Chapter 10: Grief and Loss Flashcards
Examples of necessary losses accompanying growth include
abandoning a favorite blanket or toy, leaving a first-grade teacher, adn giving up adolescent hope of becoming a famous rock star.
What is grief?
Subjective emotions and affect that are a normal response to the experience of loss
What is grieving?
Also known as bereavement, refers ot process by whcih person experiences the grief
What does grieving involve?
Not only the content (what a person thinks, says, feels) but also the process ((how a person thinks, says, and feels)
What is anticipatory grieving?
When people facing an imminent loss begin to grapple with the possibility of the loss or death in the near future
What is mourning?
Outward expression of grief. Rituals of mourning include having a wake, sitting shiva, holding religious ceremonies, and arranging funerals
Types of Losses: According to Maslow, hierarchy of needs motivates
human actions
Types of Losses: Levels of Maslow?
Physiologic Needs -> Safety Needs -> Security and Belonging -> Self Esteem -> Self Actualization
Type of Losses: Examples of Physiologic Loss?
Amputation of a limb, mastectomy, or hysterectomy, or loss of mobility
Type of Losses: Example of Safety Loss?
Loss of a safe environment evident in domestic violence, child abuse, or public violence
Type of Losses: Examples of Loss of Security and A sense of belonging?
Loss of a loved one affects the need to lvoe. Love accompanies changes in relationships
Type of Losses: Loss of Self-Esteem Example?
Any change in how a person is valued at work or in relationships. Deatho f a loved one, broken relationship, or loss of a job
Type of Losses: Loss related to self-actualization example?
External or internal crisis that blocks or inhibits striving toward fulfillment may threaten personal goals
Grieving Process: By understanding the phenomena that clients experience as they deal with the discomfort of loss, nurses may promote what?
The expression and release of emotional as well as physical pain during grieving
Who created some of the well known theories of grieving?
Elizsabeth Kubler-Ross
John Bowlby
George Engel
Mardi Horowitz
Kubler-Ross Stages of Grieving: What did she establish?
A basis for understanding how loss affects human life. Attended to clients with terminal illnesses. Developed a model of five stages to explain how people grieve and mourn
Kubler-Ross Stages of Grieving: What are the five stages in her model?
Denial Anger Bargaining Depression Acceptance
Kubler-Ross Stages of Grieving: What happens in denial?
Is shock and disblief regarding the loss
Kubler-Ross Stages of Grieving: What happens in Anger?
May be expressed toward God, relatives, friends, or health care providers
Kubler-Ross Stages of Grieving: What happens in Bargaining?
Occurs whne the person asks God or fate for more time to delay inevitable loss
Kubler-Ross Stages of Grieving: What happens in Depression?
Results when awareness of the loss becomes acute
Kubler-Ross Stages of Grieving: What happens in acceptance?
Occurs when the person shows evidence of coming to terms with death
Bowlby’s Phases of Grieving: What theory did he propose?
That humans instinctively attain and retain affectional bonds with significant others through attachment behaviors. Attachments crucial to the development of a sense of security and survival
Bowlby’s Phases of Grieving: People experience the most intense emotions when forming a bond such as
falling in love, maintaining abond such as loving someone, disrupting a bondas divorce, and renewing an attachment
Bowlby’s Phases of Grieving: An attach that is maintained is a source of
security
Bowlby’s Phases of Grieving: An attachment that is renewed is a source of
joy
Bowlby’s Phases of Grieving: When a bond is broken, person responds with
anxiety, protest, and anger
Bowlby’s Phases of Grieving: Described grieving process as what foour stages?
Experiencing numbness and denying the loss
Emotionally yearning for the lost loved one and protesting permanence of loss
Experiencing cognitive disorganization and emotional despair with difficulty functioning in everyday world
Reoganizing and reintegrating sense of self
Engel’s Stages of Grieving: Described grieving in what five stages?
Shock and Disbelief
Developing Awareness
Restitution
Resolution of Loss
Recovery
Engel’s Stages of Grieving: What happens in Shock and Disbelief
Initial reaction to loss is stunned, numb, accompanied by refusal to acknowledge the reality of the loss in attempt to protect the self against stress
Engel’s Stages of Grieving: What happens in developing awareness
As they acknowledge their less, there maybe crying , feelng of helplessness, frustration, or despair
Engel’s Stages of Grieving: What happens in Restitution?
Participation in the rituals assocaited with death such as funeral, wake, family gathering that help accept reality of loss
Engel’s Stages of Grieving: What happens in resolution of loss?
