Post Mortem Care and Other Funda Checklist

MISSION
VISION “MABINI COLLEGES provides quality

“MABINI COLLEGES shall cultivate instruction, research and extension service
a CULTURE of EXCELLENCE in programs at all educational levels as its
Education.” MABINI COLLEGES, INC. monumental contribution to national and global
Governor Panotes Avenue, growth and development.
Daet, Camarines Norte Specifically, it transforms
Tel. no. (054) 721-1281 local 102 students into:
Email: [email protected] God – fearing
Nation – loving
NAME________________________________COURSE&SEC____________
DATE________________________________ SCORE__________________
CARE OF THE BODY AFTER DEATH
(POST MORTEM CARE)
EQUIPMENT:
Bath towels, washcloths, washbasin, scissors, shroud kit with name tags, bed linen, documentation
forms.
STEP 5 4 3 2 1
1. Confirm that the health care provider certified the

death and documented the time of death and
action taken.
2. Determine if the health care provider requested an
autopsy. An autopsy is required for deaths that
occur under certain circumstances.
3. Validate the status of request for organ or tissue
donation. Given the complex and sensitive nature
of such requests, only specially trained personnel
make the requests. Maintain sensitivity to
personal, religious, and cultural beliefs in this
process.
4. Identify the patient using two identifiers (e.g.,
name and birthday or name or medical record
number according to agency policy).
5. Provide sensitive and dignified nursing care to the
patient and family.
a. Elevate the head of the bed as soon as possible
after death to prevent discoloration of the face.
b. Collect ordered specimens.
c. Ask if the family wishes to participate in the
preparation of the body. Offer to make
arrangements for supportive company for the
family (patient/ family religious leader, spiritual
care personnel, or bereavement specialist)
during body preparation.
d. Ask about family requests for body preparation
such as wearing special clothing or religious
artifacts. Be aware that personal, religious, or
cultural practices determine whether or not to
shave male facial hair. Get permission before
shaving beard.
e. Remove all equipment, tubes and indwelling
lines. Note that autopsy or organ donation
often poses exception to removal; thus consult
agency policy in these situations.
f. Cleanse the body thoroughly, maintaining the
safety standards for body fluids and
contamination when indicated. Comb patient’s
hair or apply personal hairpieces.
g. Cover body with a clean sheet, place head on
pillow, and leave arms outside covers if
possible. Close eyes by gently holding them
shut; leave dentures in the mouth to maintain
facial shape; cover any sign of the body
trauma.
h. Prepare and clean environment, deodorize
room if needed, and lower the lights.
i. Offer family members the option to view the
body and ask if they want you or other support
people to accompany them. Honor and respect
individual choices.
j. Encourage grievers to say good bye in their
own way; words, touch, singing religious
rituals, or prayers.
k. Provide privacy and well ventilated atmosphere.
Assess family members’ need or desire for your
presence at this time. If you leave, tell them
how to reach you.
l. Determine which personal belongings stay with
the body (e.g., wedding ring or religious
symbol) and give other personal items to family
members. Document time, date, description of
the items taken, and who received them. Save
any items that are left behind accidentally and
contact family for further instructions.
m. Apply identifying name tags and shroud
according to agency policy before transporting
the body. Follow safety procedures for body
fluid precautions or contamination concerns.
n. Complete documentation in the narrative notes
o. Maintain privacy and dignity when transporting
the body to another location; cover the body or
stretcher with a clean sheet.
_____________________________________________ _________________________________
STUDENT SIGNATURE OVER PRINTED NAME CLINICAL INSTRUCTOR
MISSION
NAME________________________________COURSE&SEC____________Nation – loving
DATE_____________ SCORE:_________________
ASSESSING APPEARANCE AND MENTAL STATUS
STEP 5 4 3 2 1
1. Explain to the client what you are going to do,

why it is necessary, and ho he can cooperate.
2. Wash hands and observe appropriate infection

control procedures.
3. Provide for client privacy.
4. Observe body build, height, and weight in relation

to the client’s age, lifestyle, and health.
5. Observe the client’s posture and gait, standing,
sitting, and walking.
6. Observe the client’s overall hygiene and grooming.
Relate these to the person’s prior to the
assessment.
7. Note body and breathe odor in relation to activity
level.
8. Observe for signs of distress in posture or facial
expression.
9. Note obvious signs of health or illness.
10. Assess the client’s attitude.
11. Note the client’s affect/mood; assess the

appropriateness of the client’s responses.
12. Listen for relevance and organization of
speech.
13. Listen for relevance and organizations of
thoughts
14. Document findings in the client record.
____________________________________ ________________________________
MISSION
Nation – loving
NAME________________________________COURSE&SEC_____________
DATE_____________ SCORE:__________________
ASSESSING THE MUSCULOSKELETAL SYSTEM
STEP 5 4 3 2 1
1. Assemble equipment and supplies:

