module g grief and loss

8/14/2019 Module G Grief and Loss

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Grief Process, Death and Dying: Nur 102, Module G

Reading assignment : Potter and Perry, Chapter 30

1. LOSS

A. Actual loss

i. Any loss of a person or object that can no longer been felt, heard, known, or

experienced by an individual. (Death, amputation, Sensory loss,

independence, divorce)

B. Perceived loss

i. Any loss uniquely defined by the client. (confidence, self-esteem, group

status)

C.Maturational loss

i. Any change in the developmental process that is normally expected in a life

time. (Empty nest syndrome, loss of senses)

D. Situational loss

i. Any sudden unpredictable event (hurricane Katrina, recessional job loss,

chronic illness; financial loss, security, family role. Hospitalization; privacy,

modesty)

2. Grief

E. Grief is the emotional response to a loss

i. Based on spirituality, religious beliefs, individual

F. Coping with grief

i. Mourning: the outward social expression of loss.

ii. Bereavement- grief and mourning together.

G.Kubler-Ross Stages of Dying (Grief)

i. Denial: the pt. acts like nothing happened. They refuse to accept that a loss

has occurred. May see outward expressions of this: deep sighs, listlessness,

cognitive impairment, refusal to comply with physicians orders.

ii. Anger: pt. may begin to recognize loss; they begin to strike out at

caregivers. Pt. is angry about loss. May become accusatory, demanding. Keep

in mind this is not personal or directed towards you.


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iii. Bargaining: Lets make a deal. Trying to barter for more time. Postponing

awareness of dealing with loss.

iv. Depression: will see all classic symptoms of depression. They begin to realize

what all the loss will entail. They realize the total impact of the loss. May

exhibit suicidal thoughts or tendencies.

v. Acceptance: pt. begins to accept loss for what it is. Begin to look toward

future and accept loss for what it is. Less introverted, participate in more

activities in environments.

2. Death and Dying

i. Assisting the patient to Live well and Die well

A.Common Fears of the Dying Patient

i. Fear of Loneliness: pt knows they are dying and that caregivers are not. Fear

of actually moment of death being alone.

ii. Fear of Sorrow: Letting go of hopes and dreams, letting go of future.

Anticipatory grief. May have grief process of disease that is going to be long

term.

iii. Fear of the Unknown: death is an unknown state. We all have beliefs and

faiths but really dont know. Fear about what will happen to your families.

iv. Fear of Loss of Self-concept and Body Integrity: Procedures that change body

appearance or function.

B.More Common Fears of the Dying Patient

i. Fear of Regression: going backwards. Not being able to take care of

self, cant do ADLs.

ii. Fear of Loss of Self Control: similar to above. Cannot control emotions,

cannot control environment. Loss of independence.

iii. Fear of Suffering and Pain: Emotional pain, physical pain, social

withdrawal, altercation of relationships. Fear family will suffer.

3. Childs Response to Illness and Death

C. Infant: birth to six months

i. No concept of death.

D. Toddler: 6 months to 2 years-old

i. May see death as reversible.


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i. Should include family members, patient.

O. Type and Stage of Grief

P. Grief reactions

i. Assess how the pt is reacting not how you think they should be reacting.

ii. No two people grieve the same way; very individualized.

Q.Symptoms of normal grief-(Box 30-5, pg. 469, Potter & Perry)

R.End-of-life decisions

i. Decisions that relate to what that pt wants with regards to end of life care.

ii. Nurse should try to discuss this with pt. when possible.

iii. DNR, Living will, etc

S. Nurses experiences

i. We each have to look inside when dealing with terminal patients. Need to

examine our own ideas on death and dying b/c it will affect care we give.

ii. Need to look out for our own emotional well being as well.

iii. Need to deal with personal phobias of death. Cannot put own personal

feelings above that of the client!

T. Client expectationsi. what can I do to help you?

ii. Discuss with family their expectations of the healthcare team.

6. Nursing Diagnoses

U.Anticipatory grieving

V.Dysfunctional grieving

W. Hopelessness

X.Powerlessness

Y. Spiritual distress

7. Planning


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Z.Goals and outcomes

1. Short-term: related to hospital

i. Getting through hospital stay, education, setting up care for ADLs, etc

2. Long-term: carry on to home.i. Renewing relationships, getting through grieving process, etc

AA. Setting priorities

i. Need to figure out what needs to be taken care of first. Ex: do not try to teach

if pt. is in level nine on pain chart.

BB. Continuity of care

i. Make sure pt. continues to receive any counseling, care, education they need

after they leave hospital setting.

8. Role of the Chaplain

CC. Can be a member of the health care team

DD. Assist with religious practices

1. Perform rites

2. Provide prayer, support, and comfort

EE. Assist with mobilizing other support systems that are important to the

client

FF. Support family members

9. Implementation

i. Help promote healthy grief resolution. Help them move through the process

and adjust to loss. Deal with stressors in their life; make health care

decisions at this time.


