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52 Cards in this Set
- Front
- Back
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Actual loss
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Can be seen; loss of a family member,amputation, or loss of a pet |
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Perceived loss
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can’t be seen by others; pending retirement,or pending cross country move |
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Anticipatory loss |
beforethe actual loss; anything that could be a loss, but has not yet happened. Aterminal diagnosis would be a good example |
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Situational loss
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becauseof illness or injury, these disrupt the normal routine of life, which can bevery unsettling
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Bereavement
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Specific term to refer to the death of an important person in one’slife, not just family – new and old friends, co-workers |
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Four tasks of grief
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1. Accept the reality of the loss 2. Process the pain of grief while caring for theself 3. Adjust to a world without the deceased Find an enduring connection with the deceased inthe midst of embarking on a new |
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Grief s/sx normal
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• Crying • Loss of sleep • Lack of concentration • Loss of appetite |
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grief abnormal s/sx
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• Severe anxiety • Prolonged depression • Anorexia with weight loss, that is prolongedover time • Severe headaches • Chest pain • Dyspnea (SOB) that is severe |
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Disenfranchised grief -going to feel |
Grief that is not socially acknowledged or publicly mourned. The lossmay include a component that is socially not “acceptable”. Examples: • Abortion, suicide, criminal, HIV/AIDS, sexualorientation, and many more • Someone who is too emotional, loud,demonstrative, that goes beyond the traditional grieving These people are going to be very isolated, feeling lonely, solitary,and emotionally uncomfortable. Nurses need to be very sensitive to any loss,and explore how they can be supportive. |
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Maladaptive grief -delayed or inhibited -distorted/exaggerated |
Occurs when an individual has difficulty facing losses in a manner thatfits the normal grief pattern.
Delayed or Inhibited –Individual may be in denial, or have been raised to maintain a “stiff upperlip”= do not show your emotions. Too many losses at once can also delaygrieving. Distorted or Exaggerated – Theseindividuals are shut down socially, to comply with acceptable grief patterns. |
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chronic or prolonged grief
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• The raising of a mentally handicapped child canbe very challenging for the parents. As growth moves on, normal developmentalbenchmarks are not met, and each time it another loss that the parents feel. They can be isolated from other families,increasing the feelings of loss.
• Patients with progressive chronic diseases suchas degenerative joint disease, heart failure, and multiple sclerosis, feellosses each time their disease has a setback or increase in S&S. • Retaining dead person’s cloths and personalbelongings years after death can be hoarders, or just people that find comfortin having the deceased personal items nearby. Some families may see this as aproblem (that is determined on an individual basis), and they may exertpressure to have the items removed. This increases anxiety in the person whohas the items, and becomes disenfranchised grief. |
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Developmental differences in experiencing death: infant and toddler
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• No understanding of death as permanent, this canimpact their developmental progress • Thinks it is temporary or abandonment |
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Developmental differences in experiencing death: preschooler
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• Believes death is reversible through magicalmeans, temporary • Thinks bad thought or behavior caused it • Loss of a parent – can lead to significantpsychosocial/developmental problems, and may revert to an earlier level. • They are often “protected” from rituals such asfunerals, and this can actually increase feelings of loss and anxiety |
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Developmental differences in experiencing death: school age
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• Knows death is permanent • Has seen death of pet or plant • Knows death will happen to them - fearful |
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Developmental differences in experiencing death: adolescent
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• Understands death intellectually, notemotionally, they feel they and their friends are invincible • Knows about connection between illness and death • Has fear of death but also sense of immortality |
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Developmental differences in experiencing death: adult
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• Has already experienced many losses: friends,spouse etc. • Accepts death as part of life, their biggestfear is that of abandonment • Fears prolonged illness, pain, being a burdenmore than the death • Some decide “when is best time to die” and self-starve,see more in the old-old (those over 90) |
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Developmental differences in experiencing death: elderly
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• Has already experienced many losses: friends,spouse etc. • Accepts death as part of life, their biggestfear is that of abandonment • Fears prolonged illness, pain, being a burdenmore than the death • Some decide “when is best time to die” and self-starve,see more in the old-old (those over 90) |
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Consideration of Risk factors for complicated grieving