● Goniometer
1. Explain do the client what you are going to do,
why it is necessary, and how she can operate.
2. Wash hands and observe other appropriate
infection control procedures.
4. Determine client’s history of the following:

● History or presence of muscle pain: onset,
location, character, associated phenomena,
aggravating and alleviating factors
● Any limitations to movement or inability to
perform activities of daily living
● Previous sports injuries
● Any loss of function without pain

5. Inspect the muscle for size.
6. Inspect the muscles and tendons for contractures.
7. Inspect the muscles for fasciculation and tremors.
8. Palpate muscles at rest to determine muscle

tonicity.
9. Palpate muscles while the client is active and
passive for flaccidity, spasticity, and smoothness of
movement.
10. Test muscle strength. Compare the right
side with left side.
11. Inspect the skeleton for normal structure
and deformities.
12. Palpate the bones to locate any areas of
edema or tenderness.
13. Inspect the joint for swelling.
14. Assess joint range of motion.

15. Document findings in the client record.
MISSION
Nation – loving
NAME________________________________COURSE&SEC_____________
DATE_____________ SCORE:__________________
ASSESSING THE NEUROLOGICAL SYSTEM
STEP 5 4 3 2 1

● Percussion hammer
● Tongue depressors (one broken diagonally,

for testing pain sensation)
● Wisps of cotton, to assess light touch
sensation
● Test tubes of hot and cold water, for skin
temperature assessment (optional)
1. Explain to the client what you are going to do, why
it is necessary, and how he can cooperate.
2. Wash hands and observe other appropriate
infection control procedures.
4. Determine client’s history of the following:

● Presence of pain in the head, back, or
extremities, as well as onset and
aggravating and alleviating factors.
● Disorientation to time, place or person
● Speech disorders
● Any history of loss of consciousness,

fainting, convulsions, trauma, tingling or
numbness, tremors or tics, limping,
paralysis, uncontrolled muscle movements,
loss of memory, or mood swings
● Alterations in smell, vision, taste, touch, or
hearing.
5. I f the client display difficulty speaking:
6. Point to common objects, and ask the client to

name them.
7. Ask the client to read some words and to match
the printed and written words with pictures.
8. Ask the client to respond to simple verbal and
written commands, e.g., “point to your toes” or
“raise your left arm”.
9. Determine the clients’ orientation to time, place,
and person by tactful questioning.
10. Listen for apses memory.
11. Test the ability to concentrate or attention

span by asking the client to recite the alphabet or
to count backward from 100.
12. Apply the Glasgow coma scale
13. Test cranial Nerves.

