1. Chapter 45 Loss and Grief

2. 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.

3. 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.

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

5. 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

6. 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.

7. 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.

8. 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.

9. 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.

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

11. 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.

12. 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.

13. 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.

14. 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

15. 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.

16. 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.

17. 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.

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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.

33. 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.

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

35. 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

36. 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.

37. 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.

38. 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

39. 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

40. 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

41. 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.