cardio pulmonary resuscitation and end of life care

8/10/2019 Cardio Pulmonary Resuscitation and End of Life Care

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CARDIO PULMONARY RESUSCITATION

AND END OF LIFE CARE

DEFINITION

Cardiopulmonary resuscitation (CPR) is an emergency procedure which is attempted in aneffort to return life to a person incardiac arrest.

It is indicated in those who are unresponsive with no breathing or only gasps. It

may be attempted both in and outside of a hospital.

INDICATIONS

Unconscious No breathing, or extremely irregular or agonal breathing, Cheyne-Stokes respiration, etc.

No circulation

Obstructed airway and the victim is an infant, pregnant or obese (i.e. too large to get yourhands around to perform a Heimlich manuver).

Many indications exist for CPR, these include

Dead cases, where no pulse and no breathing can be detected

Drug over dosage

Drowning

Poisoning Non-fatal cardiac arrhythmia

Shocks and seizures

PURPOSES

Preserve life

To restore airway, breathing and circulation.

To prevent complication

To make the victim as comfortable as possible to conserve the strength.

CPR TRAINING OBJECTIVES

Recognizing an Emergency

The first objective of a CPR course, according to the American Red Cross, is to train

participants to recognize an emergency and activate the emergency response

system. This involves learning the main life-threatening conditions that occur, the

signs of a heart attack and the steps to take during an emergency, such as calling
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911.

The CPR instructor will also teach the cardiac chain of survival, a process that helps

maximize a victim's chance of survival.

Assessing the Victim

After the participants learn to recognize an emergency, they are trained to assess a

victim. Participants learn how to check an unconscious individual for signs of life,and have to demonstrate that they know how to properly check for breathing and

feel for a pulse. CPR training participants will learn to determine whether CPR or

some other first aid measure is appropriate, and identify any other life-threatening

conditions.

Providing Basic Care

Finally, the participants will learn to how to provide basic care to a victim, which

involves demonstrating how to take basic precautions during cardiac and breathing

emergencies, how to care for a conscious and unconscious choking individual and

how to give compressions and breaths during CPR. Many CPR courses also train

participants to use an automatic external defibrillator (AED), which delivers a shock

to the heart to help it resume a normal rhythm.

Signs of cardio pulmonary arrest

Immediate loss of consciousness

Absence of pulse

Cessation of perceptible respirations and after 45 seconds arrest dilatation of pupils.

Resuscitation/ ABCDs of basic CPR

When the victim appears unconscious or lifeless the ABCDs of resuscitation needs to

be performed in order to assess his/her most urgent needs. This should be done as quickly

as possible by following 4 steps

1. Open the airway(A): By removing blockage and lifting chin

2.

Check the breathing: by looking for chest movements, listening for sounds of

breathing and feeling or breath for 5 seconds

3.

Check for circulation: By feeling for the carotid pulse for five seconds.

4.

Defibrillation: if witnessed arrest use automatic external defibrillator. If un

witnessed arrest deliver 5 cycles of CPR before using automatic external

defibrillator.

LOOK LISTEN AND FEEL-- When you LLF, you are checking to see if the victim is

breathing on their own. After performing the Head tilt-chin lift, lean down and place your ear

close to the victim's mouth and nose. LOOK for a rise in the chest; LISTEN for air passing

through the mouth and nose; FEEL any air passing over your face.

Open the airway


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To clear the airways remove obstructing substances from the mouth with finger.

Use first finger as a hook to dislodge any material causing obstruction.

Head tilt chin lift maneuver:

The head tilt chin lift maneuver is used to open the victims airway to give mouthto mouth resuscitation. A) rescuer places one head on the victims fore head and

applies firm, backward pressure with the palm to tilt the head back. The chin is

lifted and brought forward with thefingers of the other hand. B) Check if breathing

is restored. If not, start mouth to mouth breathing.

