Loss and Grief Chapter 42 Unit 11/12

Question 1

What is Loss

Answer 1

Absence of someone or
something to which the
affected person has formed
an attachment

Examples are loss of a family member to death, loss of a body part to disease or accident, loss of health or independence to illness or old age, loss of financial stability to catastrophe, and even loss of choice to dementia or other illness that affects cognition.

Question 2

What is Grief

Answer 2

Emotional response to a loss

Produces feelings including
anger, frustration, loneliness,
sadness, guilt, regret, a sense
of resolution, and peace

Question 3

What is Anticipatory Grief

Answer 3

Anticipatory grief is defined as the cognitive, affective, cultural, and social reactions to an expected death, felt by the patient as well as family members and friends.

This type of grief is experienced before an actual loss occurs and can arise when a person is initially diagnosed with an acute illness, chronic disease, or terminal disease.

Nursing Intervention: Nursing interventions for anticipatory grieving include provision of emotional support with a positive presence, active listening, and reassurance while encouraging verbalization of the anticipated loss.

Question 4

Physical Reaction to Loss

Answer 4

Tightness in the chest and throat
Oversensitivity to noise
Breathlessness
Muscular weakness
Lack of energy Fatigue
Sleep disturbances
Changes in appetite

Question 5

Emotional Reaction to Loss

Answer 5

Numbness
Loneliness
Sadness
Sorrow
Guilt
Shock
Anxiety
Depression
Anger
Agitation
Lack of interest or motivation Lower level of patience or tolerance

Question 6

Cognitive Reaction to Loss

Answer 6

Preoccupation with the deceased
Forgetfulness
Preoccupation with the loss
Inability to concentrate
Inability to retain information
Disorganization
Feeling confused

Question 7

Behavioral Reaction to Loss

Answer 7

Crying
Insomnia
Restlessness
Withdrawal
Irritability
Apathy
Impaired work performance

Question 8

Kubler-Ross 5 Stages of Grief

Answer 8

Denial:
* A temporary defense to assist in the coping process * The dying person: “No, it can’t be me!”
* The person experiencing loss: “He did not die in an
accident!”

Anger:
* Occurs after denial when true realization of the circumstances of the loss begin to emerge
* The dying person: “Why me? This is not fair.”
* The person experiencing loss: “Whose fault is it? I am
going after them!”

Bargaining:
* Beginning understanding of the loss with the hope that negotiation can change the circumstances
* The dying person: “I will change my ways and behave if I can live longer. I just want to live!”
* The person experiencing loss: “I will do anything to have him back

Depression:
Understanding of the certainty of impending death or loss occurs, and the process of grieving, which includes crying and sadness, is able to begin
* The dying person: “It doesn’t matter anymore

Acceptance:
* Coming to terms with the reality of the loss
* The dying person: “Somehow this is going to be okay.” * The person experiencing loss: “Life will go on
somehow!”

Question 9

Bowlby Model of Grief

Answer 9

Shock and numbness:
Describes the time immediately after the loss, when the bereaved person feels numb; this is thought to be a natural defense mechanism that allows the person to survive the emotional response to the loss

Searching and yearning:
Time when the grieving person longs for the deceased and when emotions, such as anger, fear, anxiety, and confusion may occur

Disorganization and despair:
Yearning for the deceased decreases, whereas apathy, withdrawal, and anguish begin to surface

Reorganization:
A new state of normal begins with a decreased intensity of the negative emotions related to the loss, and a sense of enjoyment of life begins to return

Question 10

Sheldons Stages of Grief

Answer 10

Initial shock:
* Common emotions and experiences: Numbness,
disbelief, relief
* Task: Accept the reality of the loss

Pangs of grief:
* Common emotions and experiences: Sadness, anger, guilt, feelings of vulnerability and anxiety, regret, insomnia, social withdrawal, transient auditory and visual hallucinations of the dead person, restlessness, searching behavior
* Task: Experience the pain of grief

Despair:
* Common emotions and experiences: Loss of meaning and direction in life
* Task: Adjust to an environment in which the deceased is missing

Adjustment:
* Common emotions and experiences: Develop new relationships or interests
* Task: Emotionally relocate the deceased to an important but not central place in bereaved person’s life and move on

Question 11

What is Normal Grief

Answer 11

Normal grief is described as feelings, behaviors, and reactions to loss; it can be physical, emotional, cognitive, and behavioral in nature (Table 42.1). An important nursing consideration is that active grieving can take months to years, with significant variability in how it progresses.

