tag:blogger.com,1999:blog-58428520224441845082024-03-21T17:31:25.849-07:00NURSING PROCCESS OF CLIENTS With LOSS -- ADEA simple explanation about grief and loss, definiton, sign, symtomps, cause, nursing proccess and case study about client with grief and lossAdeFariyanihttp://www.blogger.com/profile/06069800024807908602noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-5842852022444184508.post-44058907932170815062009-12-04T04:47:00.000-08:002009-12-20T20:55:11.595-08:00Nursing Process of Client with Loss<span style="font-family: georgia;font-size:100%;" ><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhw3GbhhsWyifsP9oBo4xbkUcLv7l8eZizjGJ5Kuj4lqsUAT9uyDAbOEKnznkYIKabHGS1Mo23tAVGp9vn8gN6gnHN_3aAmcEeds_3ytfX6JCmZ6nbH4-7j7Mo6NpWSpXLSDDXz0Kd49pFF/s1600-h/ist2_9014662-sad-and-tired.jpg"><img style="margin: 0pt 10px 10px 0pt; float: left; cursor: pointer; width: 266px; height: 266px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhw3GbhhsWyifsP9oBo4xbkUcLv7l8eZizjGJ5Kuj4lqsUAT9uyDAbOEKnznkYIKabHGS1Mo23tAVGp9vn8gN6gnHN_3aAmcEeds_3ytfX6JCmZ6nbH4-7j7Mo6NpWSpXLSDDXz0Kd49pFF/s320/ist2_9014662-sad-and-tired.jpg" alt="" id="BLOGGER_PHOTO_ID_5411377129959721586" border="0" /></a>
<br /></span><div style="text-align: justify; font-family: georgia;font-family:georgia;"><span style=";font-size:100%;" ><span style="font-weight: bold;">A. Introduction</span></span><span style="font-size:100%;">
<br /></span><meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><link rel="File-List" href="file:///C:%5CDOCUME%7E1%5Cempat%5CLOCALS%7E1%5CTemp%5Cmsohtml1%5C01%5Cclip_filelist.xml"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-ansi-language:EN-US; mso-fareast-language:EN-US;} a:link, span.MsoHyperlink {mso-style-noshow:yes; color:blue; text-decoration:underline; text-underline:single;} a:visited, span.MsoHyperlinkFollowed {color:purple; text-decoration:underline; text-underline:single;} p {mso-style-noshow:yes; mso-margin-top-alt:auto; margin-right:0in; mso-margin-bottom-alt:auto; margin-left:0in; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-ansi-language:IN; mso-fareast-language:IN;} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]--> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.</span></span></p><div face="georgia" style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.</span></span></p><div face="georgia" style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.</span></span></p><div face="georgia" style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.</span></span></p><div face="georgia" style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">"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.</span></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.<a href="http://cancernet.nci.nih.gov/cgi-bin/srchcgi.exe?DBID=pdq&TYPE=search&UID=280+02909&ZFILE=patient&SFMT=pdq_support/1/0/0#2">
<br /></a></span></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.</span></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1WrFiGP80F1c4ZRYfNTeFXqDa32fwTDKdnLVXxydsASxcRhmEV6WyQJ1YcU1RVFfVm22tm4SFIYUqzquh4s4cxKVNMjO7IKn_bdDOOxjkDdqmxq3Q_1mMERFH-oyPb21z25ycvIZ0BvLG/s1600-h/ist2_4114023-grief-asian-portraits.jpg"><img style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 224px; height: 314px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1WrFiGP80F1c4ZRYfNTeFXqDa32fwTDKdnLVXxydsASxcRhmEV6WyQJ1YcU1RVFfVm22tm4SFIYUqzquh4s4cxKVNMjO7IKn_bdDOOxjkDdqmxq3Q_1mMERFH-oyPb21z25ycvIZ0BvLG/s320/ist2_4114023-grief-asian-portraits.jpg" alt="" id="BLOGGER_PHOTO_ID_5411379126448754306" border="0" /></a></span><span style="font-size:100%;"><span lang="IN">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.</span></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.</span></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.</span></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">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.</span></span></p><p style="font-weight: bold; text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;"><span lang="IN">B. Definition</span></span></p><p style="text-align: justify; font-family: georgia;font-family:georgia;"><span style="font-size:100%;">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:</span></p><div style="text-align: justify; font-family: georgia;"> </div><table style="text-align: left; margin-left: 0px; margin-right: 0px; font-family: georgia;font-family:georgia;" width="100%" border="0" cellpadding="0" cellspacing="0"> <tbody><tr> <td width="50%" valign="top"><ul><li><span style="font-size:100%;">A relationship breakup</span></li><li><span style="font-size:100%;"> Loss of health</span></li><li><span style="font-size:100%;"> Losing a job</span></li><li><span style="font-size:100%;"> Loss of financial stability</span></li><li><span style="font-size:100%;"> A miscarriage</span></li></ul> </td> <td width="50%" valign="top"><ul><li><span style="font-size:100%;"> Death of a pet</span></li><li><span style="font-size:100%;"> Loss of a cherished dream</span></li><li><span style="font-size:100%;"> A loved one’s serious illness</span></li><li><span style="font-size:100%;"> Loss of a friendship</span></li><li><span style="font-size:100%;"> Loss of safety after a trauma</span></li></ul> </td> </tr> </tbody></table><div style="text-align: justify; font-family: georgia;"> <meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><link rel="File-List" href="file:///C:%5CDOCUME%7E1%5Cempat%5CLOCALS%7E1%5CTemp%5Cmsohtml1%5C01%5Cclip_filelist.xml"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]--> </div><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN">
<br /></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN">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
<br />
<br />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.
