L8: Loss, Death, and Grief: Including Spirituality & Sleep Flashcards
what do patients and families need most from nurses at the end of life(3)?
1) compassion
2) attentiveness
3) patient-centered care
what are the types of loss(5)?
1) loss of possessions or objects
2) loss of known environment
3) loss of significant other
4) loss of an aspect of self
5) loss of life
what are the categories of loss(5)?
- Actual losses
- Necessary losses
3. Maturational losses
4. Situational losses - Perceived losses
what is a necessary loss?
A loss that is necessary for change; most necessary losses are replaced by something different or better
what is a maturational loss?
A form of Necessary Loss which includes all normally expected changes across the lifespan.
Maturational losses associated with normal life transitions help people develop coping skills to use when they experience unplanned, unwanted, or unexpected loss.
what is situational loss?
Sudden, unpredictable losses brought on by external events
what is an actual loss?
occurs when a person can no longer feel, hear, see, or know a person or object
what is a perceived loss?
a uniquely defined form of loss by the person experiencing the loss that is less obvious to other people.
what influences depth and duration of grief?
the type of loss and a persons perception of it
what are some factors that influence the way a person approaches death(6)?
1) culture
2) spirituality
3) personal beliefs
4) values
5) previous experiences with death
6) degree of social support
what are the different types of grief?
1) normal (uncomplicated) universal reaction
2) anticipatory
3) disenfranchised (ambiguous)
4) complicated (chronic, exaggerated, delayed, masked)
Normal grief
universal reaction characterized by complex, emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death.
Anticipatory grief
Before the actual loss or death occurs. Especially in situations of prolonged or predicted loss like caring for patients diagnosed with dementia or ALS.
Disenfranchised grief
When someone’s relationship to the deceased was not socially accepted and cannot be openly shared or seems insignificant to others
Ambiguous loss
A type of disenfranchised grief. Occurs when the lost person is physically present but is not psychologically available.
(e.g. severe dementia or brain injury)
type of disenfranchised grief
Complicated grief
when someone has a prolonged or significantly difficult time moving forward after a loss
what are some characteristics of complicated grief (6)?
1) chronic or disruptive yearning for the deceased
2) trouble accepting the death
3) trouble trusting others
4) excessive bitterness
5) emotional numbness
6) anxiety of the future
Chronic grief
type of complicated grief
a normal grief response that lasts longer than normal
Exaggerated grief
type of complicated grief
when a grief response involves destructive or maladaptive behavior, obsessions, or psychiatric disorders.
Suicide is a risk for these individuals.
Delayed grief
type of complicated grief
grief response is unusually delayed or postponed because the loss is so overwhelming that the person must avoid the full realization of the loss.
Masked grief
type of complicated grief
when a grieving person behaves in a way that interferes with normal functioning but is unaware that the disruptive behavior is the result of the loss and ineffective grief resolution
what is bereavement?
a period of both grief and mourning
You are caring for a patient who is depressed because the only child has gone away to college. The nurse will assess this type of depression as:
A. actual loss.
B. perceived loss.
C. situational loss.
D. maturational loss.
Answer: D
Rationale: When life keeps moving, such as kids growing up and moving away, it is considered maturational loss.
what do more recent grief theories take into consideration(3)?
1) humans construact their own meanings when confronted with loss and death
2) everyone’s grief is different
3) grief is not linear, it is cyclic and moved forward and backward (good days and bad days)
describe the End-of-Life Nursing Education Consortium (ELNEC)
Organization that assist in end-of-life care by providing basic curriculum for grief, death, and bereavement
How is the American Nurses Associated tied with loss and grief?
Organization that assist in end-of-life care by having scope and standards for hospice and palliative care
how does the American Society of Pain Management Nurses and the American Associated of Critical Care Nurses tie into loss and grief?
Organization that assist in end-of-life care by providing guidelines for managing clinical and ethical issues
what factors influence loss and grief(8)?
1) human development
2) personal relationships
3) nature of loss
4) coping strategies
5) socioeconomic status
6) culture and ethnicity
7) spiritual and religious beliefs
8) hope
Patient age and stage of development affect the grief response.
School-aged Children ___.
understand the concepts of permanence and irreversibility but do not always understand the cause of loss.
Patient age and stage of development affect the grief response.
Young Adults ___.
undergo many necessary developmental losses related to their evolving future
Patient age and stage of development affect the grief response.
For Older Adults ___.
the aging process leads to necessary and developmental losses.
encouraging patients to share information about their losses will help us…
better develop appropriate interventions that meet the individualized needs of our patients
The Dying Person’s Bill of Rights
- I have the right to be treated as a living human until I die.
