Types of Loss
vActual loss: can be recognized by others
vPerceived loss: is felt by person but intangible to
others
Chapter 44
vPhysical loss versus psychological loss
vMaturational loss: experienced as a result of natural
developmental process
Loss, Grief, and Dying
Fall 2023
vSituational loss: experienced as a result of an
unpredictable event
vAnticipatory loss: loss has not yet taken place
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Definitions
Engel’s Six Stages of Grief
vGrief: internal emotional reaction to loss
vShock and disbelief
vBereavement: state of grieving from loss of a loved
one
vDeveloping awareness
vRestitution
vMourning: actions and expressions of grief, including
the symbols and ceremonies that make up outward
expression of grief
vResolving the loss
vIdealization
vDysfunctional grief: abnormal or distorted; may be
either unresolved or inhibited
vOutcome
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Definition of Death
Clinical Signs of Impending Death
v Difficulty talking or swallowing
vUniform Definition of Death Act: An individual who
has sustained either (1) irreversible cessation of
circulatory and respiratory functions or (2)
irreversible cessation of all functions of the entire
brain, including the brainstem, is dead.
v Nausea, flatus, abdominal distention
v Urinary and/or bowel incontinence or constipation
v Loss of movement, sensation, and reflexes
v Decreasing body temperature, with cold or clammy skin
vMedical criteria used to certify a death: cessation of
breathing, no response to deep painful stimuli, and
lack of reflexes (such as the gag or corneal reflex)
and spontaneous movement, flat encephalogram.
v Weak, slow, or irregular pulse
v Decreasing blood pressure
v Noisy, irregular, or Cheyne-Stokes respirations
v Restlessness and/or agitation
v Cooling, mottling, and cyanosis of the extremities and
dependent areas
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Providing Care to Facilitate a Good Death
Kübler-Ross’s Five Stages of Grief
vGuided by the values and preferences of the
individual patient
vDenial and isolation
vAnger
vIndependence and dignity are central issues
vBargaining
vProviding control
vDepression
vPalliative care
vAcceptance
vFocus on the relief of symptoms
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Terminal Illness
Advance Care Planning
vAn illness in which death is expected within a limited
period of time.
vAdvance Directives include living wills and durable
power of attorney; indicate:
o Effect on the patient
o who will make decisions for the patient in case
the patient is unable.
o Effect on the family
o The Dying Person’s Bill of Rights
o the kind of medical treatment the patient wants
or doesn’t want.
o Palliative Care
o how comfortable the patient wants to be.
o Hospice Care
o how the patient wants to be treated by others.
o what the patient wants loved ones to know.
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Special Orders
Factors Affecting Grief and Dying
vAllow natural death, do-not-resuscitate, or no-code
orders
vDevelopmental considerations
vTerminal weaning-gradual withdrawal of mechanical
ventilation.
vFamily
vSocioeconomic factors
vVoluntary cessation of eating and drinking-
vCultural, sex assigned at birth, and religious
influences
vActive and Passive euthanasia
v
Active- taking specific steps to cause a pt’s
death- doing something to cause death.
v
Passive- withdrawing medical treatment with the
intention of causing death.
vCause of death
vPalliative care with sedation- palliative are to
prevent suffering and relieve suffering.
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Developing a Trusting Nurse–Patient
Relationship
Needs of Dying Patients
vPhysiologic needs: physical needs, such as hygiene,
pain control, nutritional needs
vExplain the patient’s condition and treatment.
vTeach self-care and promoting self-esteem.
vPsychological needs: patient needs control over fear
of the unknown, pain, separation, leaving loved
ones, loss of dignity, loss of control, unfinished
business, isolation
vTeach family members to assist in care.
vMeet the needs of the dying patient.
vMeet family needs.
vNeeds for intimacy: patient needs ways to be
physically intimate that meets needs of both
partners
vSpiritual needs: patient needs meaning and
purpose, love and relatedness, forgiveness and hope
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Providing Postmortem Care
Postmortem Care of the Body
vCare of the body
vPrepare the body for discharge.
vCare of the family
vCare of other patients
vPlace the body in anatomic position, replace
dressings, and remove tubes (unless there is an
autopsy scheduled).
vCaring for oneself
vPlace identification tags on the body.
vFollow local law if patient died of communicable
disease.
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Postmortem Care of the Family
vListen to family’s expressions of grief, loss, and
helplessness.
vOffer solace and support by being an attentive
listener.
Chapter 45
vArrange for family members to view the body.
Sensory Functioning
Fall 2023
vIn the case of sudden death, provide a private place
for family to begin grieving.
vIt is appropriate for the nurse to attend the funeral
and make a follow-up visit to the family.
