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45-2Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Loss
Loss is any situation in which a valued object is changed or is no longer accessible to the individual.
45-3Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Loss
Maturational loss occurs as a result of moving from one developmental stage to another.
Situational loss occurs in response to external events.
45-4Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Loss
Actual loss Perceived loss Physical loss Psychological loss
45-5Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Loss
Categories of Loss• Loss of an external object• Loss of familiar environment• Loss of aspect of self• Loss of significant other
45-6Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Loss
Loss as Crisis• Loss precipitates anxiety and a feeling of
vulnerability, which may lead to crisis.• When an individual is overwhelmed and his
or her usual coping mechanisms are no longer effective, crisis occurs.
45-7Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Loss
All Americans experienced significant loss as a collective, as a result of a terrorist attack in the World Trade Center on September 11, 2001.
45-8Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Grief
Grief is a normal, natural, necessary, and adaptive response following a loss.• Bereavement is the period of grief following
a significant loss, especially death of a person or pet.
• Mourning is the period of time during which the grief is expressed.
• Mourning is an adaptive response to loss.
45-9Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Grief
Theories of the Grieving Process• Lindemann coined the phrase grief work.• Engle described three stages of mourning.
- Shock and Disbelief- Developing Awareness- Restitution and Resolution
• Worden identified four tasks in dealing with a loss.
45-10Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Grief
Types of Grief• Uncomplicated grief• Dysfunctional grief• Anticipatory grief
45-11Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Grief
Persons experiencing dysfunctional grief do not progress through the stages of overwhelming emotions associated with grief, or they may fail to demonstrate any behaviors commonly associated with grief.
45-12Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Grief
Disenfranchised grief is grief experienced in situations where grief is discouraged and social supports are absent.
45-13Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Types of Grief
Anticipatory grief is the occurrence of grief work before an expected loss.
Promotes adaptive grieving by freeing up the mourner’s emotional energy.
45-14Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Factors Affecting Grief
Developmental Considerations
• Childhood
• Adolescence
• Early Adulthood
• Middle Adulthood
• Older Adulthood
45-15Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Children
Concept of death varies with the child’s developmental level.
Children need to be included in mourning rituals as appropriate to their developmental level.
Children need explanations about death that are honest and comprehensible.
45-16Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Adolescence
Adolescents perceive themselves as being invulnerable and death as something that will not happen to them.
45-17Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Middle Adulthood
The death of peers forces acknowledgement of one’s own vulnerability to death.
Other losses during middle age are those associated with changes in employment and relationships.
45-18Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Older Adulthood
Most older adults recognize the inevitability of death.
Older adults commonly experience the loss of loved ones and friends, occupational role, material possessions, dreams and hopes, and physical and cognitive function.
45-19Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Factors Affecting Grief
Religious and cultural beliefs Relationship with the lost entity
45-20Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Factors Affecting Grief
Cause of Death• Anticipated death• Unexpected death• Traumatic death• Suicide
45-21Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Nursing Care of theGrieving Person
Assessment• Determination of the personal meaning of
the loss• Understanding that the stages of grief the
client is experiencing are not necessarily sequential
45-22Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Nursing Care of theGrieving Person
Nursing Diagnoses• Dysfunctional Grieving• Anticipatory Grieving
45-23Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Outcome Identification and Planning
Verbalization of feelings of grief Sharing grief with significant others Acceptance of the loss Renewal of activities and relationships
45-24Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Implementation
Listening to gain understanding of the significance of the client’s loss
A nonjudgmental, accepting attitude while the bereaved expresses anger
Appropriate referrals to community support groups
45-25Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Evaluation
Resolution of the loss is generally a process of life-long adjustment.
The nurse has a unique opportunity to lay the foundation for adaptive grieving.
Goals mutually established with client and family are the foundation for evaluation.
45-26Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Death
Stages of Death and Dying (Elizabeth Kubler-Ross)• Denial• Anger• Bargaining• Depression• Acceptance
45-27Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Ethical and Legal Issues Related to End of Life
End-of-Life Care Physician-Assisted Suicide
45-28Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Nursing Care Plan of the Dying Client
Assessment• Client’s and family’s knowledge about the
nature of terminal illness• Availability of support systems• Physical condition and symptoms• Emotional status including depression
45-29Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Assessment
Presence of advance directives for health care decisions
Concern about unfinished business Client priorities and preparation needs
45-30Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Nursing Diagnoses
Powerlessness Helplessness High Risk for Spiritual Distress Altered Family Processes
45-31Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Outcome Identification and Planning
Promoting an optimal quality of life Treating client and family respectfully Providing a safe environment Meeting the holistic needs and goals of
client and family
45-32Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Implementation
Sitting with the client, touching the client, and being physically present are often the most effective in communicating a caring, compassionate, and accepting attitude.
45-33Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Nursing Care Plan of the Dying Client
Implementation• Palliative Care
- Focus is on symptom management.- The most common symptoms are pain, dyspnea,
anxiety, and fatigue.
45-34Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Implementation
Physiological Needs• Nutrition• Breathing• Elimination• Comfort• Mobility
45-35Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Implementation
Promoting Comfort• Pain relief• Keeping client clean and dry• Providing a safe, nonthreatening
environment
45-36Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Implementation
Hospice Care• Concept of allowing individuals to die with
dignity and be surrounded by those who love them
• An interdisciplinary team is essential for delivering quality, compassionate care.
45-37Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Implementation
Psychosocial Needs• Clients may fear helplessness, dependence
on others, loss of abilities, mutilation, uncontrollable pain.
Spiritual Needs• Dying can be a time of spiritual crisis.
45-38Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Implementation
Support for the Family Learning Needs of Client and Family
• Client’s physical condition• Treatment regimen• How to handle medical crises• Emergency care
45-39Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Evaluation
Evaluating the death experience for the family and friends
Determining if the goals for a peaceful death and provision of a supportive environment were met
Discussing the process in order to assist in providing care for future dying clients
45-40Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Care After Death
Care of the Body• Physiological changes
- Algor mortis- Liver mortis- Rigor mortis
• Autopsy• Organ donation
Care of the Family