- I have the right to maintain a sense of hopefulness, however changing its focus may be.
- I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this might be.
- I have the right to express my feelings and emotions about my approaching death in my own way.
- I have the right to participate in decisions concerning my care.
- I have the right to expect continuing medical and nursing
attention even though “cure” goals must be changed to “comfort” goals. - I have the right not to die alone.
- I have the right to be free from pain.
- I have the right to have my questions answered honestly.
- I have the right to retain my individuality and not be judged for my decisions that may be contrary to beliefs of others.
- I have the right to expect that the sanctity of the human body will be respected after death.
- I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and be able to gain some satisfaction in helping me face my death.
ANA Scope and Standards of Hospice and Palliative Nursing (2014)
Hospice and palliative nurses work side-by-side with patients, their families and an interdisciplinary team to provide care to palliative patients. Attending to the patient’s end-of-life physiological and psychological responses and requirements as well as the social and cultural factors and the spiritual aspects of care is the essence of palliative nursing.
what are the grief variables that need to be assessed?
1) meaning of loss
2) coping style
3) nature of family relationships
4) social support systems
5) nature of the loss
6) cultural and spiritual beliefs
7) life goals
8) family grief patterns
9) self-care
10) sources of hope
describe proper communication strategies for a grief and loss assessment
1) be present
2) ask open-ended questions
3) use honest, open communication
4) use active listening, silence, and therapeutic touch if appropriate
what are some common grief reactions?
1) sorrow
2) disbelief
3) confusion
4) headaches
what should be assessed in the terminally ill?
1) preferred place of death
2) desired level of intervention
3) expectations for pain and symptom management
Nursing clinical problem related to Grief:
Grief
Anticipatory Grief
Complicated Grief
Dysfunctional Grieving
Risk for Dysfunctional Grieving
Dysfunctional grieving
a nursing clinical problem: a failure to follow the predictable course of grieving to resolution, including becoming overwhelmed and using maladaptive coping
what does health promotion in serious chronic illness or death focus on?
successful coping and optimizing physical, emotional, and spiritual health
Palliative care
- primary goal is to help patients and families achieve the best possible quality of life
- can include care of the dying
Hospice care
1) care of terminally ill patients
2) managing pain, providing comfort, ensuring quality of life
3) adhering to patient wishes
As a first-year nursing student, you are assigned to care for a dying patient. To best prepare you for this assignment, you will want to:
A. complete a course on death and dying.
B. control your emotions about death and dying.
C. compare this experience to the death of a family member.
D. develop a personal understanding of your own feelings about grief and death.
Answer: D
Rationale: The nurse cannot provide patient-centered nursing if the nurse does not understand his or her own feelings about death and dying.
When caring for patients, the nurse must understand the difference between religion and spirituality. Religious care helps individuals:
A. maintain their belief systems and worship practices.
B. develop a relationship with a higher being.
C. establish a cultural connectedness with the purpose of life.
D. achieve the balance needed to maintain health and well-being.
Answer: A
Rationale: Religion is associated with the “state of doing,” or a specific system of practices associated with a particular denomination, sect, or form of worship. It is a system of organized beliefs and worship that a person practices to outwardly express spirituality. Religious care helps patients maintain their faithfulness to their belief systems and worship practices. Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships and a relationship with a higher being or life force.
To assess, evaluate, and support a patient’s spirituality, the best action a nurse can take is to:
A. assist the patient to use faith to get well.
B. refer the patient to the health care facility chaplain.
C. provide the patient with a variety of religious literature.
D. determine the patient’s perceptions and belief system.
Answer: D
Rationale: By understanding the patient’s perceptions and belief system, the nurse is able to provide patient-centered care for the patient.
During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as:
A. cataplexy.
B. insomnia.
C. narcolepsy.
D. sleep apnea.
D
WHO summarized palliative care philosophy(6):
1) Affirms life and regards dying as a normal process.
2) Neither hastens or postpones death.
3) Integrated psychological and spiritual aspects of patient care.
4) Offers a support system to help patients live as actively as possible until death.
5) Enhances the quality of life.
6) Uses a team approach to meet the needs of patients and families.
Hospice programs are built on the following core beliefs and services(8):
1) Patient and family are the unit of care.
2) Coordinated home care with access to inpatient and nursing home beds when needed.
3) Symptom management.
4) Physician-directed services.
5) Provision of an interdisciplinary care team.
6) Medical and nursing services available at all times.