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• Dependent on the deceased, financial and oremotional • Persistent unresolved conflict with the deceased • Support systems/ and their coping skills • Previous losses can be an indicator of how theymanage loss. The death of a child can be a substantial challenge. • Cultural stigma • Past difficulty with bereavement - how did theymanage historically? History ofdepression, psychiatric illness, drug use will complicate grieving in asignificant way • Veteran, victim of war, or violence, brings inall of the emotions that surround this type of death • Spiritual beliefs |
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Nursing diagnoses
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• Powerlessness • Hopelessness • Anticipatory grieving • Fear • Ineffective coping • Death anxiety • Spiritual distress • Social isolation • Other medical/surgical diagnoses |
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Pt outcome -short term goal -long term goal |
• Ability to focus, short term o Short Term Goal: Person is able to speak aboutit to the nurse or others for a measured period of time • Grief resolution, longer period of time o Long Term Goal: Using own internal as well ascommunity resources |
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General interventions for loss and adaptation
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• Listen and accept who they are in the moment • Teach and reassure (they are not crazy) they mayfeel heart palpitations, light headed, and have no appetite, all of which arenormal grief responses • Encourage full expression of emotions, providean environment conducive to expressing feelings which allows for their privacy,quiet, comfortable • Refer to social work • Refer to chaplain • Ask for a referral to psych – needs a PCP |
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General interventions for loss and adaptation: children
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• Use simple terms, at their developmental level,the family can guide you here • Reassure that they did nothing to cause it • Involve child in mourning rituals as it helpsthem find closure, and they will see how others respond and demonstrates theyare not alone • Discuss open casket appearance, make sure thatany involvement is discussed with them, and that they are prepared for whatthey will see |
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General interventions for loss and adaptation: adults
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• Allow people to cry. Be a good listener, the useof silence is extremely effective • Stay with them and give support • Use silence and touch and personal presence, isespecially helpful when you are unsure what they need |
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General interventions for loss and adaptation: needs of the family
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• Allow chairs, visitation time and privacy. Nolimits should be placed as a general rule. • Self-care for support system; encourage food,drink and rest. Provide this in the room or nearby • Sedation for family members may interfere withgrief process. If sedation is used that is a medical decision • After a death let the family stay, don’t forceaway. Be knowledgeable of your facilities policy, and you may need to considerif rigor mortis is expected to set in (2-4 hours after death) |
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The nurse's needs for mourning and self care
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• Nurses often feel a huge loss with a patient’sdeath, it can be worse if their unit has had multiple deaths The result is thenurse has to balance own grieving needs with continuing to provide nursing careto others • For staff retention and job satisfaction, it isappropriate to have a debriefing and support group available after a death • The nurses will function better if they haveaccepted their own mortality. • If the death of their patient affects them thenurse needs to admit this. • There may be fear of losing emotional control. • The nurse may identify with the dying person orfamily. • Other uninvolved nurses may need to help thenurse with other floor duties. |
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hospital role in loss and adaptation
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• Can provide palliative or comfort care • May be preferred by family or patient • Not as peaceful a place to die, normal hospitalnoises, other patients and families who are happy and getting better. IVsbeeping and the hustle in the hallway are distracting • New trend in palliative care: Music thanatology |
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Hospice role in loss and adaptation |
• A philosophy, not a place. It is a philosophythat embraces reduction in pain, as well as providing emotional and spiritualneeds • Century’s old tradition, the modern modelprovides palliative care to those with 6 months or less to live. Patience mustnot be seeking active treatment such as chemotherapy to be eligable • Can be at home or in a facility • Emphasizes caring not curing • Uses palliative care (control of symptoms) |
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Death
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• Ceasing breathing • Cessation of metabolism • No pulse • Documentation: No detectable apical pulse, chestauscultated no breath sounds, and describe changes in body color (they indicateshut down of metabolism) |
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Major system changes approaching death: cardiovascular
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• HR and BP decrease, Korotkoff sounds diminish(BP sounds) Pulse erratic • Skin cool and clammy, circulation decreases seendistally first, feet, hands • Mottling on extremities-spotted appearance,distal first • Dependent area blood pooling-darkens |
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Major system changes approaching death: respiratory system
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• Poor cardiac functioning leads to congestion inlungs • “Death rattle” is caused by secretions pooling,it can be very startling to listen to, and the actual physiological feelingsare not as significant as it sounds. Nurses often clear it to help out familydistress • Air hunger • Shallow/irregular breathing • Irregular (agonal – gaspy sound, Cheyne-stoke –rapid shallow breathes followed by deeper breaths with increasing space inbetween) |
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Major system changes approaching death: Musculoskeletal system