Individual preoccupied wiht the loss, lost person idealized, and mourner may imitate the lost person. Usually disappears after a year
Engel’s Stages of Grieving: What occurs in recovery?
Previous preoccupation and obsession ends and individual is able to go on with life
Horowitz Stages of Loss and Adaption: What does he do?
Divides normal grief into four stages of loss and adaptation
Horowitz Stages of Loss and Adaption: What are teh stages here?
Outcry
Denial and Intrusion
Working Through
Completion
Horowitz Stages of Loss and Adaption: What occurs in outcry?
First realization of loss. May be outward, expressed by screaming/yelling. Can also be suppressed. Takes great energy to sustain and short lived
Horowitz Stages of Loss and Adaption: What occurs in Denial and Intrusion?
People move back and forth during this stage.
Denial: Person becomes distracted or involved in activites that they sometime isnt thinking about loss.
Intrusion: Loss intrudes into every moment and activity
Horowitz Stages of Loss and Adaption: What occurs in working through?
As time passes, person spends less time bouncing back and forth between denial and intrusion
Horowitz Stages of Loss and Adaption: What occurs in completion?
Life begins to feel normal again, though different after losss. memories less painful. Pain occurs around anniversary dates
Tasks of Grieving: What is this?
Mourning, that the bereaved person face involve active rather than passive participation. Difficult and requires tremendous effort and energy to accomplish
Tasks of Grieving: What did Rando describe?
Taks inherent to grieving that she calls teh six Rs
Tasks of Grieving: What did Rando describe as the six R’s?
Recognize
React
Recollect and Reexperience
Relinquish
Readjust
Reinvest
Tasks of Grieving:What occur in recognize?
Expeirence the loss, understand it is real, and that is happened
Tasks of Grieving: What happens in react?
Emotional response to loss, feeling the feelings
Tasks of Grieving: What occurs in recollect and reexperience?
Memories are reviewed and relived
Tasks of Grieving: What occurs in relinquish?
Accepting that the world has changed and there is no turning back
Tasks of Grieving: What happens in Readjust?
Beginning to return to daily life. Loss feels like acute and ovewhelming
Tasks of Grieving: What occurs in reinvesting?
Accepting changes have occured, reentering world, , forming new relationships
Tasks of Grieving: How does Worden view Step 1 of Grieving?
Accepting reality of loss. Common for people initially to deny that loss occured. Too painful to acknowledge fully. Over time, personw avers between belief and denial . Funerals helpful to some
Tasks of Grieving: How does Worden view Step 2 of Grieving?
Working through the pain of grief. Loss causes pain, both physical and emotional, and must be deailt with. Attempting to avoid may delay or prolong grieving process
Tasks of Grieving: How does Worden view Step 3 of Grieving?
Adjusting to an environment that has changed because of loss. May take months for person to realize what life is like after the loss. Individual must develop new coping skills, adapt to new environment
Tasks of Grieving: How does Worden view Step 4 of Grieving?
Emotionally relocating that which has been lost and moving on with life. Bereaved person identifies a special place for what was lost and memories.
Questioning and Trying to Make Sense of the Loss: What may help someone accept the reality of why someone died?
Questioning. May help realize that losses are realities everyone must face
Emotional Responses to Grief: What are the predominant emotional responses to loss?
Anger, sadness, and anxiety
Emotional Responses to Grief: Example of anger and resentment?
He should have stopped smoking years ago
It took the doctor too long to diagnose his illness
Physiologic Responses to Grief: What issues may they complain of?
Insomnia, Headaches, Impaired Appetite, Weight Loss, Lack of Energy, Palpitations, Indigestion, and changes of the immune system
Cultural-Specific Rituals: What is acculturation?
Altering cultural values or behaviors as a way to adapt to another culture
Cultural-Specific Rituals: What do the Hmong believe?
That deceased persons enter the next world appear as she or he did at the time of death
Cultural-Specific Rituals & African Americans: What occurs in Catholic and Episcopalian services?
Hymns may be sung, poetry read, and eulogy spoken
Cultural-Specific Rituals & African Americans: Less form baptist and holiness tradition may involve what?
singing, speaking in other languages, and liturgical dancing
Cultural-Specific Rituals & African Americans: Mourning period may last how long?
few weeks to a few years
Cultural-Specific Rituals & Japanese Americans: Buddhist Japanese americans view death as?
life passage
Cultural-Specific Rituals & Japanese Americans: How does theirs occur?
Close family members bathe the decreased with warm water and dress in white kimono. For 2 days, family and friends bearing gifts may visit or offer money
Cultural-Specific Rituals & Filipino Americans: What is customary during mounring?