<br /><span style="font-weight: bold;"> </span></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">
<br /></span></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">C. Defining Characteristics: Patient and family members express feelings reflecting a sense of loss</span></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN">
<br /></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"> Patient and family members begin to manifest signs of grief :
<br />* Denial of potential loss
<br />* Sorrow
<br />* Crying
<br />* Guilt
<br />* Anger or hostility
<br />* Bargaining
<br />* Depression
<br />* Acceptance
<br />* Changes in eating habits
<br />* Alteration in activity level
<br />* Altered libido
<br />* Altered communication patterns
<br />* Fear
<br />* Hopelessness
<br />* Distortion of reality
<br />* Related Factors: Perceived potential loss of any sort
<br />* Perceived potential loss of physiopsychosocial well-being
<br />* Perceived potential loss of personal possessions
<br />* Expected Outcomes Patient or family verbalizes feelings, and establishes and maintains functional support systems</span></span></p><div style="text-align: justify; font-family: georgia;"><meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-ansi-language:EN-US; mso-fareast-language:EN-US;} p {mso-style-noshow:yes; mso-margin-top-alt:auto; margin-right:0in; mso-margin-bottom-alt:auto; margin-left:0in; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-ansi-language:IN; mso-fareast-language:IN;} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]--><span style="font-size:100%;"><strong><span style="background: rgb(62, 126, 191) none repeat scroll 0% 0%; -moz-background-clip: border; -moz-background-origin: padding; -moz-background-inline-policy: continuous;color:white;" lang="IN"> </span></strong>
<br /></span><span style="font-size:100%;"><span style="color: rgb(0, 0, 0);" lang="IN"><span style="font-weight: bold;">The 5 stages of grief, according to Elizabeth Kubler-Ross, are:</span>
<br /></span></span> </div><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgF3iFNvBsYsGZDI5ccJhcNIWDOdiqnRxa3y54ffj0rqgMfOAocuDe1ew-8SKO8cJgnne_fRdiJthnpvpqf5mcdy8plNw0WLZsKKo7xbI1YlBW-gj_LiL-IiHP0udRJJnkAxGgOZxaOJ-g/s1600-h/ist2_8775530-going-mad.jpg"><img style="margin: 0pt 10px 10px 0pt; float: left; cursor: pointer; width: 213px; height: 320px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgF3iFNvBsYsGZDI5ccJhcNIWDOdiqnRxa3y54ffj0rqgMfOAocuDe1ew-8SKO8cJgnne_fRdiJthnpvpqf5mcdy8plNw0WLZsKKo7xbI1YlBW-gj_LiL-IiHP0udRJJnkAxGgOZxaOJ-g/s320/ist2_8775530-going-mad.jpg" alt="" id="BLOGGER_PHOTO_ID_5411380335006404578" border="0" /></a></span><span style="font-size:100%;"><span style="background: rgb(62, 126, 191) none repeat scroll 0% 0%; -moz-background-clip: border; -moz-background-origin: padding; -moz-background-inline-policy: continuous;color:white;" >Shock:</span> 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.</span> </p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify;font-family:georgia;"><span style="font-size:100%;"><span style="background: rgb(62, 126, 191) none repeat scroll 0% 0%; -moz-background-clip: border; -moz-background-origin: padding; -moz-background-inline-policy: continuous;color:white;" lang="IN">Denial </span><span lang="IN">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.</span><span lang="IN"> </span></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify; font-family: georgia;"><span style="font-size:100%;"><span style="background: rgb(62, 126, 191) none repeat scroll 0% 0%; -moz-background-clip: border; -moz-background-origin: padding; -moz-background-inline-policy: continuous;color:white;" lang="IN">Bargaining and self blaming</span><span lang="IN"> 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."</span><span lang="IN"> </span></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify;font-family:georgia;"><span style="font-size:100%;"><span style="background: rgb(62, 126, 191) none repeat scroll 0% 0%; -moz-background-clip: border; -moz-background-origin: padding; -moz-background-inline-policy: continuous;color:white;" lang="IN">Anger and anxiety</span><span style="background: rgb(62, 126, 191) none repeat scroll 0% 0%; -moz-background-clip: border; -moz-background-origin: padding; -moz-background-inline-policy: continuous;" lang="IN"> </span><span lang="IN">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.