Interpretation of the scope of practice of the South African

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                                                                                                 CRITICAL CARE

Interpretation of the scope                                         The aim of this paper is to describe, with practical
                                                                  examples, the professional-ethical responsibilities of the

of practice of the South                                          South African GGN. These responsibilities, in terms of the
                                                                  Scope of Practice (South African Nursing Council (SANG)
                                                                  Regulation 2598) as amended,2 regulate the practice of the
African critical care nurse                                       registered nurse in South Africa These are not
                                                                  specialisation-specific and are not always well understood
J. Scribante, M. E. Muller, J. Lipman                             by the practising GCN. It is also very important that all
                                                                  members of the critical care team understand and
                                                                  appreciate the professional-ethical responsibilities of the
GriticaJ care is a constantly evolving discipline. The aim of
this paper is to describe the professional-ethical
responsibilities of the South African critical care nurse
(CCN). These responsibilities, outlined in the Scope of
Practice (South African Nursing Ccuncil Regulation 2598),         Interpretation of the Scope of
are not speciaJisation-specmc and are not always well             Practice
understood by the practising CeN. The regulation consists
                                                                  The description of a profession's scope of practice is very
of 20 responsibilities, including supervision and
                                                                  difficult.. Anything that is left out automatically falls outside
maintenance of bodily mechanics, oxygen supply. acid
                                                                  the scope of practice. It is not advisable simply to list a
base status, fluids and electrotyte levels of patients. In this   series of procedures.'
paper each of these 20 responsibilities are used, with               To assist in the critical care patient's return to health, the
practical examples, to explain in detail the role of the          GCN engages in the nursing process, a methodology
CCN and the importance of this role in total patient              through which critical nursing care is provided. It includes
management As the discipline of critical care develops            assessment, planning, implementation and evaluation as
                                                                  continued and interlocking actions. Crucial decision-making
further the responsibilities of the CCN must adapt
                                                                  is reqUired in the various steps of the nursing process.
accordingly. This paper provides a framework for such
                                                                     The authors have interpreted the Scope of Practice
adaptation. It is only with the full understanding of             (R2598) as amended' for the South African CCN. Each point
professional--ethical responsibilities by aJl members of the      will be discussed with a short explanatory note illustrating
critical care team that the professional-ethical                  how the CCN is involved.
responsibilities of the CCN can be appreciated and utilised          The interpreted Scope of Practice is as follows:
S Afr Med J 1995; 85: 435-439.
                                                                  (a) 'The diagnosis of a health need and the
                                                                  prescribing, provision and execution of a nursing
                                                                  regimen to meet the needs of a patient or a group
                                                                  of patients or where necessary, by referral to a
AI1y nationaJly registered profession requires a description of   registered person. J
fts scope of practice to ensure that only persons registered
                                                                    The CCN is responsible for nursing the patient, 24 hours a
in that profession are permitted to conduct the actions
                                                                  day. This intense involvement places her in the position
related to n. Description of the scope of practice indicates
                                                                  where she is often the first to detect a change in the
how far a specific profession can expand legally.'
                                                                  patient's condition. The GGN should have the ability
   There are many unavoidable overlapping or grey areas           (knowledge, skills, values) to make a correct nursing
between the professions, especially between the health            diagnosis, and prescribe, provide and execute a nursing
professions. The problem is addressed in that the                 regimen. If necessary in view of the patient's condition the
practitioner never purports that she practises a profession
                                                                  CCN should report to another registered person, such as a
that she is not registered in. Both the critical care nurse       medical doctor or a registered GCN. Diagnosis is made
(CCN) and the physiotherapist will perform bronchial toilet       within a whole-person framework of body, mind and spirit,
on a mechanically ventilated patient, for example, but for the
                                                                  but focusing on the body.
CCN this is a nursing action and for the physiotherapist it is
a physiotherapy action. In these situations each profession
                                                                  (b) 'The execution of a programme of treatment or
has unique competency in its own practice domain.!
                                                                  medication prescribed by a registered person for a
                                                                  patient. '

