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NURS 3105
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Chapter 36
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Dealing with loss is inevitableNecessary lossMaturational
lossSituational lossActual lossPerceived loss
Ultimate loss
Type of loss & perception of it influence depth/duration of
grief response
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Emotional response to loss
Normal (uncomplicated)AnticipatoryDisenfranchisedAmbiguous
ComplicatedExaggeratedDelayedMasked
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Kbler-Ross Stages of Dying (DABDA):
Wordens Grief Tasks ModelTask I: Accept the realityTask II:
Experience the pain of griefTask III: Adjust to a world in which
the deceased is missingTask IV: Emotionally relocate the deceased
and move on
Post Modern Grief Theories
INDIVIDUALIZE the Grieving Process
Bowlbys Attachment TheoryNumbingYearning and
seekingDisorganization and despairReorganization
DenialAngerBargainingDepressionAcceptance
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Developmental StagePersonal RelationshipsMeaning of LossCoping
StrategiesCognitions (Thought Patterns)Culture and Ethnicity
Spiritual and Religious BeliefsHopePhysical
SensationsSelf-Care
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Anticipatory grievingCompromised family copingDeath
anxietyFearImpaired comfortIneffective denialGrievingComplicated
grievingRisk for complicated grievingHopelessnessPain (acute or
chronic)Risk for lonelinessSpiritual distressReadiness for enhanced
spiritual well-being
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Dying with dignityPeaceful deathCompassionate
careAdvocacyCommunication
A GOOD DEATH.
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Knowing patient needsEnsuring needs/preferences are metSymptom
managementPromote meaningful interaction between
patient/family/caregiverFacilitate peaceful death
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HospiceInterdisciplinary approach to assess and address the
holistic needs of patients and families to facilitate quality of
life and a peaceful deathPalliative careActive total care of
patients who have disease unresponsive to curative treatment
[WHO]Control of pain, of other symptoms, and of psychological,
social and spiritual problems is paramount
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Affirms life and rewards death as a normal processNeither
hastens nor postpones deathProvides relief from pain and other
distressing symptomsIntegrates the psychological and spiritual
aspects of careSupport system to assist in living actively to their
potentialSupport system to family for coping and bereavement
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Pre-active phase of dyingIncreased restlessness,
confusionWithdrawal sociallyIncreased sleep/lethargyDecreased PO
intakeSeeing persons who have already diedNeed to tie up loose
endsBeginning to have pauses in breathingEdema
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Circulatory ChangesCool skinMottling/cyanosisDecrease BPVariable
HR
CNS changesAgitationRestlessFatigueDrowsinessDisorientedImpaired
swallowingImpaired communication
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Respiratory changes Gurgling-Death RattlePulmonary
congestionDyspneaCheyne-StokesShallow breathing
Metabolic ChangesDecreased food/fluid intakeSlowed digestive
processesElimination changesBowel/bladder incontinence
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Recognize clinical manifestations of impending death
Assess coping difficulties
Communication
Dignity and quality of lifeEnvironmentAbandonment and
isolation
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Pain Management/Comfortmost significant concern
PsychosocialSupport for significant othersClear
communication
Interdisciplinary team management
Table 36-2 (p. 721)
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Maintain dignity and hope
Nursing strategies that promote hope are often quiet simple:Be
presentProvide holistic care that affirms the patients lifeMaintain
dignity
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The heart stops beatingBreathing stopsPupils become fixed and
dilatedBody color becomes pale and waxen as blood settlesBody
temperature dropsMuscles and sphincters relax (muscles stiffen 4-6
hours after death as rigor mortis sets in)Urine and stool may be
releasedEyes may remain openThe jaw can fall openObservers may hear
the trickling of fluids internally, even after death
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Identify the patient. Use the hospital ID tag if available. Note
the general appearance of the body. Test for response to verbal or
tactile stimuli. Overtly painful stimuli are not required. Nipple
or testicle twisting, or deep sternal pressure, are inappropriate
and unnecessary. Listen for the absence of heart sounds and blood
pressure; feel for the absence of carotid pulse.
Look and listen for the absence of spontaneous respirations.
