grief, loss, pain, and comfort

Engel's Stages of Grieving

-Shock and disbelief -Developing awareness -Restitution -Resolving the loss -Idealization -Outcome

Physical dependence

is an expected physical response when a client who is on long-term opioid therapy has the opioid significantly reduced or withdrawn.

Patient-controlled analgesia (PCA)

is an interactive method of pain management that permits clients to treat their pain by self administering doses of analgesics.

Dysesthesia

is an unpleasant abnormal sensation.

neuropathic pain

is associated with damaged or malfunctioning nerves due to illness (e.g., post-herpetic neuralgia, diabetic peripheral neuropathy), injury (e.g., phantom limb pain, spinal cord injury pain), or undetermined reasons.

anticipatory loss

is experienced before the loss actually occurs. For example, a woman whose husband is dying may experience actual loss in anticipation of his death.

perceived loss

is experienced by one person but cannot be verified by others. For example, a woman who leaves her employment to care for her children at home may perceive a loss of independence and freedom.

Nociceptive pain

is experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care. For example, the pain experienced following a cut or broken bone alerts the person to avoid further damage until it is properly healed.

Preemptive analgesia

is the administration of analgesics before surgery to decrease or relieve pain after surgery. An example would be treating clients preoperatively with local infiltration of an anesthetic or an oral or parenteral administration of an opioid to reduce postoperative pain.

mourning

is the behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs, and custom.

Algor Mortis

is the gradual decrease of the body's temperature after death.

Pain threshold

is the least amount of stimuli that is needed for a person to label a sensation as pain.

Pain tolerance

is the maximum amount of painful stimuli that a person is willing to withstand without seeking avoidance of the pain or relief.

Grief

is the total response to the emotional experience related to loss. Grief is manifested in thoughts, feelings, and behaviors associated with overwhelming distress or sorrow.

equianalgesia

refers to the relative potency of various opioid analgesics compared to a standard dose of parenteral morphine (gold standard opioid).

Peripheral neuropathic pain

(e.g., phantom limb pain, post-herpetic neuralgia, carpal tunnel syndrome) follows damage or sensitization of peripheral nerves.

visceral pain

(pain arising from organs or hollow viscera) is often perceived in an area remote from the organ causing the pain.

Types and source of loss

Actual loss, perceived loss, anticipatory loss

Which of the following may be considered normal or "healthy" types of grief? Select all that apply. 1. Abbreviated grief 2. Anticipatory grief 3. Disenfranchised grief 4. Complicated grief 5. Unresolved grief 6. Inhibited grief

Answer: 1, 2, and 3. Rationale: Correct answers include abbreviated (normal grief that is briefly experienced), anticipatory grief (experienced before the loss/death but appropriate), and disenfranchised grief (the emotions are felt privately, just not expressed in public). Unhealthy/abnormal types of grief include complicated grief (option 4) in several different forms: Unresolved grief is extended in length and severity (option 5). With inhibited grief, symptoms are suppressed, and other effects, including somatic, are experienced instead (option 6). Cognitive Level: Remembering.

10. In working with a dying client, the nurse demonstrates assisting the client to die with dignity when performing which action? 1. Allows the client to make as many decisions about care as is possible 2. Shares with the client the nurse's own views about life after death 3. Avoids talking about dying and focuses on the present 4. Relieves the client of as much responsibility for self-care as is possible

Answer: 1. Rationale: Assisting the client to die with dignity involves allowing the client to participate in and choose the direction of the remainder of his or her life. Sharing the nurse's own views about life after death (option 2) does not enhance client dignity. The nurse should not assume that avoiding talking about dying and emphasizing the present (option 3) is therapeutic for the client. Only if the client wishes to have someone else perform care is doing so supporting death with dignity (option 4). Otherwise, it may have the opposite effect.

10. A client recovering from abdominal surgery refuses analgesia, saying that he is "fine, as long as he doesn't move." Which nursing diagnosis should be a priority? 1. Deficient Knowledge (pain control measures) 2. Ineffective Health Maintenance 3. Risk for Ineffective Airway Clearance 4. Impaired Physical Mobility

Answer: 1. Rationale: Based on the information provided, the nurse needs to determine the client's understanding of the effects of pain on recovery and if the client has misconceptions about pain. Option 2 usually pertains more to chronic pain and fatigue. Options 3 and 4 could be true, but the priority is option 1. Movement enhances respiratory, cardiovascular, and GI recovery from general anesthesia and the outcomes associated with a surgical procedure.

When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response? 1. "Tell me what it means to you to have this surgery." 2. "You must be very glad to be having this lesion removed." 3. "I cry when I am happy or relieved sometimes, too." 4. "Isn't it wonderful that the lesion is not cancer?"