7) Bereavement follow-up after patient’s death.
8) Use of trained volunteers for visitation and respite support.
what are some common strategies that nurses use to provide end-of-life care(8)?
1) therapeutic communication
2) provide psychological care
3) manage symptoms
4) promote dignity and self-esteem
5) maintain comfortable and peaceful environment
6) protect spiritual comfort and hope
7) protect against abandonment and isolation
8) support the grieving family
9) assist with end-of-life decision making
10) facilitate mourning
11) care after death
what are some psychological symptoms associated with end-of-life experiences(5)?
1) anxiety
2) depression
3) powerlessness
4) uncertainty
5) isolation
Side effects of opioid administration(5):
1) constipation
2) nausea
3) sedation
4) respiratory depression
5) myoclonus (involuntary muscle twitching)
what are some nursing strategies that promote hope(2)?
1) be present
2) provide whole-person care
antimuscarinic drugs
(e.g. Atropine)
Used to dry up respiratory secretions so not to scare family at end of life.
what are common physical changes that occur hours or days before death?
1) increased periods of sleeping/unresponsiveness
2) circulatory changes with coolness and color changes in the extremities, nose, and fingers (cyanosis, pallor, mottling)
3) bowel or bladder incontinence
4) decreased urine output; dark-colored urine
5) restlessness, confusion, disorientation
6) decreased intake of foods/fluid; inability to swallow
7) congestion/increased respiratory secretions; noisy respirations (death rattle)
8) altered breathing (apnea, labored or irregular breathing, Cheyne-stokes pattern)
9) decreased muscle tone, relaxed jaw muscles, sagging mouth
10) weakness and fatigue
how do you assist with end of life decision making?
support and educate patients and families as they identify, contemplate, and decide the best journey to the end of life
how do you facilitate mourning?
provide bereavement care
how do you provide care after death?
ensure respect for the body
what are some outcomes that indicate the effectiveness of short-term grief related interventions(3)?
1) talking about loss without becoming overwhelmed
2) improved energy level
3) normalized sleep and dietary patterns
what are some outcomes that indicate the effectiveness of long-term grief related interventions(3)?
1) return to sense of humor and normal life patterns
2) renewed or new personal relationships
3) a decrease in inner pain
what is spirituality often defined as today?
an awareness of one’s inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself
what does spirituality help individuals to achieve?
the balance needed to maintain health and well-being and cope with illness
many of the benefitial effects of spirituality are tied to…
hormonal and neurological function
What are the Constructs of Spirituality (4)
Self-transcendence
Connectedness
Faith
Hope
what is the definition of spirituality?
complex concept that is unique to each individual; it depends on a person’s culture, development, life experiences, beliefs, and ideas about life. It is an inherent human characteristic that exists in all people, regardless of their religious beliefs.
what is self-transcendence(2)?
- a sense of authentically connecting to ones inner self
*It allows people to have new experiences and develop new perspectives that are beyond normal physical boundaries
(example of transcending moments are: feeling awe when holding a new baby or looking at a beautiful sunset)
what is connectedness(3)?
1) being intra-personally connected to oneself
2) being inter-personally connected to others and the environment
3) being trans-personally connected with god (or an unseen higher power)
what is faith(2)?
1) allows people to have firm beliefs despite lack of physical evidence
2) allows people to believe in and establish transpersonal connections
what is hope?
Several meanings that vary on the basis of how it is being experienced; it usually refers to an energizing source that has an orientation to future goals and outcomes.
what are the two dimensions of spiritual well-being?
1) One dimension supports the transcendent relationship between a person and god or a higher power
2) The other dimension describes positive relationships and connections that people have with others
what are the other definitions of faith(2)?
1) a cultural or institutional religion such as judaism, buddhism, islam, christianity
2) a relationship with a divinity, higher power, or spirit that incorporates a reasoning faith (belief) and a trusting faith (action)
what is religious care?
helping patients maintain faithfulness to their belief system and worship practices
what is spiritual care?
helping people identify meaning and purpose in life, look beyond the present, and maintain personal relations as well as a relationship with a higher being or life force
the beliefs of older people varies based on many factors which include(5):
1) gender
2) past experiences
3) religion
4) economic status
5) ethnic background
what is spiritual distress?
an impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a higher power
what does spiritual distress cause(3)?
