the loss of a partner from acquired immuno deficiency syndrome (AIDS), children
experiencing the death of a step parent, or the mother whose child is in utero.
Factors influencing loss and grief:
The way an individual perceives a loss and respond to it during treatment is heavily influenced
by many factors.
(a) Human development: persons of different ages and stages of development will display
different and unique symptoms of grief.
eg. Toddlers are unable to understand loss or death but they feel great anxiety over loss of objects
and separation from parents. School age children experience grief loss of a body part or function.
They often associate misleads causing deaths. Middle age adults usually begin to renew life and
are sensitive to their own physical changes. Older adults often experience anticipatory grief
because of aging and the possible loss of self care abilities. Aging is frequently associated with
losses such as physical changes, loss of employment, loss of social respect, loss of relationships,
and threat to sense of fulfillment
(ii) Psychosocial perspectives of loss of grief: Loss and death are life experiences that each
person faces. Death is an overwhelming experience that affects everyone involved in the loss
situation or in the death of the individual.
(iii) Socio-Economic Status: Socio economic status influences person's ability to obtain options
Generally an individual feels greater burden from loss when there is lack of financial,
educational, or occupational resources. eg. a patient with limited finances may not be able to
replace home lost in a fire or may not be able to purchase necessary medications to manage a
newly diagnosed disease. These patients require referral to community social services agencies
that can provide needed resources.
(iv) Personal relationships: When loss involves a loved one, the quality and meaning of the
relationship are critical in understanding a persons' grief experience. It has been said that to lose
your parents is to lose your past, to lose your spouse in to lose you two individuals has been very
close and well connected, it can be very difficult for the one left behind to cope.
(v) Nature of the loss: A sudden and unexpected death is generally more difficult for family to
accept than one following a chronic disease.
(vi) Culture and Ethnicity: Interpretation of loss and the expansion of grief arises from cultural
background and family practices. Culture affects how patients and their support systems or
families respond to loss.
Spiritual belief: Individual's spirituality significantly influences their ability to cope with loss.
Loss can sometimes cause internal conflicts about spiritual values and the meaning of life.
Signs of impending death: The clinical signs of impending or approaching death include:

 Inability to swallow
 Bowel and bladder incontinence
 Loss of motion, sensation and reflexes
 Low temperature, cold or clammy skin, cyanosis.
 Lowered blood pressure
 Weak and thready pulse
 Noisy or irregular respirations.
 Cheyne - stroke respirations.
 Loss of consciousness

CARE OF DYING PATIENT

Dying and deaths: Dying may occur suddenly as a result of an accident; injury, or pathologic
crisis, such as heart attack; or it may occur often a prolonged experience of debilitating disease,
such as cancer, AIDS or multiple sclerosis.. Some choose to die at home surrounded by loved
ones. Others die alone or in intensive care surrounded by health care professionals and
technological equipments.
Responses to dying and death:
The stages of dying and the duration of any stage may range from few hours to as long as
months. The process varies from person to person. Some people may be in one stage for a very
short time. Sometimes a person returns to previous stage. The five stages of dying are:

 Denial and isolation

 Anger
 Bargaining
  Depression
 Acceptance
(i) In the denial and isolation stage, the patient feels that he or she will die, he may isolate
himself or herself from reality. The patient may think, "they made a mistakes in the diagnosis
,may be they mixed up my records with someone else's"
(ii) In the anger stage the patient experiences anger, hostility and adopts a "why me"? attitude,"
why me? I quit smoking and watches what I ate. Why did this happen to me.”?
(iii) In the bargaining stage, the patient tries to bargain for more time! If I can just make it to my
son's marriage I'will be satisfied. Just let me live until then. Many patients put their personals in
order, make wills and fulfill lost wishes, such as trips, visiting relative etc.. It is important to
meet these wishes if possible, because bargaining helps patients more into later stages of dying.
(iv) In the depression stage, the patient goes through a period of grief before death. The grief is
characterized by crying and not speaking much". eg.I waited all these years to see my daughter
get married and now I may not be here to see her walk down. I can't bear the thought of not
being there for the wedding and of not seeing my grand children.
(v) When the stage of acceptance is reached, the patient feels tranquil. She or he has acceptance
to death and is prepared to die. The patient may think." I've tied up all the loose ends! made the
will, made arrangements for my daughter to live with her grandparents. Now I can go in peace
knowing everyone will be fine.
Death: Death is defined as a state when an individual has sustained either irreversible damage to
circulatory and respiratory functions or irreversible malfunctioning of the entire brain, including
the brain stems.
The following characteristics must be present before death can be declared:

 Lack of receptivity and responsiveness

 Lack of movement or breathing
 Lack of reflexes
 Flat encephalogram, flat ECG
 Absence of pulse
 Dilated pupils
CARE AFTER DEATH
When a patient dies in a hospital setting the nurse is the one who provides postmortem care. It is
important for the nurse to care for the patient's body with dignity and sensitivity respecting
patient's religious or cultural beliefs. After death, the body undergoes many physical changes.
For that reason, care must be provided as soon as possible to prevent tissue damage or
disfigurement of body part.
State legislation requires hospitals to formulate policies and procedures based on current
law to validate death, identify potential organ or tissue donors and to provide postmortem care.
For transplantation of organs, the patient must be maintained on ventilator and circulatory
support until vital organs are harvested. The family must clearly understand that the patient is
"brain dead" that the equipment is not keeping the patient alive but keeping the physical body in
a state so that the organs will not be damaged before harvesting. Each nurse should receive his or
her state's organ retrieval law and institutional policy and procedure regarding the formal consent
process.
The nurse is responsible for coordination of all respects of care surrounding a patient's death. It is
important for the nurse to be familiar with institutional policies and procedure that one
established for postmortem care.
Documentation of all of the events surrounding patient's death is important to avoid
misunderstanding and for legal implications. The guide lines that are suggested by each state/
institution policies and procedures must be followed and accurately documented to avoid break
in the laws such as:

 Time of death and actions taken to prevent the death, if applicable.

 The name of person who pronounced the death of the patient.
 Any special preparation and type of donation, including time, company.
 The name of persons or groups present for representing donor organizations and the
family members making decision in this regard.
 Personal articles left on the body and taped to skin or tubes left in.
 Personal items given to the family- with specific names and descriptions of items.
 Time of discharge and destination of the body.
 Location of name tags on the body.
 Special request by the family.
 Any other personal statements that might be needed to clarify the situation.
Documentation will validate the success of meeting the goals identified for the patient. Complete
and accurate documentation save the nurse and the institution from legal investigations.
Care of Body after Death:
Equipment: Towels, wash clothes, wash basins, gloves, nonabsorbent cotton balls, scissors, name
tags, bed linen, room deodorizer, documentation forms.
(i) Physician must certify the death - time pronounced, therapy used and actions taken.
(i) Physicians may request an autopsy, especially for unusual circumstances.
f) Trained staff member provides an option for donation of organs or tissue - personal, religious
and cultural needs should be included during this process.
(iv) Nurses should provide dignity and sensitivity to the body and the family.
(a) Check orders for any specimen or special orders needed by the physicians.
(b) Make arrangements for staff, pastor, or others to stay with the family; ask for
c) Before shaving of male patient; determine if the family wishes patient to remain unshaven if it
was his custom to wear beard. Determine if patient's religion or culture has a preference to facial
hair.
(d) Remove all equipment, tubes, supplies and dirty linens according to protocols, if organ
donations to take place, leave support system in place.
(e) Clean the body thoroughly, put clean sheets and remove all trash from the room
(f) Plug the orifices with non absorbent cotton
(g) Brush and comb the hair, apply any personal hair piece.
(h) Position the body according to protocol - The eyes should be closed by gently holding them
down to few minutes; dentures should be in the mouth to maintain facial alignment; packing
should not be visible during viewing.
(i) Cover with a clean sheet up to the chin with arms outside covers if possible
(1) Lower the lighting and spray a deodorizer to remove unpleasant odors.
(k) Give the family the option to view or not to view.
(1) Clarify that either option is acceptable.
(m) Encourage the family to say good bye through both touch and talk.
(n) Do not rush this process. Once the family is more comfortable, ask if they would like to be
left alone. Remind them that they can call you if needed.
(o) Clarify personal belongings that are to stay with the body or who has to take personal items;
documentation will require both description of the objects as the name of person who received
them, with the time and date.
(p) Discard nothing. if items are found , call the family and tell them what was found and as who
might pick it up.
(q) Apply name tags according to protocol-such as at the wrist, right big toe or outside a box,
(r) Documentation of end of life care.
(5) Remain sensitive to other hospitalized patients or visitors, when transporting the body. Avoid
visitors when moving the body to another part of the hospital or to the exit for the funeral home