Answer: 1. Rationale: The nurse needs to assess and explore the meaning of the client's crying. Options 2 and 4 leap to assumptions about the meaning of the tears and ignore the possibility of the client's distress. Option 3 suggests that the client has the same feelings as the nurse, which may not be correct.

4. A client who had abdominal surgery 4 hours ago is receiving a continuous epidural infusion of an analgesic. Which of the following observations indicates the nurse should monitor the client closely? 1. Drowsy; drifts off to sleep before completing a sentence 2. Respirations = 18/min 3. Drowsy; easily aroused 4. Pain rating 1-2/10

Answer: 1. Rationale: This indicates an increasing level of sedation, which can be an early sign of impending respiratory depression. Option 2 is normal. Option 3 can indicate increasing sedation; however, option 1 describes a higher level of sedation and an intervention such as notifying the primary care provider. Option 4 indicates pain management that may be tolerable for the client.

The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following initial greetings is most appropriate? 1. "I'm very sorry for your loss." 2. "I'll take you in to view the body." 3. "I didn't know your father but I am sure he was a wonderful person." 4. "How long will you want to stay with your father?"

Answer: 1. Rationale: This statement acknowledges the family's grief simply. Avoid statements that may be interpreted as overly impersonal (option 2), false support (option 3), or harsh (option 4).

7. Which interventions, when implemented by the nurse, would apply the gate control theory of pain? Select all that apply. 1. Oral analgesics around the clock 2. Massage 3. Patient-controlled analgesia 4. Heat or cold application 5. Acupressure

Answer: 2, 4, and 5. Rationale: Massage, heat and cold, and acupressure are cutaneous stimulation techniques that can "close" the gates and inhibit the transmission of further pain. Options 1 and 3 are pharmacologic interventions, which are important; however, they inhibit the pain during the transmission phase of nociception. Cognitive Level: Applying.

When a client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments? 1. Pain tolerance 2. Pain intensity 3. Location of pain 4. Pain history

Answer: 2. Rationale: The client's pain intensity needs to be assessed first for effective pain management. In a postoperative client it is important to assess pain intensity frequently to manage the acute pain experience. Option 1: The most pain a person is willing to tolerate before taking action can be discussed with the client after the pain intensity has been assessed. Option 3, location of pain, is important, but it is not the priority. Option 4: This information is important but not for a client in acute pain. The priority would be to assess the pain intensity.

8. Which statement best reflects the nurse's assessment of the fifth vital sign? 1. "Do you have any complaints?" 2. "Are you experiencing any discomfort right now?" 3. "Is there anything I can do for you now?" 4. "Do you have any complaints of pain?"

Answer: 2. Rationale: The words pain or complain may have emotional or sociocultural meanings (options 1 and 4). It is better to ask clients if they are having any discomfort—they can then elaborate in their own words. Option 3 is too general and expects clients to report their pain without being asked.

A client's family tells the nurse that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 6:00 pm when mortuaries are closed, bodies are to be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation? 1. Gently explain the policy to the family and then implement it. 2. Inquire of the nursing supervisor how an exception to the policy could be made. 3. Call the client's primary care provider for advice. 4. Move the deceased to an empty room and assign an aide to stay with the body.

Answer: 2. Rationale: When possible, modifications of policy that demonstrate respect for individual differences should be explored. The primary care provider is in no position to modify the implementation of hospital policy (option 3). Utilizing an empty room and a staff member for a deceased client is an inappropriate use of resources (option 4). J., Berman Audrey; Snyder Shirlee; Frandsen Geralyn. Kozier & Erb's Fundamentals of Nursing (2-downloads) (Fundamentals of Nursing (Kozier)) (p. 1396). Pearson Education. Kindle Edition.

9. When planning care for pain control of older clients, which principles should the nurse apply? Select all that apply. 1. Pain is a natural outcome of the aging process. 2. Pain perception increases with age. 3. The client may deny pain. 4. The nurse should avoid use of opioids. 5. The client may describe pain as an "ache" or "discomfort."

Answer: 3 and 5. Rationale: Older clients may deny complaints of pain because it may indicate a worsening of their condition that may threaten their independence. Older adults may use words other than pain. Although many perceive pain as a natural outcome of aging, it is not a natural part of aging (option 1). Pain perception may decrease (option 2) and narcotics can be used with careful monitoring by the nurse (option 4).

3. A client who describes his pain as 7 on a scale of 0 to 10 is classified as having which of the following? 1. No pain 2. Mild pain 3. Moderate pain 4. Severe pain

Answer: 3. Rationale: A rating of 7 is considered severe and demands immediate attention.