Question 12

Mourning

Answer 12

Mourning is the outward, social expression of loss. It is demonstrated on an individual basis related to the person’s cultural norms, customs, rituals, traditions, and religious or spiritual beliefs. Life experiences and personality traits influence the outward expression of loss.

Question 13

What is Worden

Answer 13

Worden (2008) describes the process of grief and mourning as a series of tasks.

The first task is to accept the reality of the loss, because the feelings of shock and disbelief that occur during the initial stage of grieving are the most common emotions felt by those experiencing a loss

The second task occurs as the grieving person begins to work through the pain of grief, experiencing the physical, emotional, cognitive, and behavioral responses common to the grieving process

This process of adjustment relates to the emotional, physical, financial, and other existing roles that the dying person once had in the life of the survivor who is grieving. Making life adjustments is necessary as implications of the loss are recognized and dealt with over a period of time.

The final task is to emotionally relocate the deceased and move on with life. This task begins the resolution stage of the initial loss. At this time, people who are grieving accept that the deceased person is really gone and become less conscious of the loss and less preoccupied with the deceased. This final task allows survivors to reinvest energy in other relationships and move on with life while still maintaining the deceased person’s presence in memories and through religious faith

Question 14

Bereavement

Answer 14

The term bereavement includes both grief and mourning, and can be described as the inner feelings and outward expressions that people experiencing loss are demonstrating.

Question 15

Interpersonal Skills in Nursing for Dying Patient

Answer 15

Interpersonal skills include the ability to listen to patients and families, as well as other members of the health care team.

Empathy and sensitivity to religious, ethnic, and individual differences in care and treatment will enhance effective communication.

Being able to convey difficult or upse ing news and providing information related to prognosis and options for treatment allow the patient and family the ability to make informed decisions.

Question 16

Scientific and Clinical Knowledge in Nursing for Dying Patient

Answer 16

Scientific and clinical knowledge that relates to the underlying disease process and the biologic basis of dying related to specific illness and injury is an essential component of nursing care at the end of life.

Assessment of symptoms at the end of life that occur with individual disease processes will allow the nurse to rapidly respond to potentially difficult and distressing problems.

Question 17

Ethical and Professional Principles in Nursing for Dying Patient

Answer 17

Ethical principles include doing good and avoiding harm. Determining and respecting patient and family preferences are essential at the end of life.

Question 18

Complicated Grief?

Answer 18

Complicated grief, also called unresolved grief, occurs when the affected person is not able to progress through the normal stages of grieving.

Symptoms of complicated grief include intense longing for the deceased, denial of the death or sense of disbelief, imagining that the loss has not occurred, searching for the person in familiar places, extreme anger or bi erness over the loss, and avoiding things that are reminders of the loss. Daily life routines are not maintained, and the person’s emotional as well as physical health becomes threatened.

4 TYPES

Chronic grief

Delayed grief

Exaggerated grief

masked grief

Question 19

What is Chronic Grief?

Answer 19

is characterized by grief reactions that do not diminish over time and continue for an indefinite period or very long period of time.

Question 20

What is Delayed Grief?

Answer 20

is characterized by suppression of the grief reaction while the grieving person consciously or unconsciously avoids the pain that has occurred with the loss.

Question 21

What is Exaggerated Grief?

Answer 21

occurs when the survivor is overwhelmed by grief and cannot function in daily life. In such instances, the affected person may use self-destructive behaviors, such as drugs or alcohol, as a coping mechanism. The potential for suicide with exaggerated grief cannot be overlooked by the health care team.

Question 22

What is Masked Grief?

Answer 22

occurs when the behaviors of the survivor interfere with normal functioning, but that person is not aware that these behaviors are concealing the actual grieving process.

Question 23

What is Disenfranchised Grief?