Cranial Nerve I-Olfactory
Ask client to close eyes and identify different mild
aromas, such as coffee, vanilla.
Cranial Nerve II-Optic
Ask client to read Snellen’s chart, check visual
fields by confrontation, and conduct an
opthalmoscopic examination.
Cranial Nerve III-Oculomotor
Assess six ocular movements and pupil reaction
Cranial Nerve IV-Trochlear
Assess six ocular movements.
Cranial Nerve V-Trigeminal
While clients looks upward, lightly touch lateral
sclera of eye to elicit blink reflex. To test light
sensation, have client close eyes and wipe a wisp
of cotton over client’s forehead and paranasal
sinuses. To test deep sensation, use alternating
blunt and sharp ends of a safety pin over same
area.
Cranial Nerve VI-Abducens
Assess directions of gaze.
Cranial Nerve VII-Facial
Ask client to smile, raise the eyebrows, frown, puff
out his cheeks, close his eyes tightly. Ask client to
identify various tastes place on tip and sides of
tongue-sugar, salt-and identify areas of taste.
Cranial Nerve VIII-Auditory
Assess client’s ability to hear spoken word and
vibrations of tuning fork.
Cranial Nerve IX-Glossopharyngeal
Apply tastes on posterior tongue for identification.
Ask the client to move tongue from side to side
and up and down.
Cranial Nerve X-Vagus
Assessed with CN IX; assess client’s speech for
hoarseness.
Cranial Nerve XI-Accessory
Ask client to shrug shoulders against resistance
from your hands and to turn his head to side
against resistance from your hand. Repeat for
other side.
Cranial Nerve XII-Hypoglossal
Ask client to protrude his tongue at midline, then
move it to side to side.
14. Test reflexes using a percussion hammer,
comparing one side of the body with other to
evaluate the symmetry of response.
15. Gross motor and Balance Tests
Walking Gait
Ask the client to walk across the room and back, and
assess the client’s gait.
Romberg’s Test
Ask the client to stand with feet together and arms
resting at the sides, first with eyes open, then closed.
Standing On One Foot With Eyes Closed
Ask the client to close his eyes and stand on one foot,
the the other. Stand close to the client during this
test.
Heel-Toe Walking
Ask the client to walk straight line, placing the heel of
one foot directly in front of the toes of the other foot.
Toe or Heel Walking
Ask the client to walk several steps on the toes and
then on the heels.
16. Fine motor Tests for the upper Extremities
Finger to Nose Test
Ask the client to abduct and extends the arms at
shoulder height and rapidly touch the nose alternately
with one index finger and then the other. Have the
client repeat the test with the eyes closed if the test is
performed easily.
Alternating Supination and Pronation of Hands
on Knees
Ask the client to pat both knees with the palms of
both hands and then with the backs of the hands
alternately at an ever-increasing rate.
Finger to Nose and the Nurse’s Finger
Ask the client to touch the nose and then your index
finger, held at a distance at about 45 cm (18 in), at a
rapid and increasing rate.
Fingers to Fingers
Ask the client to spread the arms broadly at shoulder
height and then bring the fingers together at the
midline, First with eyes open and then closed, first
slowly and then rapidly.
Fingers to Thumb (Same Hand)
Ask the client to touch each finger of one hand to the
thumb of the same hand as rapidly as possible.
17. Fine motor Tests for the Lower Extremities

Ask the client to lie supine and to perform these tests:
Heel Down Opposite Shin
Ask the client to place the heel of one foot just below
the opposite knee and run the heel down the shin to
the foot. The client may also use a sitting position for
this test.
Toe or Ball of Foot to the Nurse’s Finger
Ask the client to touch your finger with the large toe
of each floor.
18. Light-Touch Sensation.

Compare the light-touch sensation of symmetric areas
of the body.
Ask the client to close the eyes and to respond by
saying “yes or now” whenever the client feels the
cotton wisp touching the skin.
With a wisp of cotton, lightly touch one specific spot

and then the same spot on the other side of the body.
Test areas on the forehead, cheek, hand, lower arm,

abdomen, foot, and lower leg. Check a specific area of
the limb first.
Ask the client to point to the spot where the touch

was left.
If areas of sensory dysfunction are found, determine

the boundaries of sensation by testing responses
about every 2.5 cm (1 in) in the area. Make a sketch
of the sensory loss area for recording purposes.
19. Pain Sensation

Assess pain sensation as follows:
Ask the client to close his eyes and to say “sharp,”
“dull,” “don’t know” when the sharp or dull of end of
the broken tongue depressor is felt.
Alternately, use the sharp and dull end of the sterile

pin or needle to lightly prick designated anatomic
areas at random. The face is not tested in this
manner.
Allow at least 2 seconds between each test
20. Temperature Sensation

Touch skin areas with test tubes filled with hot or cold
water.
Have the client respond say saying “hot,” or “cold,”

“don’t know”.
21. Position or Kinesthetic Sensation

Commonly, the middle fingers and the large toes are
tested for the kinesthetic sensation.
To test fingers, support the client’s arm with one hand

and hold the client’s palm in the other. To test the toes,
place the client’s heels on the examining table.
Ask the clients to close his eyes
Grasp a middle finger or a big toe firmly between your

thumb and index finger, and exert the same pressure on
both sides of the finger or toe while moving it
Move the finger or toe until it is up, down or straight out,

and ask the client to identify the positions.
22. Tactile Discrimination

For all tests, the clients eyes need to be closed:
One and Two Point Discrimination
Alternately stimulate the skin with two pins
simultaneously and then with one pin. Ask whether
the client feels one or two pinpricks.
Stereognosis
Place familiar objects-such as a key, paper clip, or
coin-in the client’s hand, and ask the client to identify
them.
If the client has a motor impairment of the hand and

