Page 576 - Saunders Comprehensive Review For NCLEX-RN

leading to constipation, gas accumulation, and
distention; incontinence may occur.
7. Musculoskeletal system: The client gradually loses
ability to move, has difficulty speaking and
swallowing, and loses the gag reflex.
F. Death
1. Death occurs when all vital organs and body systems
cease to function.
2. In general, respirations cease first, and then the
heartbeat stops a few minutes thereafter.
3. Brain death occurs when the cerebral cortex stops
functioning or is irreversibly damaged.

G. Nursing care

1. Frequency of assessment depends on the client’s
stability (at least every 4 hours); as changes occur,
assessment needs to be done more frequently.
2. Physical care (Box 18-14)
3. Psychosocial care
a. Monitor for anxiety and depression.
b. Monitor for fear (Box 18-15).
c. Encourage the client and family to
express feelings.
d. Provide support and advocacy for the
client and family.
e. Provide privacy for the client and
family.
f. Provide a private room for the client.
4. See Chapter 67 for information on grief and loss.
5. Postmortem care (Box 18-16)
a. Maintain respect and dignity for the
client.
b. Determine whether the client is an
organ donor; if so, follow appropriate
procedures related to the donation.
c. Consider cultural and religious rituals,
state laws, and agency procedures
when performing postmortem care.
d. Prepare the body for immediate
viewing by the family.
e. Provide privacy and time for the family
to be with the deceased person.
f. Medical examiner jurisdiction
guidelines are determined by each
state and usually include nonnatural,
traumatic, or question of criminal
involvement deaths; any forensic
evidence is preserved and the body is

576