CH 36 - GRIEF, LOSS, and P Flashcards
Grief is the
inner emotional response to
loss and
grief is exhibited through
thoughts, feelings,
and behaviors
Bereavement includes both
grief and mourning (the outward display of
loss) as the individual deals with the death of a
significant individual
Palliative or end‑of‑life care is an important
aspect of nursing care and attempts to meet
the client’s
physical, spiritual, and psychosocial
needs
Advance directives:
Legal documents that direct
end‑of‑life issues
Living will:
Directive documents for medical treatment
per clients’ wishes
Health care proxy
(also known as durable power of
attorney for health care): A document that appoints
someone to make medical decisions when clients are no
longer able to do so on their own behalf
TYPES OF LOSS
necessary loss
Actual Loss
Perceived loss
Maturational or developmental loss
situational loss
anticipatory loss
Necessary loss:
A loss related to a change that is part of
the cycle of life and is anticipated but still can be intensely
felt. This type of loss can be replaced by something
different or better.
Actual loss:
Any loss of a valued person, item, or status
(loss of a job) that others can recognize
Perceived loss:
Anything clients define as loss but that is
not obvious or verifiable to others
Maturational or developmental loss:
Any loss normally
expected due to the developmental processes of life. These
losses are associated with normal life transitions and help
people develop coping skills (a child leaving home for
college).
Situational loss:
Any unanticipated loss caused by an
external event (a family loses their home during tornado)
Anticipatory loss:
Experienced before the loss happens
KÜBLER‑ROSS MODEL
Denial
Anger
Bargaining
Depression
Acceptance
Denial:
The client has difficulty believing in an expected
or actual loss.
Anger:
The client directs anger toward the self, others, a
deity, objects, or the current circumstances.
Bargaining:
The client negotiates for more time or a cure.
Depression
The client is overwhelmingly saddened by the
inability to change the situation.
Accetpance
The client acknowledges what is happening
and plans for the future by moving forward.
In the Kubler Ross Model of Grief Clients might not experience these
stages in order, and the length of each
stage
varies from person to person
FACTORS INFLUENCING LOSS,
GRIEF, AND COPING ABILITY (9)
Current stage of development
● Gender
● Interpersonal relationships, social support networks
● Type, significance of loss
● Culture, ethnicity
● Spiritual, religious beliefs and practices
● Prior experience with loss
● Socioeconomic status
● Coping strategies
FACTORS THAT CAN INCREASE AN INDIVIDUAL’S RISK FOR
DYSFUNCTIONAL GRIEVING (4)
Being exceptionally dependent on the deceased
● Unexpected death at a young age, through violence or in
a socially unacceptable manner
● Inadequate coping skills, lack of social supports
● Lack of hope or preexisting mental health issues
(depression, substance use disorder)
MANIFESTATIONS OF GRIEF REACTIONS -Normal Grief
This grief is considered uncomplicated.
● Emotions can be negative, (anger, resentment,
withdrawal, hopelessness, and guilt) but
should change to acceptance w/ time.
● Some acceptance should be evident
by 6 months after the loss.
● Somatic complaints can include chest pain, palpitations,
headaches, nausea, changes in sleep patterns, and
MANIFESTATIONS OF GRIEF REACTIONS -Anticipatory Grief
This grief implies the “letting go” of an object or person
before the loss, as in a terminal illness.
● Individuals have the opportunity to start the grieving
process before the actual loss.
Types of complicated grief include
chronic, exaggerated,
masked, and delayed grief.
MANIFESTATIONS OF GRIEF REACTIONS -Complicated Grief
Types of complicated grief include chronic, exaggerated,
masked, and delayed grief.
● Complicated grief involves difficult progression through
the expected stages of grief.
● Usually, the work of grief is prolonged. The manifestations
of grief are more severe, and they can result in depression
or exacerbate a preexisting disorder.
● The client can develop suicidal ideation, intense feelings
of guilt, and lowered self‑esteem.
● Somatic complaints persist for an extended period of time.
MANIFESTATIONS OF GRIEF REACTIONS -Disenfranchised Grief
This grief entails an experienced loss that cannot be publicly
shared or is not socially acceptable (suicide and abortion).
Nursing interventions - Ways to faciliate mourning - allow time for
grieving process
Nursing interventions - Ways to faciliate mourning - identify expected grieving behaviors
crying, somatic
manifestations, and anxiety
Nursing interventions - Ways to faciliate mourning -therapeutic communication
● Name emotion the client is feeling. For
example, the nurse can say, “You sound as though you
are angry.
● active listening, open‑ended questions,
paraphrasing, clarifying, summarizing,
while using therapeutic communication.
● Use silence / personal presence to facilitate mourning.
● Avoid communication that inhibits open
expression of feelings .
● Assistgrieving individual to
accept reality of loss.
● Support efforts to “move on” in face of the loss.
● Encourage the building of new relationships.
● Provide continuing support. Encourage
support of family and friends.
● Share information about the tasks and stages of mourning
and grieving with the client, who might not realize that
feelings (anger toward the deceased) are expected.