Wearing black clothing or armbands
Cultural-Specific Rituals & Filipino Americans: How do they celebrate?
Place wreaths on casket and drape a broad black cloth on the home of deceased. PLaces ads in newspaper asking for blessings
Cultural-Specific Rituals & Vietnamese Americans: They are predominately what?
Buddhists , who beathe and dressthem in black clothes
Cultural-Specific Rituals & Vietnamese Americans: What do they do?
Put few grains of rice in mouth and place money with deceased so they can buy drink as a spirit. Body displayed in home and when friends enter, music is played
Cultural-Specific Rituals & Hispanic Americans: They are predominately what?
Roman Catholic
Cultural-Specific Rituals & Hispanic Americans: How does this work?
Pray for soul during novena (9 day devotion) and rosary (devotional prayer). Wear black and try not to do events to not offend deceased. Bring flowers and crosses to decorate the grace
Cultural-Specific Rituals & Hispanic Americans: Guatemalan Americans may include what?
A marimba band in funeral procession and services. Lighting candles placed in home
Cultural-Specific Rituals & Native Americans: How does this work?
TRibes medicine man is an essential spiritual guide.
Ceremonies ward off depression.
Cultural-Specific Rituals & Native Americans: How can death be viewed?
As a state of unconditional love in which spirit of decreased remains present. Another belief in a happy afterlife called the land of the spirits
Cultural-Specific Rituals & Orthodox Jewish Americans: Jewish custom is for a relative to
stay with the dying person so soul does not leave body while person alone
Cultural-Specific Rituals & Orthodox Jewish Americans: How does this work?
Body covered with sheet. Eyes closed and untouched until someone can begin rites. Burial must occur within 24 hours unless delayed. Shiva then begins
Cultural-Specific Rituals & Orthodox Jewish Americans: What is Shiva?
7-day period that begins day of funeral. represents time for mourners to step out of day-to-day life to reflect on changes
Cultural-Specific Rituals: What could a nurse ask hispanic or latino client?
If they would like to pray for deceased
Cultural-Specific Rituals: What would nurse do for jewish?
Nurse could offer to stay with the body while client notifies relatives
Disenfranchised Grief: What is this?
GRief over a loss that is not or cannot be acknowledged openly, mourned pubicly, or supported socially
Disenfranchised Grief: Examples of that?
Loss itself is not recognized
Griever is not recognized
Disenfranchised Grief: Examples of those who would not be recognized or supported as grievers?
Loss of job, death of pet, or prenatal death
Complicated Grieving: What is this?
Response outside the norm, occuring when a person is void of emotion, grives for prolonged periods, or has expressions of grief that are disproportionate
Characteristics of Susceptibility: People who are vulnerable to complicated grieving include those wiht the following characteristics:
Low self-esteem
Low trust in others
Previous psychiatric disorder
Previous suicide threats
Ambivalent, dependent, or insecure attachment to decreased person
Characteristics of Susceptibility: What is an ambivalent attachment?
One partner is unclear about how the couple loves or does not love each other
Characteristics of Susceptibility: Example of ambivalent attachment?
When women is uncertain about and feels pressure from others to have an abortion
Characteristics of Susceptibility: What is dependent attachment?
One partner relies on the other to provide for his or her needs without necessarily meeting the partners needs
Characteristics of Susceptibility: What is insecure attachment?
Forms during childhood, especially if fchild has learnedfear and helplessness
RF Leading to Vulnerability: What do these include?
Death of spouse/child
Death of a parent
Sudden, unexpected or untimely death
Multiple deaths
Complicated Grieving as a Unique and Varied Experience: Person with complciated grieving can also experience what?
Physiologic and emotional reactions
Complicated Grieving as a Unique and Varied Experience: Physical reactions include what?
Impaired immune system, increased adrenocortical activity, increased GH, psychosomatic disorders, and increased mortality from heart disease
Complicated Grieving as a Unique and Varied Experience: What difficulties were identified?
Maladaptive thoughts
dysfunctional behaviors
inadequate emotional regulation
Complicated Grieving as a Unique and Varied Experience: Example of maladaptive thoguths?
Rumination, catastrophizing and worry about the right thing
Complicated Grieving as a Unique and Varied Experience: Example of dysfunctional behaviors?
Avoiding all reminders of deceased person or immersing oneself in the lost loved ones possessions, pictures
Complicated Grieving as a Unique and Varied Experience: Example of inadequate emotional regulation?
Focus on negative emotions, not taking a break for smooth pursuits, and ignoring regular routines for eating, sleeping, activites, and social contact
Application of Nursing Process: What did Aquilera and Messick create?
