Chapter 45
Loss and Grief
Loss
 Loss is any situation in which a valued
object is changed or is no longer
accessible to the individual.
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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.
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Types of Loss
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Actual loss
Perceived loss
Physical loss
Psychological loss
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Types of Loss
 Categories of Loss
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Loss of an external object
Loss of familiar environment
Loss of aspect of self
Loss of significant other
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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.
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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.
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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.
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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.
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Grief
 Types of Grief
• Uncomplicated grief
• Dysfunctional grief
• Anticipatory grief
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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.
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Types of Grief
 Disenfranchised grief is grief experienced
in situations where grief is discouraged
and social supports are absent.
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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.
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Factors Affecting Grief
 Developmental Considerations
• Childhood
• Adolescence
• Early Adulthood
• Middle Adulthood
• Older Adulthood
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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.
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Adolescence
 Adolescents perceive themselves as
being invulnerable and death as
something that will not happen to them.
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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.
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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.
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Factors Affecting Grief
 Religious and cultural beliefs
 Relationship with the lost entity
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Factors Affecting Grief
 Cause of Death
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Anticipated death
Unexpected death
Traumatic death
Suicide
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Nursing Care of the
Grieving Person
 Assessment
• Determination of the personal meaning of
the loss
• Understanding that the stages of grief the
client is experiencing are not necessarily
sequential
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Nursing Care of the
Grieving Person
 Nursing Diagnoses
• Dysfunctional Grieving
• Anticipatory Grieving
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Outcome Identification and
Planning
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Verbalization of feelings of grief
Sharing grief with significant others
Acceptance of the loss
Renewal of activities and relationships
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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
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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.
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Death
 Stages of Death and Dying (Elizabeth
Kubler-Ross)
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Denial
Anger
Bargaining
Depression
Acceptance
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Ethical and Legal Issues
Related to End of Life
 End-of-Life Care
 Physician-Assisted Suicide
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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
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Assessment
 Presence of advance directives for health
care decisions
 Concern about unfinished business
 Client priorities and preparation needs
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Nursing Diagnoses
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Powerlessness
Helplessness
High Risk for Spiritual Distress
Altered Family Processes
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Outcome Identification and
Planning
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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
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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.
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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.
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Implementation
 Physiological Needs
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Nutrition
Breathing
Elimination
Comfort
Mobility
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Implementation
 Promoting Comfort
• Pain relief
• Keeping client clean and dry
• Providing a safe, nonthreatening
environment
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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.
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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.
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Implementation
 Support for the Family
 Learning Needs of Client and Family
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Client’s physical condition
Treatment regimen
How to handle medical crises
Emergency care
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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
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Care After Death
 Care of the Body
• Physiological changes
- Algor mortis
- Liver mortis
- Rigor mortis
• Autopsy
• Organ donation
 Care of the Family
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Nurse’s Self-Care
 Grief is a common experience for many
nurses who are confronted with death
and loss daily.
 To cope with their own grief, nurses need
support, education, and assistance in
coping with the death of clients.
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