                                                                  (c) 'The treatment and care of and the
Nursing Department., Rand Afrikaans University, Johannesburg      administration of medicine to a patient, including
J. Scribante. RN.. u..CUfl (PROF Nt..I'lSINGl                     the monitoring of the patient's vital signs and of
                                                                  his reaction to disease conditions, trauma, stress,
M. E. Muller. RN_ f..·m (PflOf MJRSINGl
                                                                  anxiety, medication and treatment.'
Department of Anaesthesia, University of the Witwatersrand,
                                                                    The CCN should have in-depth knowledge of the
                                                                  programme of treatment to be executed or the prescribed
J.lipman. MA aa-t. CA. FCA. FFA (CRIT. CARE)
     medication. She should know how the treatment or                   the reason for this inappropriate reading -     for example, is
     medication is going to act in a critically ill patient, because    the transducer at the correct level?
      the action might differ from that in less ill patients. For
      example, the dose of certain antibiotics should be adjusted       (d) 'The prevention of disease and promotion of
      according to the individual patient's needs. A patient in         health and family planning by teaching and
      acute renal failure may need a smaller than standard dose,        counselling individuals and groups of persons. '
      whereas a patient with an increased third-space loss. as in          This concept is not always associated with the high-tech
      septic shock, may need a bigger than standard dose to             critical care situation, but the critical care unit is one of the
      achieve an effective serum level of the antibiotic. The           ideal situations to prevent disease and promote health and
      indications, interactions and complications of medicines and      family planning. The patient and those close to him usually
      the treatment of adverse events should all be part of the         trust the CCN and respect her abilities; this promotes
      CCN's knowledge base, before the programme of treatment           confidence, which is essential for counselling and teaching.
      is executed or prescribed medication is given. If the             People confronted with critical illness go through various
      registered person who prescribed the treatment or                 stages of acceptance. The CCN should be sensitive and
      medication makes a mistake. and the CCN who executes              guide the patient and significant others accordingly. For
      the treatment or gives the prescribed medication does so          example, if the patient who has just had a myocandial
      without questioning the prescription. she and the registered      infarction has difficuny accepting his new physical state,
      person are both accountable for the wrong action. The             attempts by the CCN to educate him in the 'do's and don'ts'
      regulations do not specify or limit any route of medication       of his future might have a negative effect; she should rather
      administration; however, the CCN should have the ability          be gUiding the patient towards accepting his new physical
      (knowledge and skilQ when medication is given via a specific      state. Very often the patient is susceptible to guidance and
      route. Until recently it was not within the scope of practice     teaching to prevent further complications of disease and
      to administer medication epidurally, but in 1993 the SANC         promote health. The opportunity to promote family planning
      issued the following policy statement=' on epidural pain          does not often arise, but should be utilised when applicable
      control by the registered nurse and registened midwife:           - for example, women with pregnancy-induced
      'SANC views epidural analgesia as part of the registered          cardiomyopathy should be advised not to fall pregnant again.
      nurse's scope of practice. If the epidural analgesia is