Heimlich maneuver (abdominal thrust method): for severe airway obstruction

Stand behind victim and wrap arms around waist

Make fist with one hand Place thumb side of fist against victims abdomen. Position fist midline , slightly

above umbilicus and well below xiphoid process

Grasp fist with other hand

Press fist in to victims abdomen using quick upward thrust. It will enhance thecoughing reflex

Repeat thrust un till object is expelled


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Place the mouth around victims mouth, make an airtight seal

Delivers a regular breath ( 4 times)

Allow patient to exhale

Assess for cessation of breathing

LOOK for chest rising and falling LISTEN for air escaping during exhalation

FEEL for flow of air

Circulation

Act quickly and restore circulation by external cardiac compression

Place the victim on hard surface and kneel at victim side

Locate the xiphoid process, measuring 1 -2 above xiphoid process

Place heel of one hand at this point on sternum

Place the other hand on top of it. Interlock fingers to keep them of the victims ribs

Keep elbows straight and lean forward

Make dull use of the body weight when delivering downward compression

Apply steady smooth pressure to depress victims sternum 3to 4

Then relax pressure completely but do not let the hand leave victim chest or may

lose correct hand position.

Repeat and perform CPR for one minute as follows

After 10 chest compression give 2 quick lung inflation by mouth to mouth breathing

(ambue bag) and then two more inflation it carotid pulse absent.

Resume CPR alternating lung inflation with chest depression.


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NURSING ASSESSMENT AND CARE

A-AIRWAY

Unconscious patient

In the unconscious patient, the priority isairway management, to avoid a preventable

cause ofhypoxia.Common problems with the airway of patient with a seriously reduced

level of consciousness involve blockage of thepharynx by thetongue, aforeign body,

orvomit.

At a basic level, opening of the airway is achieved through manual movement of the head

using various techniques, with the most widely taught and used being the "head tilt chin

lift", although other methods such as the "modified jaw thrust" can be used, especially

where spinal injury is suspected, although in some countries, its use is not recommended

for lay rescuers for safety reasons.

Higher level practitioners such as emergency medical service personnel may use more

advanced techniques, fromoropharyngeal airways tointubation,as deemed necessary

Conscious patients

In the conscious patient, other signs of airway obstruction that may be considered by the

rescuer include paradoxical chest movements, use of accessory muscles for breathing,

tracheal deviation, noisy air entry or exit, andcyanosis.

Once oxygen can be delivered to the lungs by a clear airway and efficient breathing, there

needs to be a circulation to deliver it to the rest of the body.

B-BREATHING

Unconscious patients

In the unconscious patient, after the airway is opened the next area to assess is the

patient's breathing, primarily to find if the patient is making normal respiratory efforts.

Normal breathing rates are between 12 and 30 breaths per minute, and if a patient is

breathing below the minimum rate, then in current ILCOR basic life support protocols, CPR

should be considered, although professional rescuers may have their own protocols to

follow, such asartificial respiration.

Rescuers are often warned against mistakingagonal breathing,which is a series of noisy

gasps occurring in around 40% of cardiac arrest victims, for normal breathing.

If a patient is breathing, then the rescuer will continue with the treatment indicated for an

unconscious but breathing patient, which may include interventions such as therecovery

position and summoning anambulance.
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Conscious or breathing patients

In a conscious patient, or where a pulse and breathing are clearly present, the care

provider will initially be looking to diagnose immediately life-threatening conditions such

as severeasthma,pulmonary edema orhaemothorax.Depending on skill level of the

rescuer, this may involve steps such as:

Checking for general respiratory distress, such as use of accessory muscles to

breathe, abdominal breathing, position of the patient,sweating,orcyanosis

Checking the respiratory rate, depth and rhythm- Normal breathing is between 12

and 20 in a healthy patient, with a regular pattern and depth. If any of these deviate

from normal, this may indicate an underlying problem (such as with Cheyne-Stokes

respiration)

Chest deformity and movement- The chest should rise and fall equally on both sides,

and should be free of deformity. Clinicians may be able to get a working diagnosis from

abnormal movement or shape of the chest in cases such

aspneumothorax orhaemothorax

Listening to external breath soundsa short distance from the patient can reveal

dysfunction such as a rattling noise (indicative of secretions in the airway)

orstridor (which indicates airway obstruction)

Checking forsurgical emphysemawhich is air in the subcutaneous layer which is

suggestive of apneumothorax

Auscultation andpercussion of the chestby using astethoscope to listen for normal

chest sounds or any abnormalities

Pulse oximetrymay be useful in assessing the amount of oxygen present in the blood,

and by inference the effectiveness of the breathing

C-CIRCULATION

Non-breathing patients

Circulation is the original meaning of the 'C' as laid down by Jude, Knickerbockers & Safar,

and was intended to suggest assessing the presence or absence of circulation, usually by

taking acarotidpulse,before taking any further treatment steps.

