0133427269 Module27 GriefandLoss LectureOutline

Module 27 Grief and Loss The Concept of Grief and Loss Every individual experiences loss, grief, death at some time during life Relationships change, deaths, life roles, material objects, ideals Grief ( reactions vary widely By understanding the emotional and physical aspects of grief, nurses are better able to care for clients during the grief process Normal presentation of grief and loss Definitions Grief ( combination of various psychological, biological, and behavior responses to a loss Bereavement ( response to having lost another through death Mourning ( the processing and resolution of grief The process of grieving Types of loss Actual loss ( one that can be recognized by others Perceived loss ( experienced by one individual but cannot be verified by others Anticipatory loss ( one that is experienced before the loss actually occurs Situational ( loss of job, death of child, loss of functional ability from illness, injury Developmental ( losses that occur in process of normal development ( grown children, retirement, death of aged parents Sources of loss Loss of aspect of oneself, e.g., losing a limb due to amputation Changes body image even though loss may not be obvious Physical, psychological losses can have impact on self-image Loss of object external to oneself Loss of inanimate objects ( money, family home burning down Loss of animate objects Loss of independence Loss due to illness such as dementia or MS Loss of mobility Types of grief Anticipatory grief ( grief that is experienced before the loss occurs Disenfranchised grief ( grief that occurs when individuals cannot acknowledge their loss to others Complicated grief ( grief that has not been processed to a point of resolution 6 months after the loss Theories related to grieving Kbler-Ross identified five stages ( denial, anger, bargaining, depression, acceptance Engel identified six stages ( shock and disbelief, developing awareness, restitution, resolving the loss, idealization, outcome Sanders described five phases of bereavement ( shock, awareness, conservation/withdrawal, healing, renewal Lifespan considerations Children and adults experience grief differently and manifestations of grief vary across the life span Children express their grief through behavioral changes, play, art Adults ( grief work can be complicated by the responsibilities of adulthood Older adults ( grief may seem more intense grief can trigger memories of earlier losses Sociological considerations The nature of the loss and the individuals support system Loss that impacts daily functioning (e.g., loss of an income-earning spouse) requires greater support Alterations from normal Normal manifestations of grief Everyone grieves differently normal grief cannot be defined Common manifestations include sadness, anxiety, guilt, anger, confusion, sleep disturbances, loss of appetite Alterations and manifestations See CONCEPTS RELATED TO GRIEF AND LOSS, p. 1745 Typically, the intense feelings of grief begin to dissipate 3 6 months following the loss Complicated grief ( characterized by extended time of denial, impairment of functioning, depression, severe physiologic symptoms, suicidal thoughts Factors that affect the grieving process Age Childhood Loss of parents, significant person can threaten childs ability to develop, sometimes resulting in regression Can feel afraid, abandoned, lonely Early and middle adulthood Loss is part of normal development Losses include death, impaired health, body functions Late adulthood Losses include loss of health, mobility, independence, work role Loss through death of longtime mate Gender Men frequently expected to be strong Women expected to grieve by crying Substance and alcohol abuse Unhealthy coping mechanisms can complicate grief Substance and alcohol abuse often employed in early stages of grief Nurses should be alert to signs/symptoms and provide support and referral for the dependence Asking for help Depending on individual, society, and culture, grief may carry a stigma Cultural beliefs can affect the grieving process Neglecting to grieve can lead to feelings of isolation Case Study Part 1 ( Jessie Duncan is a 32-year-old African American woman whose 7-year-old daughter, Tasha, died 3 months ago after fighting leukemia, p. 1747 See ALTERATIONS AND THERAPIES Grief, p. 1747 Assessment Nursing assessment Includes assessing the many factors that contribute to a clients grief rection Be attentive to the clients needs See ASSESSMENT INTERVIEW Grief and Loss, p. 1748 See GRIEF AND LOSS ASSESSMENT, p. 1748 Spiritual and cultural considerations Accurate assessment requires awareness of the clients cultural influences Use the client interview to glean appropriate information Awareness of cultural values and beliefs can prevent miscommunication and conflict Case Study Part 2 ( Mrs. Duncan tells you that she has been working a lot since her daughter died because she needs something to help occupy her mind, p. 1749 Interventions and therapies Independent Ask open-ended questions to engage client in discussion Use active listening techniques to show full engagement Collaborative Facilitate meetings with hospital chaplain or social worker Group