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18
Senses Involved in Sensory Reception
Four Conditions to Receive Data
vVisual (vision)
vStimulus
vAuditory (hearing)
vReceptor
vOlfactory (smell)
vNervous pathway to the brain
vGustatory (taste)
vFunctioning brain to receive and translate impulse
into a sensation
vTactile (touch)
vStereognosis (perception of solidity of objects)
vKinesthetic and visceral (basic internal orienting
systems)
vProprioception (senses body position)
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Reticular Activating System (RAS)
Reticular Activating System
vPoorly defined network
vExtends from hypothalamus to medulla
vMediates arousal
vOptimal arousal state: sensoristasis
vMonitors and regulates incoming sensory stimuli,
maintaining, enhancing, or inhibiting cortical arousal
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States of Awareness
Factors Contributing to Sensory Alteration
vConscious
vSensory overload
o Delirium, dementia, confusion, normal
consciousness, somnolence, minimally conscious
states, locked-in syndrome
vSensory deprivation
vSensory deficits
vSensory poverty
vUnconscious
o Asleep, stupor, coma
o Vegetative state
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Sensory Deprivation
Effects of Sensory Deprivation
vOccurs when a person experiences decreased
sensory input; Patients at high risk include:
vPerceptual disturbances
vCognitive disturbances
o Environment with decreased or monotonous
stimuli
vEmotional disturbances
o Impaired ability to receive environmental stimuli
o Inability to process environmental stimuli
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Sensory Overload
Additional Sensory Alterations
vThe patient experiences so much sensory stimuli
that the brain is unable to respond meaningfully or
ignore stimuli
vSensory deficits
o Impaired sight or hearing
o Altered taste
vThe patient feels out of control and exhibits
manifestations observed in sensory deprivation
o Numbness or paralysis
vNursing care focuses on reducing distressing stimuli
and helping the patient gain control over the
environment
vSensory processing disorders
vSensory poverty
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Factors Affecting Sensory Stimulation
Assessment of the Sensory Experience
vDevelopmental considerations
vStimulation
vCulture
vReception
vPersonality and lifestyle
vTransmission–perception–reaction
vStress and illness
vSigns and symptoms of sensory deprivation and
overload
vMedications
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Physical Assessment
Patient Outcomes for Sensory Alterations
vAssessment of the ability to perform self care
vLive in a developmentally stimulating and safe
environment
vVision and hearing assessments
vExhibit a level of arousal that allows for meaningful
organization of stimuli
vSchedule appropriate health screenings
vMaintain orientation of time, place, and person
vRespond appropriately to sensory stimuli while
executing self-care activities
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Improving Sensory Functioning
Caring for Visually Impaired Patients #1
vAcknowledge your presence in the patient’s
room
vPrevent disturbed sensory perception and stimulate
the senses:
vSpeak in a normal tone of voice
o Teach about sensory experiences
o Promote health literacy
vExplain the reason for touching the patient before
doing so
o Meet the needs of patients with reduced vision
or hearing
vKeep the call light within reach
vOrient the patient to sounds in the environment and
the arrangement of furnishings
o Communicate with a patient who is confused or
unconscious
vClear pathways
vAssist with ambulation
vIndicate when leaving the room
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Communicating With a Patient
Who is Confused
Caring for Hearing-Impaired Patients
vOrient the patient to your presence before speaking
v Use frequent face-to-face contact to communicate the social
process
vDecrease background noises before speaking
v Speak calmly, simply, and directly to the patient
vCheck the patient’s hearing aids
v Orient and reorient the patient to the environment
vPosition yourself so that light is on your face
v Orient the patient to time, place, and person
vTalk directly to the patient while facing him or her
v Communicate that the patient is expected to perform self-care
activities
vUse pantomime or sign language as appropriate
v Offer explanations for care
vWrite any ideas you cannot convey in another
manner
v Reinforce reality if the patient is delusional
v Emphasize patient’s strengths rather than weaknesses
vDo not chew gum, cover your mouth, or turn away
when speaking
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Communicating With an
Unconscious Patient
vBe careful what is said in the patient’s presence;
hearing is the last sense that is lost
vAssume that the patient can hear you and talk
in a normal tone of voice
Chapter 46
vSpeak to the patient before touching
Sexuality
Fall 2023
vKeep environmental noises at a low level
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Terminology
Sexual Identity
vSexuality encompasses biologic sex or sex assigned
at birth, sexual activity, gender identities and roles,
and sexual orientation
vSelf identity-a person’s self identity, biological sex,
gender identity.
vBiologic sex—chromosomal development
vSexual health represents the integration of the
somatic, emotional, intellectual, and social aspects
of sexual being in ways that are positively enriching
vGender identity-inner sense of what is your sex
vGender role behavior or expression- how a person
presents themselves.
vSexual orientation –attraction to other people.
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Additional Terminology
Sexual Orientation
v Gender identity
vHeterosexual
v Gender expression
vGay or lesbian
v Gender diverse-wide range of gender identities.
v Gender dysphoria-biological sex is contrary to their gender identity.
vBisexual
v Cisgender-gender identity matches society’s expectations.
vAsexual
v Transgender-male identifies as female- female identifies as male.
vQuestioning –unsure of sexual orientation.
v Gender binary-male or female identification is not the only option.
v Gender fluid-gender identity shift from time to time.