In modern protocols for lay persons, this step is omitted as it has been proven that lay

rescuers may have difficulty in accurately determining the presence or absence of a pulse,and that, in any case, there is less risk of harm by performing chest compressions on a

beating heart than failing to perform them when the heart is not beating. For this reason,

lay rescuers proceed directly to cardiopulmonary resuscitation, starting with chest

compressions, which is effectively artificial circulation. In order to simplify the teaching of

this to some groups, especially at a basic first aid level, the C for ' Circulation'is changed

for meaning 'CPR'or 'Compressions'
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It should be remembered, however, that health care professionals will often still include a

pulse check in their ABC check, and may involve additional steps such as an

immediateECG when cardiac arrest is suspected, in order to assess heart rhythm.

Breathing patients

In patients who are breathing, there is the opportunity to undertake further diagnosis and,depending on the skill level of the attending rescuer, a number of assessment options are

available, including:

Observation of colour and temperature of hands and fingerswhere cold, blue, pink,

pale, or mottled extremities can be indicative of poor circulation

Capillary refillis an assessment of the effective working of the capillaries, and involves

applying cutaneous pressure to an area of skin to force blood from the area, and

counting the time until return of blood. This can be performed peripherally, usually on a

fingernail bed, or centrally, usually on the sternum or forehead Pulse checks, both centrally and peripherally, assessing rate (normally 60-80 beats per

minute in a resting adult), regularity, strength, and equality between different pulses

Blood pressure measurementscan be taken to assess for signs of shock

Auscultation of the heartcan be undertaken by medical professionals

Observation for secondary signs of circulatory failure such as edema or frothing

from the mouth (indicative of congestive heart failure)

ECG monitoringwill allow the healthcare professional to help diagnose underlying

heart conditions, includingmyocardial infarctions

ABCD

There are several protocols taught which add a D to the end of the simpler ABC (or DR

ABC). This may stand for different things, depending on what the trainer is trying to teach,

and at what level. It can stand for:

DefibrillationThe definitive treatment step for cardiac arrest

Disabilityor Dysfunction Disabilities caused by the injury, not pre-existing

conditions

DeadlyBleeding

(Differential) Diagnosis

Decompression

ABCDE

Additionally, some protocols call for an 'E' step to patient assessment. Allprotocols that use

'E' steps diverge from looking after basic life support at that point, and begin looking for

underlying causes. In some protocols, there can be up to 3 E's used. E can stand for:
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Expose and ExaminePredominantly for ambulance-level practitioners, where it is

important to remove clothing and other obstructions in order to assess wounds.

Environment only after assessing ABCD does the responder deal with

environmentally-related symptoms or conditions, such ascold andlightning.

Escaping Air checking for air escaping, such as through a sucking chest wound,which could lead to a collapsed lung.

Elimination

Evaluate Is the patient "time-critical" and/or does the rescuer need further

assistance.

ABCDEF

An 'F' in the protocol can stand for:

Fundus relating to pregnancy, it is a reminder for crews to check if a female ispregnant, and if she is, how far progressed she is (the position of the fundus in relation

to the bellybutton gives a ready reckoning guide)

Family(in France) indicates that rescuers must also deal with the witnesses and the

family, who may be able to give precious information about the accident or the health of

the patient, or may present a problem for the rescuer.

FluidsA check for obvious fluids (blood, cerebro-spinal fluid (CSF) etc.)