      administered by the critical care nurse she should have the       (e) the prescription, promotion or maintenance of
      necessary knowledge or competence and is accountable for          hygiene, physical comfort and reassurance of the
      her acts and omissions.'                                          patient. '
         Monitoring the critically ill patient's vital signs, both
                                                                        (f) 'The promotion of exercise, rest and sleep with
     invasivety and non-invasivefy, comprises an important part
     of the CCN's direct patient care function. Vrtal sign              a view to healing and rehabilitation.'
     monitoring is one of the most dynamic fields in criIicaJ care         To maintain hygiene in a crilicaJly ill patient can pose
     units, with constant development of new technology. n is the       numerous problems. Hygiene needs, although a basic health
     CCN's responsibility to gain the necessary knowledge and           need, can only be met by a highly skilled CCN with the
     skill to use new technology safely. Furthermore, the CCN           necessary insight into the nature of each patient's particular
     should know the advantages and limilalions of invasive and         condition. The CCN should monitor the vital signs and look
     non-invasive monitoring methods. ft is now known that              out for a sudden change from baseline in the course of a
     blood pressure, which was so important for many years in           procedure.
     the criticaJ care unit, has a vast number of limitations. For         Physical comfort, rest and sleep are heaJth needs that are
     example, the way arterial blood pressure is measured poses         difficun to satisfy in the intensive care setting. High-tech
     a problem if there is a difference between non-invasive and        treatment methods can cause severe physicaJ discomfort.
     invasive measurement readings. Blood pressure is a product         An empathetic CCN who explains the necessity of the
     of flow and resistance and does not always reflect the             treatment can make the discomfort more tolerable. A patient
     body's needs. Measurements of regional blood flow, such as         who knows how important the intra-aortic balloon pump is
     gastric tonometry, may be of far greater value. It is policy in    in assisting his heart, and what complications will arise if he
     certain units to monitor vital signs on an hourly basis, but if    bends his legs, is likely to be more willing to keep his legs
     the patienrs condition is unstable, vital sign monitoring          straight in spite of the discomfort. The CCN can undertake
     should be done according to the patient's individual needs         various actions to ensure physical comfort, for example
     and be reflected in the patient's reconds.                         securing an endotracheal tube in such a way that tension to
        Accurate reconding of changing vital signs is essential. n is   the nose or mouth is minimised, and by asking the doctor to
     also important that the patient should be assessed                 prescribe medication to improve physical comfort. PaIienIs
     holislicaJly - he is not jUst a blood pressure or a pulmonary      in the critical care unit often complain of lack of sleep and
     capillary wedge pressure. Individual parameters should be          rest. The severity of their illness requires these units to be
     evaluated within the total clinical picture. For example, if the   planned in a way that is not conducive to the individual
     pulmonary artery capillary wedge pressure is suddenly              patient's privacy. There is always a certain noise level, and
     unexpectedly low, immediate therapeutic action should not          no distinguishing between day and night, and as far as the
     be taken - assess the patient's clinical state as a whole,         patient's condition permits, the CCN must ensure privacy,
     and if this low pressure is in keeping with the total clinical     control noise and take measures such as dimming lights at
     picture, undertake the appropriate action. If not, determine       night.

