Week Fifteen Flashcards
Actual Loss
Can be recognized by others
Loss
An actual or potential situation in which something that is valued is changed or is no longer available or is gone
Grief
The total response to the emotional experience related to loss. Manifested in thoughts, feelings, & behaviors.
Bereavement
The subjective response experienced by surviving loved ones after the death of someone they have shared a significant relationship with
Mourning
The behavioral process through which grief is eventually resolved of altered. It is often influenced by culture, spiritual beliefs, and customs.
Perceived Loss
Experienced by one person but cannot be verified by others
Anticipatory Loss
Experienced before the loss actually occurs
Sources of Loss
loss of aspect of self, loss of external objects, separation from familiar environment, loss of loved ones
Losses that may be experienced by individuals with chronic illnesses
loss of: personal identity, body image and self esteem, feelings on indestructibility, role function and/or performance, independence, privacy, and control over situation, mobility
Factors that affect the loss reactions
age, meaning of the loss/significance of the loss, culture, spiritual beliefs, gender, socioeconomic status, support system, cause of loss or death
Loss of Aspect of Self
body part, physiologic function, mastectomy, psychologic attribute
Loss of External Objects
inanimate or animate objects
Separation from Familiar Environment
environment and people
Loss of loved ones
loss or change of a loved one
Meaning of the loss/significance of the loss
carefully assess this without subjectively ascribing your own values that of the patient as you may incorrectly assume that a specific loss either is or is not traumatic
Culture (Factors that affect loss reaction)
How grief is expressed. customs associated with grieving
Spiritual beliefs
nurses should gain knowledge of the specific cultural and religious beliefs of the patient and help the patient deal with loss in a manner that is appropriate with their cultural and religious beliefs and practices
Socioeconomic Status
A person who is confronted with both severe loss and economic hardship may not be able to cope with either
Support System
The social support that is available from family, friends, coworkers, and former institutions.
What are some institutions that help with grief?
grief camps, churches, hospice
Cause of loss or death (factors)
individual and societal views of the death. Clean VS repulsive death that is beyond the control of others VS a preventable death
Assessing Loss and Grief
nursing history, assessment of personal coping resources, physical assessment, state of awareness
Assessing the state of awareness
The state of awareness shared by the dying person and the family affects the nurse’s ability to communicate freely with the patient and other healthcare team members to assist in the grieving process
Closed Awareness
The patient is unaware of the impending death. The family may lack full understanding and believe the patient will recover. PCP may believe it is best not to communicate diagnosis or prognosis. RN is then confronted with an ethical dilemma.
Mutual Pretense
The patient, family and healthcare team know that the illness is terminal but not not talk about it and make an effort not to raise the subject. The patient refrains from discussion of death to protect the family from distress. May sense discomfort on the part of the health care works. Permits the patient a degree of privacy and dignity but also places a burden on the patient.
Open Awareness
The patient and others know about the impending death and feel comfortable talking about it even thought it is difficult. It provides the patient an opportunity to finalize affairs - may even plan funeral arrangements. Not everyone can cope with and embrace open awareness.