</span><span lang="IN"> </span></span></p><div style="text-align: justify; font-family: georgia;"> <span style="font-size:100%;"><span style="background: rgb(62, 126, 191) none repeat scroll 0% 0%; -moz-background-clip: border; -moz-background-origin: padding; -moz-background-inline-policy: continuous;color:white;" >Acceptance </span>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</span></div><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN">
<br /><span style="font-weight: bold;">D. Nursing Process</span></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">
<br /></span></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGNkk7AYOEsDd0VpwDhkxxej8H5eMKB14WkRbXxq2mJhezKRWqOv4I2_EcP0S1t_vOjBO0uOaKTOryVn_ml5T8gLVhBc9P9JkJUxcli6xkZW4mrcY2FU2C0VXnYxVzpZKmCIWuqG48UkeA/s1600-h/ist2_296911-grieving-02.jpg"><img style="margin: 0pt 0pt 10px 10px; float: right; cursor: pointer; width: 304px; height: 204px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGNkk7AYOEsDd0VpwDhkxxej8H5eMKB14WkRbXxq2mJhezKRWqOv4I2_EcP0S1t_vOjBO0uOaKTOryVn_ml5T8gLVhBc9P9JkJUxcli6xkZW4mrcY2FU2C0VXnYxVzpZKmCIWuqG48UkeA/s320/ist2_296911-grieving-02.jpg" alt="" id="BLOGGER_PHOTO_ID_5411377885145991730" border="0" /></a></span><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">a. Ongoing Assessment</span>
<br /></span></span></p><ul style="text-align: justify;font-family:georgia;"><li><span style="font-size:100%;"><span style="" lang="IN">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.</span></span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li></ul><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"> </span><span style="" lang="IN">
<br /></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"> <span style="font-weight: bold;">b. Diagnosis</span></span>
<br /></span></p><ol style="text-align: justify;font-family:georgia;"><li><span style="font-size:100%;">Anxiety</span></li><li><span style="font-size:100%;">Caregiver role strain</span></li><li><span style="font-size:100%;">Compromised family coping</span></li><li><span style="font-size:100%;">Ineffective community coping</span></li><li><span style="font-size:100%;">Ineffective denial</span></li><li><span style="font-size:100%;">Fear</span></li><li><span style="font-size:100%;">Anticipatory Grieving</span></li><li><span style="font-size:100%;">Dysfunctional Grieving</span></li><li><span style="font-size:100%;">Hopelessness</span></li><li><span style="font-size:100%;">Powerlessness</span></li><li><span style="font-size:100%;">Social Isolation</span></li><li><span style="font-size:100%;">Spiritual Distress</span></li><li><span style="font-size:100%;">Readiness for Enhanced Spiritual Well-Being</span></li><li><span style="font-size:100%;">Pain</span></li><li><span style="font-size:100%;">Ineffective coping</span></li></ol><div style="text-align: justify; font-family: georgia;"><meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:536902279 -2147483648 8 0 511 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} /* List Definitions */ @list l0 {mso-list-id:-2; mso-list-type:simple; mso-list-template-ids:-166540380;} @list l0:level1 {mso-level-start-at:0; mso-level-text:*; mso-level-tab-stop:none; mso-level-number-position:left; margin-left:0in; text-indent:0in;} @list l0:level1 lfo1 {mso-level-number-format:bullet; mso-level-numbering:continue; mso-level-text:•; mso-level-tab-stop:none; mso-level-number-position:left; mso-level-legacy:yes; mso-level-legacy-indent:0in; mso-level-legacy-space:0in; margin-left:0in; text-indent:0in; mso-ansi-font-size:13.0pt; font-family:Times;} ol {margin-bottom:0in;} ul {margin-bottom:0in;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]--> </div><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><o:p> </o:p></span></p><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">
