Loss Greiving And Death

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Loss

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An actual or potential situation in which something that is valued is changed or no longer available
Body image, possessions, jobs, person possessions, beliefs, illness, loss of significant others, death, and hospitalization

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Loss-meaning

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People experiencing loss often look for meaning in the event and it is generally accepted that meaning is needed for healing to occur

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Types of loss

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actual, percieved, anticipatory, situational and developmental

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Actual loss

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Spouse/loved one -death

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Perceived

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experienced by one person but cannot be verified by others.
Example: Woman who leaves her employment to care for her children at home may perceive a loss of independence and freedom

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Anticipatory loss

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is experienced before the actual loss occurs

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situational loss

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loss of job, death of a child, loss of functional ability because of acute illness

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Developmental loss

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Children move from home, parents move into an nursing home, retirement. losses that occur in the process of normal development

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Sources of loss

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Aspect of self, external objects, familar environment, loved ones,

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Aspect of self

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the loss of an aspect of self changes a person's body image even though the loss may not be obvious.
the degree to which these losses affect a person, largely depends on the integrity of body image, loss of part of the body

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external objects

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inanimate objects of importance
animate objects such as pets or companionship
inanimate (not alive) money or the burning down of a family home. Animate (alive) pets

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familar environment

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separation from an environment and people who provide security can result in a sense of loss.

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loved ones

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the loss of a loved one or valued person through illnesses, divorce, separation or death.

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Grief

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manifested in thoughts, feelings and behavior
is essetioal for good mental and physical well-being
is the total response to the emotional experience related to loss.

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bereavement

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A state of being sad because a family member or friend has recently died. is the subjective response experienced by the surviving loved lone.

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Mourning

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is the behaviorial process in which greif is eventually resolved or altered. influenced by culture spiritual beliefs and customs

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types of grief responses

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abbreviated grief, anticipatory greif, disenfranchised grief, complicated grief,

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Complicated grief

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intense longing and yearning for the deceased.
intrusive thoughts or images of your loved one.
Denial of the death or sense of disbelief.
imagining that the loved one is alive
searching for the person in familar places
avoiding things that remind the person of their loved one.
Extreme anger or bitterness over the loss
feeling that life is empty or meaningless

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symptoms that accompany grief

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Anxiety, depression, weight loss, difficulties in swallowing, vomiting, fatigue,"", headaches, dizziness, fainting, blurred vision, skin rashes, excessive sweating,menstrual disturbances, palpitations, chest pain, and dyspnea.

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Abbreviated grief

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Anxiety, depression, weight loss, difficulties in swallowing, vomiting, fatigue,"", headaches, dizziness, fainting, blurred vision, skin rashes, excessive sweating,menstrual disturbances, palpitations, chest pain, and dyspnea.

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anticipatory grief

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Is experienced in advance of the event such as the wife who grieves before her ailing husband dies.

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Deinfranchised grief

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Occurs when a person is unable to acknowledge the loss to other persons. [example; Not spoken about, suicide, abortion, or giving a child up for adoption]. Socially unsanctioned and may not be known to other people. [ Homosexuality or extramarital relationships].

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complicated grief

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Unhealthy Grief, exists when the strategies to cope with the loss are maladaptive. Including prior traumatic loss, family or cultural barriers to the emotional expression of grief, sudden death, strained relationships between the survivor and the deceased, and lack of adequate support for the survivor.

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unresolved grief

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Extended in length or severity. May deny the loss, or may grieve beyond the expected time.
ambivalence (intense feeling both positive and negative)toward lost person, overwhelming losses. Loss of something with high emotional value. lack emotional support, brave face. uncertainty about loss (missing in action)

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Stages of Grief
Kubler-Ross's Stages of grieving

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Denial, anger, bargaining, depression and acceptance

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Denial

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Refuses to believe that loss is happening

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Anger

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Client or family may direct anger at nurse or staff about matters that normally would not bother them;

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Bargaining

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Seeks to bargain to avoid loss, may express felling of guilt or fear of punishment for past sins, real or imagined. negotiating

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Depression

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Grieves over what has happened and what cannot be done, may talk freely or may withdraw. Begins to understand the certainty of death. INdividual may become silent, refuse visitors and sopend much of the time crying or grieving. "i'm too sad to do anything. slow speech and body movements. Inability to fuction at work, home and or school. seeing or hearing things that aren't there.