Answer 23

as any loss that is not validated or recognized. This type of grief is encountered when a loss happens that cannot be openly acknowledged or publicly shared by the grieving person. It occurs when society does not want to acknowledge the grief, or does not know how to deal with the loss or with the response of the grieving person.

Persons at risk for this type of grief include ex- spouses, ex-partners, friends, lovers, mistresses, co-workers, mothers of stillborn babies, and even those who have terminated a pregnancy.

Question 24

What is Complicated Loss?

Answer 24

Complicated loss occurs with a sudden death, a violent or traumatic death, multiple deaths, loss that is related to a social stigma, and with the death of a young person. Sudden death does not allow the survivor time to prepare for the impending loss, and this type of event can leave the survivor with a sense of feeling out of control and wondering about the meaning of the death and even of life.

Question 25

What are the Signs and Symptoms of a patient at the End of Life Stage?

Answer 25

physical symptoms at the end of life include weakness and fatigue, increased drowsiness, and sleeping more and responding less. A decrease in oral intake and a decrease in the swallow reflex may occur. Surges of energy may occur as the dying person begins to make the transition to death. Changes in bowel and bladder elimination are common and include constipation, diarrhea, and potential incontinence. Patients and families need to know that these are normal changes, and education about these changes will enhance coping abilities during the time of anticipatory grief.

Physical symptoms at the end of life
* Weakness and fatigue, increased drowsiness, and sleeping
more and responding less
* Decrease in oral intake and decrease in the swallow reflex
* Surges of energy may occur as the dying person begins to
make the transition to death.
* Changes in bowel and bladder elimination
Physical assessment of the dying patient

Question 26

What are the Signs Symptom of a patient with Impending Doom?

Answer 26

Universal manifestations of imminent death include a decrease in urine output, cold and mo led extremities, and changes in vital signs, in that the blood pressure decreases and heart rate often increases but can decrease. Changes in breathing patternss , with the occurrence of periods of apnea that increase as the body shuts down, and apparent respiratory congestion or the “death ra le” from the inability to swallow secretions are common manifestations of impending death.

• Decrease in urine output
• Cold and mottled extremities
• Changes in vital signs
• Changes in breathing patterns

Question 27

What are the Signs and Symptoms of a Patient with Impending Doom?

Answer 27

• Absence of heartbeat and respirations
• Involuntary release of stool and or urine
• Lack of any response to verbal or tactile stimuli
• Drop in body temperature as the body begins to cool
  Signs and symptoms of death

Signs and symptoms of actual death include absence of heartbeat and respirations, an involuntary release of stool and or urine, lack of any response to verbal or tactile stimuli, and a drop in body temperature as the body begins to cool. This cooling is called algor mortis, or cooling after death. The eyes may remain open, the jaw will drop as the mouth appears to be open, and the color of the skin becomes pale and then bluish (livor mortis) as blood se les. After a period of time, rigor mortis, or stiffening of the joints of the body, will set in

Question 28

Care of the dying patient and the patient’s family

Answer 28

-Provide education about the stages of grief
– Encourage healthy behaviors
– Listen while patients or families tell the story of their loss
– Include the entire family or significant others in the
assessment and planning
– Use community resources and make appropriate
referrals
15

Question 29

Advance care planning for end of life

Answer 29

– Ongoing process that involves making decisions about
future health care
– Advance directives: legal documents that can inform
health care providers about a patient’s goals of care
and whom to contact for decisions about that care

Question 30

Palliative Care

Answer 30

Palliative care emerged in response to the needs of patients who were not terminally ill but needed high-quality symptom control for a serious or life-threatening illness. This type of care is appropriate for anyone who has a chronic, debilitating condition.

Palliative care begins at the time of a diagnosis and includes curative measures.

– Provides relief from pain and other symptoms
– Affirms life and regards dying as a normal process
– Intends to neither hasten nor postpone death
– Integrates the psychological and spiritual aspects of
patient care
– Offers a support system

Question 31

Hospice Care

Answer 31

Hospice is defined by the NHPCO as a program that provides comfort and supportive care for terminally ill patients and their families, either directly or on a consulting basis with the patient’s physician or another community agency.