<br /></span></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">c. Planning</span></span></span></p><div style="text-align: justify; font-family: georgia;"><meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:536902279 -2147483648 8 0 511 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} /* List Definitions */ @list l0 {mso-list-id:-2; mso-list-type:simple; mso-list-template-ids:-166540380;} @list l0:level1 {mso-level-start-at:0; mso-level-text:*; mso-level-tab-stop:none; mso-level-number-position:left; margin-left:0in; text-indent:0in;} @list l0:level1 lfo1 {mso-level-number-format:bullet; mso-level-numbering:continue; mso-level-text:•; mso-level-tab-stop:none; mso-level-number-position:left; mso-level-legacy:yes; mso-level-legacy-indent:0in; mso-level-legacy-space:0in; margin-left:0in; text-indent:0in; mso-ansi-font-size:13.0pt; font-family:Times;} ol {margin-bottom:0in;} ul {margin-bottom:0in;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]--><ul><li><span style="font-size:100%;"><span style="font-family:georgia;">Goals can be long or short-term but are forever evolving.</span></span></li><li style="font-family:georgia;"><span style="font-size:100%;">In clients suffering from terminal illnesses, pain and symptom control, maintaining autonomy, and achieving spiritual comfort are all important goals to achieve.</span></li><li style="font-family:georgia;"><span style="font-size:100%;">The nurse must continually assess what are the client’s most urgent physical or psychological needs requiring immediate attention.</span></li><li style="font-family:georgia;"><span style="font-size:100%;">Plan for care when the client leaves the hospital through a multidisciplinary and collaborative approach.</span></li></ul></div><p class="MsoNormal" style="margin-left: 0in; text-indent: 0in; text-align: justify;font-family:verdana;"><!--[endif]--></p><div style="text-align: justify; font-family: georgia;"> </div><p class="MsoNormal" face="verdana" style="margin-left: 0in; text-indent: 0in; text-align: justify;"><!--[endif]--></p><div style="text-align: justify;"> </div><p class="MsoNormal" face="verdana" style="margin-left: 0in; text-indent: 0in; text-align: justify;"><!--[endif]--></p><div style="text-align: justify;"> </div><p class="MsoNormal" face="verdana" style="margin-left: 0in; text-indent: 0in; text-align: justify;"><!--[endif]--></p><p class="MsoNormal" face="verdana" style="margin-left: 0in; text-indent: 0in; text-align: justify;"><span style="font-size:100%;">
<br /></span></p><div style="text-align: justify;"> </div><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitX6kCZrb_1MgqElwKYuF4yPe61-81U0rSDfg3-a87GFPmNDoWKM1v1wB3UGYOWDt6yKF27X94JAIhKpNQ7K41YAIpYde7Aad_MfqYVRHSZbc2T9W6NrBtH4R0DNhh0kDYn3mc2xfNIX2I/s1600-h/ist2_8909380-bestfriend-consoling-friend.jpg"><img style="margin: 0pt 10px 10px 0pt; float: left; cursor: pointer; width: 320px; height: 212px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitX6kCZrb_1MgqElwKYuF4yPe61-81U0rSDfg3-a87GFPmNDoWKM1v1wB3UGYOWDt6yKF27X94JAIhKpNQ7K41YAIpYde7Aad_MfqYVRHSZbc2T9W6NrBtH4R0DNhh0kDYn3mc2xfNIX2I/s320/ist2_8909380-bestfriend-consoling-friend.jpg" alt="" id="BLOGGER_PHOTO_ID_5411378417459697714" border="0" /></a></span><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">d. Implementation</span></span></span></p><ol style="text-align: justify;font-family:georgia;"><li><span style="font-size:100%;"><span style="" lang="IN">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.</span></span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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).</span></li><li><span style="font-size:100%;">Minimize environmental stresses or stimuli. Provide the mourners with a quiet, private environment with no interruptions.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">Anticipate increased affective behavior. All affective behavior may seem increased or exaggerated during this time.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li></ol><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN">
<br /></span></span></p><p style="text-align: justify; font-family: georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"> Offer encouragement; point out strengths and progress to date. Patients often lose sight of the achievements while engaged in the struggle.
