Jumat, 04 Desember 2009

Nursing Process of Client with Loss

A. Introduction

People cope with the loss of a loved one in many ways. For some, the experience may lead to personal growth, even though it is a difficult and trying time. There is no right way of coping with death. The way a person grieves depends on the personality of that person and the relationship with the person who has died. How a person copes with grief is affected by the experience with cancer, the way the disease progressed, the person's cultural and religious background, coping skills, mental history, support systems, and the person's social and financial status.

The terms bereavement, grief, and mourning are often used in place of each other, but they have different meanings. Bereavement is the state of having suffered a loss and experiencing many emotions and changes. The time spent in a period of bereavement depends on how attached the person was to the person who died, and how much time was spent anticipating the loss.

Grief is the normal process of reacting to the loss. Grief reactions may be felt in response to physical losses (for example, a death) or in response to symbolic or social losses (for example, divorce or loss of a job). Each type of loss means the person has had something taken away. As a family goes through a cancer illness, many losses are experienced, and each triggers its own grief reaction. Grief may be experienced as a mental, physical, social, or emotional reaction. Mental reactions can include anger, guilt, anxiety, sadness, and despair. Physical reactions can include sleeping problems, changes in appetite, physical problems, or illness. Social reactions can include feelings about taking care of others in the family, seeing family or friends, or returning to work. As with bereavement, grief processes depend on the relationship with the person who died, the situation surrounding the death, and the person's attachment to the person who died. Grief may be described as the presence of physical problems, constant thoughts of the person who died, guilt, hostility, and a change in the way one normally acts.

Mourning consists of the conscious, unconscious, and cultural reactions to loss. Mourning includes the process of incorporating the experience of loss into ongoing life. Mourning is also influenced by cultural customs, rituals, and society's rules for coping with loss.

"Grief work" includes the processes that a mourner needs to complete before resuming daily life. These processes include separating from the person who died, readjusting to a world without him or her, and forming new relationships. To separate from the person who died, a person must find another way to redirect the emotional energy that was given to the loved one. This does not mean the person was not loved or should be forgotten, but that the mourner needs to turn to others for emotional satisfaction. The mourner's roles, identity, and skills may need to change to readjust to living in a world without the person who died. The mourner must give other people or activities the emotional energy that was once given to the person who died in order to redirect emotional energy.

People who are grieving often feel extremely tired because the process of grieving usually requires physical and emotional energy. The grief they are feeling is not just for the person who died, but also for the unfulfilled wishes and plans for the relationship with the person. Death often reminds people of past losses or separations. Mourning may be described as having three phases, including the urge to bring back the person who died, disorganization and sadness, and reorganization.

It is not easy to cope after a loved one dies. You will mourn and grieve. Mourning is the natural process you go through to accept a major loss. Mourning may include religious traditions honoring the dead or gathering with friends and family to share your loss. Mourning is personal and may last months or years.

Grieving is the outward expression of your loss. Your grief is likely to be expressed physically, emotionally, and psychologically. For instance, crying is a physical expression, while depression is a psychological expression.

It is very important to allow yourself to express these feelings. Often, death is a subject that is avoided, ignored or denied. At first it may seem helpful to separate yourself from the pain, but you cannot avoid grieving forever. Someday those feelings will need to be resolved or they may cause physical or emotional illness.

Many people report physical symptoms that accompany grief. Stomach pain, loss of appetite, intestinal upsets, sleep disturbances and loss of energy are all common symptoms of acute grief. Of all life’s stresses, mourning can seriously test your natural defense systems. Existing illnesses may worsen or new conditions may develop.

Profound emotional reactions may occur. These reactions include anxiety attacks, chronic fatigue, depression and thoughts of suicide. An obsession with the deceased is also a common reaction to death.

