Chapter 36
Loss and Grief
Scientific Knowledge Base
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Loss
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Actual loss
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Necessary loss (i.e., Maturational loss)
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Situational loss
Perceived loss
Each person responds to loss differently
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Culture, spirituality, personal beliefs, previous experience and degree of
social support influences the way a person responds to death
Scientific Knowledge Base
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Grief
Mourning
Bereavement
Types of grief
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Normal (uncomplicated)
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Anticipatory
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Disenfranchised (ambiguous)
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Complicated (chronic, exaggerated, delayed, masked)
Quick Quiz!
You are caring for a client who is depressed because the only child has
gone away to college. The nurse will assess this type of depression as:
A. actual loss.
B. perceived loss.
C. situational loss.
D. maturational loss.
Scientific Knowledge Base
! Theories
of grief and
mourning
" Stages
of Dying
" Attachment Theory
" Grief Tasks Model
" Rando’s “R” Process
Model
" Dual Process Model
Nursing Knowledge Base
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Organizations that assist in end-of-life care
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End-of-Life Nursing Consortium (ELNEC)
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American Nurses Association (ANA)
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American Society of Pain Management Nurses
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American Association of Critical Care Nurses
Dealing with the Death of a Patient Video
Nursing Knowledge Base
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Factors influencing loss and grief
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Human development
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Personal relationships
Nature of the loss
Coping Strategies
Socioeconomic loss
Culture
Spiritual and religious beliefs
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Critical Thinking
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Be familiar with commonly experienced responses to loss.
Integrate theory, prior experience, subjective experiences, and selfknowledge.
Use Professional Standards:
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Nursing Code of Ethics
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Dying Person’s Bill of Rights
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ANA Scope and Standards of Hospice and Palliative Nursing
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American Society of Pain Management Nursing’s position statement
Nursing Process: Assessment
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Through the client’s eyes
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Grief variables
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Use presence, active listening, silence, therapeutic touch and open, honest
communication
Assess coping style, social support, nature of the loss, beliefs, life goals,
grief patterns, self-care, hope
Grief reactions
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Assess grief response; most grieving people show some common outward
signs and symptoms
Nursing Diagnosis
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Nursing diagnoses relevant for clients experiencing grief, loss, or death
include:
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Impaired family coping
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Death anxiety
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Pain (Acute or Chronic)
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Dysfunctional Grief
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Anticipatory Grief
Planning/Prioritize hypotheses & generate solutions
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Goals and outcomes
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Based on nursing diagnosis
Setting priorities
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Encourage client to share their priorities for care
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Give priority to a client’s most urgent physical or psychological needs
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Maintain an ongoing assessment to revise the plan of care according to
client needs and preferences
Teamwork and collaboration
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Interprofessional care
Implementation/ Take action
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Health promotion
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Palliative care
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Focuses on the prevention, relief, and reduction of symptoms
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Goal is to help achieve the best possible quality of life
Hospice care
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Focuses on the care of terminally ill clients
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Goal is to manage pain, provide comfort, ensure quality of life
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Prioritize care according to client wishes
Implementation
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Therapeutic communication approaches
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Establish a caring and trusting relationship
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Use open-ended questions
Provide psychological care
Manage symptoms
Promote dignity and self-esteem
Maintain a comfortable and peaceful environment
Implementation
Promote spiritual comfort
and hope
! Protect against
abandonment and isolation
! Support the grieving family
! Facilitate mourning
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Provide bereavement care
Implementation
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Care after death
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Organ and tissue donation
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Autopsy
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Postmortem care
Evaluation/ Evaluate Outcomes
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Through the client’s eye
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Assess if the client’s goals are being met.
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Be alert for signs and symptoms of grief.
Client outcomes
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Review the goals and expected outcomes of the plan of care to determine if
nursing interventions were successful or if modifications are needed.
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Continue to evaluate the client’s progress, the effectiveness of interventions
and client and family interactions.
Quick Quiz!
As a first-year nursing student, you are assigned to care for a
dying clientTo best prepare you for this assignment, you
will want to:
A. complete a course on death and dying.
B. control your emotions about death and dying.
C. compare this experience to the death of a family member.
D. develop a personal understanding of your own feelings
about grief and death.