Record the position of the pupils and the absence of pupillary
light reflex. Record the time at which your assessment was
completed.
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InpatientNurse determines death has occurred & contacts
HCP/hospice nurse to pronounceFederal and state laws require
institutions to:Request organ or tissue donationPerform an
autopsyCertify and document the occurrence of a deathProvide safe
and appropriate postmortem carePostmortem careFamily assist?Family
time with patientTransport of body to morgue
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Continue to maintain dignity and respect of the bodyAllow for
observation of cultural and religious practicesDocumentationBox
36-9Care of the survivors/caregivers
*Loss, grief, and death affect ALL of usBut we often want to
avoid it Saving the patient at all costWestern culture dont remind
me of MY mortalityPatients and families have great difficulty
accepting and managing loss and death. Alongside our duty to
prevent illness and injury lies our potential to help patients and
families navigate loss and grief and to have a positive death
experience
Experiencing and dealing with loss is inevitable. Throughout our
lives, we grieve the loss of many things.
Necessary losses are a part of life. These cause us to undergo
some type of change. When a loss occurs, oftentimes it can be
replaced by something different or better. (divorce, change in
level of independence
Maturational losses are a type of necessary loss that occur
across the life span. Should equip us with coping skills to deal
with unexpected losses
Situational lossUnexpected suddenMVC, loss of limb,
etc.Unnecessary losses are uniquely defined by the person
experiencing the loss and are less obvious to other people.
An actual loss occurs when a person can no longer feel, hear, or
know a person or object.A perceived loss is defined by the person
experiencing the loss. This is often less obvious to others but is
real to that person.
Death is the ultimate loss, and it is part of the continuum of
life.
*Manifested many ways
Normal: common universal reaction to loss with complex
emotional, cognitive, social, physical, behavioral and spiritual
responses.
Disengaging or letting go before the actual loss/death
occursprolonged & predicted loss
Disenfranchised = marginal / unsupported grief---relationship to
deceased is not socially sanctioned, not openly shared or given
less significance.
`````Ambiguous lost person is physically present but not
psychologically available.
Complicated occurs when people do not experience a normal grief
process. Prolonged or significantly difficult time moving forward
after loss
``````exaggerated: exaggerated grief response with
self-destructive or maladaptive behavior, obsessions or psych
disorders. High risk for suicide. `````delayed: unsually delayed or
postponedloss is too overwhelming to deal with and avoids fully
realizing loss`````masked: behavior interferes with normal
functioning, but individual does not recognize or is not aware tha
the behavior is a result of loss
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In addition to numerous diagnoses related to physical symptoms
at the end of life, nursing diagnoses relevant for patients
experiencing grief, loss, or death are listed on the slide.
**The Institute of Medicine defined a good death a one that is
free from avoidable suffering for patients, families and caregivers
in general accordance with the patients and families wishes; and
reasonably consistent with clinical, cultural, and ethical
standards. ********Dignity Allow for reminiscing Speak to
patientCont to explainPersonal hygiene and elimination
***Documentation of a death provides a legal record of the
event. Some medical forms, such as a request for autopsy, must be
signed by a physician or coroner, but the registered nurse gathers
and records much of the remaining information surrounding a death.
Nursing documentation becomes relevant in risk management or legal
investigations into a death, underscoring the importance of
accurate, legal reporting. Documentation also validates success in
meeting patient goals or provides justification for changes in
treatment or expected outcomes.
A human body deserves the same respect and dignity as a living
person and needs to be prepared in a manner consistent with the
patients cultural and religious beliefs. Health care providers need
to understand the makeup of a family network and to know which
individuals should be involved in end-of-life decisions and care.
After death assist the family with decision making such as
notification of a funeral home, transportation of family members,
and collection of the patient's belongings. DOCUMENTATION Nurses
are a primary source of family support. Remember that, because of
differing responses to grief, some family members prefer to be
alone at the time of a death, whereas others want to be surrounded
by a support community. When uncertain about what a family member
prefers for support, pose simple questions and offer suggestions
for assistanceFamily members deserve and expect a clear description
of what happened to their loved one**