<br />This is the same strength and reserve each of them will use to reconstitute their lives after the loss.</span></span></p><ol style="text-align: justify;font-family:georgia;"><li><span style="font-size:100%;"><span style="" lang="IN">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.</span></span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">Encourage patient’s or significant others’ active involvement with rehabilitation team.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">Carry out the following throughout each stage: Provide as much privacy as possible.</span></li><li><span style="font-size:100%;">Allow use of denial and other defense mechanisms.</span></li><li><span style="font-size:100%;">Avoid reinforcing denial.</span></li><li><span style="font-size:100%;">Avoid judgmental and defensive responses to criticisms of health-care providers.</span></li><li><span style="font-size:100%;">Do not encourage use of pharmacological interventions.</span></li><li><span style="font-size:100%;">Do not force patient to make decisions.</span></li><li><span style="font-size:100%;">Provide patient with ongoing information, diagnosis, prognosis, progress, and plan of care.</span></li><li><span style="font-size:100%;">Involve the patient and family in decision making in all issues surrounding care. This acknowledges their right and responsibility for self-direction and autonomy.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">Promote discussion on what to expect when death occurs.</span></li><li><span style="font-size:100%;">Encourage significant others and patient to share their wishes about which family members should be present at time of death.</span></li><li><span style="font-size:100%;">Help significant others to accept that not being present at time of death does not indicate lack of love or caring.</span></li><li><span style="font-size:100%;">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.</span></li><li><span style="font-size:100%;">Initiate process that provides additional support and resources such as clergy or physician.</span></li><li><span style="font-size:100%;">Provide anticipatory guidance and follow-up as condition continues.
<br /></span></li></ol><p style="text-align: justify; font-family: georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN">
<br /></span></span></p><p style="text-align: justify; font-family: georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">
<br /></span></span></span></p><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><span style="" lang="IN"><span style="font-weight: bold;">Education/Continuity of Care</span>
<br /></span></span></p><ul style="text-align: justify;font-family:georgia;"><li><span style="font-size:100%;"><span style="" lang="IN"> Involve significant others in discussions. This helps reinforce understanding of all individuals involved.</span></span></li><li><span style="font-size:100%;"><span style="" lang="IN">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. <o:p></o:p></span></span></li></ul><div style="text-align: justify; font-family: georgia;"><meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><link rel="File-List" href="file:///C:%5CDOCUME%7E1%5Cempat%5CLOCALS%7E1%5CTemp%5Cmsohtml1%5C05%5Cclip_filelist.xml"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:536902279 -2147483648 8 0 511 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} /* List Definitions */ @list l0 {mso-list-id:-2; mso-list-type:simple; mso-list-template-ids:-166540380;} @list l0:level1 {mso-level-start-at:0; mso-level-text:*; mso-level-tab-stop:none; mso-level-number-position:left; margin-left:0in; text-indent:0in;} @list l0:level1 lfo1 {mso-level-number-format:bullet; mso-level-numbering:continue; mso-level-text:•; mso-level-tab-stop:none; mso-level-number-position:left; mso-level-legacy:yes; mso-level-legacy-indent:0in; mso-level-legacy-space:0in; margin-left:0in; text-indent:0in; mso-ansi-font-size:12.5pt; font-family:Times;} ol {margin-bottom:0in;} ul {margin-bottom:0in;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]--> </div><p class="MsoNormal" style="margin-left: 0in; text-indent: 0in; font-family: verdana; text-align: justify;"><!--[if !supportLists]--><span style="font-size:100%;"><span style="font-weight: bold;">
<br /></span></span></p><p class="MsoNormal" style="margin-left: 0in; text-indent: 0in; text-align: justify;font-family:georgia;"><span style="font-size:100%;"><span style="font-weight: bold;">e. Evaluation:
<br /></span></span></p><p class="MsoNormal" style="margin-left: 0in; text-indent: 0in; text-align: justify;font-family:georgia;"><span style="font-size:100%;">
<br /></span></p><p class="MsoNormal" style="margin-left: 0in; text-indent: 0in; text-align: justify;font-family:georgia;"><span style="font-size:100%;">Compare Outcomes with Established Goals.</span></p><p class="MsoNormal" style="margin-left: 0in; text-indent: 0in; text-align: justify;font-family:georgia;"><span style="font-size:100%;">