B. Definition

Grief is a natural response to loss. It’s the emotional suffering you feel when something or someone you love is taken away. You may associate grief with the death of a loved one – and this type of loss does often cause the most intense grief. But any loss can cause grief, including:

  • A relationship breakup
  • Loss of health
  • Losing a job
  • Loss of financial stability
  • A miscarriage
  • Death of a pet
  • Loss of a cherished dream
  • A loved one’s serious illness
  • Loss of a friendship
  • Loss of safety after a trauma

NANDA Definition: Grief is intellectual and emotional responses and behaviors by which individuals, families, communities work through the process of modifying self-concept based on the perception of potential loss

Anticipatory grieving is a state in which an individual grieves before an actual loss. It may apply to individuals who have had a perinatal loss or loss of a body part or to patients who have received a terminal diagnosis for themselves or a loved one. Intense mental anguish or a sense of deep sadness may be experienced by patients and their families as they face long-term illness or disability. Grief is an aspect of the human condition that touches every individual, but how an individual or a family system responds to loss and how grief is expressed varies widely. That process is strongly influenced by factors such as age, gender, and culture, as well as personal and intrafamilial reserves and strengths. The nurse must recognize that anticipatory grief is real grief and that, in all likelihood, as the loss actually occurs, it will evolve into grief based on an accomplished event. The nurse will encounter the patient and family experiencing anticipatory grief in the hospital setting, but increasingly, with more hospice services provided in the community, the nurse will find patients struggling with these issues in their own homes where professional help may be limited or fragmented. This care plan discusses measures the nurse can use to help patient and family members begin the process of grieving.

C. Defining Characteristics: Patient and family members express feelings reflecting a sense of loss

Patient and family members begin to manifest signs of grief :
* Denial of potential loss
* Sorrow
* Crying
* Guilt
* Anger or hostility
* Bargaining
* Depression
* Acceptance
* Changes in eating habits
* Alteration in activity level
* Altered libido
* Altered communication patterns
* Fear
* Hopelessness
* Distortion of reality
* Related Factors: Perceived potential loss of any sort
* Perceived potential loss of physiopsychosocial well-being
* Perceived potential loss of personal possessions
* Expected Outcomes Patient or family verbalizes feelings, and establishes and maintains functional support systems

The 5 stages of grief, according to Elizabeth Kubler-Ross, are:

Shock: experiences of shortness of breath, tightness in the throat, a need to sigh, muscular limpness, and loss of appetite occur in the first hours after a loss is experienced. As the shock abates, the physical symptoms lose their intensity and we begin to absorb reality. If there is a persistent wish during grief, it is that the loss could be reversed.

Denial allows the slow assimilation of the loss. At first the thought is that the report must be wrong. There is often the feeling that a mistake has been made or that the person will walk through the door at any minute. As time passes and preparation for change or for the funeral begins, reality is faced.

Bargaining and self blaming requires a greater level of acknowledgment that the loss has occurred, but resistance lingers to the extent that we attempt to make deals to reverse fate. There is a litany of "I should have's," such as, "I should have paid more attention, said something positive, been more patient."

Anger and anxiety are emotional signals that our psychological equilibrium is out of sync. A loss stirs feelings of rejection and powerlessness that lead to feeling anxious. In the first hours or days, feeling restless and unable to sleep is common. Anger at the loss, the one who is gone, the people who made the decision, all are normal reactions to loss. Anger often causes the most consternation as it is an emotion with which many are uncomfortable. Anger is a healthy indication that we are beginning to accept the facts.

Acceptance occurs with time. The realization sets in that the situation is not going to be the same as before, or that the person is not going to return and there is nothing that could have been done to change the outcome. There will be moments when a return to any or all of the stages occurs, yet accepting the loss allows us to move forward in the grief process