Fluid resuscitation

Final StepsConsulting the nearest definitive care facility

ABCDEFG

A 'G' in the protocol can stand for

Go Quickly! A reminder to ensure all assessments and on-scene treatments are

completed with speed, in order to get the patient to hospital within theGolden Hour

GlucoseThe professional rescuer may choose to perform ablood glucose test, and

this can form the 'G' or alternately, the 'DEFG' can stand for "Don't Ever Forget

Glucose

PROCEDURE FOR RECOVERY POSITION

Any unconscious victim should be placed in the recovery position. This position prevents

the tongue from blocking the throat and because the head is slightly lower than the rest of

the body, it allow liquid to drain from the mouth, reducing the risk of casualty inhalingstomach contents.
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Kneeling besides the victim, open her/his airway by tilting the head or lifting the

chin. Straighten his or her leg. Place the arm nearest you out at right angles to her or

his body, elbow bent and with the hand palm uppermost.

Bring the arm from you across the chest, and hold the hand, palm outwards, against

the victims nearer cheek.

With the other hand grasp the thigh further from you and pull the knee up keepingthe foot flat on the ground

Keeping her or his hand pressed against her or his cheek, pull, at the thigh to roll the

victim towards you and on to her side.

Tilt the head back to make sure the airway remains open, adjust the hand under the

cheek, if necessary so that the head stays in this tilted position.

Adjust the upper leg if necessary, so that both the hip and the knee are bent at right

angles

Dial for an ambulance (108). Check breathing and pulse frequently while waiting for

help to arrive.

COMPLICATIONS

Broken Bones

Rib fractures are the most common complication of CPR. Chest compressions administered

during CPR are given quickly and with enough force to compress the chest about 1 inch in

depth. This provides pressure to the ribs, which can be strong enough to cause ribs to

fracture. Victims who are elderly, small in stature or children have the highest risk of

developing rib fracture during chest compressions. Additionally, the chest bone, or

sternum, also endures pressure and stress during chest compressions and can fracture as

well.

Internal Injuries

Internal organs lie within the area pressured by chest compressions. As the chest is

compressed during CPR, ribs and chest bones can break, puncturing the lungs and liver.

Additionally, internal bruising of the heart and liver can occur.

Vomiting and Aspiration

As chest compressions are administered, pressure builds inside the body, which can force

stomach contents up the esophagus and result in vomiting. This causes the risk of

aspiration, or absorbing the vomit into the respiratory system. Aspiration is a serious

complication which makes it difficult to provide the victim with adequate air and canultimately damage lung tissue or result in infection, like pneumonia.

Body Fluid Exposure

CPR presents the risk of exposure to body fluids. Providing mouth-to-mouth rescue

breathing to a victim without use of a mask results in saliva exposure between victim and

rescuer. Blood and vomit may also be present during CPR, which carries the risk of


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Be able to identify a plan of care for terminally ill patients, which is based upon a

comprehensive interdisciplinary assessment of the patient and familys expressed values,goals and needs, and communicate the plan to the patient and family.(Patient Care, Medical

Knowledge, Interpersonal Communications)

Optimize treatment plans for terminally ill patients via integrating knowledge of local

palliative and hospice care resources, as well as state and federal resources.(Practice-based

Learning, Systems-based Practice)

Recognize the signs and symptoms of the imminently dying patient. (Medical Knowledge)

Demonstrate systematic recognition, assessment and management of pain syndromesutilizing evidence-based medicine. This should include both pharmacologic (opiate and

non-opiate) and nonpharmacologic treatments as well as possible side effects. (Patient

Care, Medical Knowledge, Practice-based Learning)

Be aware of the ethical and legal issues from which the terminally ill patients preferences

and choices may be based upon and/or limited within. Further, skilfully negotiatetreatment decisions with terminally ill patients and his or her family within this context.

(Professionalism, Interpersonal Communications) Attitudes

The resident should demonstrate attitudes that encompass:

The process of breaking bad news, including choice of setting, talking with the patient

and family members, summarizing, using appropriate wording and questioning and the

impact of this process on the patient and family.

An understanding of the psychosocial issues and family dynamics affecting the terminallyill patient.

An understanding of the spiritual and religious issues affecting the terminally ill patient.

An understanding of the family cultural issues and particular customs in the context of

death and dying.

An understanding of the dying patients need for palliative care, pain relief, control and

dignity.

An understanding of the special issues associated with children, either as terminally ill

patients or as family members of a terminally ill patient.

