Chapter 45 Loss and Grief

45-2 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Loss  Loss is any situation in which a valued object is changed or is no longer accessible to the individual.

45-3 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Loss  Maturational loss occurs as a result of moving from one developmental stage to another.  Situational loss occurs in response to external events.

45-4 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Loss  Actual loss  Perceived loss  Physical loss  Psychological loss

45-5 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Loss  Categories of Loss Loss of an external object Loss of familiar environment Loss of aspect of self Loss of significant other

45-6 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Loss  Loss as Crisis Loss precipitates anxiety and a feeling of vulnerability, which may lead to crisis. When an individual is overwhelmed and his or her usual coping mechanisms are no longer effective, crisis occurs.

45-7 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Loss  All Americans experienced significant loss as a collective, as a result of a terrorist attack in the World Trade Center on September 11, 2001.

45-8 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Grief  Grief is a normal, natural, necessary, and adaptive response following a loss. Bereavement is the period of grief following a significant loss, especially death of a person or pet. Mourning is the period of time during which the grief is expressed. Mourning is an adaptive response to loss.

45-9 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Grief  Theories of the Grieving Process Lindemann coined the phrase grief work. Engle described three stages of mourning. -Shock and Disbelief -Developing Awareness -Restitution and Resolution Worden identified four tasks in dealing with a loss.

45-10 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Grief  Types of Grief Uncomplicated grief Dysfunctional grief Anticipatory grief

45-11 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Grief  Persons experiencing dysfunctional grief do not progress through the stages of overwhelming emotions associated with grief, or they may fail to demonstrate any behaviors commonly associated with grief.

45-12 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Grief  Disenfranchised grief is grief experienced in situations where grief is discouraged and social supports are absent.

45-13 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Types of Grief  Anticipatory grief is the occurrence of grief work before an expected loss.  Promotes adaptive grieving by freeing up the mourner’s emotional energy.

45-14 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Factors Affecting Grief  Developmental Considerations Childhood Adolescence Early Adulthood Middle Adulthood Older Adulthood

45-15 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Children  Concept of death varies with the child’s developmental level.  Children need to be included in mourning rituals as appropriate to their developmental level.  Children need explanations about death that are honest and comprehensible.

45-16 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Adolescence  Adolescents perceive themselves as being invulnerable and death as something that will not happen to them.

45-17 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Middle Adulthood  The death of peers forces acknowledgement of one’s own vulnerability to death.  Other losses during middle age are those associated with changes in employment and relationships.

45-18 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Older Adulthood  Most older adults recognize the inevitability of death.  Older adults commonly experience the loss of loved ones and friends, occupational role, material possessions, dreams and hopes, and physical and cognitive function.

45-19 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Factors Affecting Grief  Religious and cultural beliefs  Relationship with the lost entity

45-20 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Factors Affecting Grief  Cause of Death Anticipated death Unexpected death Traumatic death Suicide

45-21 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Care of the Grieving Person  Assessment Determination of the personal meaning of the loss Understanding that the stages of grief the client is experiencing are not necessarily sequential

45-22 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Care of the Grieving Person  Nursing Diagnoses Dysfunctional Grieving Anticipatory Grieving

45-23 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Outcome Identification and Planning  Verbalization of feelings of grief  Sharing grief with significant others  Acceptance of the loss  Renewal of activities and relationships

45-24 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Listening to gain understanding of the significance of the client’s loss  A nonjudgmental, accepting attitude while the bereaved expresses anger  Appropriate referrals to community support groups

45-25 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Evaluation  Resolution of the loss is generally a process of life-long adjustment.  The nurse has a unique opportunity to lay the foundation for adaptive grieving.  Goals mutually established with client and family are the foundation for evaluation.

45-26 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Death  Stages of Death and Dying (Elizabeth Kubler-Ross) Denial Anger Bargaining Depression Acceptance

45-27 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Ethical and Legal Issues Related to End of Life  End-of-Life Care  Physician-Assisted Suicide

45-28 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Care Plan of the Dying Client  Assessment Client’s and family’s knowledge about the nature of terminal illness Availability of support systems Physical condition and symptoms Emotional status including depression

45-29 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Presence of advance directives for health care decisions  Concern about unfinished business  Client priorities and preparation needs

45-30 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Diagnoses  Powerlessness  Helplessness  High Risk for Spiritual Distress  Altered Family Processes

45-31 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Outcome Identification and Planning  Promoting an optimal quality of life  Treating client and family respectfully  Providing a safe environment  Meeting the holistic needs and goals of client and family

45-32 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Sitting with the client, touching the client, and being physically present are often the most effective in communicating a caring, compassionate, and accepting attitude.

45-33 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Care Plan of the Dying Client  Implementation Palliative Care -Focus is on symptom management. -The most common symptoms are pain, dyspnea, anxiety, and fatigue.

45-34 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Physiological Needs Nutrition Breathing Elimination Comfort Mobility

45-35 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Promoting Comfort Pain relief Keeping client clean and dry Providing a safe, nonthreatening environment

45-36 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Hospice Care Concept of allowing individuals to die with dignity and be surrounded by those who love them An interdisciplinary team is essential for delivering quality, compassionate care.

45-37 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Psychosocial Needs Clients may fear helplessness, dependence on others, loss of abilities, mutilation, uncontrollable pain.  Spiritual Needs Dying can be a time of spiritual crisis.

45-38 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Support for the Family  Learning Needs of Client and Family Client’s physical condition Treatment regimen How to handle medical crises Emergency care

45-39 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Evaluation  Evaluating the death experience for the family and friends  Determining if the goals for a peaceful death and provision of a supportive environment were met  Discussing the process in order to assist in providing care for future dying clients

45-40 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Care After Death  Care of the Body Physiological changes -Algor mortis -Liver mortis -Rigor mortis Autopsy Organ donation  Care of the Family

45-41 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nurse’s Self-Care  Grief is a common experience for many nurses who are confronted with death and loss daily.  To cope with their own grief, nurses need support, education, and assistance in coping with the death of clients.