Subjective Assessment
of the patient’s perception of the loss, of those factors that influence the patient’s loss and grief responses, nursing history, personal coping resources
Personal Coping Resources
spiritual and/or cultural practice, whom can you turn to for support, what kind of help do you think you will need, who can help, are there organizations that may help, physical symptoms, what are you doing to help you deal with the loss
A decrease in peristalsis is evident by
Hypoactive bowel sounds
Physiologic Changes (Stress Response)
dilated pupils, increase HR, increase R, SOB, dry mouth, muscle tension, diaphoresis, pallor, decrease urine output, decrease peristalsis, increase blood glucose
Psychologic changes of loss
crying, tearful, change in appetite, sleep disturbance, difficulty concentration, verbalization about the loss
Other things that might be seen during a loss
denial, guilt, anger, fear, crying, despair, hallucinations, delusions, inability to concentrate, feeling of worthlessness, thoughts of suicide
George Engel
Local man. Developed Engel’s 6 stages of grieving with corresponding behavioral responses
Elisabeth Kubler-Ross
Has 5 stages of grieving and associated behavioral responses to each stage
Kubler-Ross Stages
Denial, Anger, Bargaining, Depression, Acceptance
Engel Stages
Shock/Disbelief, Developing Awareness, Restitution, Resolving the Loss, Idealization Outcome
Denial Kubler
refuses to believe loss happened, unready to deal with practical problems
Anger Kubler
Client or family may be angry at matters that normally wouldn’t bother them
Bargaining Kubler
Seeks to avoid loss, may express feelings of guilt or fear of punishment for past sins
Depression Kubler
grieves over what happened, may talk freely or withdraw
Acceptance
comes to terms with loss, may have decreased interest in surroundings and support person, may wish to begin making plans
Shock/Disbelief Engel
refusal to accept loss, stunned feelings, may assume artificial cheeriness, intellectual acceptance but emotional denial
Developing Awareness Engel
Reality of loss begins to penetrate, anger, crying and self-blame
Restitution Engel
Rituals of mourning
Resolving the Loss Engel
attempts to deal with painful void, unable to accept new love to replace lost person, may feel guilty
Idealization Engel
unconsciously internalizes admired qualities of deceased, reminders of the deceased evoke fewer sad feelings, reinvests feelings in others
Outcomes Engel
behavior influenced by several factors: importance of lost object, degree of dependence on relationship, degree of ambivalence toward deceased, number and nature of other relationships, number and nature of previous grief experiences
Define Grieving
A normal, complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate a loss into their daily lives.
Define Complicated Grieving
A disorder that occurs after the death of a significant other in which the experience of distress is accompanying bereavement fails to follow normative expectations and manifests in functional impairment
Complicated Greif two forms
unresolved or inhibited
Unresolved Complicated Grief
Some factor interferes with the progression of grief
Inhibited Complicated Grief
Normal symptoms of grief are suppressed
When is “normal” grief considered complicated grief
1 year after the loss
Normal findings of grief if up to year post loss
excessive/persistent expression of affect, inability to experience joy, clinical sx of depression, inability to form new relationships, inability to speak about the deceased without intense emotion, hearing or seeing the deceased, feelings of emptiness or meaninglessness
Abnormal findings if present past one year
leaves deceased’s room/belongings in tact, avoids visiting grave or attending memorial service, becomes recurrently symptomatic on the anniversary of loss or during holidays, develops persistent guilt and decreased self esteem, after a prolonged period continues to search for lost person, may consider suicide as an attempt to reunite, a relative minor event can trigger symptoms of grief, reported physical sx similar to those the deceased experienced before dying, relationships with friends and family worsen after the death
Factors that contribute to unresolved grief
ambivalence toward the deceased, perceived need to be brave and in control, fear of losing control in front of others, multiple losses, extremely high emotional value invested in the deceased, failure to grieve helps the survivor avoid the reality of the loss, uncertainty about the loss, lack of support systems
Ambivalence
love/hate feelings
Grieving r/t
anticipatory loss of significant object (possession, job, status, home, parts and processes of the body), anticipatory loss of significant other, death of a significant other, loss of a significant object (possession, job, status, home, parts and processes of the body)
Grief Defining Characteristics
alteration in activity level, alterations in immune function, alterations in sleep patterns, alterations in dream patterns, alterations in neuroendocrine function, anger, blame, detachment, despair, disorganization, experiencing relief, maintaining connection to the deceased, making meaning of the loss, pain, panic behavior, personal growth, psychological distress, suffering
Complicated Grieving r/t
death of a significant other, emotional instability, lack of social support, sudden death of a significant other
Complicated Grieving defining characteristics
decrease functioning in life roles, decrease sense of well-being, depression, experiencing somatic symptoms of the deceased, fatigue, grief avoidance, longing for the deceased, low levels of intimacy, persistent emotional distress, preoccupation with thoughts of the deceased, rumination, searching for the deceased, self-blame, separation distress, traumatic distress, verbalizes anxiety, verbalizes distressful feeling about the deceased, feeling dazed, feeling empty, feeling in shock, stunned, verbalizes feelings of anger, detachment from others, feelings of disbelief, feelings of mistrust, verbalizes lack of acceptance of the death, persistent painful memories, or self blame, yearning
Nursing Interventions to facilitate the grieving process
evaluate/assess the client’s grief process, allow family members to participate in care of loved one or body of deceased if desired, help the bereaved client survive during periods of acute grief, utilize therapeutic communication skills to ensure effective communication and encourage expression of feelings by the client, encourage the client to reminisce or share stories/memories, refrain from giving advice, interpreting, offering unwarranted reassurance, and self-disclosure, assist the client in identifying previous successful personal coping strategies, provide information about the grieving process, assist client in determining best way to obtain social supports, assess/identify available community resources, assess for causes of dysfunctional grieving, recognize times when you as a nurse are affected by loss and need grief resolution, allow choices, it is okay to give permission to die, encourage clients to take care of any unfinished business, encourage client and family to live one day at a time
What is requested after a death in New York State?