During the transduction phase of nociception, which method of pain control is most effective? 1. Tricyclic antidepressants 2. Opioids 3. Ibuprofen 4. Distraction

Answer: 3. Rationale: During the transduction phase, tissue injury triggers the release of biochemical mediators such as prostaglandin. Ibuprofen works by blocking the production of prostaglandin. The coanalgesic medication in option 1 would affect the modulation phase because coanalgesics inhibit the reuptake of norepinephrine and serotonin, which increases the modulation phase that helps inhibit painful ascending stimuli. Opioids block the release of neurotransmitters, particularly substance P, which stops the pain at the spinal level that occurs during the transmission phase (option 2). Distraction is best used during the perception phase when the client becomes conscious of the pain. Distraction (e.g., music, guided imagery, TV) can help direct the client's attention away from the pain (option 4).

9. The client has been close to death for some time and the family asks how the nurse will know when the client has actually died. Which of the following would be the most accurate response from the nurse? 1. When the blood pressure can no longer be measured 2. When the gag reflex is no longer present 3. When there is no apical pulse 4. When the extremities are cool and dark in color

Answer: 3. Rationale: If there is no heartbeat, the client has died. Before death, the blood pressure may not be able to be heard on auscultation because it is very low (option 1). Loss of the gag reflex (option 2) occurs with loss of muscle tone but can exist in many circumstances unrelated to dying. Vasodilation and pooling of fluids at the end of life may cause cool and darkened extremities but these are not reliable signs of death (option 4).

At which age does a child begin to accept that he or she will someday die? 1. Less than 5 years old 2. 5-9 years old 3. 9-12 years old 4. 12-18 years old

Answer: 3. Rationale: Until children are about 5 years old, they believe that death is reversible. Between ages 5 and 9, the child knows death is irreversible but believes it can be avoided (option 2). Between 9 and 12 years of age, the child recognizes that he, too, will someday die (option 3). At 12 to 18 years old, the child builds on previous beliefs and may fear death, but often pretends not to care about it (option 4).

An 82-year-old man has been told by his primary care provider that it is no longer safe for him to drive a car. Which statement by the client would indicate beginning positive adaptation to this loss? 1. "I told the doctor I would stop driving, but I am not going to yet." 2. "I always knew this day would come, but I hoped it wouldn't be now." 3. "What does he know? I'm a better driver than he will ever be." 4. "Well, at least I have friends and family who can take me places."

Answer: 4. Rationale: Adaptive responses indicate the client can put the loss into perspective and begin to develop strategies for coping with the loss. Although the other options are responses the client might likely give and feel, and are not pathologic, they do not demonstrate movement toward a goal of adaptation nor problem solving.

6. During an admission nursing assessment, a client with diabetes describes his leg pain as a "dull, burning sensation." The nurse recognizes this description to be characteristic of which type of pain? 1. Physiological 2. Somatic 3. Visceral 4. Neuropathic

Answer: 4. Rationale: Options 2 and 3 are subcategories of physiological pain (option 1). A clue to the answer is that the client has diabetes, which often leads to diabetic peripheral neuropathy.

A nursing care plan includes the desired outcome of "quality of life" for a client with a chronic degenerative illness who is likely to live for many more years. Which of the following is one example that would indicate the outcome has been met? 1. The client demonstrates having adequate financial resources to pay for health care for many more years. 2. The client spends the majority of his or her time in spiritual reflection. 3. The client has no signs or symptoms of preventive complications of the illness. 4. The client verbalizes satisfaction with current relationships with other people.

Answer: 4. Rationale: Quality of life is determined by the client and expressed in terms of his or her satisfaction with a variety of aspects of life. Although being able to pay for care (option 1), having apparent spiritual peace (option 2), and absence of physiological complications (option 3) may appear to contribute to good quality of life, only the client's expression of satisfaction can provide the data the nurse requires to evaluate the goal.

5. The client has an order of morphine 2.5 to 5.0 mg intravenous (IV) every 4 hours. He received 2.5 mg IV 4 hours ago for pain rated at 3 on a scale of 0 to 10. He is now watching television and visiting with family members. When asked about his pain, he rates it as a 5. His vital signs are stable. What nursing intervention is the most appropriate? 1. Give morphine 3.5 mg IV and inform him to continue watching TV because it is a distraction from the pain. 2. Give 2.5 mg of morphine IV to avoid the client becoming addicted. 3. Give nothing at this time because he is not exhibiting any signs of pain. 4. Give morphine 5.0 mg IV and reassess in 20 minutes.

Answer: 4. Rationale: The client's perception/intensity rating of his pain is the most important even though other signs may suggest he is not having pain. His pain rating warrants a higher dose of the asneeded (prn) morphine. With option 1, you would be undermedicating the client based on his perception or rating of the pain. Option 2: Research shows that few clients become addicted, plus there are no signs of addiction. This answer, based on the data, would lead to the client being undermedicated. Option 3 does not address the intensity as well as option 4.