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Sexual Expression
Factors Affecting Sexuality
vRanges from adaptive to maladaptive
vDevelopmental considerations
vMasturbation
vCulture
vSexual intercourse—vaginal or anal
vReligion
vOral–genital stimulation
vEthics
vAbstinence
vLifestyle
vAlternative: voyeurism, sadism, masochism,
sadomasochism, pedophilia
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Schematic Representation of One Ovarian
Cycle
Menstruation
vMenstruation: normal vaginal bleeding that prepares
for the presence of a fertilized ovum
vFour Phases:
o Follicular: one follicle produces a mature ovum
o Proliferation: the endometrium becomes thick
and velvety
o Luteal: the corpus luteum develops
o Secretory: the endometrial lining disintegrates
vMenopause: cessation of menstrual activity
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Causes of Menstrual Cycle Irregularities
Four Phases of Sexual Response Cycle
vPregnancy or breast-feeding
vExcitement
vEating disorders, extreme weight loss, extreme
exercise
vPlateau
vOrgasm
vPolycystic ovary syndrome (PCOS)
vResolution
vPremature ovarian failure
vPelvic inflammatory disease (PID)
vUterine fibroids
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Sexually Transmitted Infections
Prevention of STIs
vHIV
vDelay having sexual relations as long as possible
vBacterial vaginosis (BV)
vHave regular checkups for STIs
vChlamydia
vLearn the common symptoms of STIs
vCytomegalovirus
vAvoid having sex during menstruation
vGenital herpes
vAvoid anal intercourse
vGonorrhea
vAvoid douching
vHyman papillomavirus (HPV)
vSyphilis
vTrichomoniasis
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Female Sexual Dysfunction
Male Sexual Dysfunction
vErectile dysfunction- unable to attain or maintain an
erection.
vInhibited sexual desire- absent or minimal vaginal
lubrication.
vPremature ejaculation- consistently reaches
ejaculation before or soon after entering the vagina.
vDyspareunia- painful intercourse
vVaginismus- involuntary muscle spasm prevents
penis penetration into the vagina- rare condition.
vRetarded ejaculation- (Ejaculatory incompetence)inability to ejaculate into the vagina or delayed
intravaginal ejaculation.
vVulvodynia- chronic vulvar discomfort or pain that
interferes with sexual activity- unknown cause.
vPremenstrual Syndrome- headaches, mood swings,
physical discomfort
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Effects of Illness, Injury, and Medications
Forms of Sexual Harassment
vDiabetes mellitus
v“Quid pro quo”: something withheld in exchange for
something else
vCardiovascular disease
vEnvironmental (hostile environment)
vDiseases of the joints and mobility
vSurgery and body image
vSpinal cord injuries
vChronic pain
vMental illness
vMedications
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Hostile Work Environment
Responding to Patient Advances
vUnwelcome sexually oriented and gender-based
behaviors
vBe self-aware
vConfront and provide feedback to patient
vSexual bantering
vSet limits
vSexual joking
vEnforce stated limits
vOffensive pictures and language
vReport and document the incident; submit to your
supervisor
vSexual innuendoes
vSexual behavior
vUnwanted attention
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Responding to Harassment by a Coworker
Nursing History
vConfront immediately
vReproductive history
vDocument date, time, and description
vHistory of STIs
vConsult a supervisor
vHistory of sexual dysfunction
vFile a grievance if behavior does not stop
vSexual self-care behaviors
vSeek legal advice
vSexual self-concept
vSexual functioning
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The Better Model Acronym
Physical Assessment
v BRING up the topic of sexuality
vPhysical examination
v EXPLAIN that you are concerned with all aspects of patients’
lives affected by disease
vAnnual gynecologic exam with pap smear
v TELL patients that sexual dysfunction can happen and that you
will address their concerns
vSuspected STI
vSuspected pregnancy
v TIMING is important to address sexuality with each visit
vWorkup for infertility
v EDUCATE patients about the side effects of their treatments
and that side effects may be temporary
vUnusual lump, discharge, or appearance of genital
organs
v RECORD your assessment and interventions in patients’
medical records (Mick, Hughes and Cohen, 2003)
vRequest for birth control
vChange in urinary function
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Patient Outcomes Regarding Sexuality
Implementation
v Establish a trusting nurse-patient relationship
vDefine individual sexuality
v Teach about sexuality and sexual health
vEstablish open patterns of communication with
significant others
v Promote responsible sexual expression
v Contraception
vDevelop self-awareness and body awareness
v Facilitating coping with special sexual needs
vDescribe responsible sexual health self-care
practices
v Health care needs of lesbian, gay, bisexual, and transgender
people
vPractice responsible sexual expression
v Advocating for patients’ sexuality needs
v Counseling the patient regarding sexuality, abortion, or in
cases of abusive relationships and rape
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Methods of Contraception
Barrier Methods of Contraception
vBehavioral
vCondom
vBarrier
vDiaphragm
vHormonal
vCervical cap
vIntrauterine devices
vSpermicides
vEmergency contraception
vVaginal sponge
vSterilization
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