Grief, Mourning, and Bereavement

Depression

"I just don't know how my kids are going to get along after I'm gone." Sadness, grief, mourning for impending losses. Nursing Implications Normal and adaptive response. Clinical depression should be assessed and treated when present. Nurses should encourage the patient and the family to fully express their sadness. Insincere reassurance or encouragement of unrealistic hopes should be avoided.

Anger

"Why me?" Feelings of rage, resentment, or envy directed at God, health care professionals, family, others Nursing Implications Anger can be very isolating, and loved ones or clinicians may withdraw. Nurses should allow the patient and family to express anger, treating them with understanding, respect, and knowledge that the root of the anger is grief over impending loss.

Nurses role with different cultures:

* Rather than assuming that he or she understands a particular culture's grieving behaviors, the nurse must encourage clients to discover and use what is effective and meaningful for them. For example, the nurse could ask a Hispanic or Latino client who is also a practicing Catholic if he or she would like to pray for the deceased. If a Jewish patient has just died, the nurse could offer to stay with the body while the client notifies relatives.

Six key processes of mourning allow people to accommodate to the loss in a healthy way

*Recognize: Experiencing the loss, understanding that it is real, and that it has happened *React: Emotional response to loss, feeling the feelings *Recollect and reexperience: Memories are reviewed and relived *Relinquish: Accepting that the world has changed (as a result of the loss) and that there is no turning back *Readjust: Beginning to return to daily life; loss feels less acute and overwhelming *Reinvest: Accepting changes that have occurred; reentering the world, forming new relationships and commitments

A client diagnosed with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief would the nurse monitor the client for? Select all that apply. 1. Stating a fear of the future and unknown 2 Engaging in periods of weeping or raging 3 Expressing anger at the medical professionals 4 Expressing a feeling of unreality and disbelief 5 Expressing a desire to run away from the situation 6 Stating that he knows all he needs to know about his condition

1. Stating a fear of the future and unknown 2 Engaging in periods of weeping or raging 3 Expressing anger at the medical professionals 4 Expressing a feeling of unreality and disbelief 5 Expressing a desire to run away from the situation Reasoning: Anticipatory grief refers to the intellectual and emotional responses and behaviors by which individuals, families, or communities work through the process of modifying self-concept based on the perception of potential loss. Signs of anticipatory grief include fears of the future and the unknown, periods of weeping or raging, anger at medical professionals, a feeling of unreality and disbelief, a desire to run away from the situation, feelings of emptiness or of being lost, a sense of being numb and fatigued, a need to oversee every detail of care, pronounced clinging to or dependency on other family members, and fear of going crazy. A statement by the client that he knows all he needs to know about his condition is not a sign of anticipatory grieving; it may indicate another client problem such as avoidance or fear. Test-Taking Strategy:Focus on the subject, the signs/client behaviors of anticipatory grief. Recall that anticipatory grief involves the intellectual and emotional responses and behaviors by which an individual works through the process of modifying self-concept based on the perception of potential loss. Read each option, keeping the subject of the question and the definition of anticipatory grief in mind to assist in answering correctly.

1.Which of the following give cues to the nurse that a client may be grieving for a loss? 1. .Sad affect, anger, anxiety, and sudden changes in mood 2. .Thoughts, feelings, behavior, and physiologic complaints 3. .Hallucinations, panic level of anxiety, and sense of impending doom 4 .Complaints of abdominal pain, diarrhea, and loss of appetite

2. .Thoughts, feelings, behavior, and physiologic complaints

Overview

A wide range of feelings and behaviors are normal, adaptive, and healthy reactions to the loss of a loved one

Acceptance

I've lived a good life, and I have no regrets." Patient and/or family are neither angry nor depressed. Nursing Implications The patient may withdraw as their circle of interest diminishes. The family may feel rejected by the patient. Nurses need to support the family's expression of emotions and encourage them to continue to be present for the patient.

Mourning

Refers to individual, family, group, and cultural expressions of grief and associated behaviors.

Bereavement

Refers to the period of time during which mourning for a loss takes place. Both grief reactions and mourning behaviors change over time as people learn to live with the loss. Although the pain of the loss may be tempered by the passage of time, loss is an ongoing developmental process, and time does not heal the bereaved individual completely. That is, the bereaved do not get over a loss entirely, nor do they return to who they were before the loss. Rather, they develop a new sense of who they are and where they fit in a world that has changed dramatically and permanently

Nursing Interventions

•Explore client's perception and meaning of his or her loss. •Allow adaptive denial. •Encourage or assist the client in reaching out for and accepting support. •Encourage client to examine patterns of coping in past and present situation of loss. •Encourage client to review personal strengths and personal power. •Encourage client to care for him or herself. •Offer client food without pressure to eat. •Use effective communication: •Offer presence and give broad openings. •Use open-ended questions. •Establish rapport and maintain interpersonal skills such as