Hospice care is provided to patients with a life expectancy of 6 months or less who decide to forego curative treatment.

Question 32

1. While caring for a patient with advanced multiple sclerosis, the nurse is discussing the difference between hospice and palliative care. Which statement by the patient indicates understanding of the difference between hospice care and palliative care?
   A. “I will need to get hospice care if I want my symptoms controlled.”
   B. “I can have palliative care right now-even though I am not going to die anytime soon.”
   C. “My doctor has to make the decision if I have hospice care.”
   D. “I can’t get any other treatments, even if they are experimental, if I choose palliative care.”

Answer 32

Answer: b
Hospice care and palliative care are focused on the management of symptoms. Hospice care is provided to those who have a prognosis of less than 6 months to live. Palliative care is provided to any person who needs assistance with management of symptoms. Physicians delineate the prognosis, but the patient and family ultimately make the decision if they want care provided by hospice.

Question 33

2. The nurse is orienting new staff to a clinical unit that provides palliative care. A new employee asks what
”grief” is exactly. Which statement indicates that the nurse has correctly defined grief?
   A. The emotional response to a loss
   B. The outward, social expression of a loss
   C. The depression felt after a loss
   D. The loss of a possession or loved one

Answer 33

Answer: a
Grief is the emotional response to a loss that is an individualized and deeply personal feeling caused by a real or perceived loss. The outward, social expression of a loss is bereavement. Depression is not a normal response to loss, although there are many emotional feelings that occur due to a loss. The loss of a possession or a loved one is considered an actual loss.

Question 34

3. The nurse has been caring for a 65-year-old male patient who has just died. In planning for follow- up bereavement care, the nurse knows that which person is at risk for disenfranchised grief?
   A. A daughter who lives in a different state
   B. The son who was with the patient when he died
   C. An estranged ex-wife of the patient who lives nearby
   D. The 16-year-old grandchild of the patient

Answer 34

Answer: c
Disenfranchised grief, a term coined by Kenneth Doka, may occur with any loss that is not validated or recognized. This type of grief is encountered when a loss is experienced that cannot be openly acknowledged or publicly shared by the grieving person. An ex-wife who has been estranged from the deceased may not be able to openly express the grief that she may feel over the loss of someone who once played a significant part in her life. Other family members (such as a daughter who lives in another state, a son who has been active in the patient’s care, or a grandchild) are able to openly express their grief and are viewed by society as having an acceptable grief response.

Question 35

4. The grandmother of two children, 8 and 10 years of age, has died. Their mother asks the nurse what she should do about her children attending the funeral. What is the nurses best response?
   A. “Take them to the funeral-they need closure. Many children attend funerals in today’s societv.”
   B. “Do not take them to the funeral–they are too young to be exposed to the emotions that are demonstrated at funerals.”
   C. “Talk to your children about how they feel about attending the funeral and encourage them to ask questions and talk about their concerns.”
   D. “Talk to your children about what your mother meant to you and how much she cared for them, and then see if they really want to attend the funeral”

Answer 35

Answer: c
Caregivers should be encouraged to openly and honestly answer any questions the child may have as they are evaluating the child’s responses to the loss while determining whether the child should attend the funeral of a family member. If young children are going to attend the funeral, they should be prepared for what they will see, who will be there, what they may feel, how they may see other people grieving, and what they will be doing during the time that they are at the funeral. It is essential to explain to the child what the body will look like and the fact that the deceased will not talk, move, or breathe. Children should be allowed to attend funerals based on their own abilities to understand the loss, but they should not be forced to attend if they are fearful or have a strong negative reaction to the loss. The nurse should not give her opinion about the children attending or not attending the funeral but can encourage the mother to evaluate each child’s feelings about the loss. The parents should make the decision about the children attending the funeral, not the children or the nurse.

Question 36

5. The nurse has been caring for a patient who has just died.
What is the preferred outcome in caring for the body after death?
   A. Make sure that the body is sent to the morgue within an hour after death.
   B. Have the family members participate in the bathing and dressing of the deceased.
   C. Notify in person or by phone all family and team members immediately after the patient’s death.
   D. Demonstrate respect for the body and provide a clean, peaceful impression of the deceased for the family.