            Volllmt 85 NQ.5 M"1'995    SAMJ

                                                                                                CRITICAL CARE

(g) 'The facilitation of body mechanics and the                     The GGN should have in-depth knowledge of the various
prevention of bodily deformities in the execution                types of ventilators and modes of ventilation used in her
of the nursing regimen. J                                        specific unit, and be skilled in their use. The patient
  The facilitation of body mechanics includes actions such       receiving mechanical ventilatory support should be assessed
as positioning the patient to ensure adequate                    at least every hour. Assessment should include the patient's
haemodynamics. If the blooc pressure is very low the             own respiratory parameters as well as the ventilatory
patient will be placed in a supine position. The patient who     parameters. The importance of ventilator alarms cannot be
needs mechanical ventilatory support for unilateral lung         over-emphasised. Alarms should be set according to the
disease will be nursed lying on the healthy lung to ensure       individual patient's needs, and ventilator alarms should be
that it receives the maximum benefit of the mechanical           attended to when triggered. It might be necessary to restrain
ventilation. Gas moves to the area of less resistance, and by    a patient receiving mechanical ventilation to prevent a
correct positioning oxygen will go to the areas where it is      catastrophic event, and if so, this should be prescribed by a
most needed. A patient receiving full mechanical ventilatory     medical doctor and should be pertormed in the most
support is nursed as flat as possible to enhance the             humane way possible to ensure the patient's dignity.
ventilationlperfusion ratio. As soon as the patient is being        Oxygenation of the patient can be improved by
weaned from mechanical ventilatocy support he should be          pertorming the appropriate physiotherapy and bronchial
put in Fowler's position, as high as his condition allows,       toilet procedures. The patient should be mon~ored dUring
again to ensure an optimal ventilationlperfusion ratio. When     the whole procedure, and in particular the oxygen saturation
body mechanics are impaired by technology, the GGN must          should be measured by non-invasive pulse oximetry. Pre-
take action. The intubated patient, for example, cannot          oxygenation before bronchial toilet has become a standard
protect his own airway. The CCN ensures a protected airway       procedure.
by inflating the endotracheal tube to safe pressures and            There are various respiratory and ventilatory parameters
monitoring these pressures regularly.                            that should be assessed by the GGN, but these fall outside
  Critical care patients might receive muscle relaxants, or      the scope of this article. In the evaluation of ventilator and
just be immobile for long periods of time. Bodily deformities    respiratory parameters, a mistake often made is to assume
can be prevented by turning patients according to their          that an arterial blooc gas level is the gold standard of
needs, performing passive exercise, ensuring that the eyes       assessing respiratory function in the critically ill patient.
are kept moist and closed when patients cannot do this           When rt is difficutt to maintain mechanics of the patient's
themselves, and reducing tension on endotracheal tubes as        ventilation, for example in asthma, Guillain-Barre syndrome
previously described.                                            and organophosphate poisoning, assessment of peak flow
                                                                 or vital capacity is of much more relevance.
(h) 'The supervision over and maintenance of a                      The GGN can maintain oxygen supply to the tissues by
supply of oxygen.'                                               ensuring maintenance of an adequate cardiac output by
   Searle' has made ~ clear that oxygen supply does not          manipulating fluid or inotropic support according to the
only mean artificial oxygen supply, but includes oxygen          individual patient's needs. Oxygen demand of, and oxygen
supply to the tissues in all situations. The GGN should have     supply to, tissues and imbalance of these contribute to the
the necessary ability (knowiedge and skills) to supervise and    patient's compromised state. This can be influenced by the
maintain patients' oxygen supply.                                CCN in various ways, from the correct administration of
   An open airway should be obtained by pos~ioning the            prescribed medication and therapeutic procedures to
patient in the best way that his physical cond~ion permits.       keeping the patient on bed rest and ensuring a peacefUl,
As far as possible the GGN should anticipate that the patient    qUiet environment, thereby decreasing oxygen consumption.
is going to need artificial airway support and should do         The GGN should mon~or the patient's haemoglobin
everything practically possible to get medical help. When a       concentration, which reflects the oxygen-earrying capacity
natural airway can no longer be maintained and no medical         of blooc. Blooc transfusion was preViously used to
help is available, the patient should be intubated correctly      supplement low haemoglobin levels; today there is
and, if there is extreme airway obatruction, an emergency         controversy about ~s safety, and the oxygen-earrying
tracheostomy should be pertormed.                                 capacity of transfused blooc is questioned. Tourniquets
   Effective ventilation can be assured by positioning as         should be used with the utmost caution.
described under (g) above.
   When ventilation is supported by the use of an oxygen
                                                                 (i) 7he supervision over and maintenance of flUid,
                                                                 electrolytes and acid base of patients.•
mask, certain important principles should be taken into
account. When the patient is breathing normally the              (m) 'The supervision over and maintenance of
prescribed oxygen flow supply to the mask should be              elimination by a patient.'
adequate. The patient in respiratory distress often needs a
                                                                    The GGN should be able to assess hydration status
very high flow of oxygen because a distressed breathing
                                                                 clinically and with the available technology. The fluid status
pattern 'pulls' extra room air into the mask, thereby diluting
                                                                 of very ill patients is critical and the fluid balance shouid be
the fractional inspired oxygen concentration. The holes on
                                                                 accurately calculated daily but also on a cumulative basis.
the oxygen mask should never be covered. When a patient
                                                                 Electrolytes and acid base status should be assessed
w~h an oxygen mask is eating, pertorming mouth care or
                                                                 according to the patient's individual needs. The GGN should
shaving, the oxygen mask should always be replaced by
                                                                 have the ability (knowledge and skilQ to make a nursing
nasal cannulae.
                                                                 diagnosis when an electrolyte or acid base imbalance