is unable to manipulate an object, write a number or
letter on the client’s palm, using a blunt instrument,
and ask the client to identify it.
Extinction Phenomenon
Simultaneously stimulate two symmetric areas of the
body, such as the thighs, the cheeks or the hands.
23. Documents findings in the client record.
____________________________________ ________________________________
MISSION
Nation – loving
NAME________________________________COURSE&SEC_____________
DATE_____________ SCORE:__________________
USING A BED OR CHAIR EXIT SAFETY MONITORING DEVICE
STEP 5 4 3 2 1
1. Assess:
● Mobility status
● Judgement about ability to get out of bed

safely
● Proximity of client’s room to nurse’s station
● Position of side rails
● Functioning status of call right

2. Determine:
● Appropriate location for the device
● If the device will be applied to a thigh,

ensure that the location has intact skin.
● Alarm and control device
● Sensor
● Connection to nurse call system (optional)

4. Explain to client and support persons the purpose
and procedure of using safety monitoring device.
Explain that the device does not limit mobility in

any manner; rather, it alerts the staff when the
client is about to get out of bed.
Explain that the nurse must be called when the

client needs to get out of bed.
5. Test the battery device and alarm sound.

6. Apply one sensor pad or leg band.
Place the leg band according to the manufacturer’s

recommendation. Place the client’s leg in straight
horizontal position.
For the bed or chair device, set the time delay for
determining the client’s movement patterns from 1
to 12 seconds.
Connect the sensor pad to the control unit and the

nurse call system
7. Instruct the client to call the nurse when the
client wants or need to get up, and assist as
required.
When assisting the client up deactivate the alarm.
Assist the client back to bed, and reattach the

alarm device
8. Ensure client safety with additional safety
precautions
Place call light within client reach, lift all side rails,
and lower the bed to its lowest position
Place ambulation monitoring stickers on the client’s

door, chat and Kardex
9. Document the type of alarm used, where it was

placed, and the effectiveness of alarm in the client
record.
10. Record all additional safety precautions and
intervention discussed and employed.
____________________________________ ________________________________
MISSION
Nation – loving
NAME________________________________COURSE&SEC_____________
DATE_____________ SCORE:_________________
IMPLEMENTING SEIZURE PRECAUTIONS
STEP 5 4 3 2 1
1. Explain to the client what you are going to do, why

it is necessary, and how he can cooperate.
control procedures.
3. Provide for client privacy
4. Pad the bed. Secure blankets or other linens

around the head, foot, and side rails of the bed.
5. Place oral suction equipment in place, and test to
confirm that it is functional.
6. If agency policy prescribes, tape the tongue
depressor that has been wrapped with gauze
padding or an oral airway within reach of the head
of the bed.
7. If a seizure occurs:
Remain with the client and call for assistance, if
needed.
If the client is not in bed, assist client to the floor

and protect the head in your lap or in a pillow.
According to policy, insert the airway or tongue

depressor between the client’s upper and lower
teeth.
Apply oxygen by mask.
Turn the client to a lateral position, if possible.

Time the seizure duration
Move items in the environment to ensure the client

does not experience an injury.
Observe the progression of the seizure, noting the

sequence and type of limb involvement. Observe
skin color. When the seizure allows, check pulse
and respirations.
Administer ordered anticonvulsant medications
Use equipment to suction the oral airway if the

clients vomits or has excessive secretions.
When the seizure has finished, assist client to a

comfortable position. Provide hygiene as
necessary. Allow client to verbalize feelings about
the seizure.
8. When the seizure has subsided, document

pertinent information in the client record.
____________________________________ ________________________________
MISSION
Nation – loving
NAME________________________________COURSE&SEC_____________
DATE_____________ SCORE:__________________
APPLYING RESTRAINTS
STEP 5 4 3 2 1
1. Explain to the client and family what you are going

to do, why it is necessary, and how they can
cooperate
control procedures.
3. Provide for client privacy, if indicated.
4. Apply the selected restraints
Belt Restraints (Safety Belt)

Determine that the safety belt is in good order. If a
Velcro safety belt is to be used, make sure that both
pieces of Velcro are intact.
If the belt has a long portion and a shorter portion, place

the long portion of the belt behind (under) the bedridden
client and secure it to the movable part of the bed frame.
Place the shorter portion of the belt around the client’s
waist over the gown. There should be finger’s width
between the belt and the client
Or:
Attach the belt around the client’s waist, and fasten it at
the back of the chair
Or:
If the belt is attached to a stretcher, secure the belt

firmly over the client’s hips or abdomen.
Jacket Restraint
Place vest on client, with opening at the front or the
back; depending on type.
Pull the tie on the end of the vest flap across the chest,
and place it through the slit in the opposite side of the
chest.
Repeat for the other tie.