Answer 36

Answer: d
Demonstrating respect for the deceased maintains the dignity of that person and also can help the family in the grieving process. Proper positioning of the body and covering the body appropriately will promote a peaceful impression of the deceased for the family. Family often will request time with the deceased, and it is not necessary to place a time frame of 1 hour for the arrival of the body at the morgue. Family members may want to participate in bathing and dressing their loved one after death, but this should be their choice. It is not the responsibility of the nurse to notify all family members and team members of the death immediately because the nurse will need to provide care to the family and determine what type of assistance they need in notifying family members.

Question 37

6. Several theorists have identified stages of the grieving process. The nurse understands these stages and knows that people progress through them in an individualized manner. Which statements are true regarding the steps of the grieving process? (Select all that apply.)
   A. There is a definite “timetable” or period of time specific to each stage of the grieving process.
   B. Nursing interventions are generalized across all stages of the grieving process.
   C. Tasks to be achieved at each stage have been identified by each theorist.
   D. There is a common stepwise progression through each stage of the grieving process.
   E. Not all individuals will experience all stages of grief.

Answer 37

Answers: c, e
Each stage of the grieving process has associated tasks that allow successful grieving to occur on an individualized basis. Theories that describe the grieving process are simply guides to understanding the process of grief, and there is no specific timeline regarding when people “should be” in a certain stage, “should” move from one stage to the next, or follow a stepwise progression. Not all people will experience all stages of grief. Essentially, there is no timetable for the process of grief and bereavement. Nurses need to understand these stages and the feelings and emotions common to each stage. This facilitates nursing interventions that can be focused on the stage the patient is experiencing or the task the person is attempting to complete related to the process of grief.

Question 38

7. Which statement is true regarding advance care planning and advance directives?
   A. Advance care planning applies only when the person is dying.
   B. Advance care planning should be done by family members of people who are incompetent.
   C. Discussion of advance care planning is a nursing responsibility.
   D. Advance directives should be kept in a safety deposit box until the person dies.

Answer 38

C. Discussion of advance care planning is a nursing responsibility.

It is a nursing responsibility to be aware of types of advance directives available and to discuss the options with patients and families. A copy of the patient’s advance directives should be part of the medical records. Advance directives are discussed in greater detail in

Question 39

8. In which scenario is palliative care provided?
   A. Only in the homes of the terminally ill
   B. For any chronic illness that requires symptom control
   C. For cancer patients only in their last weeks of life
   D. Only in hospital settings based on the seriousness of the illness

Answer 39

Answer: b
Palliative care is provided in a variety of settings, including home care, freestanding inpatient units, hospitals, long-term care facilities, and prisons. It is also administered to the homeless and to patients with any disease or illness that has been determined to be chronic and in need of symptom control. Any patient who is experiencing symptoms—physical, psychological, or spiritual—benefits from palliative care. Once a patient is terminal or has less than 6 months to live, the patient can choose to seek hospice care.

Question 40

9. In caring for a dying patient, what is an appropriate nursing action to increase family involvement?
   A. Insisting that all bedside care be performed by the family
   B. Demonstrating care and supporting family participation
   C. Expecting the family to consistently perform the patient’s ADLs
   D. Refusing all assistance from the family to decrease family stress

Answer 40

Answer: b
Many family members would like to be involved in the care of their loved one while the person is dying. It is the responsibility of the nurse to assess the level of involvement in which the family would like to participate related to patient care. Teaching about care measures is a nursing intervention that can be implemented to assist family members during the process of anticipatory grief. Family members should not be expected to meet all of the patient’s needs but should not be excluded from caring for their loved one.

Question 41

10. The nurse cares for dying patients and understands that
”nearing death awareness” is a phenomenon evident by which patient statements)? (Select all that apply.)
    A. “Where are my shoes? I need to get ready for the trip.”
    B. “Is my daughter from California going to come and visit before I die?”
    C. “When do you think that I am going to die?”
    D. “I was just talking to my daughter (deceased).”
    E. “How much longer can I live without food or water?”