                                                                                          SAMJ Volume 85 No. 5 May 1995
     occurs and should undertake emergency measures to                   of the utmost importance that the selected antibiotic be
     correct these imbalances, which can be life-threatening.            given in the correct way to ensure adequate serum levels
        Elimination should be monitored, and the CCN should              and optimal pharmacokinetics. Dosages of certain
     undertake the necessary nursing action to ensure                    antibiotics should be evaluated during the course of
     elimination.                                                        treatment by determining serum levels. In this way patients
                                                                         with renal impairment will not receive too high a dose and
     (j) 'The facilitation of the healing of wounds and                  those with a third-space loss will not be under-dosed.
     fractures, the protection of skin and the
     maintenance of sensory functions in a patient.'                     (I) 'The facilitation of the maintenance of nutrition
        This includes effective wound care. The CCN should be            of the patient. '
     knowledgeable about the most current wound care that will               Nutrition of the critically ill patient is of the utmost
     enhance wound healing. Prevention of wound infection is of           importance. Research in this field is very difficult, but there
     the utmost importance, and will include an effective infection       is increasing evidence that patients should be fed as quickly
     control programme in the critical care unit. Fractures should        as possible. It is better to feed the patient enterally than
     be immobilised effectively. The CCN should understand the            parenterally, for it is more natural and there is a lower risk of
     principle of orthopaedic traction to ensure effective               complications.
     immobilisation. Correct positioning of the patient to prevent           When enteral feeding is chosen, patients can be fed
     nerve and skin damage is important. The correct position            continuously or with bolus feedings. Different feeds are
     and the frequency of position change should be determined           available, none of which has been proved to be superior.
     by the individual patient's needs and physical condition.           Whichever feed or method of feed is chosen, the CCN
        The CCN should ensure that the critically ill patient            should know the advantages and disadvantages involved. If
     receives basic nutritional support that will provide essential      the patient is going to receive long-term enteral a1imentation,
     minerals, proteins and vitamins for the healing process, the        a thin, soft nasogastric tube should be considered. Its
     protection of skin and the maintenance of sensory functions.        correct position should be monitored while it is in place.
                                                                         Absorption should be checked according to the unit's policy.
     (k) 'The facilitation of the maintenance of bodily                      Bolus alimentation should be given after bronchial toilet,
     regulatory mechanisms and functions in a patient.'                  and endotracheal cuff pressure monitoring should be done
         The bodily regulatory mechanisms that most critical care        with the patient in a slightly elevated position, if his
      patients need to maintain, regardless of their underlying          condition permits.
      disease, are homeostasis of fluid, cardiovascular, respiratory,        Total parenteral alimentation is more expensive and
      renal and gastro-intestinal systems, and enhancement of            involves more risks than enteral feeding, but it has definite
      natural defence mechanisms.                                        advantages for selected patient groups. The CCN should be
         This statement encompasses many of the basic principles         aware of the complications involved and should take the
      of critical care. Owing to its vast scope it will be illustrated   necessary nursing actions to prevent them. The speed of
      by the sketch of a specific scenario. A patient with intra-        infusion should be monitored hourly. The increased viscosity
      abdominal sepsis develops septic shock and is admitted to          of the parenteral a1imentation might cause the infusion pump
      the critical care unit. The aim of critical care management,       not to function optimally. A slow infusion will result in the
      both medical and nursing, is to maintain body functions and        patient not receiving enough glucose. On the other hand, a
      regulatory mechanisms both naturally and artificially until the    too rapid infusion of glucose is detrimental to the unstable
      primary insult resolves.                                           critically ill patient, because increased insulin secretion may
        Respiratory function will be maintained by a mechanical          lead to a period of low blood glucose, especially if the
     ventilator. The mode of ventilation may vary from                   alimentation completed is premature and hours pass before
     uncomplicated volume control to complicated pressure-               the next day's parenteral feed is commenced.
     controlled ventilation with inverse ratios and high fractional         Total parenteral feeding should not be stopped abruptly
     inspired oxygen levels. These will be selected to satisfy the       when enteral feeding is going to be commenced. A 1- or
     individual patient's respiratory needs appropriately.               2-day period of overlap to ensure that the patient is
        It is of the utmost importance that cardiac output should        tolerating the enteral feeding may solve many problems.
     be maintained to ensure adequate blood flow to vital organs.           The CCN should be aware of clinical situations such as
     This can be done either by administration of vasa-active            renal failure which necessitate specific dietary limitations.
     medication or by fluid therapy, according to the patient's
     individual needs. The disease may cause a decrease in               (n) 'The facilitation of communication by and with
     blood flow to the gastro-intestinal tract as reflected by the       a patient in the execution of the nursing regimen. '
     intragastric mucosal pH, which may lead to translocation of            Patient records are vital communication instruments in the
     bacteria and bacterial products, a vicious circle in the septic     critical care unit, but the CCN should be aware of other
     shock process and a bad prognostic sign. The                        methods of communication. The patient himself
     cardiovascular status may therefore be evaluated by cardiac         communicates with the critical care team, sometimes very
     output measurements in conjunction with intragastric                subtly, and the CCN should be receptive to this. Being a
     mucosal pH by gastric tonometry.                                    good listener, giving clear explanations, consulting with the
        The choice of antibiotic will be influenced by the critical      patient and family, and the 'meaningful touch' improve
     care unit's antibiotic resistance profile and the laboratory        interpersonal relationships and are communication skills that
     sensitivity report on any tissue cultured from the patient. It is   every CCN should obtain.'