● Provide information on available community resources.
Nursing interventions - Ways to faciliate mourning -therapeutic communication - DO NOT DO THESE
(offering false reassurance,
giving advice, changing the subject, and taking
the focus away from the grieving individual)
When relating to someone who is bereaved, avoid
cliches
(“They are in a better place now.”). Rather, encourage
the individual to share memories about the deceased.
What is an example of ineffective coping with grieving process
Assess for evidence of ineffective coping (a client refusing
to leave the home months after the death of a partner).
Palliative care
● The nurse serves as an advocate for the client’s sense of
dignity and self‑esteem by providing palliative care at
the end of life.
what is goal of palliative care
Goal is to learn to live fully with an incurable condition
Palliative care improves what
quality of life of clients and
their families facing end‑of‑life issues.
Palliative care interventions are primarily used when
caring for clients who
are dying and family members
who are grieving but can be used for any client who has
a chronic or curable illness, regardless of the stage of
the disease process. Assessment of the client’s family is
very important as well
Palliative care interventions focus on
the relief of
physical manifestations (pain) as well as addressing
spiritual, emotional, and psychosocial aspects of the
client’s life
what type of team provides palliative care
interprofessional team of physicians, nurses, social
workers, physical therapists, massage therapists,
occupational therapists, music/art therapists, touch/
energy therapists, and spiritual support staff
Hospice care is comprehensive care delivered in
variety of settings,
can be implemented when a client is not
expected to live > 6 months.
in hopsice care, further medical care aimed toward a cure is
stopped
what is focus of hospice care
enhancing quality of life and supporting the
client toward a peaceful and dignified death
CHARACTERISTICS OF DISCOMFORT
Pain
● Anxiety
● Restlessness
● Dyspnea
● Nausea, vomiting
● Dehydration
● Diarrhea, constipation
● Urinary, fecal incontinence
● Inability to perform ADLs
MANIFESTATIONS OF APPROACHING DEATH
Decreased level of consciousness
● Loss of muscle tone, with obvious relaxation of the face
● Labored breathing (dyspnea, apnea, Cheyne‑Stokes
respirations), “death rattle”
● Touch diminished, but client is able to feel the
pressure of touch
● Mucus collecting in large airways
● Incontinence of bowel and/or bladder
● Mottling, cyanosis occurring with poor circulation
● Pupils no longer reactive to light
● Pulse slow and weak, blood pressure dropping
● Cool extremities
● Perspiration
● Decreased urine output
● Inability to swallow
PREVENTION OF ABANDONMENT
AND ISOLATION
Prevent fear of dying alone.
● Make your presence known - answering call lights -
timely manner / making frequent contact.
● Keep client informed of procedure /
assessment times.
● Allow family members to stay overnight.
● Determine where client is most comfortable (in a
room close to nurses’ station).
● If client chooses to be at home, consider moving
client’s bed to a central location in home rather than
isolated bedroom.
Postmortem care - Nurses are responsible for following federal and state
laws regarding requests for
organ or tissue donation,
obtaining permission for autopsy, ensuring the
certification and appropriate documentation of the
death, and providing postmortem (after‑death) care.
After postmortem care is completed, who
becomes the nurse’s primary focus
the client’s family
provider certifies death by
pronouncing the time and documenting therapies used,
and actions taken prior to the death.
post mortem
● Elevate the client’s head to prevent
facial discoloration
by raising the head of the bed and placing a pillow
under the head and shoulders. Do this as soon as
possible after the client’s death
PREPARING THE BODY FOR VIEWING Cleanse and align the body how
supine with a pillow under
the head, arms with palms of hand down outside the
sheet and blanket, dentures in place, and eyes closed
fresh linens with absorbent pads on bed
and a gown.
Brush/comb the client’s hair. Replace any hairpieces.
Remove excess supplies, equipment, soiled linens
from room.
● Dim lights / minimize noise to provide a
calm environment.
Postmortem of infant - Adhere to the same procedures as adult except for
Swaddle the infant’s body in a clean blanket.
◯ Transportinfant in nurse’s arms or in an
infant carrier based on facility protocol.
◯ Offer mementos of infant (identification bracelets,
footprints, the cord clamp, a lock of hair, photos)
requests for tissue and organ donations
must be made by
specifically trained personnel.
Maintain ventilatory and cardiovascular support for
vital organ retrieval.
who typically approaches the family to request an autopsy
provider
nurse’s role with regard to autopsy
answer the family members’
questions and support their choices
Autopsies can be conducted to
advance scientific
knowledge regarding disease processes, which can lead
to the development of new therapies
The law can require an autopsy to be performed if the
death is due to
homicide, suicide, or accidental death, or
if death occurs within 24 hr of hospital admission
Most facilities require that all tubes
remain in place for
an autopsy
autopsy Documentation and completion of forms following
federal and state laws typically includes the following.