Answer 41

Answers: a, d
Nearing death awareness has been described as a state manifested by a special communication of the dying that may occur in patients who are approaching death or are imminently dying. People experiencing this “nearing death awareness” may appear confused, but they may actually be making the transition from life to death. All of the other options are questions that dying people may ask, but they do not represent nearing death awareness.

Question 42

A patient who has recently expired must be cleaned, they also have their dentures laying on the counter. What is the priority action for the nurse, to keep the pt’s normal anatomical appearance?
A. insert dentures before the rigor mortis occurs
B. leave the dentures out on the counter, to not interfere with the patient’s facial symmetry
C. dunk the dentures in water to keep the dentures in great shape.
D. throw the dentures away since the patient has expired and does not need them anymore.

Answer 42

A. insert dentures before the rigor mortis occurs

Dentures and or other prosthetics are inserted if available to maintain normal anatomic appearance.

After a period of time, rigor mortis, or stiffening of the joints of the body, will set in.

Question 43

What is the proper positioning of an expired Patient?
A. supine, anatomical position
B. Prone , crossing arms and legs
C. sims position’
D. Trendelunburg position

Answer 43

A. supine, anatomical position

The body is placed in a supine position (on the back) in normal anatomic position, to prevent abnormal pooling of the blood.
* Arms at side (palms down) or across the abdomen * Head/shoulders elevated on one pillow (to prevent
discoloration of the face secondary to blood pooling)

• Dentures and or other prosthetics are inserted if available to maintain normal anatomic appearance.
• Close the eyes and hold them closed for several seconds so that they remain shut.

NO STERILE TECHNIQUE
CLEAN TECHNIQUE ONLYYYY FOR EXPIRED PATIENTS

Question 44

A patient family decided to go through an autopsy for the patient due to a complicated loss and unexpected death in the hospital. What is the priority action of the nurse and health care team?
A. keep all invasive tubes or lines
B. remove all lines and invasive tubes
C. instruct patients family to remove lines
D. instruct UAP to remove lines and invasive tubes

Answer 44

A. keep all invasive tubes or lines

if an autopsy is going to be performed as required by law or family request, any invasive tubes or lines must remain in the body. Such devices include intravenous (IV) lines, nasogastric (NG) tubes, tracheostomy appliances, endotracheal tubes, Foley catheters, drainage tubes, and any other invasive device that was used before death.

After death in any se ing, any medical equipment or tubes in the body are removed from the room unless an autopsy is to be performed.

Question 45

What is a shroud

Answer 45

After the family has left the hospital or health care facility, the body may be wrapped in a SHROUD, a cloth, sheet, or bag, for transportation to the morgue or funeral home.

Question 46

Can UAP’S assist with Post mortem Care?
A. Yes
B.No

Answer 46

A. Yes

Question 47

What is the best form of therapeutic communication for the patient’s family who’s just experienced a loss.
A. tell them everything is fine, at least they’re alive. Life goes on.
B. Listen to the patient’s family emotions and concerns, and provide a quiet and calm environment
C. shut out the patient’s family and decide not to engage or provide support
D. splash water in they face to stop crying.

Answer 47

B. Listen to the patient’s family emotions and concerns, and provide a quiet and calm environment

Skills of interpersonal communication, which include empathy, unconditional positive regard, genuineness, a ention, and listening skills, are essential at this time. Nurses must be comfortable “being with” the dying patient and family. Being present, by being in the room or close to the area and through active listening, is an essential part of caring for those at the end of life.

Question 48

What is the proper positioning of a patient dying?
A. Semi fowlers (30 - 45 DEGREES)
B. High fowlers (90 DEGREES)
C. low fowlers
D. Trendelenburg

Answer 48

A. Semi fowlers (30 - 45 DEGREES)

Question 49

What psyiological changes in a patient that is dying?

Answer 49

Physical symptoms at the end of life
* Weakness and fatigue, increased drowsiness, and sleeping
more and responding less
* Decrease in oral intake and decrease in the swallow reflex
* Surges of energy may occur as the dying person begins to
make the transition to death.
* Changes in bowel and bladder elimination