organ donation
Advance Directives
include a variety of legal and lay documents that allow patients to specify aspects of care they wish to receive should they become incapacitated and unable to make their wishes known
The Patient Self-Determination Act
requires: all health care institutions that receive medicare/medicaid reimbursement recognize advance directives, asking patients whether they have an advance directive, providing educational materials advising clients of their right to declare their personal wishes regarding treatment decisions, including the right to refuse medical treatment
What is critical thinking?
Intentional higher level reasoning process that is intellectually delineated by one’s world view, knowledge, and experience with skills, attitudes, and standards as a guide for rational judgement and actions. Purposeful, reflective, mental activity using skills of reasoning, analysis, and decision making relevant to the discipline of nursing. Discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns.
What is critical thinking interrelated to?
problem solving and decision making
How do nurses use critical thinking skills?
knowledge other subjects, deal with change/stressful environment, make important decisions
What enhances critical thinking?
Creativity. Creative nurses generate many ideas rapidly, are flexible and natural, create original solutions to problems, tend to be independent and self-confident, and demonstrate individuality
Critical Analysis
Application of a set of questions to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas
Inductive Reasoning
Generalizations are formed from a set of facts or observations
Deductive Reasoning
Reasoning for the general premise to the specific conclusion
Attitudes that foster critical thinking
independence, fair mindedness, insight into egocentricity, intellectual humanity, intellectual courage to challenge the status quo and rituals, integrity, perseverance, confidence, curiosity
What are the characteristics of critical thinking?
clarity, accuracy, precision, relevance, depth, logical, breadth, significance, fairness
Clarity
What is an example of this?
Accuracy
How can I find out if this is true?
Precision
Can I be more specific?
Relevance
How does that help me with this issue?
Depth
What makes this a difficult problem?
Logical
Does that follow from the evidence?
Breadth
Do I need to consider another point of view?
Significance
Which of these facts is most important?
Fairness
Am I considering the thinking of others?
Assessment Critical Thinking
making reliable observations, distinguish relevant from irrelevant data, distinguish important and unimportant data, validating data, organizing data, categorizing data according to a framework, recognizing assumptions, identifying gaps in data
Diagnosis Critical Thinking
Finding patterns and relationships among cues, making inferences, suspending judgement when lacking data, stating the problem, examining assumptions, comparing patterns with normals, identifying factors contributing to the problem
Planning Critical Thinking
forming valid generalizations, transferring knowledge from one situation to another, developing evaluative criteria, hypothesizing, making interdisciplinary connections, prioritizing client problems, generalizing principles from other sciences
Implementation Critical Thinking
Applying knowledge to perform interventions, testing hypotheses
Evaluation Critical Thinking
deciding whether hypotheses are correct, making criterion-based evaluations
What is problem solving?
Obtaining information that clarifies the nature of the problem and suggests possible solutions
What is decision making?
Critical Thinking process for choosing the best actions to meet a desired goal
What are the steps in decision making?