<br /></span></p><p class="MsoNormal" style="margin-left: 0in; text-indent: 0in; text-align: justify; font-weight: bold;font-family:georgia;"><span style="font-size:100%;"><span style="font-size:130%;">Case Study</span>
<br /></span></p><p class="MsoNormal" style="margin-left: 0in; text-indent: 0in; font-family: georgia; text-align: justify;"><span style="font-size:100%;">
<br /></span></p><div style="text-align: justify;"><span style="font-size:100%;"><span style="font-family:georgia;">Pearl Rogers is a 79-year-old African American woman who is ad</span></span><span style="font-size:100%;"><span style="font-family:georgia;">mitted to the Methodist Home Nursing Center. Mrs. Rogers lived</span></span><span style="font-size:100%;"><span style="font-family:georgia;">with her husband of 58 years until his death 9 months ago. She</span></span><span style="font-size:100%;"><span style="font-family:georgia;">had one son who died in an auto accident 2 years ago,and she has</span></span><span style="font-size:100%;"><span style="font-family:georgia;">one daughter who lives nearby. After her husband’s death, Mrs.</span></span><span style="font-size:100%;"><span style="font-family:georgia;">Rogers lived with her daughter until her admission to the nursing</span></span><span style="font-size:100%;"><span style="font-family:georgia;">center.Mrs.Rogers has become increasingly agitated and helpless,</span></span><span style="font-size:100%;"><span style="font-family:georgia;">complaining constantly of pain. Her daughter states that Mrs.</span></span><span style="font-size:100%;"><span style="font-family:georgia;">Rogers is chronically constipated, has difficulty sleeping, and has</span></span><span style="font-size:100%;"><span style="font-family:georgia;">stopped engaging in all social activities, including weekly church</span></span><span style="font-size:100%;"><span style="font-family:georgia;">services. She cries frequently. Extensive medical testing prior to</span></span><span style="font-size:100%;"><span style="font-family:georgia;">her admission to the nursing center revealed Mrs. Rogers has</span></span><span style="font-size:100%;"><span style="font-family:georgia;">arthritis but no other pathologic disorder.</span>
<br />
<br /></span><span style="font-weight: bold;font-size:100%;" ><span style="font-family:georgia;">ASSESSMENT</span></span><span style="font-size:100%;">
<br />
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">On admission to the nursing center, Mrs. Rogers says, “I’m a sick</span></span><span style="font-size:100%;"><span style="font-family:georgia;">woman, and no one will listen to me! I can’t walk, I’m so weak.My</span></span><span style="font-size:100%;"><span style="font-family:georgia;">head hurts, and I’m always sick at my stomach. I haven’t had a</span></span><span style="font-size:100%;"><span style="font-family:georgia;">bowel movement in a week, and I never sleep more than 3 hours</span></span><span style="font-size:100%;"><span style="font-family:georgia;">a night.” Physical assessment finding include swollen knees and</span></span><span style="font-size:100%;"><span style="font-family:georgia;">ankles,with limited mobility of the lower extremities.</span>
<br />
<br /></span><span style="font-weight: bold;font-size:100%;" ><span style="font-family:georgia;">DIAGNOSES</span></span><span style="font-size:100%;">
<br />
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">• Dysfunctional grieving related to stress of husband’s death</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">• Sleep pattern disturbance related to grieving</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">• Constipation related to inactivity</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">
<br /><span style="font-weight: bold;">EXPECTED OUTCOMES</span></span>
<br />
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Engage in normal grief work:Work through grief process, dis</span></span><span style="font-size:100%;"><span style="font-family:georgia;">cuss reality of losses, use nondestructive coping mechanisms,</span></span><span style="font-size:100%;"><span style="font-family:georgia;">and discuss positive and negative aspects of the loss.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Experience adequate and restful sleep: fall asleep 20 to 30 min</span></span><span style="font-size:100%;"><span style="font-family:georgia;">utes after retiring and awaken feeling rested after 7 to 8 hours</span></span><span style="font-size:100%;"><span style="font-family:georgia;">of sleep.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Have a bowel movement with soft formed stools at least every</span></span><span style="font-size:100%;"><span style="font-family:georgia;">other day.</span>
<br />
<br /></span><span style="font-weight: bold;font-size:100%;" ><span style="font-family:georgia;">PLANNING AND IMPLEMENTATION</span></span><span style="font-size:100%;">
<br />