            Volumr 85 No.5 May 1995    SAMJ

                                                                                                                 CRITICAL CARE

(o) 'The facilitation of the attainment of optimum                   It is important that the CCN adheres to this policy to
health for the individual, the family, groups and                    safeguard her from possible legal problems. Although her
the community in the execution of the nursing                        focus is on the physical health needs of the critically ill
regimen.'                                                            patient, critical care nursing should accommodate the
  To ensure that optimal health is attained in the execution         whole-person approach of body, mind and spirit.
of the nursing regimen the CCN should be aware of recent
research, implement research findings and undertake
research to ensure high-quaJity nursing.
(p) 'The establishment and maintenance, in the                       The Scope of Practice (R2589) regUlates the practice of the
execution of the nursing regimen, of an                              registered nurse in South Africa. This regulation is not
environment in which the physical and mental                         specialisation-specific and should be interpreted for the
health of a patient is promoted.'                                    different nursing specialisations. The authors are of the
  This function entails all the activities relevant to the control   opinKJn that the interpretation of this regulation for critical
of the patient's situation, his environment, his nursing             care nursing would be of value for the CCN, critical care
regimens, his care and record keeping.'                              managers, Mors and all members of the intensive care
                                                                     health team.
(q) 'Preparation for and assistance with operative,                     In the management of the critical care patient it is
diagnostic and therapeutic acts for the patients. J                  sometimes vital to make crucial decisions before the
   Operative, diagnostic and therapeutic acts in the critical        situation becomes critical. Some of the authors'
care unit such as the insertion of an intercostal drain or a         interpretations might be contentious, but this will reflect the
pacemaker are often life-saving. It is of the utmost                 previously referred to 'grey areas'. While it is sometimes
importance that the CCN should have the necessary                    necessary to make critical decisions to prevent catastrophe,
knowledge and skills to assist in these procedures. If new           it is important to remember that although the CCN
diagnostic and therapeutic acts are implemented, it is her           undertakes these interactions as a nursing sister and not as
responsibility to obtain the skill and knowledge required to         a medical doctor, like a doctor she must take full
assist in these procedures safely before an emergency                responsibility for all actions undertaken. The problems
situation occurs, for example, continuous vena-vena-                 posed by the 'grey areas' in critical care patient
haemofittration.                                                     management can be addressed to some extent by standard
                                                                     policies in each unIT.
(r) 'The co-ordination of the health care regimens                       It is important to note that the interpretation of this
provided for the patient by other categories of                      regulation is dynamic and should be re-interpreted as the
health personnel. '                                                  practice of critical care evolves in order to ensure that the
  This is a very important professional function of the CCN,         patients receive quality care.
for various health personnel are involved in the treatment of
the critically ill patient. One doctor can order a diuretic while      This paper is part of a M.Cur. dissertation entitied: 'A South
                                                                     African critical care patient classification system', submitted to
another can order a fluid challenge on the same patient.
                                                                     the Nursing Department, Rand Afrikaans University, and
Proper co-ordination of the health care regimens guarantees
                                                                     presented in part at the 1994 Southern African Critical Care
high-quality care. The CCN should be aware of and point              Congress.
out discrepancies and even challenge such orders.
(s) 'The provision of effective patient advocacy to                  1.   Searle c. Profeuionele Praktyk: 'n Suid·A!riktiiilllSff VerpleegpetSpektief. 1s1 ed.
enable the patient to obtain the health care he                           Durban: 8ut1efWorth, 1987: 188·208.
                                                                     2.   South Atncan Nur$ing Council Regu/etJon 2598: Reguhluons RNting to the
needs.'                                                                   Scope of Pracrice of PersOM Who Are Registered or EnroI.ltKJ Under the Nur3ing
                                                                          Act '978. Pretona: South African NUl'Slng Council. 1991.
  The CCN is the member of the health team who is in the             3.   South Afm;;an Nursing CQurw;:JI. Epidural pain control by the regl$t-.d nurse and
                                                                          r8glstef'ed midwife. NUfSIIIg News 1993; H(8); 11.
best position to be the patient's advocate. This entails
ensuring that the patient's human rights are respected, and          Accepled 8 Feb 1995.
being a spokesman to make sure that his heatth needs are
met The CCN should at all times be self-assertive but

(t) 'Care of the dying patient and the care of a
recently deceased patient within the execution of
the nursing regimen.'
   The CCN should be able to give death guidance to the
critically ill patient and significant others when specialised
facilities for such guidance are not available. The South
African popUlation has many cultures. The CCN should
know and be sensitNe to their various practices with regard
to the dying patient and the dead body. Every unit has its
own policy for the nursing action involved in this situation.

                                                                                                         SAMJ Vollolmt 85 No. 5 MtlTI995

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