Identify the purpose, set the criteria, weigh the criteria, seek alternatives, examine alternatives, project, implement, evaluate the outcome
Change Agent
Helps the client modify behaviors
Caregiver
This can be provided by the nurse
Manager
Supervises and evaluates performance
Research Consumer
Sensitive to protecting the rights of human subjects
Client advocate
Acts to protect the client
Leader
Influences others to work together to reach a common goal
Communicator
Done verbally or written
Case manager
care is oriented to the client and controls costs
Counselor
helps promote personal growth
Teacher
Assess readiness to learn
Leaders
Influence others to work together to accomplish a specific goal
Manager
An employee of an organization who is given the authority, power, and responsibility for planning, organizing, coordinating, and directing the work of others, and for establishing and evaluating standards
What is the role of the leader?
may or may not have an official appointment to the position, power and authority to enforce decisions only so long as followers are willing to be led, influence others toward goal setting, either formally or informally, interested in risk taking and exploring new ideas, relate to people personally in an intuitive and empathetic manner, feel rewarded by personal achievements, may or may not be successful as managers, manage relationships, focus on people
what is the role of the manager?
appointed officially to the position, power and authority to enforce decisions, carry out predetermined policies, rules, and regulations, maintain an orderly, controlled, rational, and equitable structure, relate to people according to their roles, feel rewarded when fulfilling organizational mission or goals, are managers as long as the appointment holds, manage resources, focus on systems
What are the characteristics of an effective leader?
vision, influence, role model
What are the characteristics of an effective manager?
critical thinking, communication, resource management, enhance employee performance, build/manage teams, manage conflict, manage time
What are the four functions of a manager?
Planning, organize, directing, coordinating
Planning Manager
assessing a situation, establishing goals or objectives based on the assessment of a situation or future tends, and developing a plan of action that identifies priorities, delineates who is responsible, determines deadlines, and describes how the intended outcome is to be achieved and evaluated
Staff Nurse Planning
manages individual clients by the use of the nursing process
Organize Manager
determining responsibilities, communicating expectations, and establishing the chain of command for authority and communication
Organize Staff Nurse
develop goals and expectations with the client, organize assignment
Directing Manager
assigning and communicating expectations about the task to be completed, providing instruction and guidance, and ongoing decision making
Directing Staff Nurse
direct the care of clients by developing a care of plan, communicating care in written care plans and hand off reports and supervising the care that is given by others
Coordinating Manager
process of ensuring that plans are carried out, and evaluating outcomes
Coordinating Staff Nurse
Determines whether therapeutic nursing interventions have helped the client achieve desired outcomes
New York State Scope of Practice for the RN
diagnosis and treating human responses to actual or potential health problems through such services as case findings, health teaching, health counseling, and provision of care supportive to restorative of life and well-being, and executing medical regimens prescribed by a licensed physician, dentist, or other licensed health care provider legally authorized under this title and in accordance with the commissioner’s regulations. A nursing regimen shall be consistent with and shall not vary with any existing medical regimen.
What is delegation?
In NYS delegate is a legal term for assigning activities that are within a licensed professional’s scope of practice to another licensee with similar knowledge, skill and judgment. The unlicensed person can not delegate tasks to another person.
What is assignment?
Designation of non-professional health care tasks to an unlicensed individual who is trained and competent to perform them.
Five rights of delegation
Right Task, Right Circumstance, Right Person, Right Direction/Communication, Right Supervision and Elevation
Why is it important for health care providers to work as a team?
roles and relationships established, purposes of team as a whole adn the role of each member must be clear, each member must feel that the manager and other members recognize their contributions, effective communication skills, effective client outcomes achieved by individual members.
Hospice
A program of palliative and supportive services which provides physical, psychological, social, and spiritual care for dying persons and their families
How many months left of life must the client have in order to receive hospice care?
