Often the most significant concern of the dying person and his/her significant others.

Can interfere with the dying person's ability to maintain control, cope, and complete end of life tasks.

Increases the likelihood of fatigue, depression, and loss of appetite.

Interferes with their ability to make thoughtful decisions and to communicate effectively with loved ones at a critical time.

Begins with a careful assessment.

Date collection needs to be performed early and often, because the patient's status can change dramatically in a relatively short period.

Watch their non verbals.

Pain is what the patient says it is, but many older patients who have lived with multiple discomforts often underreport the amount of pain they're experiencing.

Self reported logs or journals are helpful because the patient and significant others are more focused and attuned to subtle changes in the individual.

May be caused by underlying disease processes, stress, anxiety, or medications.

Fatigue can interfere with the dying person's ability to carry out necessary end of life tasks, including communicating with loved ones.

Because of metabolic changes, the patient may begin to sleep more and may be difficult to awaken as the end of life nears.

Diminished peripheral circulation already is likely to worsen as death nears, resulting in dry, pale, or cyanotic extremities.

Peripheral pulses are often weak.

BP typically is decreased by 20 or more points from the normal range and may be difficult to ausculate.

Body temp may elevate significantly as death nears.

Can give tylenol or use a cold compress to reduce body temp if needed.

SOB, dyspnea, and Cheyne-Stokes respirations during sleep are commonly observed in older adults are death nears.

Mild respiratory difficulty usually can be relieved by changing positioning, elevating the upper body, opening the windows or using a fan to increase ventilation or adminstering O2 by nasal cannula.

Fast breathing followed by periods of apnea.

The longer the periods of apnea the closer they are to death.

Loss of appetitie (anorexia) and muscle wasting (cachexia) are commmonly observed with advanced terminal conditions, particularly some forms of cancer. They'll have eyes sunken in and concave abdomen.

Dry mouth (xerostomia) and ulcerations of the mouth. Morphine can cause dry mouth. Moisten their mouth first to help absorption.

N/V are not signs of impending death, rather, they are distressing symptoms of underlying problems.

Levsine-can be used to tx the "death rattle" for the large amount of secretions. This medication has anticholingeric effects.

Constipation is common and distressing problem for the terminal patient. Due to the narcotics.

Diarrhea is a less of a problem at the end of life, but one that can have a profound effect on the quality of life.

Oliguria (little/no output) is commonly observed because of decreases in fluid intake, BP, and kidney perfusion.

Urinary incontinence is also common.

Absorbent pads or an indwelling catheter can be used to reduce the need for bed changes that may disturb the dying person.

Skin breakdown is a problem with malnourished patients near the end of life.

Interventions designed to rpevent skin tears or pressure sores include proper skin cleansing, careful handling of the skin, frequent turning and positioning, and measures to reduce pressure.

Use of soft, nonconstricting, nonirritating clothing helps promote comfort and minimize risk for skin dryness and rash.

Vision diminishes and the visual field narrows as death nears.

Hearing remains acute until death, even if the dying person does not respond.

Calm, supportive, loving messages should be delivered even when unresponsive.

Negative or disturbing conversations should be avoided to reduce stress and agitation.

Delirium, a series of changes in mental status is present in as many as 80% to 85% of older adults in the last days of life.

Causes of delirium include hypotension, oxygen deprivation, resulting from apnea or hypoventilation, fever, neurologic changes, metabolic abnormalities such as hyperglycemia and uremia, dehydration, and other physiologic or emotional disturbances.

Often wish to be present at the time of death.

Some families can spend only limited time with their dying loved one and wish to be called only when there is a significant change in the person's status.

Others would rather be notified only after death has occurred.

Increased sleepiness and decreased responsiveness

Confusion in a person who has been oriented

Hallucinations about people

Increased withdrawal from visitors or other social interaction

Loss of interest in food/fluids and loss of control of bowel and bladder

Altered breathing patterns such as shallow breathing, Cheyne-Stokes respirations, rattling or gurgling respirations.

Involuntary muscle movements and diminished reflexes

If family members are present, they should be allowed to sit at the bedside and say farewells or grieve as long as they need.

It is appropriate for the nurse to remove O2, IV lines, or other medical devices that are visible discreetly.

Do not remove if they are doing an autopsy.

Cultural practives regarding grieving and preparation of the body should be respected and accommodated whenever possible.

Survivors often express having ambivalent feelings regarding death

On one hand they feel a sense of relief that they struggle is over and that the loved one is at rest.

On the other hand, they seriously grieve and miss the loved one's prescence.

Even when death is anticipated, the initial feeling of shock and numbness typically occurs.