An understanding of the impact of attitudes and experiences about death and dying inrelation to caring for terminally ill patients.

KNOWLEDGE

In the appropriate setting, the resident should demonstrate the ability to apply knowledge

of:

1. The philosophy of palliative care


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a. Home-based approach

b. Family-as-care unit

c. Pain control

d. Symptom control

2. Hospice team roles

a. Physician

I. Identification of appropriate patients for hospice care

1). Cancer-related

2). Non-cancer-related

a). Pulmonary

b). Cardiovascular

c). Neurologic

d). Infectious

ii. Referral process and criteria

iii. Insurance and medical care coverage

iv. Cost of care for terminally ill in various settings

b. Nurses c. Social worker

d. Pharmacists

e. Home health care aides

f. Volunteers

g. Family

3. Prognosis of terminal illness

a. Accuracy of prognosis

b. Clinical indicators of time until death

c. Value of medical therapies

d. Psychosocial stages of the dying process for patient and family

4. Major pain syndromes


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a. Neuropathic

b. Bone pain

c. Visceral pain

d. Non-physiologic pain

5. Pain control

a. Opiates (long- and short-acting)

b. Non-opiates

c. Addiction, habituation and dependence

d. Baseline dosing and rescue

e. Complementary and alternative medicines

f. Nonpharmacologic pain control measures

g. Side effects of pain control measures

6. Causes and treatment of non pain symptoms

a. Nausea

b. Shortness of breath

c. Loss of appetite

d. Vomiting

e. Sleeplessness

f. Depression

g. Anxiety

h. Cough

i. Constipation

j. Diarrhea

k. Xerostomia

7. Nutrition and hydration in the terminally ill

a. Artificial feeding

b. Intravenous fluids


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If the comatose client has not previously made his wishes known, family

members must be given accurate and truthful information.

For the person in irreversible coma, withholding artificial nutrition does not

causes death rather it allows life to take its natural course and it should be

discontinue to support nutritionally if the client request.

Mouth, Eyes & Nose:

MOUTH

Oral discomfort is the only documented side effect of dehydration in the terminally

ill client.

Both the administration of oxygen and mouth breathing increase the need for

meticulous oral care. Caregiver can use saliva substitutes and moisturizers to

alleviate discomfort.

Regular brushing of teeth should be encouraged and the tongue must also be given

the same attention as is the rest of the mouth.

Ice chips and sips of favourable beverages should be offered frequently andpetroleum jelly applied to the lips.

Oral care must be given every 2-3 hrs to maintain the clients comfort.

EYES

Due to the dryness the eyes may become irritated and artificial tears can alleviate

this discomfort

Therefore wiping off the tears from inner to outer cantus to remove the discharges.

NOSE

The nares may become dry and crusted. Oxygen given by the cannula can furtherirritate the nares.

So, a thin layer of water soluble jelly applied to the nares will be helpful to alleviate

discomfort.

Mobility:

As the clients condition deteriorates, mobility decreases. Te client become less able

to move about in bed or to get out of the bed and requires more assistance.

Therefore physical dependence increases the risk of complication related to

immobility. E.g Atrophy &pressure ulcer.

Nursing Management:

Frequently re-positioning according to the patient and considering the underlining

condition of the patient such as arthritis & lung disease.

Passive range of motion exercise should be done 2 times (twice) a day to prevent

stiffness and aching of the joints.

Using a wheelchair can also increase the clients environmental space, giving theclient more mobility, control, and independence.


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Skin Care

Prevention of pressure ulcer is the priority. These are painful and can cause

secondary complication such as sepsis and are costly to treat.

In addition to the care of the pressure point keeping the skin clean moisturized

promotes healthy tissue.

The skin should be inspected twice daily.

Gentle massages with soothing lotion are comforting.

Bed bath are adequate if the client cannot get into the tub or sit in the shower chair.

Elimination

Constipation may occur due to the side effects of the analgesics and the lack of

physical activities.

Fluids and foods with high fibre contained can be effective preventive measures for

the client with adequate oral intake.

It can also be alleviated by maintaining a scheduled time for bowel elimination and

administering suppositories if necessary

The client may have incontinence of bladder and bowel, so the nurse need to check

the client frequently, clean the skin the peri-wash, apply a moisture barrier after

each incontinence episode.