therapy, bereavement groups, and grief therapists can all be resources Hospice programs provide services for those experiencing grief Pharmacologic interventions may be appropriate ( see MEDICATIONS Antidepressants, p. 1750 Review The Concept of Grief and Loss Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( Before the doctor talks with Mrs. Duncn, you discuss her complaints of sleeplessness and weight loss with him, p. 1750 Exemplar 27.1 Childrens Response to Loss Overview Sources of loss for children Loss of loved one Loss of an aspect of oneself Loss of an object Separation from an accustomed environment Childrens grief response Vary depending on number of factors ( developmental stage and significance of the loss Death anxiety ( feelings of fear and/or apprehension connected with death Development stage Four tasks help children adapt to loss Accept the loss and its permanence Experience the emotions associated with grief, such as anger, fear, sadness, guilt, and loneliness Adjust to daily life without the individual who has been lost Come to see the relationship with the deceased as one based on memories in place of continuing experience Ages 2 4 Cannot yet fully comprehend loss May see death as temporary or reversible Reactions may be changes in sleeping and eating habits regression in toilet training May lose interest in usual activities May crave attention and become clingy Caregivers should maintain normal routines and provide extra reassurance and attention Ages 5 7 Death may still be seen as reversible, or seen as another place the child cannot reach Child may feel responsible for the death ( magical thinking Child may be worried that others will die as well Reactions may include changes in eating and sleeping patterns Encourage children to express their feelings and fears Caregivers should provide reassurance and be available to talk about the childs grief Ages 8 11 Children begin to understand that death is permanent Children become more curious about death and what happens after someone dies May feel responsible for the death ( a form of punishment for misbehavior Grief reactions are typically behavioral and may involve becoming more aggressive, acting out at school, or mishaving at home Or the child may become withdrawn and engage in solitary activities Ages 12 18 More capable of understanding the abstract idea of death Grief responses are similar to those of adults Adolescents should be encouraged, but not forced, to voice their feelings about the loss Significance of the loss Significance of loss determines amount and type of grieving Understanding, behavioral responses vary with developmental level, previous experience Death of a parent Extremely traumatic event ( significant impact on childs self-concept, health, social and economic circumstances Childs reaction influenced by surviving parents reaction to death, support of child Additional losses may occur as a result of parents death Death of a grandparent Often first experience with death Reaction to loss depends on significance of grandparent to child Death of a sibling Can be as traumatic as loss of a parent Generates questions of mortality May have feelings of guilt and confusion Children ages 5 11 may exhibit magical thinking Death of a friend Due to chronic condition, acute illness, injury Prepare friends of chronically ill children for potential death Some schools offer grief support, counseling Other losses Examples parental divorce, deployment of parent, moving to new home/location, long-term illness, acute or chronic injury Parents should offer honest, simple, developmentally appropriate explanations Complications Complicated grief reactions Loss of an abuser can lead to development of complicated grief reaction ( feelings of grief are mixed with sense of relief Childhood traumatic grief Grief reaction to the traumatic death of an individual who is important to the child Examples witnessing a parents death in a motor vehicle crash, fire, or act of violence finding a loved ones body after death Children are often prevented from moving through grief as they normally would have Difficult for children to remember the loved one in happy circumstances Clinical manifestations Behavioral response to grief Vary depending on developmental age, temperament May be immediate or delayed Withdrawal or acting out Anger and aggression Trouble with eating or sleeping Overall feeling of anxiety Nurses should encourage caregivers to allow children to express their grief Cultural considerations Recognizing, understanding familys cultural traditions, practices guides nursing care Nurse should understand ( ceremonies, rituals based on culture, spiritual beliefs Faith and spirituality may be fundamental coping mechanism Faith-based, spiritual leaders may be helpful to family See CLINICAL MANIFESTATIONS AND THERAPIES Childhood Grief, p. 1755 Collaboration Pharmacologic therapy Therapy and counseling should be tried first Can keep children from developing their own coping and healing mechanisms Low doses of antidepressants may be presribed Increased risk for suicide should be discussed with caregivers Nonpharmacologic therapy Individual sessions with therapist Childrens bereavement groups Therapeutic writing Nursing