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Poor nutrition leads to muscle weakness. • Unable to move independently they will need moreassistance – encourage family to help if they are interested. • Mayneed catheter if turning too painful. • Difficulty swallowing • Secretions pool in oropharynx “death rattle” • Becomes lethargic, withdrawn, drowsy;combination of decreased urinary output and poor oxygenation |
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Major system changes approaching death: Renal system
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• Poor cardiac function leads to reduced kidneyfunction – low urine output • Giving fluids can lead to third spacing – fluidthat is outside the vascular system i.e. edema • Sphincters relax and incontinence common ofurinary and bowel. |
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Nursing care of the dying pt
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• Personal hygiene and comfort are highpriorities. • Light covers, to relieve the feeling of beingtrapped without air • Keep mouth moist – good oral care, this can helprelieve the death rattle sounds • Monitor skin – cleanse as needed • Pain relief – treated readily - oral opioidsusually Morphine works well sublingually to ease breathing, decrease anxiety,as well as pain control |
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Nursing care for nonverbal indications of pain
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• Moaning, groaning • Grimacing – when providing interventions • Refusal of food • Guarding of body part • Resisting care • Restlessness • Diaphoresis or other changes in vital signs(Increased B/P and Pulse from current baseline) |
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Nursing care for the dying pt: elimination
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• Usually no catheter, use absorbent pad, thecatheter itself is a mode of infection and discomfort. • Bowel and bladder incontinence common, hygiene,pads or briefs, and barrier creams should be used |
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Nursing care for the dying pt: nutrition
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• Anorexia common, although there are certaintastes that may be enjoyed, research historical preferences • Avoid oral fluids if unable to swallow. • Use of feeding tube depends on Living Will,family & MD discussion; it is not used in many cases as it only prolongsthe dying process |
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Nursing care for the dying pt: respiratory system
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O2 use for comfort, it is not used fortreatment, but it does help with air hunger and associated anxiety • Morphine – reduces anxiety, gives pain relief,& dilates pulmonary vessels – helps with perfusion • Anti cholinergics decrease secretions, may helpease family concerns as well • Elevate head of bed, side lying |
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Nursing care for the dying pt: cognitive
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Nursing care for the dying pt: sleeping |
• A person nearing death may stop talking orresponding and begin sleeping more and more as the body changes how it usesenergy. Always assume the patient can hear, even if the patient seemsunconscious and no longer communicates. Keep talking to the patient and providetouch if it provides comfort. |
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Nursing care for the dying pt: surge of energy |
• Occasionally, when a patient is close to deaththey experience a temporary increase in energy and alertness. It is not a signof recovery, encourage the family to enjoy the time, it seldom lasts for morethe a few hours. |
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algor mortis
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body temp decrease (below room temp)
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liver mortis |
bluish discoloration in dependent body areas
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rigor mortis
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stiffening of the body 2-3 hours after death
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organ donation post mortem care: -prohibited in religion/culture -ok in religion/ culture |
-muslims, jahovah's witness -western, buddhist |
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autopsy post mortem care:
-prohibited in religion/culture -ok in religion/ culture |
-eastern orthodox, muslims, Jehovah's witness, orthodox jews -western if cause of death unclear |
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cremation post mortem care:
-prohibited in religion/culture -ok in religion/ culture |
- Mormon, eastern orthodox, Islamic, roman catholic -hidnus |
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medically prolonged life
-prohibited in religion/culture |
Christian scientists, some jewish people, buddhist
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Nursing care: post mortem
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• Bathe gently, only soiled areas • Remove tubes unless an autopsy is scheduled.Leave ID band on • Place body in natural position on back. (close eyes, and mouth, insert dentures,tape wedding ring on, give other personal effects to family). Place pad underbuttocks • Use of a shroud is up to facility policy |
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cremation
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hightemperature burning of the body that leaves no health risk
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embalming
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Art and science that delays decomposition,goals are to provide sanitation, presentation, and preservation
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green burial
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• Green burial uses no chemicals, there arelimited places to bury do to sanitation requirements, so should be planned wellahead |
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Legal issues
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• Advanced Directives for Health Care Decisions,written instructions regarding health care wishes to be followed in the eventthey become incapacitated • Living Will a type of advanced directive • Durable power of attorney Person designated tomake decisions should the patient be incapacitated • DNR order “do not resuscitate” • Comfort care order not specifically for hospice,yet it stops treatment of illness, and does provide comfort care includingalleviating S&S of minor issues such as a rash • Organ donation • Oregon’s Death with dignity Act 1997-2002, |
