Chapter 43 - Loss Grief and Dying Flashcards
Key Terms
Actual Loss Perceived Loss Physical Loss Psychological Loss Maturational Loss Situational Loss Anticipatory Loss Grief ***Necessary to maintain quality in both emotional and physical well-being Individual experience (thoughts, feelings, behaviors) Manifested in a variety of ways Bereavement Mourning
Stages of Grieving
Kubler-Ross Denial/Isolation Anger Bargaining Depression Acceptance
Dysfunctional Grief
Prolonged, disruptive, unresolved or inhibited
Intensity extends over lengthy period
Inhibited grief
Conflicted grief
Bereaved person appears to be coping, carrying on as if nothing has happened
Goals of Grieving
Goals for the grief process Resolving emotions Reflecting on the dying person Expressing feelings of loss and sadness Valuing what has been shared
Three Definitions of Death
Traditional heart-lung—irreversible cessation of spontaneous respiration and circulation
Whole brain—irreversible cessation of all functions of the entire brain
Higher brain—irreversible loss of all “higher” brain function
Respiratory System
↑ respiratory rate Cheyne-Stokes respiration Irregular breathing Slowing down to terminal gasps Inability to cough or clear secretions Grunting, gurgling, or noisy congested breathing (death rattle) Elevated Temperature
Cardiovascular System
↑ heart rate Later slowing and weakening of pulse Irregular rhythm ↓ blood pressure Pitting edema Skin cold and clammy (although patient may be febrile) Cyanosis
Gastrointestinal & Urinary Systems
Inability to swallow
Slowing of gastrointestinal and urinary tracts and possible cessation of function
Accumulation of gas
Distention and nausea
Loss of sphincter control for both systems
Bowel movement and urinary incontinence may occur before imminent death or at the time of death
Musculoskeletal System
Gradual loss of ability to move, sensation and reflexes
Sagging of jaw
Loss of facial muscle tone
Difficulty speaking
Swallowing can become more difficult
Difficulty maintaining body posture and alignment
Loss of gag reflex
Jerking seen in patients on large amounts of opioids
Psychosocial Manifestations
May or may not lose consciousness Altered decision making Anxiety about unfinished business/ Restlessness ↓ Socialization / Fear of loneliness/meaningless/pain Helplessness Life review Peacefulness / Saying goodbyes Unusual communication Vision-like experiences Withdrawal
Components of a Good Death
Pain and symptom management Clear decision making Preparation for death Completion Contributing to others Affirmation of the whole person
End Of Life Care
Goals
Provide comfort and supportive care during the dying process
Improve the quality of the remaining life
Advance care planning
Help ensure a dignified death
Support bereavement needs of family
Goals
Provide comfort and supportive care during the dying process
Improve the quality of the remaining life
Advance care planning
Help ensure a dignified death
Support bereavement needs of family
Variables Affecting EOL Care Attitudes Beliefs Cultural, religious, family influences Spiritual needs Avoid stereotyping by completing assessments on an individual basis
Attitudes Beliefs Cultural, religious, family influences Spiritual needs Avoid stereotyping by completing assessments on an individual basis
Five Principles of Palliative Care
Respects goals, likes, and choices of the dying person and his loved ones
Looks after the medical, emotional, social, and spiritual needs of the dying person
Supports the needs of family members
Helps to gain access to needed healthcare providers and care setting
Builds ways to provide excellent care at end of life
Advance Directives
Decide the kind of medical treatment the patient wants or doesn’t want
Decide who will make decisions for the patient in case he or she is unable
Decide how comfortable the patient wants to be
Decide how the patient will be treated by others
Decide what the patient wants loved ones to know
Special Orders
Do-Not-Resuscitate Limited Code Orders Comfort measures only Do-not-hospitalize Terminal weaning
Legal and Ethical Issues
Organ Donation Autopsy Death Certificate Assisted Suicide Active Euthanasia
Factors that Affect Grief & Dying
Developmental Considerations Family Socioeconomics factors Cultural & Gender Influences Religious Influences Causes of Death
Nursing Assessment
Be sensitive
Do not impose repeated, unnecessary assessments
Use health history data available in chart
Important to assess the patient’s status frequently
Assess patient’s & family’s:
Knowledge
Perceptions
Coping strategies
Resources
Nursing Diagnosis
Response to Loss as the problem
–Impaired adjustment r/t newly diagnosed terminal illness
–Caregiver role strain r/t demands of caring for dying wife
–Impaired skin integrity r/t immobility
–Impaired gas exchange r/t ventilation-perfusion imbalance
Response to Loss as the Etiology
–Anxiety r/t unpredictability of the course of illness
–Nausea r/t effects of chemotherapy
–Fatigue r/t constant demands of caring for dying husband
Outcome Identification & Planning
Patient/family will
Verbalize feelings, needs, fears, and concerns
Identify and use effective coping strategies
Accept need for help and use available resources
Participate in decision-making process
Report sufficient relief of pain
Experience a dignified and comfortable death
Resolve grief and resume meaningful roles and daily activities
Nursing Implementation
Develop a trusting nurse-patient/family relationship
Holistic (psychosocial, physical needs)
Assess patient’s and family’s grieving process
Explain the patient condition & treatment
Teach self-care & promote self-esteem
Teach family to assist in care
Meet patient’s and family’s needs
Provide postmortem care
Physical Care
Symptom management
- -Priority is to meet physiologic and safety needs
- (Pain, Mobility, Elimination, Nutrition, Skin care)
- -Pain relief / Oxygen
- -Deserve same care as people who are expected to recover
Psychosocial Care
Anxiety
Frequently related to fear
Management (Pharmacologic & Nonpharmacologic interventions)
Encouragement, support, and education to ↓ anxiety
Fear
Typical feeling
Nurse assists with coping
Three specific fears (Pain, loneliness and abandonment, meaninglessness)
Communication
Therapeutic communication is an important nursing intervention
Empathy and active listening are essential
Allow patients and families time to express their feelings, thoughts
Grief
Provide an environment that allows the patient to express feelings
Patient should be free to express feelings of anger, fear, or guilt without judgment
Let patient and family know that the grief reaction is normal
Respect for patient’s privacy and need or desire to talk (or not talk) is important
Honesty in answering questions and giving information is essential
Grief
Families and patients need encouragement to continue their usual activities as much as possible
Planning for the future or for the funeral may be needed based on patient’s or family’s coping abilities
Anger is a common and normal response
Nurses are sometimes the target of anger
Do not react on a personal level
Feelings of hopelessness, powerlessness are common
Providing Postmortem Care
Care of the body Care of the family Discharging legal responsibilities Death certificate issued and signed Labeling body Reviewing organ donation arrangements if any Care of other patients
Postmortem Care of the Body
Prepare body for discharge
Place body in anatomical position, replace dressings, and remove tubes (unless there is an autopsy scheduled)
Place identification tags on the body
Follow local law if patient died of communicable disease
Postmortem Care of the Family
Listen to family’s expressions of grief, loss, and helplessness
Offer solace and support by being an attentive listener
Arrange for family members to view the body
In the case of sudden death, provide a private place for family to begin grieving
It is appropriate for the nurse to attend the funeral and make a follow-up visit to the family
Special Needs of Nurses
Common for nurse to feel helpless and powerless when dealing with death
Feelings of sorrow, guilt, frustration need to be expressed
Recognize and acknowledge what can and cannot be controlled
Recognize personal feelings to allow openness
Okay to cry with the patient or family during the grieving process