process Assessment Psychosocial assessment of all family members Assessment of cultural, spiritual influences Assessment of social support system Diagnosis Fear Death Anxiety Spiritual Distress Grieving Ineffective Coping Planning Goals may include Child will demonstrate healthy and age-appropriate coping mechanisms Child will express fears concerning death Implementation Encourage child to honestly express feelings about the loss Assure the child that it is normal to feel angry, sad, and confused Education the child and parents about healthy outlets for childhood grief such as drawing, painting, writing Provide parents with information about explaining death in an age-appropriate manner Evaluation Child must be allowed to go through grieving process at own pace Outcomes include Child expresses fears related to death or the dying process Child acknowledges grief felt at the loss of a loved one Review Childrens Response to Loss Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 27.2 Death and Dying Overview Death, process of dying, clients response to/perception of it highly individualized Pathophysiology and etiology Signs and symptoms of death can present up to 3 months before death Changes in attitude Physiological changes ( decreasing blood pressure, abnormal breathing Etiology Death may result from accident, injury, violent act, suicide, or illness Actions leading to death often determine how client, family members, and care team react Clinical manifestations Anticipatory grief Can affect both the dying client and the clients family Grief that is experienced in advance of death Not everyone experiences anticipatory grief Helping the client cope with death Those who are working to accept the reality of them impending death experience a wide range of emotions Some of the emotions can be directed at the nurse Aiding clients and families in understanding the dying process helps reinforce positive coping mechanisms Lifespan and cultural considerations Build relationships with clients on respect and mutual goals Culture can affect pain management, expression of needs, Nurses should encourage open lines of communication See FOCUS ON DIVERSITY AND CULTURE Culture and the Dying Client, p. 1760 Physiological changes in the dying client Dyspnea Respiratory changes are normal as death nears Respirations often become fast or slow, shallow and labored Client may have apnea or Cheyne-Stokes respirations Fluids may accumulate in the lungs Oxygen, suctioning only temporary, may be traumatic for client Hypotension Cardiac output, intravascular blood volume decrease, causing blood pressure to gradually decrease Pulse often rapid, irregular Anorexia, nausea, and dehydration Anorexia, decrease in food in fluid intake normal in dying client Parenteral or enteral feedings do not improve symptoms or prolong life Nausea a common problem Caused by reduced gastric emptying, constipation, bowel obstruction Dehydration less a problem than overhydration Causes discomfort from dry mouth, thirst Altered levels of consciousness Neurological dysfunction results from any or all of the following Decreased cerebral perfusion Hypoxemia Metabolic acidosis Sepsis Accumulation of toxins from liver and renal failure Effects of medications Disease-related factors Pain Common problem for clients at end of life What people often say they fear the most Keep client comfortable ( comfort measures, administration of medications Psychosocial needs As clients condition deteriorates, nurses knowledge of client, family guides care Client needs opportunity to say good-bye to others Death The following signs and symptoms indicate that death has occurred Flat encephalogram No pulse or respiratory activity no response to external stimuli no reflexes no muscle movement The nurses response to death and dying All nurses will encounter the death of a client at some point in their career Nurses must learn how to acknowledge, accept death, grieve loss of clients Do not give false reassurance to clients or families Nurses need to honestly assess their own feelings about death to as not to impose them on clients Coping with the loss of a client Nurses are not immune to the effects of grief over the death of a client It is easy to form bonds with client who are dying Nurses should seek support for grief that they feel for clients Discussions with peers Debriefing group sessions with mental health professionals Collaboration Pharmacologic therapy Pain management Nonpharmacologic therapy Massage and touch Heat therapy Acupuncture Mouth and oral care Meditation and breathing techniques Nursing process Assessment Assess for signs of approaching death and physical comfort Take vital signs every 2 hours or as ordered Include fifth vital sign pain Assess for signs of impending death Assess for spiritual and emotional comfort Client needs to have comforting items nearby Nurse works with family to determine what will provide emotional, spiritual comfort to the client Diagnosis Death Anxiety Fear Grieving related to impending death Planning Client will maintain human dignity throughout the dying process Client will remain free of pain throughout the dying process Client will participate in decision-making process as long as he or