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Nurse intervention-depression

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it's important for grieving it must be processed.
Not recommended to attempt to cheer up individual.

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Acceptance

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comes to terms with loss, may have decreased interest in surrounding in surroundings and support people. "i'm at peace with what happened".
May wish to began making plans. Will, prosthesis, altered living arrangements.

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Engel's Stages of Grieving

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1]Shock and Disbelief 2] Developing awareness 3] Restitutuon 4] Resolving the loss 5] Idealization 6] Outcome

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complicated Grieving

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Extended time of denial , depression, severe physiologic symptoms, or suicidal thoughts.

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Factors influening loss and grieving

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Age, Significance of loss, culture, spritual beliefs, gender, socioeconomic status, support system, cause of loss or death, gender

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age

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familarity increases understanding of and reaction to loss.
as people grow , they come to experience loss as part of normal development.
comping with the death of an aged parent has been viewed as an essential developmental task of middle aged adults.

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children

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The loss of a parent or other significant person can threaten the child's ability to develop, and regression sometimes results. Assisting the child with the grief experience includes helping the child regain the normal continuity and pace of emotional development

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middle aged adult

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The loss of a parent through death seems a more normal occurrence compared to the death of a younger person. Coping with the death of an aged parent has even been viewed as an essential developmental task of the middle-aged adult.

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late adulthood

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For older adults, the loss through death of a lifelong mate is profound. Although individuals differ in their ability to deal with such a loss, research suggests that health problems for widows and widowers increase following the death of the spouse

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gender

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traditionally men are assumed to have the role of support of family and being strong.
Crying for women can be viewed as more acceptable.
Changes in body image cn change with gender.

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socioeconomic

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A pension plan or insurance, for example, can offer a widowed or disabld person a chioce of ways to deal with a loss; a person who is confronted with both severe loss and economic hardship may not be able to cope with either,

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Support system

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People closest to you are often the first to recognize and provide needed emotional, physical, and functional assistance. However, because many people are uncomfortable or inexperienced in dealing with losses, the usual support people may instead withdraw from the grieving individual

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cause of death

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Individuals and societal views on the cause of a loss or death may significantly influence the grief response. A loss or death that is beyond the control of those involved may be more acceptable than one that is preventable, such as a drunk driving accident. Injuries or deaths occurring during respected activities, such as "in the line of duty" are considered honorable.

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Sander's Phases of Bereavement

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Shock, Awareness of loss, Conservation/withdrawal, Healing;the turning point, Renewal

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Martocchio described five clusters of grief

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Shock and disbelief; Yearning and protest; Anguish, Disorganization, and Despair

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significance of loss

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importance of lost person, object or function, degree of change required because of loss, the persons belief's and values. elderly can fear loss of control or being a burden more than death

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Assessment

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Nursing history: Current or recent loss, greater detail is needed in the assessment.
Assessment of personal coping resources. HOw th e client copes with loss and what resources are availableto assist the client in coping.
Physical assessment: general health staus , cultural and spirtual traditions, rituals and beliefs related to loss and grieving and the person support network. might identify complicated grief

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home care assessment

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knowldedge, self care abilities, current coping, current manifestatins of grief response, role expectations. adls

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diagnosis

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1. grieving 2. complicated grieving: risk for 3.dysfunctional grieving, 4.risk for complicated grieving
5.. interrupted family process6.. risk prone health behavior7. risk for loneliness 8. risk for dysfunctional grieving,9. risk for complicated grieving
10. Care giver role strain 11. interupted family process

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Defining Characteristics for nursing diagnosis
Grieving
fear
hopelessness
Powerlessness

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1.denial, guilt, anger, dispar
2.Disruption, crying immobility physical characteristics,
3.apathy, pessimism, inability to make decisions
4. Anger, violence, acting out, depression, passive behavior

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Planning

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for loss of body

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diagnosing grieving

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a normal complex process that includes emotional, physical, spiritual, social and intellectual responses and behaviors by which individuals, families and communities incorporate an actual, anticipated or precieved lossinto thier daily lives

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diagnosing complicated grieving or risk for

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a disorder that occurs after the death of an significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment

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diagnosis interrupted family processes

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if the loss has such an impact on the individual and family that usual effective roles and interactions are negatively affected

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Risk prone health behavior-diagnosis

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if the client has great great difficulty placing the loss in appropriate perspective to his or her other life activities

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risk for loneliness

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related to the loss of relationship of others

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planning for loss of body function

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adjustment to the change ability and redirection into rehabilitation

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planning for the loss of a loved one

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is to be able to remember them without feelings of pain

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implementation for grieving

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attentive listening, silence, open and closed questioning, paraphrasing, clarifying and reflecting feelings

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evaluation

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difficult because of the long term nature of the life transition, criteria for evaluation must be based on goals set by the client and family

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if out comes are not recieved

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explore why the plan was not successful. reassess the client. Do the clients grieving behaviors indicate dysfunctional grieving or another nursing diagnosis? Is the expected outcome unrealistic for the given time frame? Does the client have additonal stressors previously not considered that are affecting grief resolution. Have nursing orders been implemented consistently, compassionately, and genuinely.

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Traditional and clinical signs of death

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cessation of apical pulse, respirations and blood pressure. referred as heart lung death

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the world medical assembly adopted the following guideline for physicians as indications of death

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total lack of response to external stimuli, no muscular movement, especially breathing, no refleses, flat encephalogram (brain waves)

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In instance of artifical support absence of brain wave for at least

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24 hours is an indication of death. only then can a physician announce death

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another definition of death

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cerebral death or higher brain death

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definitions and signs of death
cerebral or higher brain death

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permeanent loss of cerebral and brainstem function
Absence of: responsiveness ot external stimuli
absence of cephalic reflexes
apnea
isoelectric EEG for 30 minutes in absense of hypothermai

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Cultural consideration
autopsy discouraged, prohibited, opposed

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Eastern-orthodox religions, muslims, jehovah witness, orthadox jews

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Cultural considerations
organ donation prohibited

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jehovah's witness, Muslim

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organ donation an act of mercy

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Buddhists in America

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Cremation prohibited, discouraged or opposed

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mormon, eastern orthodox, islamic, roman catholic

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perfer cremation

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hindu and cast ashes on holy river

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prolongation of life discouraged in

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Christain science, jewish with irreversible brain damage, budhist may permit euthanasia

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Death related ritual

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last rites
chanting at bedside
special procedures for washing, dressing, positioning, shroding and attending the dead.
(gives closure)

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closed awareness

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client is not made aware of impending death

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mutual pretense

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client, family and health personnel know the prognosis but do not talk about it.

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Open awareness

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everyone knows

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nursing responsibilities

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to minimize loneliness, fear, and depressions,
to maintain the clients sense of security , self-confidence, dignity and self-worth
to help the client accept losses
to provide physical comfort

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dying with dignity

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focus on the clients needs
talk with family and client about how they normally cope with stress
establish a communication relatioship of concern and commitment
determine wht the client knows about the illness and prognosis. respond with honesty and directiness to question about death.
Make time to be available to the client to provide support, listen and respond

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Hopspice

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hospice care focuses on support and care of the dying client and family with the goal of a peaceful and dignified death.
a holistic concept
can be done in a variety of settings the most commin in the hospital or home
clients likely to die in 6 months

supports client and families emotiona, physical and importantly pain needs.
includes bereavement counciling

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palliative care

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differs from hospice in that the client is not necessarily believed to be imminently dying.
is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life.
incleds investigations needed to better understand and manage distressing clinical complication

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Rigor mortis

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stiffening of the body that occurs about 2 to 4 hours after death and leaves the body about 96 hours after death

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algo mortis

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gradual decrease of the body temperature

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livor mortis

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discolorationof tissues caused by rbc break down.

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Grief

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is the total response to the emotional experience related to loss.

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Grief is manifested in

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thoughts, feelings and behaviors associated with overwhelming distress or sorrow

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symptoms that can accompany grief

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Axiety, depression, weight loss, difficulties in swallowing, vomiting, fatigue, headaches, dizziness, fainting, blurred vision, skin rashes, excessive sweating, menstral distubance, palipitations, chest pain, dypsnea, alterations in blibdo, concentration, patterns of eating, sleeping, activity and communication