Who pronounced the death and at what time
◯ Consideration of and preparation for organ donation
◯ Description of any tubes or lines left in or on the body
◯ Disposition of personal articles
◯ Who was notified, and any decisions made
◯ Location of identification tags
◯ Time the body left the facility and the destination
Caring long‑term for clients can create____ for nurses
personal attachments
Nurses can use coping strategies (with consideration of
professional boundaries) (5)
Going to the client’s funeral
◯ Communicating in writing to the family
◯ Attending debriefing sessions with colleagues
◯ Using stress management techniques
◯ Talking with a professional counselor
List five physical care
interventions appropriate for the care of a client who is dying
Give priority to controlling findings.
● Administer medications - manage pain, air hunger, and anxiety.
● Perform ongoing assessment - determine effectiveness
of treatment, need for modifications of
treatment plan (lower or higher doses of medications).
● Manage adverse effects of medications.
● Reposition client to maintain airway patency / comfort.
● Maintain integrity of skin / mucous membranes.
● Provide an environment - promotes dignity / self‑esteem.
● Remove products of elimination ASAP - maintain clean / odor‑free environment.
● Offer comfortable clothing.
● Provide careful grooming for hair, nails, skin.
● Encourage family members to bring comforting
possessions - make client feel at home.
● If appropriate, encourage use of relaxation
techniques, (guided imagery / music).
● Promote decision‑making in food selection, activities,
health care - give client as much control as possible.
● Encourage client to perform ADLs as able / willing to do so.
List five psychological care interventions
appropriate for the care of a client who is dying
Use an interprofessional approach.
● Provide care to client / family.
● Use volunteers when appropriate to provide nonmedical care.
● Use therapeutic communication - develop /
maintain nurse‑client relationship.
● Facilitate understanding of information regarding
disease progression / treatment choices.
● Facilitate communication between client, family, provider.
● Encourage client - participate in religious / other
practices - bring comfort / strength, if appropriate.
● Assist client in clarifying personal values in
order to facilitate effective decision‑making.
● Encourage client - use coping mechanisms
-worked in the past.
● Be sensitive to comments made in presence of clients who
are unconscious - hearing is last sensation lost.
What is the last sensation lost when dying
hearing
- A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self‑care should the nurse communicate to the family?
A. Allowing the client to function independently
will strengthen muscles and promote healing.
B. The client needs privacy at times for
self‑reflecting and organizing life.
C. The client’s sense of loss can be lessened
through retaining control of some areas of life.
D. Performing ADLs is a requirement prior to
discharge from an acute care facility.
- A. Strengthening of muscles is not a priority of palliative care.
B. Privacy for periods of self‑reflection can be achieved at times apart from performance of ADLs.
C. CORRECT: Allowing the client as much control as possible maintains dignity and self‑esteem.
D. Performance of ADLs is not a criterion for discharge from an acute care facility.
- A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, “I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child’s wedding.” Based on the Kübler‑Ross model, which stage of grief is the client experiencing?
A. Anger
B. Denial
C. Bargaining
D. Acceptance
- A. This statement does not reflect anger.
B. The client is not denying the severity of the diagnosis and prognosis.
C. CORRECT: The client is bargaining by attempting to negotiate more time to live to see the child get married.
D. Although the client might have accepted his diagnosis and prognosis, this statement does not convey coming to terms with the situation.
- A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, “I hate them for leaving me.” Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.)
A. “Would you like me to contact the chaplain to come and speak with you?”
B. “You will feel better soon. You have been expecting this for a while now.”
C. “Let’s talk about your children and how they are going to react.”
D. “You know, it is quite normal to feel anger toward your loved one at this time.”
E. “Tell me more about how you are feeling.”
- A. CORRECT: Asking whether the grieving individual desires spiritual support at this time is an acceptable nursing intervention to facilitate mourning.
B. Avoid giving false reassurance and offering assumptions while intervening to facilitate mourning.
C. Avoid changing the subject and bringing the focus away from the grieving individual while intervening to facilitate mourning.
D. CORRECT: Educate the grieving individual about the grieving process and emotions to expect at this time.
E. CORRECT: Encourage the open communication of feelings by using therapeutic communication to facilitate mourning.
- A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client’s family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include?
A. Regular breathing patterns
B. Warm extremities
C. Increased urine output
D. Decreased muscle tone
- A. Labored breathing and irregular patterns indicate imminent death.
B. Cool extremities indicate imminent death.
C. Decreased urine output indicates of imminent death.
D. CORRECT: Muscle relaxation is an expected finding when a client is approaching death.
- A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.)
A. Remove the dentures from the body.
B. Make sure the body is lying completely flat.
C. Apply fresh linens and place a clean gown on the body.
D. Remove all equipment from the bedside.
E. Dim the lights in the room.
- A. Insert the client’s dentures so that the face looks as natural as possible.
B. The body should not be completely flat. Place one pillow under the head and shoulders to prevent discoloration of the face.
C. CORRECT: The body and the environment should be as clean as possible. This includes washing soiled areas of the body and applying fresh linens and a clean gown.
D. CORRECT: The environment should be as clutter‑free as possible. The nurse should remove all equipment and supplies from the bedside.
E. CORRECT: Dimming the lights helps provide a calm environment for the family.