Quick Quiz!
Which statement is true regarding advanced directives?
A. Advance directives apply only when the person has a chronic illness
B. Advanced directives should be drawn up by family members of people
who are incompetent
C. Discussion of advanced directives is a nursing responsibility
D. Advance directives should be kept in a safety deposit box unti the
person dies.
Quick Quiz!
The RN is orienting a new employee to a clinical unit for palliative care.
The AU graduate asks what grief is exactly? Which statement correctly
defines grief?
A. The emotional response to a loss
B. The outward, social expression of loss
C. The depression felt after the loss
D. The loss of a loved one or possession
Quick Quiz!
The nurse has been caring for a client who recently died. What is the
preferred outcome in caring for the body after death?
A. Make sure the body is sent to the morgue within an hour after death
B. Have the family members participate in bathing and dressing of the
deceased
C. Notify the person by phone immediately after the death.
D. Demonstrate respect for the body and provide a clean, peaceful
impression for the deceased family
Quick Quiz!
In which scenario is hospice care provided?
A. Only in the homes of the terminally ill
B. For any terminal illness that requires symptom control
C. For cancer clients only in their last week’s of life
D. In hospital settings that are very serious
Quick Quiz!
In caring for a dying client what is the appropriate nursing action to
increase family involvement?
A. Insisting that all bedside care be performed by the family
B. Asking family members what they would like to do for their loved one
and allowing them to participate
C. Expecting the family to perform the client’s daily needs so they are met
consistently
D. Refusing all assistance from the family to decrease their stress
Quick Quiz!
A nurse is caring for a terminally ill pt during the 11pm to 7am shift. The
pt says, “I just can’t sleep. I keep thinking about what my family will do
when I am gone.” What response by the nurse is most appropriate?
A. “Oh don’t worry about that now. You need to sleep.”
B. “What seems to be concerning you the most?”
C. “I have talked with your wife and she told me she will be fine”
D. “I am not qualified to advise you, I suggest you talk with your wife”
Quick Quiz!
A home health nurse has been visiting a client with AIDS who says, “ I’m
no longer afraid of dying. I think I have made my piece with everyone,
and I am ready to move on.” This reflects the client’s progress to which
stage of death and dying?
A.
Acceptance
B.
Anger
C.
Bargaining
D.
Denial
Quick Quiz!
The AU graduate nurse has been caring for a 65 year old male who has
just died. In planning for follow up bereavement care, the smart AU
graduate knows that which person is at risk for disenfranchised grief?
A. A daughter who lives in a different state.
B. The son who was with the client when he died
C. An estranged wife who lives nearby
D. The 16 year old grandchild of the client
Chapter 37
Stress and Coping
Introduction
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Stress
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An actual or alleged hazard to the balance of homeostasis
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Can impact the physical and mental well-being of clients
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Nurses need to consider their own stress by recognizing stress in the form
of burnout, compassion fatigue, and second victim syndrome.
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Stressors
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Appraisal
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Trauma
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Scientific Knowledge Base
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General adaptation
syndrome (GAS)
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Alarm stage (fight-or-flight)
" Resistance stage
" Exhaustion stage
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Allostatic load
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Immune response
" Reaction to psychological
stress
Coping
! Defense mechanisms
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General Adaptation Syndrome
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A three-stage reaction to stress:
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Alarm reaction
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Resistance stage
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Exhaustion stage
https://www.youtube.com/watch?v=U0rqDKMYALM
Quick Quiz!
You are a nurse working in the college student health center. You receive a
call that an athlete has just fallen and has been injured. You know that
according to the general adaptation syndrome, the athlete will be
exhibiting:
A. an increased appetite.
B. an increased heart rate.
C. a decrease in perspiration.
D. a decrease in respiratory rate.
General Adaptation Syndrome (Cont.)
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Immune response
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Stress response directly influences the immune system
Reaction to psychological stress
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Coping
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Ego-defense mechanisms
Types of Stress
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Chronic
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Acute
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Chronic stress occurs in stable conditions and results from stressful roles.