she competent Family will receive emotional support needed throughout the dying process Implementation All terminally ill clients reach point when they can no longer care for themselves Nursing care to prevent impairments in skin integrity, prevent/alleviate pain, maintain hygiene Using artificial tears if client does not blink Keeping lights at low level Keeping skin clean and dry Covering only with light blanket Using adult incontinence pads, pants for incontinence Turning every 2 hours, maintaining joint positions Ensure client, family comfort and support Refer clients, families to social services, other agencies that provide financial support Provide bedside activities, distractions to decrease boredom, limit obsessing about death Encourage clients who are able to form support groups to discuss fears and ways to alleviate them Ensure clients who are still competent have opportunity to visit lawyer, financial representative to make necessary arrangements Evaluation Expected outcomes Client expresses fears related to death or the dying process Client informs nurse about increases in pain Client is made comfortable Clients family remains informed of any changes in clients condition Review Death and Dying Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 27.3 Older Adults Response to Loss Overview Accumulation of losses may compound new grief Pathophysiology and etiology Grief and loss may be more complicated than at other ages Older adults lose friends and acquaintances in their age group May begin to anticipate their own death as well as death of partner Etiology Losses associated with aging are varied ( loss of independence, loss of mobility, loss of health, loss of memory Ageism ( stereotypes about older adults Factors affecting grieving process Older adults at greater risk for depression Suicide in older adults is commonly the result of untreated depression Nurses should be alert for signs of depression in older adults experiencing grief Clinical manifestations May be more profound than those observed in younger clients Older clients response to grief Anger, sadness, longing, disbelief, depression Intensity will vary from client to client May neglect their own needs ( eating habits, personal hygiene, and health maintenance may fluctuate Clients history Inquire about other recent losses Determine present health concerns suchs as dementia, depression Complicated grief Unrelenting feelings of preoccupation and yearning resulting from the loss Experienced over 6 months or more Clients may manifest trust issues, thinking that family and friends are judging their pain Lifespan and cultural considerations Common misconception that all older adults are frail, have dementia, or cannot handle upsetting news Many older adults find deep meaning in their religious or spiritual beliefs and practices Nurses should assist clients in meeting these needs See LIFESPAN CONSIDERATIONS Mental Health Concerns and Older Adults, p. 1765 See FOCUS ON DIVERSITY AND CULTURE Loss Among Older Adults, p. 1765 Collaboration Pharmacologic therapy Depressions may require use of antidepressants Complicated grief sometimes requires use of SSRIs Older adults taking antidepressants should be monitored closely for side effects or complications Nonpharmacologic therapy Group therapy can be successful Individual therapy may be helpful Complicated Grief Treatment may be needed Nursing process Assessment Health history Nature of loss, activities in which client participated to honor loss Changes in sleep, appetite Past, current coping mechanisms Examination of resources Family, social, financial Physical examination Changes in cognitive skills Symptoms of depression Diagnosis Grieving Complicated Grieving Disturbed Sleep Pattern Risk for Situational Low Self-Esteem Self-Neglect Planning Client will participate in group therapy or one-on-one therapy Client will use healthy coping mechanisms Client will discuss any instances of depression onr suicidal thoughts Client will move on to acceptance of loss Implementation Teach client about the grieving process Discuss the benefits of different forms of therapy Inform the client about warning signs of depression and/or suicide Teach the client about healthy coping mechanisms Provide judgment-free area for client to discuss feelings and fears Encourage client to share emotions and fears with friends and family Provide referrals as necessary Evaluation Client employs healthy coping mechanisms Client asks for help and support when needed Client begins to accept loss as evidenced by return to normal activities and decrease of emotions associated with grief Review Older Adults Response to Loss Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 27.4 Perinatal Loss Overview Perinatal loss ( death of fetus, infant that occurs between time of conception and end of newborn period 28 days after birth Pathophysiology and etiology Intrauterine fetal death (IUFD) ( occurs after 20 weeks gestation often referred to as stillbirth or fetal demise Miscarriage, spontaneous abortion ( loss of fetus prior to 20 weeks gestation Etiology Miscarriage Most common cause is blighted ovum Generally occur during first trimester, but second trimester can occur Stillbirth Cause may