Broad approach to assessment and intervention in their work on crisis intervention. State of disequilibrium causes person to return to homeostasis
Application of Nursing Process: Factors that influence the grieving persons return to homeostasis are
adequate perception of the situation , adequate situation support, and adequate coping
Application of Nursing Process: For nurse to support and facilitate the grief process for client, they must what?
Observe and listen for cognitive, emotional, spiritual, behavioral, and physiologic cues
Application of Nursing Process: To maintain the clients needs effectively, what must the nurse do?
examine his or her own personal attitudes, maintain attentive presence, and provide psychologically safe environment
Application of Nursing Process: What is attentive presesnce?
Being with the client and focusing intently on communicating with and understanding him or her. Nurse can maintain attentive presence using open body language
Application of Nursing Process & Assesment: Effective assessment involves observing all dimensions of human response including
what the person is thinking, how the person is feeling, what the persons values and beliefs are, and how the person is actin g
Application of Nursing Process & Assesment: How would you give cognitive resposnes?
Disruption of assumption and beliefs
Questioning and trying to make sense of loss
Attempting to keep loved one present
Application of Nursing Process & Assesment: Emotional Responses examples?
Vacillating Emotions,
Profound Sorrow, Loneliness
Intense desire to restore bond with lone one or object
Application of Nursing Process & Assesment: Spiritual REsponses example
Anguish of abandonment or perceived abandonment
Hopelessness , Meaninglessness
Tearful, sobbing uncontrollable crying
Application of Nursing Process & Assesment: Behavioral Responses example
Seeking and avoiding lpaces and activies shared with lost one
Possibly abusing drugs or alcohol
Possible suicidal or homicidal gestures or attempts
Application of Nursing Process & Assesment: Physiologic Response examples
Impaired appetite, weight loss
Lack of energy
Palpitations , indigestion
Application of Nursing Process & Assesment: While observing client responses in terms of grieving, the nurse explores what three critical components in assessment?
Adequate perception regarding the loss
Adequate support while grieivng
Adequate coping behaviors during the process
Perception of Loss: Assessment begins with exploration of clients what?
Perception of loss. People have different reactions to the same scenario
Perception of Loss: What are the three major areas to explore when assessing a grieving client?
Perception, Coping, Support
Support: Purposeful assessment of support systems provides the grieving client with
an awareness of those who can meet his or her emotional and spiritual needs for security and love
Coping Behaviors: The nurse must never assume what?
That a client is in a particular phase.
Coping Behaviors: What are some questions the nurse can ask themselves about a clients coping?
How has person dealth with loss previously?
How is person currently impaired?
How does current experience compare to previous ones?
Coping Behaviors: What a person thinks about during greiving affects
his or her feelings, adn those feelings influence his or her behavior
Nursing Diagnoses used for clients experiencing grief include..
Grieving
Complicated GRieving
RF Complicated GRieving
Anticipatory Grieving
Examples of outcome are that the client will:
Identify effects of their less
Identify meaning of their loss
Seek adequate support while expressing grief
Exploring the Perception of Loss: What is the first step that can help alleviate the pain of what some would call the initial emotional overload in grieivng?
Exploring the clients perception and meaning of the loss
Exploring the Perception of Loss: When loss occurs, especially if it is sudden and without warning, the cognitive defense mechanism of denial acts as
a cushion to soften the effects. Typical response are “I can’t believe this has happened”, “It can’t be true” and “There’s been a mistake”
Exploring the Perception of Loss: What is adaptive denial?
When client gradually adjusts to the reality of the loss, can help the client let go of previous perceptions while creating new ways of thinking about him or herself, others, and the world
Promoting Coping Behaviors: Interventions involve what?
Giving the client the opportunity to compare and contrast ways in which he or she has coped with significant loss in past and helping him or hew review strengths
Dimensions of human response include..
cognitive, emotional, spiritual, behavioral, and physiologic
Disenfranchised grief often involves
death, mourners, or siutations that are not socially supported or sanctioned
COmplicated grieivng is a response that lies outside the norm . Person may be void of
emotion, grieve for a prolonged period, or excess feelings that seem out of proportion
Siutaitons considered RF for complciated grief in those already vulnerable include
death of a spouse or child, a sudden unexpected death, and murder
Crisis theory can be used to help the nurse working with a grieving client. Critical factors include
adequate perception, adequate support, and adequate coping
What is key to successfsul assessment and interventions?
effective communication skills
Interventions focused on the perception of loss include
exploring the meaning of hte loss and allowing adaptive denial, which is the process of gradually adjusting to reality of loss