1) feel doubt
2) lose faith
3) feel a sense of being alone or being abandoned
what is a NDE?
near death experience - a psychological phenomenon of people who either came close to death or recovered after being declared dead
what are common experiences describes by many who have had a NDE?
many describe feeling totally at peace, having an out of body experience, being pulled into a dark tunnel, seeing bright lights, and meeting people who previously died
people who have been through a NDE are often reluctant to discuss it, why?
they think family or caregivers will not understand; isolation and depression often occur
what are assessment tools used to assess spirituality in your patients(6)?
1) listening
2) asking direct questions
3) ask about a religious source of guidance
4) understand your patient’s philosophy of life
5) FICA
6) SWB scale
what is FICA?
a spirituality assessment tool
F - faith or belief
I - importance and influence
C - community
A - address (interventions to address)
what is the SWB scale?
spiritual well-being scale - 20 questions that assess a patient’s relationship with god and his or her life purpose and life satisfaction
what are some questions that can help you assess a patient’s level of spirituality and the effects of illness on it(7)?
1) life and responsibility - ask about patient’s understanding of illness limitations or threats and how the patient will adjust
2) connectedness - ask about patient’s ability to express a sense of relatedness to something greater than self
3) life satisfaction
4) culture - ask about faith and belief systems to understand culture and spiritual relationships
5) fellowship and community - ask about support networks
6) ritual and practice - ask about life practices used to assist in structure and support during difficult times
7) vocation - ask whether illness or hospitalization has altered spiritual expression
what does establishing presence involve?
involves giving attention, answering questions, having an encouraging attitude, and expressing a sense of trust; “being with” rather than “doing for”
how do you facilitate a supportive healing relationship(3)?
1) mobilize hope
2) provide interpretation of suffering that is acceptable to patient
3) help patient use resources
how do you promote spiritual health in acute care settings(3)?
1) support systems - connectedness promotes sense of hope
2) diet therapies - food is often connected to rituals and spirituality
3) supporting rituals - facilitate rituals related to patient’s spirituality
how do you promote spiritual health in restorative and continuing care settings(3)?
1) prayer - effective coping resource for physical and psychological symptoms
2) meditation - creates relaxation response to reduce daily stress
3) supporting grief work - nurses need to support patient’s in times of grief and loss
what is circadian rhythm affected by(4)?
1) light
2) temperature
3) social activities
4) work routines
what happens when people don’t sleep enough(2)?
1) ability to concentrate, make judgements, and participate in daily activities decreases
2) irritability increases
what does sleep provide to the human body?
healing and restoration
what controls the circadian rhythm?
the hypothalamus
what predictable changes depend on maintenance of the 24-hour circadian cycle(6)?
1) body temp
2) HR
3) BP
4) hormone secretion
5) sensory acuity
6) mood
what are the two processes that help to regulate sleep/wake cycles?
1) Process S (homeostatic) - regulates length and depth of sleep
2) Process C (circadian rhythms / biological time clocks) - influences the internal organization of sleep and the timing and duration of sleep-wake cycles
describe the relationship between process S and process C
operates simultaneously to regulate sleep and wakefulness
time of wakeup is defined ass the…
intersection of process S and process C
what are the two sleep phases?
1) nonrapid eye movement (NREM)
2) rapid eye movement (REM)
what is the function of sleep(3)?
1) restoration
2) memory consolidations
3) prep for the next period of wakefulness
Stages of Sleep
4
NREM 1 -
NREM 2 -
NREM 3 -
REM
how many complete sleep cycles does a person typically pass through every night?
4-6 cycles consisting of 3 stages of NREM and a period of REM sleep
describe what happens with each successive sleep cycle
with each successive cycle, stage 3 of NREM shortens and REM lengthens
how long does REM last for each sleep cycle?
up to 60 minutes during the last cycle
what happens biologically during sleep?
1) reduced HR
2) reduced BP
3) reduced RR
4) reduced temp
5) reduced muscle tone
what happens to sleep with age?
becomes more fragmented with aging and there is more time spent in the lighter stages of sleep
What are some common Physical Illnesses that may cause sleep disturbances?
Hypertension
Respiratory disorders (COPD, Emphysema, cold)
Nocturia
Restless leg syndrome (RLS)
what is Restless Leg Syndrome (RLS)?
RLS, onset occurs before sleep and is an itching sensation in the muscles of the legs, relieved by movement; interrupts sleep
The American Academy of Sleep Medicine developed the International Classification of Sleep Disorders version 2 (ICSD-2), which classifies sleep disorders into eight major categories:
Insomnia Most Common
Sleep-related Breathing Disorders
Hypersomnias
Circadian Rhythm Sleep Disorders
Parasomnias
Sleep-related Movement Disorders
Isolated Symptoms
“Other”
Insomnia
Difficulty falling or staying asleep at night, which can lead to daytime fatigue. Insomnia is the more common of the two disorders.