The nurse is caring for a family in a shelter 2 days after the loss of their home due to a fire. The fire caused minor burns to several members of the family but no life-threatening conditions. Which of the following is the most important assessment data for the nurse to gather at this time? 1. Availability of insurance coverage for rebuilding the house 2. Family members' understanding of the extent of their physical injuries 3. Psychological support resources available from friends or other sources 4. Family members' grief responses and coping behaviors

Answer: 4. Rationale: To plan with and assist the family, the nurse needs more data regarding the family's reactions to their loss. Information on issues such as insurance coverage (option 1) can wait until later and may be more appropriately the responsibility of social services rather than the nurse. It is important for the nurse to determine their understanding of their injuries but they are stated as minor (option 2). Once the nurse has assessed the family's responses it will be important to determine availability of outside resources to assist them (option 3).

Stage of Grief

DABDA - denial - anger - bargain - depression - acceptance

liver mortis

Discoloration; appears in the lowermost or dependent areas of the body.

nociception

The physiological processes related to pain perception are described as

acute pain

When pain lasts only through the expected recovery period, it is described as

shroud

a large piece of plastic or cotton material used to enclose a body after death.

mortician (also referred to as an undertaker)

a person trained in care of the dead.

chronic pain

also known as persistent pain, is prolonged, usually recurring or lasting 3 months or longer, and interferes with functioning.

nonsteroidal antiinflammatory drugs (NSAIDs)

aspirin or ibuprofen.

actual loss

can be recognized by others

Hospice

care focuses on support and care of the dying person and family, with the goal of facilitating a peaceful and dignified death.

Pathologic or complicated grief

exists when the strategies to cope with the loss are maladaptive and out of proportion or inconsistent with cultural, religious, or age-appropriate norms.

anticipatory grief

grief experienced prior to a loss. Examples, the wife who grieves before her ailing husband dies. A young person may grieve before an operation that will leave a scar.

Allodynia

includes nonpainful stimuli (e.g., light touch, contact with linen, water, or wind) that produces pain.

pain

is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage".

placebo

is "any sham medication or procedure designed to be void of any known therapeutic value"

nerve block

is a chemical interruption of a nerve pathway, caused by injecting a local anesthetic into the nerve.

Addiction

is a chronic, relapsing, treatable disease influenced by genetic, psychosocial, and environmental factors

Pseudoaddiction

is a condition that results from the under treatment of pain where the client may become so focused on obtaining medications for pain relief that they become angry and demanding, may "clock watch," and may otherwise seem inappropriately "drug seeking."

coanalgesic (formerly known as an adjuvant)

is a medication that is not classified as a pain medication.

Transcutaneous electrical nerve stimulation (TENS)

is a method of applying low-voltage electrical stimulation directly over identified pain areas, at an acupressure point, along peripheral nerve areas that innervate the pain area, or along the spinal column.

Loss

is an actual or potential situation in which something that is valued is changed or no longer available.

Palliative care

is an approach that improves the quality of life of clients and their families facing the problem associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care.

terms hyperalgesia and hyperpathia

may be used interchangeably to mean heightened responses to a painful stimuli (e.g., severe pain response to a paper cut).

cancer pain

may result from the direct effects of the disease and its treatment, or it may be unrelated.

Sympathetically maintained pain

occurs occasionally when abnormal connections between pain fibers and the sympathetic nervous system perpetuate problems with both the pain and sympathetically controlled functions (e.g., edema, temperature and blood flow regulation).

Tolerance

occurs when the client's opioid dose, over time, leads to a decreased sensitivity of the drug's analgesic effect.

cerebral death or higher brain death

occurs when the higher brain center, the cerebral cortex, is irreversibly destroyed.

Types of pain

of location, duration, intensity, and etiology.

somatic pain

originates in the skin, muscles, bone, or connective tissue.

Mild pain

pain in the 1 to 3 range

moderate pain

pain in the 4 to 6 range

severe pain

pain in the 7 to 10 range

Central neuropathic pain

spinal cord injury pain, post stroke pain, multiple sclerosis pain) results from malfunctioning nerves in the central nervous system (CNS).

bereavement

state of sorrow over the death or departure of a loved one

Rigor mortis

stiffness of the body that sets in several hours after death

Pain management

the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client

end of life care

the care provided in the final weeks before death.

open awareness

the client and others know about the impending death and feel comfortable discussing it, even though it is difficult.

closed awareness

the client is not made aware of impending death. The family may choose this because they do not completely understand why the client is ill or they believe the client will recover.

mutual pretense

the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject.

heart-lung death

the traditional clinical signs of death: cessation of the apical pulse, respirations, and blood pressure

referred

to other parts of the body. For example, cardiac pain may be felt in the shoulder or left arm, with or without chest pain.