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Promote trust: Show empathy and caring,demonstrate respect</span></span><span style="font-size:100%;"><span style="font-family:georgia;">for her culture and values, offer support and reassurance, be</span></span><span style="font-size:100%;"><span style="font-family:georgia;">honest, engage in active listening.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Assist in labeling her feelings: anger, fear,</span></span><span style="font-size:100%;"><span style="font-family:georgia;">loneliness, guilt, isolation.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Explore previous losses and the ways in which the client has</span></span><span style="font-size:100%;"><span style="font-family:georgia;">coped.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Encourage review of her relationship with her dead husband.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Reinforce expressions of behaviors associated with normal</span></span><span style="font-size:100%;"><span style="font-family:georgia;">grieving.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Encourage participation in usual spiritual practices.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Encourage participation in a grief group that meets at the </span></span><span style="font-size:100%;"><span style="font-family:georgia;">facility.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Consult with the physical and recreational therapist to help the</span></span><span style="font-size:100%;"><span style="font-family:georgia;">nursing staff provide afternoon activities.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Provide measures that assist in bowel evacuation: encourage</span></span><span style="font-size:100%;"><span style="font-family:georgia;"> exercise as tolerated, including walks and rocking in a rocking</span></span><span style="font-size:100%;"><span style="font-family:georgia;">chair. Offer foods that stimulate bowel movements. Offer pri</span></span><span style="font-size:100%;"><span style="font-family:georgia;">vacy: Close the door,ensuring that the emergency call bell is</span></span><span style="font-size:100%;"><span style="font-family:georgia;"> within reach, and do not interrupt.</span>
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">•Administer a mild laxative and/or stool softener, if necessary,</span></span><span style="font-size:100%;"><span style="font-family:georgia;">but discontinue as soon as possible.</span>
<br /></span><span style="font-weight: bold;font-size:100%;" ><span style="font-family:georgia;">
<br />EVALUATION</span></span><span style="font-size:100%;">
<br />
<br /></span><span style="font-size:100%;"><span style="font-family:georgia;">After 4 weeks at the nursing center,Mrs. Rogers states,“I don’t feel</span></span><span style="font-size:100%;"><span style="font-family:georgia;">any better,but I know I have to accept my situation.”Although Mrs.</span></span><span style="font-size:100%;"><span style="font-family:georgia;">Rogers states that she doesn’t feel better, she is walking the length</span></span><span style="font-size:100%;"><span style="font-family:georgia;">of the hall, sleeping better, and having regular bowel movements.</span></span><span style="font-size:100%;"><span style="font-family:georgia;">Mrs. Rogers is also less withdrawn and has openly discussed her</span></span><span style="font-size:100%;"><span style="font-family:georgia;">feelings related to her husband’s death, including her anger at the</span></span><span style="font-size:100%;"><span style="font-family:georgia;">loss of her son and her husband less than2 years apart.She has at-</span></span><span style="font-size:100%;"><span style="font-family:georgia;">tended the grief group once and has attended chapel services on</span></span><span style="font-size:100%;"><span style="font-family:georgia;">Sunday for the past 2 weeks.Her daughter visits her each Saturday</span></span><span style="font-size:100%;"><span style="font-family:georgia;">and takes her in a wheelchair to the shopping mall.</span>
<br /></span></div><span style="font-size:100%;">
<br /><span style="font-weight: bold;">Reference</span></span><span style="line-height: 115%;font-size:100%;" >
<br /><span style=";font-family:georgia;" >Sundeen & Stuart. 1995. <i>Principle and Practice of Psychiatry Nursing, 6<sup>th</sup> Ed</i>. Philadelphia: The CV Mosby.<o:p></o:p></span></span><span style=";font-family:georgia;font-size:100%;" >
<br /></span> <div style="text-align: justify; font-family: georgia;"><span style="font-size:100%;"><span style="line-height: 115%;font-size:100%;" >Yosep, Iyus. 2007. <i>Keperawatan Jiwa</i>. Bandung: Refika Aditama. </span>
<br /><span style="line-height: 115%;font-size:12pt;" ><span style="font-size:100%;"><o:p></o:p>Rawlins, Ruth Parmelee. 1993. <i>Clinical Manual of Psychiatric Nursing 2<sup>nd</sup> Ed</i></span><span style="font-size:100%;">. St. Louis Missouri: Mosby Year.