Hypersomnia
Excessive daytime sleepiness and a tendency to fall asleep during the day. People with hypersomnia may feel like they need to sleep more, even after getting more than 11 hours of sleep a day.
Parasomnias
Undesirable behaviors that occur usually during sleep.
Somnambulism (sleepwalking), Night terrors, Nightmares, Nocturnal enuresis (bed-wetting), Body rocking, Bruxism (teeth grinding)
A person with parasomnias may seem to be alert.
More Common in children
Isolated Symptoms
Sleep-related symptoms that fall between normal and abnormal sleep.
- Some isolated sleep symptoms include:
- Sleep talking
- Sleep starts - Also known as hypnagogic jerks, these are sudden jerking motions that occur when falling asleep.
- Isolated sleep paralysis
- Cramped foot muscles
Sleep-related Movement Disorders
Conditions that cause abnormal movements or behaviors during sleep, which can disrupt sleep quality and lead to daytime fatigue. ie
Restless legs syndrome (RLS)
what is a polysomnogram?
the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during night time sleep.
what is a multiple sleep latency test (MSLT)?
Test that provides objective information about sleepiness and selected aspects of sleep structure by measuring eye movements, muscle tone changes, and brain electrical activity during at least four napping opportunities spread throughout the day
What are the 3 types of sleep apnea?
Central
Obstructive Most Common
Mixed
Obstructive Sleep Apnea (OSA)
Major risk factors (2):
Most common symptom:
Occurs when muscles or structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, diminishing nasal airflow (hypopnea) or stopping it (apnea) for as long as 30 seconds.
Major risk factors (2): Obesity and Hypertension
Most common symptom: Excessive daytime sleepiness
Central sleep apnea
Common in patients with:
Involves dysfunction of the respiratory control center in the brain. The impulse to breathe fails temporarily, and nasal airflow and chest wall movement cease.
Common in patients with:
1) brainstem injury
2) muscular dystrophy
3) encephalitis
< 10%
what occurs in people with narcolepsy(4)?
During the day a person feels an overwhelming wave of sleepiness; REM sleep occurs within 15 minutes of falling asleep
- cataplexy during intense emotions like anger, sadness, or laughter occurs at any time during the day
- sleep paralysis can also occur
what is cataplexy?
sudden muscle weakness
what are some causes of sleep deprivation(6)?
1) fever
2) difficulty breathing
3) pain
4) emotional stress
5) medications
6) disturbances in the medical setting
what is the sleep requirement for:
Neonates
Infants
Toddlers
Preschoolers
Neonates : 16 hours/day
Infants : 8-10 hours per night; total of 15 hrs/day
Toddlers: 12 hrs/day
Preschoolers: 12hrs at night
what is the sleep requirement for:
School-Aged Children
Adolescents
Young Adults
Middle and Older Adults
School-Aged Children: 8-10 hours/night
Adolescents: ~ 7.5 hrs/night
Young Adults: 6 - 8.5 hrs/night
Middle and Older Adults: Total number of hours decline
How does pregnancy affect sleep?
Pregnancy increases the need for sleep and rest. However, a majority of pregnant women describe variations in sleep habits. Estrogen has been shown to decrease REM sleep.
what are some factors that influence sleep?
1) lifestyle
2) work schedule, social activities, routines
3) emotional stress
4) exercise and fatigue
5) sleep patterns
6) environment
7) food and calorie intake
8) caffeine, nicotine, alcohol intake
what are three effective subjective measures of sleep(3)?
1) epworth sleepiness scale
2) pittsburgh sleep quality scale
3) numeric scale with 0-10 sleep rating
what are some sleep related health promotion strategies(8)?
1) environmental controls
2) promote bedtime routines
3) promote safety
4) promote comfort
5) establish periods of rest and sleep
6) stress reduction
7) bedtime snacks
8) pharmacological approaches
what are some drugs/substances that can affect sleep(8)?
1) hypnotics
2) diuretics
3) narcotics
4) antidepressants
5) alcohol
6) caffeine
7) beta-blockers
8) anticonvulsants
what are some herbal remedies that may assist with sleep(3)?
1) valerian - is effective in mild insomnia and RLS. It effects the release of neurotransmitters and produces very mild sedation
2) kava - helps promote sleep in patients with anxiety. It should be used cautiously because of its potential toxic effects on the liver.
3) chamomile - has a mild sedative effect that may be beneficial in promoting sleep.
