Bereavement and Grief (ATI Ch 27)

Types of Loss

-*Necessary loss:* Part of the cycle of life; anticipated, but can still be intensely felt -*Actual loss:* Any loss of a valued person or item -*Perceived loss:* Any loss defined by a client that is not obvious to others -*Maturational loss:* Losses normally expected due to the developmental processing of life -*Situational loss:* Unanticipated loss caused by an external event

Nursing Interventions: Facilitating Mourning

-Allow time for the grieving process -Educate the client and family on the stages and tasks associated with the grieving process -Identify expected grieving behaviors such as crying, somatic manifestations, anxiety -Use therapeutic communication. Name the emotion that the client is feeling. For example, a nurse might say "You sound as though you are angry. Anger is a normal feeling for someone who has lost a loved one. Tell me about how you are feeling." -Avoid communication that inhibits open expression of feelings, such as offering false reassurance, giving advice, changing the subject, and taking the focus away from the individual who is grieving -When relating to someone who is bereaved, avoid cliches such as, "She is in a better place now." Rather encourage the individual to share memories about the deceased. -Assist the individual to accept the reality of the loss -Support the client's efforts to "move on" in the face of the loss -Encourage the building of new relationships -Provide continuing support. Encourage the support of family and friends -Assess for indications of ineffective coping, such as refusing to leave home months after a client's partner has died. -Share information about mourning and grieving with the client, who might not realize that feelings such as anger toward the deceased are expected. -Encourage the client who is grieving to attend a bereavement or grief support group -Initiate a referral for psychotherapy for a client who is having a maladaptive grief response -Provide information on available community resources -Ask the client if contacting a spiritual adviser would be acceptable, or encourage the client to do so -Participate in debriefing provided by professional grief or mental health counselors

A nurse is caring for a client following the loss of her partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience. (Select the stages of grief in order of occurrence. All steps must be used) A. Developing Awareness B. Restitution C. Shock and disbelief D. Recovery E. Resolution of the loss

Answer: 1. C. Shock and disbelief 2. A. Developing awarness 3. B. Restitution 4. E. Resolution of the loss 5. D. Recovery

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply) A. "I may experience feelings of resentment" B. "I will probably withdraw from others" C. "I can expect to experience changes in sleep" D. "It is possible that I will experience suicidal thoughts" E. "It is expected that I will have a loss of self esteem"

Answer: A. "I many experience feelings of resentment" B. "I will probably withdraw from others" C. "I can expect to experience changes in sleep"

A nurse is caring for a client who lost his mother to cancer last month. The client states, "I'd still have my mother if the doctor would have diagnosed her sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group" C. "I understand just how you feel. I felt the same way when my mother died." D. "Do other members of your family also feel this way?"

Answer: A. "You sound angry. Anger is a normal feeling associated with loss

A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence a client's grief and coping ability? (Select all that apply) A. Interpersonal relationships B. Culture C. Birth Order D. Religious beliefs E. Prior experience with loss

Answer: A. Interpersonal relationships B. Culture D. Religious beliefs E. Prior experience with loss

A charge nurse is reviewing Kubler-Ross: Five Stages of Grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply) A. Disequilibrium B. Denial C. Bargaining D. Anger E. Depression

Answer: B. Denial C. Bargaining D. Anger E. Depression

Kubler-Ross: Five Stages of Grief

Client might not experience the stages in order, and the length of each stage will vary from person to person. -*Denial:* The client has difficulty believing a terminal diagnosis or loss -*Anger:* Anger is directed toward self, others, or objects -*Bargaining:* The client negotiates for more time or a cure -*Depression:* The client mourns and directly confronts feelings related to the loss -*Acceptance:* The client accepts what is happening and plans for the future

Worden: Four Tasks of Mourning

Completion of all four tasks generally takes about a year, but this can also vary from person to person -*Task I:* accepting the reality of the loss -*Task II:* Processing the pain of grief. The client uses coping mechanisms to deal with the emotional pain of the loss -*Task III:* Adjusting to a world without the lost entity. The client changes the environment to accommodate the absence of the deceased -*Task IV:* Finding an enduring connection with the lost entity in the midst of embarking on a new life. The client finds a way to keep the lost entity a part of his/her life while at the same time moving forward with life and establishing new relationships.