<br /><o:p></o:p></span></span></span></div><meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><link style="font-family: georgia;" rel="File-List" href="file:///C:%5CDOCUME%7E1%5CPANCAN%7E1%5CLOCALS%7E1%5CTemp%5Cmsohtml1%5C01%5Cclip_filelist.xml"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;</style><span style=";font-family:georgia;font-size:100%;" ><span style="font-size:12pt;"><span style="font-size:100%;">Parker, Judith,</span> <span style="font-size:100%;">1995.</span></span><span style="font-size:100%;"><span style="font-style: italic;">Understanding </span><i style="font-style: italic;">Grief</i><span style="font-style: italic;"> & Loss</span> (online).</span><span style="line-height: 115%;font-size:12pt;" ><span style="font-size:100%;">(accessed by 5 December 2009.)</span>
<br /></span></span><meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><link style="font-family: georgia;" rel="File-List" href="file:///C:%5CDOCUME%7E1%5CPANCAN%7E1%5CLOCALS%7E1%5CTemp%5Cmsohtml1%5C03%5Cclip_filelist.xml"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]--><span style="font-size:100%;"><span style=";font-family:";font-size:100%;" >Geddes, LaDonna McMurray, 1992<!--[if !supportLineBreakNewLine]--></span><span style=";font-family:";font-size:100%;" >.<span style="font-style: italic;">Change, Loss, </span><i style="font-style: italic;">Grief</i><span style="font-style: italic;"> and Communication</span>. </span><span style=";font-family:";font-size:100%;" >accessed by 5 December 2009</span>
<br />Blackwel<span style=";font-family:";font-size:100%;" >l, </span>Christopher W.,<span style="font-style: italic;">The Nurse as a Provider of Care:</span><u><span style="font-style: italic;">The Experience of Loss, Death, and Grief </span>(online) (</u><span style=";font-family:";font-size:100%;" >accessed by 5 December 2009.)</span><o:p></o:p>
<br /></span><meta equiv="Content-Type" content="text/html; charset=utf-8"><meta name="ProgId" content="Word.Document"><meta name="Generator" content="Microsoft Word 11"><meta name="Originator" content="Microsoft Word 11"><!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:compatibility> <w:breakwrappedtables/> <w:snaptogridincell/> <w:wraptextwithpunct/> <w:useasianbreakrules/> <w:dontgrowautofit/> </w:Compatibility> <w:browserlevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:latentstyles deflockedstate="false" latentstylecount="156"> </w:LatentStyles> </xml><![endif]--><style> <!-- /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style><!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} </style> <![endif]--><h1 style="font-weight: normal;font-family:georgia;"><span style="font-size:100%;">____.2009.<span style="font-style: italic;"> Coping with Grief and Loss</span></span><span style="font-size:100%;"><span style="font-style: italic;">:Support for Grieving and Bereavement</span> (online) (available at http://www.helpguide.org/mental/grief_loss.htm , accessed by 5 Desember 2009)
<br /></span></h1> <!-- InstanceEndEditable --> <div style="font-weight: bold; font-family: georgia;" id="printoff"> <!-- ADDTHIS BUTTON BEGIN --> <script type="text/javascript"> addthis_pub = 'helpguide'; addthis_logo_background = 'EFEFFF'; addthis_logo_color = '666699'; addthis_brand = 'Helpguide.org'; addthis_options = 'favorites, email, digg, delicious, myspace, facebook, google, live, more'; </script> <script type="text/javascript" src="http://s7.addthis.com/js/152/addthis_widget.js"></script> <!-- ADDTHIS BUTTON END --></div><p style="font-weight: bold;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><o:p></o:p></span></p><span style="font-size:100%;">____.2009.<span style="font-style: italic;"> Grief and Loss</span> (online) (available at http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=404 ,accessed by 6 Desember 2009)</span><p class="MsoNormal"><span style="font-size:100%;"><o:p> </o:p></span></p> <p class="MsoNormal"><span style="font-size:100%;"><o:p></o:p></span></p> <span style="font-size:100%;">
<br /></span><span style=";font-family:";font-size:100%;" > <!--[if !supportLineBreakNewLine]-->
<br /><!--[endif]--></span><span style="font-size:100%;">
<br />
<br /></span><span style=";font-family:";font-size:100%;" >
<br /><o:p></o:p></span><div style="text-align: justify; font-family: georgia;"> </div><p style="text-align: justify;font-family:georgia;" class="MsoNormal"><span style="font-size:100%;"><o:p> </o:p></span></p><div style="text-align: justify;"> </div><p style="text-align: justify;font-family:verdana;" class="MsoNormal"><span style="font-size:100%;"><o:p> </o:p></span></p> AdeFariyanihttp://www.blogger.com/profile/06069800024807908602noreply@blogger.com1