D. Nursing Process

a. Ongoing Assessment

  • Identify behaviors suggestive of the grieving process (see Defining Characteristics). Manifestations of grief are strongly influenced by factors such as age, gender, and culture. What the health care provider observes is a product of these feelings after they have been modified through these layers. The health care provider can enter dangerous territory when he or she attempts to categorize grief as appropriate, excessive, or inappropriate. Grief simply is. If its expression is not dangerous to anyone, then it is normal and appropriate.
  • Assess stage of grieving being experienced by patient or significant others: denial, anger, bargaining, depression, and acceptance. Although the grief is anticipatory, the patient may move from stage to stage and back again before acceptance occurs. This system for categorizing the stages of grief has been helpful in teaching people about the process of grief.
  • Assess the influence of the following factors on coping: past problem-solving abilities, socioeconomic background, educational preparation, cultural beliefs, and spiritual beliefs. These factors play a role in how grief will manifest in this particular patient or family. The nurse needs to restrain any notion that individuals of a given culture or age will always manifest predictable grief behaviors. Grief is an individual and exquisitely personal experience.
  • Assess whether the patient and significant others differ in their stage of grieving. People within the same family system may become impatient when others do not reconcile their feelings as quickly as they do.
  • Identify available support systems, such as the following: family, peer support, primary physician, consulting physician, nursing staff, clergy, therapist or counselor, and professional or lay support group. If the patient’s main support is the object of perceived loss, the patient’s need for help in identifying support is accentuated.
  • Identify potential for pathological grieving response. Anticipatory grief is helpful in preparing an individual to do actual grief work. Those who do not grieve in anticipation may be at higher risk for dysfunctional grief.
  • Evaluate need for referral to Social Security representatives, legal consultants, or support groups. It may be helpful to have patients and family members plugged into these supports as early as possible so that financial considerations and other special needs are taken care of before the anticipated loss occurs.
  • Observe nonverbal communication. Body language may communicate a great deal of information, especially if the patient and his/her family are unable to vocalize their concerns.

b. Diagnosis

  1. Anxiety
  2. Caregiver role strain
  3. Compromised family coping
  4. Ineffective community coping
  5. Ineffective denial
  6. Fear
  7. Anticipatory Grieving
  8. Dysfunctional Grieving
  9. Hopelessness
  10. Powerlessness
  11. Social Isolation
  12. Spiritual Distress
  13. Readiness for Enhanced Spiritual Well-Being
  14. Pain
  15. Ineffective coping

c. Planning

  • Goals can be long or short-term but are forever evolving.
  • In clients suffering from terminal illnesses, pain and symptom control, maintaining autonomy, and achieving spiritual comfort are all important goals to achieve.
  • The nurse must continually assess what are the client’s most urgent physical or psychological needs requiring immediate attention.
  • Plan for care when the client leaves the hospital through a multidisciplinary and collaborative approach.

d. Implementation

  1. Establish rapport with patient and significant others; try to maintain continuity in care providers. Listen and encourage patient or significant others to verbalize feelings. This may open lines of communication and facilitate eventual resolution of grief.
  2. Recognize stages of grief; apply nursing measures aimed at that specific stage. Shock and disbelief are initial responses to loss. The reality may be overwhelming; denial, panic, and anxiety may be seen.
  3. Provide safe environment for expression of grief. This assumes a tolerance for the patient’s expressions of grief (e.g., the ability to see a man cry, to see mourners make wide gestures with hands and their bodies, loud vocalizations and crying).
  4. Minimize environmental stresses or stimuli. Provide the mourners with a quiet, private environment with no interruptions.
  5. Remain with patient throughout difficult times. This may require the presence of the care provider during procedures, difficult discussions, and conferences with other family members or other members of the health care team. The patient or family may need a trusted person present to represent their interest or feelings if they feel unable to express them. They may require someone to "witness" with them.
  6. Accept the patient or the family’s need to deny loss as part of normal grief process. The nurse needs to see these events as a time during which the individual or family member consolidates his or her strength to go on to the next plateau of grief. Other mourners will need to stop progressing through the process of anticipatory grief, unable to grieve the loss any further until the loss actually happens. Realization and acceptance may only occur weeks to months after loss. Reality may continue to be overwhelming; sadness, anger, guilt, hostility may be seen.
  7. Anticipate increased affective behavior. All affective behavior may seem increased or exaggerated during this time.
  8. Recognize the patient or family’s need to maintain hope for the future. They may continue to deny the inevitability of the loss as a means of maintaining some degree of hope. As the loss begins to manifest, the mourners start accepting aspects of the loss, piece by piece, until the whole is actually grasped.
  9. Provide realistic information about health status without false reassurances or taking away hope. Defensive retreat can occur weeks to months after the loss. The patient attempts to maintain what has been lost; denial, wishful thinking, unwillingness to participate in self-care, and indifference may be seen.
  10. Recognize that regression may be an adaptive mechanism. The sheer volume of emotional reconstituting and reconstruction that must be accomplished after a loss occurs makes it reasonable to assume that time to restore energy will be needed at intervals.
  11. Show support and positively reinforce the patient’s efforts to go on with his or her life and normal activities of daily living (ADLs), stressing the strength and the reserves that must be present for the patient and family to feel enabled to do this.