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GG. Therapeutic communication: open ended statements, will learn more in

Mod. E. No topic that a dying client wants to talk about is off limits. CLIENT

NEEDS THAT OUTLET!

HH. Promoting hope: can be an energizing resource for anyone dealing with

loss. Have cheerful attitude, encourage positive coping mechanisms, offering

info about illnesses to dispel misconceptions, using external resources.

II. Facilitating mourning: Give them time to grieve, allow family to be

there as much as possible, allow family to help with care as much as possible.

10. List nursing strategies appropriate for grieving persons

JJ. Open ended statements

1. Patient sets the pace

KK. Accept any grief reaction

1. Be awarenurse may be target of anger

LL. Remove barriers

1. Sensory barriers

2. Family members that are not in control of emotions

3. Social workers may help.

MM. Avoid giving advice

NN. Allow patient to talk

OO. Allow patient to express signs of hope

PP. Support hope by helping focus

11. Palliative Care

QQ. Palliative care defined:

The prevention, relief, reduction, or soothing of symptoms of disease or

disorders without affecting a cure.

1. Some aspects of Palliative Care

i. Symptom control assist with related symptoms of

illness, provide comfort.


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ii. Maintaining dignity and self-esteem attend to

clients appearance, help keep self-esteem high,

keep family and pt well informed.

iii. Preventing abandonment and isolation answer call

lights promptly, talk and spend time with pt, usecaring touch when appropriate, keep family

involved and part of care, provide peaceful and

comfortable environment.

iv. Providing a comfortable and peaceful environment

preferential activities, clean room, lighting, temp,

etc

12. Guidelines concerning Communicating Terminal Illness

RR.Physician tells patient

i. Patient has right to know prognosis, but we do not give it to them.

SS. The nurse:

i. Clarifies: answer any questions that may not have come up when the

initial diagnosis was given.

ii. Listens

iii. Fosters communication: between physician and patient/pt family.

iv. Allows expression of feelings

v. Facilitates grief through nursing process

vi. Is available

vii. Assists with goals

viii. Connects with resources

13. Support for the Grieving Family

TT. Primary caregivers

1. Information and education

2. Planning


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KKK. Skin changes-cold, clammy: can become diaphoretic though.

LLL. Pulse-irregular, and rapid

MMM. Respirations-strenuous, irregular, Cheyne stokes

NNN. Death rattle: a lot of congestion in chest that moves around and

rattles as they are breathing.

OOO. Decrease Blood Pressure

PPP. Jaw and Facial muscles relax

QQQ. MOST POSITIVE SIGN OF DEATH=Absence of brain waves (Need two

MDs to sign off)

18. Nursing Care Postmortem (after death)

RRR. Tissue and Organ Donation: will want to talk to pt. and pt. family about

organ donations prior to death.

i. Heart, liver, kidney, lung, pancreas

ii. Non-vitals that can be harvested: long bones, corneas, middle ear bones, skin

iii. If pt is donor keep cardiovascular systems going. Call donor bank rep.

iv. All family members must agree to donation.

SSS. Autopsy: examination performed after a persons death to confirm ordetermine cause of death

TTT. Cultural issues (Table 30-10, pg. 481)

19. Postmortem Care

i. Nurses responsibility

ii. Family becomes client

iii. Know facility Policy and Procedure

iv. Seek support resources as appropriate

v. Proper documentation: DOCUMENT ALL EVENTS SURROUNDING CLIENTS

DEATH.

20. Care of the Body after Death


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UUU. Procedural Guidelines (pg.481 in Potter & Perry)

1. Check orders

VVV. Family/sig others: allow them to say goodbye and have closure.

WWW. Equipment: remove equipment by protocol. IV, Catheters, etc

remove from room.

XXX. Cleansing: clean bed if needed, clean trash, etc

YYY. Hair care

ZZZ. Position/Cover: most of the time supine, covered with sheet.

AAAA.Environment: try to have nice clean environment for family to view

body after death.

BBBB.Viewing time: give family time to say goodbye. Do not rush family!

21. After the family leaves...

i. Some sort of identifying tag on the body.

ii. May have to wrap body certain way, go by policy for prep to travel to

morgue.

iii. Documentation: pg 480 box 30-9 Potter and Perry.

22. Nurses response to the dying patient

CCCC. Nurses grieve also

DDDD. Nurses personal view of life and mortality

EEEE. Common feelings: Frustrations, associated guilt, Sadness, anxiety.

FFFF. Coping methods: Attend viewings if possible, Send card or letter to

family, other nurses, personal support systems, positive stress managementtechniques.

23. Evaluation

GGGG. Client Care


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HHHH. Client expectations

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