How to Assess a Dying Patient

A nursing assessment of someone who is about to die is a special one that nobody really teaches you how to do; it's as if nursing instructors think you should just...KNOW. So I thought I'd write up a little post about it.

Keep a few things in mind. First, dying people don't like noise. They're mostly pretty tuckered out and seem to be concentrating on the task at hand, so keep your voice low and avoid your Perky Nurse Tone or chatting them up. Second, they may be unable to participate in your assessment at all. It can be similar to an assessment of a plain old unconscious person. Third, "normal" has to be skewed. Crazy vital signs and deranged assessments become the norm. What you find cannot be construed as abnormal.

Neuro: The person will go through decreasing levels of consciousness until they may be totally unresponsive. Don't go pressing their nail beds to assess this. It's mean. They may be progressively confused, talking to people you can't see. They typically sleep almost all the time (as I've said [before], it's called actively dying for a reason).

Vital signs: These get funky. As the process really gets under way, typically the heart rate will go up and blood pressure will decrease. A fever is common. Respirations will be all over the map (more on that below), and the oxygen saturation will drop no matter how much oxygen is flying through the nose hose. Don't be surprised if you get these vital signs: 102.2, 130, 28, 78/32, 82%.

Respiratory: Lots of weirdness here. Changes in breathing are important to notice. There is the infamous death rattle to contend with, and if you hear it, you'll know that you're probably looking at 72 hours or less. The lungs will sound like a swimming pool housing a woodwind section. Accessory muscles will be used, particularly diaphragmatic breathing: the patient may start doing a two-part breath, using the diaphragm to kind of squeeze the last of a breath out. Start looking for apeneic spells, and count how long they are. They may be combined with very fast respirations as well. The very last breaths you may see are agonal breaths, and these may be nothing more than the person opening and closing their jaw a few times.

Skin: Google “mottling images” if you haven’t seen mottling before. It can happen anywhere, including the nose and ears, but mostly it starts on the bottoms of the feet, around the knees, or on the lower legs. The skin may be very cool or very hot, if the patient has a fever. The patient may be pale, flushed, cyanotic, sallow, or even downright yellow. All are normal.

Output: People usually quit eating and drinking a few days before death. If someone is very edematous, it takes longer to eliminate those fluids, but at some point urination will stop. Track what’s going in and out.

This is just a short bit on the basics, and they apply to someone dying a natural death. All bets are off when you start contending with ventilators and intravenous fluids and medicines. I have much more to say about all of this so I may write more in-depth posts at some point: leave comments or send me an e-mail if there’s something you all want to know about.