6 months although they may indeed outlive that prognosis and continue in the program
What is one of the basic tenets of hospice?
the belief and recognition that dying is a normal process whether or not it is from disease
What is the goal of hospice care?
to reduce the distressful symptoms of the process of dying
What are the WHO guidelines regarding palliative care?
provides relief from pain and other distressing symptoms, affirms life and regards dying as a normal process, intends to neither hsten nor post pone death, integrates the psychological/spiritual aspects of client care, offers a support system to help clients live as actively as possible until death, offers a support system to help the family cope during the client’s illness, uses a team approach to address the needs of clients and their families, including bereavement counseling, will enhance quality of life and may also positively influence the course of illness, is applicable early in the course of the illness in conjunction with other therapies that are intended to prolong life, such as chemotherapy/radiation and investigations needed to better understand and manage distressing clinical complications
Hospice care differs somewhat from palliative care in that hospice care focuses on:
support and care of the dying person and family with the goal of facilitating a peaceful and dignified death. It is focused on holistic concepts and emphasizes care to improve quality of life rather than care and supports the client and the family through the dying process and the family through bereavement.
What are the signs of impending death?
loss of muscle tone, slowing of circulation, changes in respiration, sensory impairment
Examples of loss of muscle tone
relaxation of facial muscles, difficulty speaking, difficulty swallowing, loss of gag reflex, decreased activity of GI tract with N, flatus, abdominal distention and retention of feces, urinary and rectal incontinence, decreased body movement
Examples of slowing of circulation
diminished sensation, mottling and cyanosis of extremities, cold skin, slower and weaker pulse, decreased BP
Examples of changes in respiration
rapid, shallow, irregular or abnormally slow respirations, cheyne-stokes respirations, noisy breathing
Examples of sensory impairment
blurred vision, impaired senses of taste and smell
Ineffective Airway Clearance TNI
Fowler’s position for the conscious client at lateral position for the unconscious client, suctioning of the upper airway and back of throat
Self-Care Deficit: Bathing/Hygiene TNI
Frequent baths and linen changes especially if diaphoretic, mouth care PRN for dry mouth
Impaired Physical Mobility TNI
assist client out of bed periodically, if able, change bedridden client’s position frequently, support client’s position with pillows, blanket rolls, etc, elevate client’s legs when sitting to prevent pooling of blood
Altered Nutrition: Less than Body Requirements TNI
antiemetics or small amounts of alcohol to stimulate appetite, encourage liquid foods as tolerated, frequent small feedings
Altered Urinary Elimination TNI
skin care in response to incontinence, bedpan, urinal, or commode within easy reach, call light within reach for assistance, absorbent pads or incontinent briefs in place, change frequently, catheterization if necessary, keep room clean and odor free
Sensory/Perceptual Alterations: Visual Tactile TNI
keep light on if client prefers, hearing is NOT diminished, speak clearly and do not whisper - remember client can probably hear you even if they don’t respond, touch is diminished but client will feel pressure of touch
Impaired Skin Integrity, Risk For TNI
reposition frequently, elevate heals off bed, keep client clean and dry, apply emollients/skin protectants frequently
Pain TNI
Medicate PRN until client has acceptable pain control, provide frequent emotional support, position for comfort
Grief TNI
encouraged expression of feelings, collaborate with clergy or spiritual advisor if acceptable to client, provide empathetic and caring presence, explain what is happening, encourage family to participate in client’s care
Rigor Mortis
Stiffening of the body that occurs 2-4 hours after death
Algor Mortis
Gradual decrease of the body’s temperature after death
Livor Mortis
Discoloration of the skin in dependent areas of the body due to the breakdown of red blood cells after circulation has ceased
Eight characteristics of the complete health history
Location, Character and Quality, Quantity or Severity, Timing, Setting, Aggravating or Relieving Factors, Associated Factors, Client’s Perception
Nonvital Tissues for Transplant
corneas, skin, long bones, middle ear bones, heart valves, connective tissue, bone marrow
Vital Organs for Transplant
heart, liver, lung, kidney, intestine, pancreas
How and when is the pancreas recovered for transplant
Recovered after a client is pronounced clinically dead or brain dead; circulatory and ventilatory support is maintained to perfuse the organs before removal