Time-limited events that threaten a person for a relatively brief period
provoke acute stress.
Crisis -facing a turning point in life
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Developmental, situational, adventitious
Types of Stress
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Posttraumatic stress disorder:
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An acute stress disorder that begins when a person experiences, witnesses,
or is confronted with a traumatic event
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May include flashbacks = Recurring and intrusive recollections of the event
Types of Crises
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Developmental
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Situational
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Developmental crises occur as a person moves through the stages of life.
External sources such as a job change, motor vehicle crash, death, or severe
illness provoke situational crises.
Adventitious
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A major natural or man-made disaster or a crime of violence can create an
adventitious crisis.
Quick Quiz!
A client comes into the emergency department complaining of chest pain.
When discussing possible reasons why the chest pain has occurred, the
nurse learns that the client is depressed because of the loss of a job.
This type of crisis can be classified as:
A. maturational.
B. situational.
C. sociocultural.
D. posttraumatic.
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Nursing Knowledge Base:
Nursing Theory and the Role of Stress
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Neuman systems model:
Uses systems approach
" Based on the concepts of stress and reaction to stress
Newman Systems Model video
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Roy’s adaptation model
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A person has the ability to modify external stimuli to allow adaptation to occur
Pender’s health promotion model
Focuses on promoting health and managing stress
Pender's Health Promotion Model video
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Nursing Knowledge Base:
Factors Influencing Stress and Coping
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Situational factors
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Maturational factors
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Arise from job changes, illness, caregiver stress
Vary with life stages
Sociocultural factors
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Environmental, social, and cultural stressors perceived by children,
adolescents, and adults
Nursing Knowledge Base: Compassion Fatigue and
Second Victim Syndrome
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Compassion fatigue
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A state of burnout and secondary traumatic stress
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Caring for others who are suffering
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Emotional exhaustion
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Can overwhelm health care providers and cause physical, mental, and
emotional health issues
Second victim syndrome
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When a medical error occurs that inflicts significant harm on a client and
the client’s family
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Critical Thinking
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Keep in mind the neurophysiological changes the client may be
experiencing.
Use crisis intervention as needed.
Be confident that you can help the client manage stress.
Use linguistic and culturally effective communication skills to clearly
and precisely understand a client's perception of stress.
Nursing Process: Assessment
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See through the client’s eyes:
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Gather information (including client’s perception)
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Synthesize the information
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Apply critical thinking
Subjective findings
Objective findings
Nursing Diagnosis
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Nursing diagnoses for stress:
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Anxiety
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Despair
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Difficulty coping
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Risk for Post Trauma Response
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Stress Overload
Planning
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Goals and outcomes
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Desirable outcomes frequently include
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Effective coping, family coping, caregiver emotional health, and psychosocial
adjustment: life change
Setting priorities
Teamwork and collaboration
Implementation
! Health
promotion
" Decrease
stress-producing
situations
" Increase resistance to
stress
" Learn skill that reduce
physiological response to
stress
! Regular
exercise and rest
Implementation
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Support systems
Time management
Guided imagery and visualization
Progressive muscle relaxation therapies
Assertiveness training
Journal writing
Mindfulness-based stress reduction (MBSR)
Stress management in the workplace
One Moment Meditation video
Implementation (Cont.)
! Acute
care
" Crisis
intervention
! Restorative
and
continuing care
Evaluation
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Through the client’s eyes:
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Has stress been reduced?
Patient outcomes
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Coping with stress takes time
Quick Quiz!
When assessing an older adult who is showing signs of anxiety insomnia,
anorexia, and mild confusion, what is the first assessment the nurse
conducts?
A.
B.
C.
D.
The amount of family support
A 3-day diet recall
A through physical assessment
Threats to safety in the home
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Quick Quiz!
A client who is having difficulty managing his diabetes mellitus responds to
the news that his hemoglobin A1c, a measure of blood sugar control
over the past 90 days had been increasing and says, “ the test is wrong
my blood sugar levels have been excellent the last 6 months”. Which
defense mechanism is the client using?
A.
B.
C.
D.
Denial
Conversion
Dissociation
Displacement
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Let’s play Plickers and Bingo