Offer encouragement; point out strengths and progress to date. Patients often lose sight of the achievements while engaged in the struggle.
This is the same strength and reserve each of them will use to reconstitute their lives after the loss.

  1. Discuss possible need for outside support systems (e.g., peer support, groups, clergy). Acknowledgment occurs months to years after loss. Patient slowly realizes the impact of loss; depression, anxiety, and bitterness may be seen. Support groups composed of persons undergoing similar events may be helpful.
  2. Help patient prioritize importance of rehabilitation needs. This allows the health care provider and patient to focus rehabilitative energy on those things that are of greatest importance to the patient.
  3. Encourage patient’s or significant others’ active involvement with rehabilitation team.
  4. Continue to reinforce strengths, progress. Adaptation occurs during the first year or later, after the loss. Patient continues to reorganize resources, abilities, and self-image. Mourning is a unique and individual process that occurs over time.
  5. Recognize patient’s need to review (relive) the illness experience. This is one way in which the patient or the family integrates the event into their experience. Telling the event allows them an opportunity to hear it described and gain some perspective on the event.
  6. Facilitate reorganization by reviewing progress. When seen as a whole, the process of reorganization after a loss seems enormous, but reviewing the patient’s progress toward that end is very helpful and provides perspective on the whole process.
  7. Discuss possible involvement with peers or organizations (e.g., stroke support group, arthritis foundation) that work with patient’s medical condition. Support in the grieving process will come in many forms. Patients and family members often find the support of others encountering the same experiences as helpful.
  8. Recognize that each patient is unique and will progress at own pace. Time frames vary widely. Cultural, religious, ethnic, and individual differences affect the manner of grieving.
  9. Carry out the following throughout each stage: Provide as much privacy as possible.
  10. Allow use of denial and other defense mechanisms.
  11. Avoid reinforcing denial.
  12. Avoid judgmental and defensive responses to criticisms of health-care providers.
  13. Do not encourage use of pharmacological interventions.
  14. Do not force patient to make decisions.
  15. Provide patient with ongoing information, diagnosis, prognosis, progress, and plan of care.
  16. Involve the patient and family in decision making in all issues surrounding care. This acknowledges their right and responsibility for self-direction and autonomy.
  17. Encourage significant others to assist with patient’s physical care. The desire to provide care to and for each other does not disappear with illness; involving the family in care is affirming to the relationship the patient has with their family.
  18. When the patient is hospitalized or housed away from home, facilitate flexible visiting hours and include younger children and extended family. No individual should be excluded from being with the patient unless that is the wish of the patient. Hospital guidelines for visiting serve staff members who organize care more than they serve patients.
  19. Help patient and significant others share mutual fears, concerns, plans, and hopes for each other including the patient. Secrets are rarely helpful during these times of crisis. An open sharing and exchange of information makes it easier to address important issues and facilitates effective family process. These times of stress can be used to facilitate growth and family development. They can be important and sometimes final opportunities for resolving conflict and issues. They can also be used as times for potential personal and intrafamilial growth.
  20. Help the patient and significant others to understand that anger expressed during this time may be a function of many things and should not be perceived as personal attacks.
  21. Encourage significant others to maintain their own self-care needs for rest, sleep, nutrition, leisure activities, and time away from patient. Somatic complaints often accompany mourning; changes in sleep and eating patterns, and interruption of normal routines are a usual occurrence. Care should be taken to treat these symptoms so that emotional reconstitution is not complicated by illness.
  22. If the patient’s death is expected: Facilitate discussion with patient and significant other on "final arrangements"; when possible discuss burial, autopsy, organ donation, funeral, durable power of attorney, and a living will.
  23. Promote discussion on what to expect when death occurs.
  24. Encourage significant others and patient to share their wishes about which family members should be present at time of death.
  25. Help significant others to accept that not being present at time of death does not indicate lack of love or caring.
  26. When hospitalized, use a visual method to identify the patient’s critical status (e.g., color-coded door marker). This will inform all personnel of the patient’s status in an effort to ensure that staff do not act or respond inappropriately to a crisis situation.
  27. Initiate process that provides additional support and resources such as clergy or physician.
  28. Provide anticipatory guidance and follow-up as condition continues.