Nursing Interventions: Protection against abandonment and isolation

Decrease the fear of dying alone: -Make presence known by answering call lights in a timely manner and making frequent contact -Keep the client informed of procedure/assessment times -Allow family members to spend the night and remain with the client as much as possible. -Determine where the client is most comfortable, such as in a room close to the nurse's station. -If the client chooses to be at home, move the client's bed to a central location in the home rather than an isolated bedroom

Bowlby: Four Stages of Grief

Identifies behaviors that are observed in clients who are grieving. These stages are present in clients as young as 6 months of age -*Numbness or protest:* The client is in denial over the reality of the loss and experiences feelings of shock -*Disequilibrium:* The client focuses on the loss and has an intense desire to regain what was lost -*Disorganization and despair:* The client feels hopelessness which impacts the client's ability to carry out tasks of daily living. -*Reorganization:* The client reaches acceptance of the loss

Engel: Five Stages of Grief

*-Shock and disbelief:* The client experiences a sense of numbness and denial over the loss -*Developing Awareness:* The client becomes aware of the reality of the loss resulting in intense feelings of grief. This begins within hours of the loss -*Restitution:* The client carries out cultural/religious rituals, such as funeral, following the loss. -*Resolution of the loss:* The client is preoccupied with the loss. Over about a 12 month period this preoccupation gradually decreases. -*Recovery:* The client moves past the preoccupation and forward with this life

Assessment: Maladaptive Grief

*Delayed or inhibited grief:* -The client does not demonstrate the expected behaviors of the normal grief process -Cultural expectations can influence the development of delayed or inhibited grief -Clients can remain in the denial stage of grief for an extended period of time -Due to client's inability to progress through the stages/tasks of grief a subsequent minor loss (even years later) can trigger the grief response *Distorted or exaggerated grief response:* -The client experiences the feelings and somatic manifestations associated with normal grief but to an exaggerated level. -The client is unable to perform activities of daily living -The client can remain in the anger stage of the grief process and can direct the anger towards himself or others -The client can develop clinical depression *Chronic or Prolonged Grief:* -This maladaptive response is difficult to identify due to the varying lengths of time required by clients to work through the stages/tasks of grief. -Clients can remain in the denial stage of grief and remain unable to accept the reality of the loss -Chronic or prolonged grief can result in the client's inability to perform activities of daily living

Factors influencing Loss, Grief, and Coping Ability

-An individual's current stage of development -Interpersonal relationships and social support network -Type and significance of the loss -Culture and ethnicity -Spiritual and religious beliefs and practices -Prior experience with loss -Socioeconomic status *Risk Factors for Maladaptive Grieving:* -Being dependent upon the deceased -Unexpected death at a young age, through violence, or by a socially unacceptable manner -Inadequate coping skills or lack of social support -Pre-existing mental health issues, such as depression or substance use disorder *Nursing Considerations:* -Clients who are experiencing a maladaptive grief response commonly experience a loss of self esteem and a sense of worthlessness not associated with normal grief. -The nurse should assess the client for risk factors and identify a normal versus a maladaptive grief response

Grief

-Clients experience loss in many aspects of their lives. -Grief is the inner emotional response to loss and is exhibited in as many ways as there are individuals -Bereavement includes both grief and mourning (the outward display of loss) as a person deals with the death of a significant individual -Bereavement can result in depression. A *bereavement exclusion* was previously used when a client experienced manifestations of depression within the first 2 months after a significant loss. Now, a client can receive a diagnosis of depression during this time so that needed treatment is not delayed -Palliative, or end of life, care is an important aspect of nursing care that attempts to meet the client's physical and psychosocial needs. End-of-life issues include decision making in a highly stressful time during which the nurse must consider the desires of the client and family. -Any decisions must be shared with other health care personnel for a smooth transition during this time of stress, grief, and bereavement.

Nursing Interventions: Support of the grieving family

-Suggest that family members plan visits in a manner that promoted client rest -Ensure that the family receives appropriate information as the treatment plan changes -Provide privacy so family members have the opportunity to communicate and express feelings among themselves -Determine family members' desire to provide physical care. Provide instruction as necessary -Educate the family about physical changes to expect as the client moves closer to death.

Theories of Grief

-The mental health care nurse should be aware of the various theories of grief. Though multiple theories are present they each tend to identify the same underlying feelings that the client who is grieving experiences.

Assessment: Anticipatory grief

-This grief implies the "letting go" of an object or person before the loss, as in the case of a terminal illness -Individuals have the opportunity to grieve before the actual loss

Assessment: Normal Grief

-This grief is considered uncomplicated -Emotions can include anger, resentment, withdrawal, hopelessness, and guilt, but should change to acceptance with time -Client should achieve some acceptance by 6 months after the loss -Somatic manifestations can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, or fatigue -The nurse should assess the client to identify a normal vs maladaptive grief response

Nursing Interventions: Psychosocial care

-Use an interprofessional approach -Provide care to the client and the family -Discuss specific concerns the client and family can have (financial, role changes). Initiate a social services or other referrals as needed -Use therapeutic communication to develop and maintain a nurse-client relationship -Facilitate communication between the client, family, and provider -Encourage the client to participate in religious/spiritual practices that bring comfort and strength, if appropriate. -Assist the client in clarifying personal values to facilitate effective decision making. -Encourage the client to use coping mechanisms that have worked in the past -Be sensitive to comments made in the presence of a client who is unconscious it is widely accepted that hearing is the last of the senses that is lost