The nurse is caring for a terminally ill woman who is in the terminal stage of diagnosed breast cancer. The nurse would know which client behavior is characteristic of anticipatory grieving? 1 Discusses thoughts and feelings related to loss 2 Has prolonged emotional reactions and outbursts 3 Verbalizes unrealistic goals and plans for the future 4 Ignores untreated medical conditions that require treatment

1. Discusses thoughts and feelings related to loss Reasoning: The nurse can determine the client's stage of anticipatory grief by observing the client's behavior. The remaining options are examples of dysfunctional grieving. Test-Taking Strategy:Focus on the subject, anticipatory grieving. Note that the remaining options are comparable or alike and indicate dysfunctional grieving. Also noting the words prolonged, unrealistic, and ignores in these options will assist you in eliminating them.

A perinatal home care nurse has just assessed the fetal status of a client with a diagnosis of partial placental abruption of 20 weeks' gestation. The client is experiencing new bleeding and reports less fetal movement. The nurse informs the client that the obstetrician will be contacted for possible hospital admission. The client begins to cry quietly while holding her abdomen with her hands. She murmurs, "No, no, you can't go, my little man." The nurse would recognize the client's behavior as an indication of which psychosocial reaction? 1 Fear of hospitalization 2 Fear of loss and the death of the fetus 3 Grief due to potential loss of the fetus 4 Cognitive confusion as a result of shock

3 Grief due to potential loss of the fetus Reasoning: Grief occurs when a client has knowledge of an impending loss, such as when signs of fetal distress accelerate. The first stages of grieving may be characterized by shock; emotional numbness; disbelief; and strong emotions such as tears, screaming, or anger. The remaining option are not focused on the mother's expressed concerns. Test-Taking Strategy:Focus on the subject, the client's psychosocial reaction. Options 1 and 4 can be eliminated because there is no indication of pain or confusion. Although options 2 and 3 are somewhat similar, one suggests a fetal death and the other a potential loss. There is no indication of fetal death. The client perceives this as a potential loss. With this knowledge, option 3 is the only correct answer

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There is no one left who cares about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind? 1. That doesn't sound like the real you talking!" 2.I'm sure you have someone if you think hard enough. 3.It sounds as though you are feeling all alone right now. 4.I don't believe that, and I really don't think you do either.

3.It sounds as though you are feeling all alone right now. Reasoning: The client is experiencing loss because of the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is the one that attempts to translate words into feelings. Communication would be discouraged by statements that deny the client's feelings or that do not address the client's concerns. Test-Taking Strategy(ies):This question tests your knowledge of therapeutic communication techniques to assist the client in expressing feelings of loneliness. Each of the incorrect options illustrates a communication block. Remember that the nurse should address the client's feelings.

Grief

Refers to the personal feelings that accompany an anticipated or actual loss. refers to individual, family, group, and culture.

Bargaining

"I just want to see my grandchild's birth, then I'll be ready...." Patient and/or family plead for more time to reach an important goal. Promises are sometimes made with God. Nursing Implications Terminally ill patients are sometimes able to outlive prognoses and achieve some future goal. Nurses should be patient, allow expression of feelings, and support realistic and positive hope.

Denial

"This cannot be true." Feelings of isolation. May search for another health care professional who will give a more favorable opinion. May seek unproven therapies. Nursing Implications Denial can be an adaptive response, providing a buffer after bad news. It allows time to mobilize defenses but can be maladaptive when it prevents the patient or the family from seeking help or when denial behaviors cause more pain or distress than the illness or interfere with everyday functions. Nurses should assess the patient's and family's coping style, information needs, and understanding of the illness and treatment to establish a basis for empathetic listening, education, and emotional support. Rather than confronting the patient with information that he or she is not ready to hear, the nurse can encourage him or her to share fears and concerns. Open-ended questions or statements such as "Tell me more about how you are coping with this new information about your illness" can provide a springboard for expression of concerns.

· Kübler-Ross's Five Stages of Grief

*Denial *Anger *Bargaining *Depression *Acceptance

A client with terminal cancer tells the nurse, "If only I can live to see my daughter graduate from law school, I can die in peace." Which of the following is this an example of? 1. Displacement 2. Compensation 3. Undoing 4. Bargaining

4. Bargaining Reasoning: This answer is correct because the client's statement indicates a characteristic of the bargaining stage of grief and loss, which is negotiating for more time. The client states he/she "can die in peace, if only he/she can live a while longer." 1. This answer is not correct because displacement is a defense mechanism that involves shifting anger or impulses from an outside situation toward another person. The client's statement does not shift anger toward the daughter or situation. 2. This answer is not correct because compensation occurs when a person works diligently to overachieve in one area in order to make up for deficits in another. 3. This answer is not correct because undoing is a defense mechanism, not a stage of loss. The person performs good acts in an effort to cancel out unhealthy memories.