be unknown Known factors include birth defects, chromosomal disorders, placental abruption, infections, slow fetal growth, umbilical cord problems Rh disease is a rare cause of fetal demise Risk factors Increased age at time of conception, particularly for women over 40 Womans health history Certain maternal conditions increase risk Woman at risk for DIC is retention of fetus is prolonged Prevention Most cases ( not possible to prevent perinatal loss Best prevention is knowledge of factors that affect the mothers health Avoid drugs, chemicals, alcohol, tobacco, and infectious diseases Clinical manifestations Changes in fetal activity Significant decrease in or stopping of fetal movement before labor may be a sign of complications Confirmed on ultrasound with visualization of fetal heart, absence of heart action Grief Loss of an infant during any stage of pregnancy can be extremely traumatic for both parents ( intense feelings of grief are expected Disenfranchised grief ( perinatal loss is often not socially recognized Postpartum depression ( can occur in women following perinatal loss Mothers should be closely monitored for signs of serious depression and/or suicidal thoughts Lifespan and cultural considerations Parents may desire to speak with a religious or spiritual leader Beliefs may affect how parents mourn the loss of the child See FOCUS ON DIVERSITY AND CULTURE Perinatal Loss and Culture, p. 1770 See CLINICAL MANIFESTATIONS AND THERAPIES Perinatal Loss, p. 1770 Collaboration Diagnostic tests Tests done to determine possible causes of fetal demise ( blood tests, placental tests, x-rays, MRIs, chromosomal studies Pharmacologic therapy Mother treated for infections or complications Placental abruption ( IV fluids and/or blood transfusions Postpartum depression ( antidepressants, hormone therapy Nonpharmacologic therapy Group therapy or grief counseling Lifestyle changes Nursing process Assessment Mothers communication to nurse of cessation of fetal movement frequently first indication of fetal death Open communication ( assess prior experiences, social supports Intrapartum loss Unanticipated, sudden May wish to hold, view deceased child Diagnosis Grieving Risk for Complicated or Disenfranchised Grieving Risk for Infection related to retained fetus Risk for Bleeding related to placental abruption Risk for Spiritual Distress Planning Parents will ask questions regarding the loss, delivery, aspects of care Client will choose how she wishes to deliver the fetus Clients health and safety will be monitored and preserved during and after labor Extended family or support systems available to help grieving parents cope with loss Parents express grief over the loss of the fetus Parents avoid taking undue or unreasonable responsibility for fetal loss Implementation Preparing family for birth Private room, away from other laboring women Provide privacy, maintain supportive environment Enable same nurse to stay with couple Ensure couple does not feel alone, isolated Facilitate couples wishes for outside support as requested Therapeutic relationship Provide opportunity to ask questions Arrange for team members to meet with family Explain details of plan of care Allow family to make decisions for labor, birth preferences Birth experience Beginning and end Family may be overwhelmed Assist couple in exploring feelings Assist with decision making Music, lighting, other environmental preferences Laboring, birthing in a specific position Having infant placed on mothers chest immediately after birth Allowing father to cut umbilical cord Including other family members, friends at birth Reassure that preference not right or wrong Couple may have waves overwhelming grief, disbelief, sadness Encourage partners to express emotions freely as able Supporting the family in viewing the stillborn infant Viewing infant aids in dispelling denial, enables couple to progress to next step Prepare couple for what they will see and how infant will feel Use infants name (if parents have selected one) when discussing baby Allow family to remain with infant as long as they choose Providing discharge care Most facilities prepare a remembrance box or package Couple can be given option of early discharge per facility protocol Choice of rooms inpatient medical floor, postpartum unit Discharge focuses on physical considerations, adaptation of mother Directions for follow-up care Information about milk coming in Additional information on grieving process Help prepare for questions, feelings of siblings, family, friends Evaluation Parents express grief about the death of their baby Parents make their preferences for the birthing process known. Parents express grief over the loss of their child. Parents are given resources to help with their grief Parents develop healthy coping mechanisms for working through the grieving process Review Perinatal Loss Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. Lecture Outline for Nursing A Concept-Based Approach to Learning, 2e, Volume 2 PAGE PAGE MERGEFORMAT 25 Y, dXiJ(x(I_TS1EZBmU/xYy5g/GMGeD3Vqq8K)fw9 xrxwrTZaGy8IjbRcXI u3KGnD1NIBs RuKV.ELM2fiVvlu8zH (W uV4(Tn 7_m-UBww_8(/0hFL)7iAs),Qg20ppf DU4p MDBJlC5 2FhsFYn3E6945Z5k8Fmw-dznZxJZp/P,)KQk5qpN8KGbe Sd17 paSR 6Q