Education/Continuity of Care

  • Involve significant others in discussions. This helps reinforce understanding of all individuals involved.
  • Refer to other resources (e.g., counseling, pastoral support, or group therapy). Patient or significant other may need additional help to deal with individual concerns.

e. Evaluation:

Compare Outcomes with Established Goals.

Case Study

Pearl Rogers is a 79-year-old African American woman who is admitted to the Methodist Home Nursing Center. Mrs. Rogers livedwith her husband of 58 years until his death 9 months ago. Shehad one son who died in an auto accident 2 years ago,and she hasone daughter who lives nearby. After her husband’s death, Mrs.Rogers lived with her daughter until her admission to the nursingcenter.Mrs.Rogers has become increasingly agitated and helpless,complaining constantly of pain. Her daughter states that Mrs.Rogers is chronically constipated, has difficulty sleeping, and hasstopped engaging in all social activities, including weekly churchservices. She cries frequently. Extensive medical testing prior toher admission to the nursing center revealed Mrs. Rogers hasarthritis but no other pathologic disorder.


On admission to the nursing center, Mrs. Rogers says, “I’m a sickwoman, and no one will listen to me! I can’t walk, I’m so weak.Myhead hurts, and I’m always sick at my stomach. I haven’t had abowel movement in a week, and I never sleep more than 3 hoursa night.” Physical assessment finding include swollen knees andankles,with limited mobility of the lower extremities.


• Dysfunctional grieving related to stress of husband’s death
• Sleep pattern disturbance related to grieving
• Constipation related to inactivity


•Engage in normal grief work:Work through grief process, discuss reality of losses, use nondestructive coping mechanisms,and discuss positive and negative aspects of the loss.
•Experience adequate and restful sleep: fall asleep 20 to 30 minutes after retiring and awaken feeling rested after 7 to 8 hoursof sleep.
•Have a bowel movement with soft formed stools at least everyother day.


•Promote trust: Show empathy and caring,demonstrate respectfor her culture and values, offer support and reassurance, behonest, engage in active listening.
•Assist in labeling her feelings: anger, fear,loneliness, guilt, isolation.
•Explore previous losses and the ways in which the client hascoped.
•Encourage review of her relationship with her dead husband.
•Reinforce expressions of behaviors associated with normalgrieving.
•Encourage participation in usual spiritual practices.
•Encourage participation in a grief group that meets at the facility.
•Consult with the physical and recreational therapist to help thenursing staff provide afternoon activities.
•Provide measures that assist in bowel evacuation: encourage exercise as tolerated, including walks and rocking in a rockingchair. Offer foods that stimulate bowel movements. Offer privacy: Close the door,ensuring that the emergency call bell is within reach, and do not interrupt.
•Administer a mild laxative and/or stool softener, if necessary,but discontinue as soon as possible.


After 4 weeks at the nursing center,Mrs. Rogers states,“I don’t feelany better,but I know I have to accept my situation.”Although Mrs.Rogers states that she doesn’t feel better, she is walking the lengthof the hall, sleeping better, and having regular bowel movements.Mrs. Rogers is also less withdrawn and has openly discussed herfeelings related to her husband’s death, including her anger at theloss of her son and her husband less than2 years apart.She has at-tended the grief group once and has attended chapel services onSunday for the past 2 weeks.Her daughter visits her each Saturdayand takes her in a wheelchair to the shopping mall.


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