(t) Follow all protocol and policies to meet all legal requirements in caring for the body.

EUTHANASIA: Euthanasia literally means "good dying" Many societies believed that the
distinction between killing and allowing to die was morally relevant. Few religions strongly
believe that no humans have the right to take away one person life. It remains a controversy since
many years. It can be either passive euthanasia or active euthanasia. The passive euthanasia is
the withholding or withdrawing medical therapies which was morally and legally justified even
when this hastened or directly caused patient's death. Making drugs available to a patient wishing
to die (assisted suicide) or administering a lethal injection or carbon-mono-oxide, even when
performed with compassionate intent at the request of the patient (active euthanasia), was
considered both immoral and illegal. Some are questioning the validity of this distinction today
and there are efforts to legalize assisted suicide and active euthanasia in numerous countries.

AUTOPSY:

An autopsy is an examination of the organs and tissues of a human body after death to determine
the exact cause and circumstances of death. Obtaining consent for autopsy is a legal requirement.
The closest surviving family member or members usually have the authority to determine
whether an autopsy is to be performed. Some religious groups prohibit autopsies except for legal
purposes.

It is commonly the physician's responsibility to obtain permission for an autopsy. Sometimes the
patient may grant this permission before death. The nurse can assist by explaining the reasons for
an autopsy. Many relatives accept the fact when they are told that the knowledge gained from an
autopsy will contribute to advances in medical sciences as well as establish the exact cause of
death.

If death is caused by accident, suicide, homicide or illegal therapeutic practice, coroner or

medical examiner must be notified, according to law. The coroner may decide that an autopsy is
advisable and an order that one be performed, even though the patient's family has refused
consent. In some cases, a death that occurs within 24 hours of admission to the hospital must be
reported to the coroner.

Coroner:

An official who holds inquests into violent ,sudden or suspicious death Autopsy is performed in
case the death is:

 Due to foul play

 Homicide
 Accidental
 Suicide, ingestion of drugs/poisons
 Due to falls, Road traffic accidents
 Death within 24 hours of hospital stay

Organ Donation: Patients who express wish to donate functional organs, such as heart, cornea,
liver, lung and kidneys, can fill out an organ donor consent card. The family of a deceased
patient also can decide to donate the patient's functional organs. The nurse should be able to
review options and provide consent forms to interested patients and their families. Until recently,
most organs were transplanted from totally brain-death patients. Now protocols for retrieving
organs from non-heart beating cadavers are raising multiple practice concerns. Comprehensive
attention to optimal patient and family care at the time of withdrawal of life-sustaining therapy
needs to remain the nurse's priority.

EMBALMING:

Embalming is the preservation of a dead body by the introduction of chemical compounds that
delay putrefaction. The ancient Egyptians raised the process to a time art in the production of
their mummies. Today embalming is employed mainly so that a body can be transported long
distances and funeral rites can be conducted without under haste. In India it is not done as a
routine.

Embalming involves four processes:

Arterial embalming in which embalming chemicals are injected in to the blood vessels

Cavity embalming: Embalming chemicals are injected in to the body cavities. The hollow
organs are punctured, the contents are aspirated, and the chemical is instilled into it.

Hypodermal embalming: The chemical is injected under the skin.

Surface embalming: the injured body parts are treated with chemicals.

The embalming chemical is a mixture of formaldehyde, gluteraldehyde, methanol, ethanol and

other solvents. These chemicals delay decomposition.

Conclusion:

The care of death and dying is a sensitive area the nurse has to face in her professional life.
Giving respect for the body after death and considering the psychological aspects of bystanders
are all important considerations.