Use a half—bow knot to secure each tie around the
movable bed frame, or behind the chair to a chair leg.
Fasten the ties together behind the chair using a square

(reef) knot.
Ensure that the client is positioned appropriately to
enable maximum chest expansion breathing.
Mitt Restraint
Apply the commercial thumb less mitt to the hand to be
restrained. Make sure the fingers can be slightly flexed
and are not caught under the hand.
Follow the manufacturer’s directions for securing the mitt.
If a mitt is to be worn for several days, remove it at least

every 2-4 hours. Wash and exercise the client’s hand,
then reapply the mitt. Check agency practices about
recommended intervals for removal.
Assess the client’s circulation to the hand shortly after the

mitt is applied and at regular intervals.
Wrist or Ankle Restraint

Pad bony prominences on the wrist or ankle, if needed to
prevent skin breakdown.
Apply the padded portion of the restraint around the

ankle or wrist.
Pull the tie of the restraint through the slit in the wrist
portion or through the buckle.
Using a half-bow or a square knot, as appropriate , attach

the other end of the restraint to the movable portion of
the bed frame.
5. Document:
Behavior(s) indicating the need for the restraint
All other interventions implemented in attempt to

avoid the use of restraints and their outcomes
The time the physician was notified of the need for

restraint
Also record:
The type of restraint applied, the time it was applied,
and the goal for its application
The client’s response to the restraint
The times that the restraints were removed and skin

care given
Any other assessments and interventions
Explanations given to the client and significant others

6. Adjust the plan of care as required.
____________________________________ ________________________________

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MISSION

VISION “MABINI COLLEGES provides quality

Tel. no. (054) 721-1281 local 102 students into:

Email: [email protected] God – fearing

1. Confirm that the health care provider certified the

Tel. no. (054) 721-1281 local 102 students into:

Email: [email protected] God – fearing

1. Explain to the client what you are going to do,

2. Wash hands and observe appropriate infection

4. Observe body build, height, and weight in relation

10. Assess the client’s attitude.

11. Note the client’s affect/mood; assess the

Tel. no. (054) 721-1281 local 102 students into:

Email: [email protected] God – fearing

1. Assemble equipment and supplies:

4. Determine client’s history of the following:

● Any loss of function without pain

6. Inspect the muscles and tendons for contractures.

7. Inspect the muscles for fasciculation and tremors.

8. Palpate muscles at rest to determine muscle

14. Assess joint range of motion.

Tel. no. (054) 721-1281 local 102 students into:

Email: [email protected] God – fearing

1. Assemble equipment and supplies:

● Tongue depressors (one broken diagonally,

4. Determine client’s history of the following:

● Any history of loss of consciousness,

6. Point to common objects, and ask the client to

11. Test the ability to concentrate or attention

13. Test cranial Nerves.

17. Fine motor Tests for the Lower Extremities

18. Light-Touch Sensation.

With a wisp of cotton, lightly touch one specific spot

Test areas on the forehead, cheek, hand, lower arm,

Ask the client to point to the spot where the touch

If areas of sensory dysfunction are found, determine

19. Pain Sensation

Alternately, use the sharp and dull end of the sterile

Allow at least 2 seconds between each test

20. Temperature Sensation

Have the client respond say saying “hot,” or “cold,”

21. Position or Kinesthetic Sensation

To test fingers, support the client’s arm with one hand

Ask the clients to close his eyes

Grasp a middle finger or a big toe firmly between your

Move the finger or toe until it is up, down or straight out,

22. Tactile Discrimination

If the client has a motor impairment of the hand and

23. Documents findings in the client record.

Tel. no. (054) 721-1281 local 102 students into:

Email: [email protected] God – fearing

USING A BED OR CHAIR EXIT SAFETY MONITORING DEVICE

● Judgement about ability to get out of bed

● Position of side rails

● Functioning status of call right

● If the device will be applied to a thigh,

● Connection to nurse call system (optional)

Explain that the device does not limit mobility in

Explain that the nurse must be called when the