Loss, Death, and Grief including Spirituality and 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 is a necessary loss(2)?
- loss that is necessary for change
- most necessary losses are replaced by something different or better
what is a maturational loss(3)?
- this is a form of necessary loss
- includes all normally expected changes across the lifespan
- can help develop coping skills to deal with unexpected loss
what is situational loss?
sudden, unpredictable losses
are losses actual or perceived?
they can be either actual or perceived
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)
2) anticipatory
3) disenfranchised (ambiguous)
4) complicated (chronic, exaggerated, delayed, masked)
what is bereavement?
a period of both grief and mourning
describe normal grief
universal reaction characterized by complex, emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death.
common
what is anticipatory grief?
grief someone feels in anticipation of a loss
(e.g. caring for someone diagnosed with ALS or dementia)
what is disenfranchised grief?
grief experienced when someone’s relationship to the deceased was not socially accepted and cannot be openly shared or seems insignificant to others
what is ambiguous loss?
occurs when the lost person is physically present but is not psychologically available
(e.g. severe dementia or brain injury)
type of disenfranchised grief
what is complicated grief?
when someone has a prolonged or significantly difficult time moving forward after a loss
what are characteristics of complicated grief(6)?
1) chronic or disruptive yearning for the deceased
2) trouble accepting the death
3) trust issues
4) bitterness
5) numbness
6) anxiety
what is chronic grief?
a normal grief response that lasts longer than normal
type of complicated grief
what is exaggerated grief?
when a grief response involves destructive or maladaptive behavior, obsessions, or psychiatric disorders
type of complicated grief
what is delayed grief?
a delayed grief response that usually occurs because the loss is so overwhelming that the person avoids the full realization of the loss
type of complicated grief
what is masked grief?
occurs 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
type of complicated grief
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 Consortium
provides basic curriculum for grief, death, and bereavement
How is the American Nurses Associated tied with loss and grief?
has 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?
provides guidelines for managing clinical and ethical issues
what is significant about grief and loss perceived by school-aged children?
children understand the concepts of permanence and irreversibility but do not always understand the cause of loss
what is significant about grief and loss perceived by young adults?
young adults undergo many necessary developmental losses related to their evolving future
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.
encouraging patients to share information about their losses will help us…
better develop appropriate interventions that meet the individualized needs of our patients
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
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
what is dysfunctional grieving?
a nursing clinical problem: a failure to follow the predictable course of grieving to resolution, including becoming overwhelmed and using maladaptive coping
describe setting priorities associated with grieving and loss(3)
1) encourage patient to share their priorities for care
2) prioritize patient’s most urgent physical or psychological needs
3) maintain ongoing assessment and make changes if needed
what does health promotion in serious chronic illness or death focus on?
successful coping and optimizing physical, emotional, and spiritual health
what does palliative care focus on?
- primary goal is to help patients and families achieve the best possible quality of life
- can include care of the dying
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
what does hospice care focus on(3)?
1) care of terminally ill patients
2) managing pain, providing comfort, ensuring quality of life
3) adhering to patient wishes
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 psychological symptoms associated with end-of-life experiences(5)?
1) anxiety
2) depression
3) powerlessness
4) uncertainty
5) isolation
managing multiple symptoms commonly experienced by chronically ill or dying patients remains a primary goal of…
palliative care nursing
remain alert to the potential side effects of opioid administration including(5):
1) constipation
2) nausea
3) sedation
4) respiratory depression
5) myoclonus
what is myoclonus?
involuntary muscle twitching
what are some nursing strategies that promote hope(2)?
1) be present
2) provide whole-person care
what kind of drugs dry up respiratory secretions?
antimuscarinic drugs
(e.g. Atropine)
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 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 anniversary reactions?
renewed grief around the time of the loss in subsequent years
what should you do if your patient is dealing with an anniversary reaction?
openly acknowledge the loss, assure that the reaction is normal, and encourage the patient to reminisce
why are autopsies performed?
to discover the exact cause and circumstances of death or to discover the pathway of a disease
who provides consent for an autopsy?
patient’s family members
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
describe the effect of spirituality on health outcomes(2)
- beneficial health outcomes occur when individuals are able to exercise their spiritual beliefs
- healing often takes place because of believing
describe the difference between religion and spirituality
spirituality is a much broader and unifying concept than religion
what is the definition of spirituality?
there is none. the subject is too subjective
what is self-transcendence(2)?
- a sense of authentically connecting to ones inner self
- 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 forms)?
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?
an energizing source that has an orientation to future goals and outcomes
what are the two dimensions of spiritual well-being(2)?
1) supports the transcendent relationship between a person and god or a higher power
2) 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 reasoning faith?
provides confidence in something for which there is no proof
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
2) connectedness
3) life satisfaction
4) culture
5) fellowship and community
6) ritual and practice
7) vocation
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 happens when people dont 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 is circadian rhythm affected by(4)?
1) light
2) temperature
3) social activities
4) work routines
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)
2) Process C (biological time clocks)
describe Process S
regulates length and depth of sleep
describe process C
influences:
* internal organization of sleep
* 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)
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 is the function of sleep(3)?
1) restoration
2) memory consolidations
3) prep for the next period of wakefulness
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
how can hypertension be associated with sleep?
BP increases when person is not sleeping well
describe how respiratory disorders can be associated with sleep
respiratory disorders like COPD, emphysema, and colds can interfere with sleep
what is restless leg syndrome?
RLS, onset occurs before sleep and is an itching sensation in the muscles of the legs, relieved by movement; interrupts sleep
what are some sleep disorders(5)?
1) breathing disorders
2) hypersomnia (excessive daytime sleepiness)
3) circadian disorder
4) parasomnia (sleep walking or nightmares)
5) psychiatric, neurological, or medical disorders
what is a polysomnogram?
the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during the night
what is a multiple sleep latency test (MSLT)?
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 is obstructive sleep apnea?
- occurs when muscles or structures of the oral cavity or throat relax and obstruct the upper airway
- results in hypopnea or apnea (for as long as 30 seconds at a time)
what is the most common symptom of OSA?
excessive daytime sleepiness
what are the two major risk factors for OSA?
1) obesity
2) hypertension
what is central sleep apnea?
- involves dysfunction of the respiratory control center in the brain
- impulse to breath fails temporarily
which patients commonly have CSA?
patients with:
1) brainstem injury
2) muscular dystrophy
3) encephalitis
what occurs in people with narcolepsy(4)?
- during the day a person feels an overwheling 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 can be defined as parasomnia(6)?
1) sleepwalking
2) night terrors
3) nightmares
4) bed-wetting
5) body rocking
6) tooth grinding
what age groups are parasomnias more common in?
children
what is the sleep requirement for neonates?
16 hours/day
what is the sleep requirement for infants?
8-10 hours per night; total of 15 hrs/day
what is the sleep requirement for toddlers?
12 hrs/day
what is the sleep requirement for preschoolers?
12hrs/night
what is the sleep requirement for school aged children?
8-10 hours/night
what is the sleep requirement for adolescents?
about 7.5 hrs/night
what is the sleep requirement for young adults?
6-8.5 hrs/night
what is the sleep requirement for middle and older adults?
sleep declines
what are factors that influence sleep(8)?
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 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 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 herbal remedies that may assist with sleep(3)?
1) valerian
2) kava
3) chamomile
how does valerian assist with sleep?
- effective for mild insomnia and RLS
- produces very mild sedation
how does kava assist with sleep?
- helps promote sleep in patients with anxiety
- use cautiously; potential toxic effects on liver
how does chamomile assist with sleep?
- mild sedative