Comfort

Pain relief

Keep the patient clean and dry.

Provide a safe and non threatening environment

Provide a respectful, careful attitude to provide psychological comfort by

establishing good rapport.

Physical environment

A soothing physical environment can significantly increase the clients comfort

Adequate lighting enhances vision without causing discomfort associated with

harsh, glaring light.

Provide night light if patient requires

As the client circulation slightly sluggish, the body temperature will fall, so

providing a light weight comforters will be helpful to warmth without adding

uncomfortable weight.

Provide quite and calm environment.( even the phone can be removed if patient find

it disturbing.

Psychosocial needs

Death presents a threat to not only ones physical existence but to ones psychological

integrity.


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Even though in the presence of the nurse, the family members should be encouraged

and invited to participated in the clients care, if they desire to do so and the client is

willing

Maintain a well groomed appearance is important. cutting the nails, shaving the

beard will help to promote patients dignity.

Combing and brushing the hair not only improves appearance but is also acomforting and relaxing activity for many clients.

Spiritual needs

The nurses play a major role in promoting the dying clients spiritual comfort. Dying

persons are among the most vulnerable members of the human family

Communicate empathy

Play music

Use touch

Pray with the client

Contact clergy if requested by the client

Read religious literature aloud, at the patient request.

Support for the family

The family member needs to be involved in the care of their dying lived one.

Guilt may be increased by the feeling of powerlessness.

Involving the family members in the treatment is a helpful intervention

The families facing the impending death of the loved one require much support from

the nurses and the care givers.

o Being with the family members is extremely important

o

Provide assistance and guidance if the family members have limited copingskills and inadequate supporting system.

o She must be supportive and non judgmental

Legal consideration during death

The Patient Self Determination Act (PSDA) was incorporated into the Omnibus

budget reconciliation Act (OBRA) of 1990

The Act was intended to provide a legal means for individuals to determine the

circumstances under which life sustaining treatment should or should not be

provided to them. The individuals choice are validated by advanced directives

An advanced directive is any written instruction including a living will or durable

power of attorney for health care that is recognised under state law( Taylor 1995)

The act applied to hospitals, long term care facilities , home care agencies, hospice

programs, and certain health maintenance organisations (HMOS)

All the clients entering into the healthcare system through this organisation must be

given information regarding the complete care. It is necessary not only to inform

about the care but also the need to indicate the wishes in regarding to artificial

feeding, intubation, chemotherapy, surgery, blood transfusion etc.


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Although the living will and durable power of attorney for health care are legal

documents, they do not preclude the need for resuscitation

The medical record must have a written DNR (Do-Not-Resuscitate) order from a

physician if this is in agreement with the client wishes and with the advanced

directives. In the absence of this order resuscitation is not initiated.

Ethical consideration during dying

Death is often fraught with ethical dilemmas that occur almost daily in health care

settings.

Many health care agencies have ethics committees to develop and implement

policies to deal with and to end-to-life issues

Ethical decision making is a complex issue. One of the most ethical dilemmas is

determining the difference between killing and allowing someone to die with

holding life-sustaining treatment methods.

The ANA distinguish reliving pain and mercy killing( euthanasia or assisted suicide)

Pain relief is a central value in nursing, where as euthanasia is viewed as unethical.

The ANAs position is that increasing dose of medication to control pain interminally ill client is ethically justified even at the expenses of maintaining life.

CONCLUSION

CPRis an emergency procedure which is attempted in an effort to return life to a person in

cardiac arrest. It is indicated in those who are unresponsive with no breathing or only

gasps. It may be attempted both in and outside of a hospital. CPR alone is unlikely to restart

the heart; its main purpose is to restore partial flow of oxygenated blood to the brain and

heart.It may delaytissue death and extend the brief window of opportunity for a successful

resuscitation without permanentbrain damage
http://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/wiki/Brain_damagehttp://en.wikipedia.org/wiki/Brain_damagehttp://en.wikipedia.org/wiki/Brain_damagehttp://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Cardiac_arrest

cardio pulmonary resuscitation and end of life care

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