Grief, Loss, and Bereavement Flashcards

Core Concepts of Grief, Loss, and Bereavement

• Loss: Defined as the absence of someone or something to which the affected person has formed a significant attachment.
• Grief: The emotional response to a loss. It produces a wide array of feelings, including:
  • Anger.
  • Frustration.
  • Loneliness.
  • Sadness.
  • Guilt.
  • Regret.
  • A sense of resolution and peace.
• Mourning: The outward, social expression of a loss.
• Bereavement: Refers to both the inner feelings and the outward expressions of people who are experiencing loss.

Theories and Classifications of Grief

• Theories and Stages of Grief: Primary theoretical frameworks mentioned include:
  • Kübler-Ross.
  • Bowlby.
  • Sheldon.
  • Worden: Specifically associated with the "Tasks of mourning."
• Anticipatory Grief: Refers to cognitive, affective, cultural, and social reactions to an expected death. These reactions are felt by the client as well as by family members and friends.
• Disenfranchised Grief: Any loss that is not validated or recognized by society or others.
• Complicated Grief: Distressing symptoms that last for at least $6\,\text{months}$ after the death of a significant person. There are four specific types:
  • Chronic: Grief reactions that do not diminish over time.
  • Delayed: The suppression of the grief reaction.
  • Exaggerated: The survivor is completely overwhelmed by grief.
  • Masked: Behaviors of the survivor interfere with normal functioning while concealing the actual grieving process.

Factors Influencing the Grieving Process

• Individual and Environmental Factors:
  • Age of the bereaved and age of the deceased.
  • Health status of the survivor.
  • Cognitive status of the survivor.
  • Relationship to the deceased.
  • Coping styles and concurrent stressors.
  • Available support systems.
  • Socio-economic status.
  • Religion and spirituality.
• Types of Loss and Complicating Factors:
  • Suicide, murder, or other forms of wrongful death.
  • Sudden, violent, or traumatic death.
  • Multiple deaths.
  • Loss related to social stigma.
  • Loss of a young person.
  • Catastrophic events.
  • Loss of the home and its contents.
  • Miscarriage or stillbirth.

Comprehensive Nursing Assessment

• General Assessment: Must include the client, family members, and significant others.
• Assessment of the Caregiver:
  • General health checkup.
  • Focused physical, mental, or emotional assessment.
  • Nutritional status assessment.
  • Sleep evaluation.
  • Ability to maintain work and family roles.
  • Maintenance of dental and visual health.
  • Assessment of the social network and evaluation of support systems.
• Assessment Tools: Use of the "Toolkit of Instruments to Measure End of Life Care: Grief and Bereavement Assessment tools."
• Nursing Knowledge for Care of the Dying:
  • Scientific and clinical knowledge.
  • Interpersonal skills.
  • Ethical, legal, and professional principles.
  • Interprofessional collaboration.

Physical Assessment and Signs of Death

• Physical Assessment of the Dying Client:
  • Weakness and fatigue.
  • Increased drowsiness, sleeping more, and responding less.
  • Decrease in oral intake and a decrease in the swallow reflex.
  • Surges of energy may occur as the individual makes the transition to death.
  • Changes in bowel and bladder elimination.
• Signs and Symptoms of Impending Death:
  • Decrease in urine output.
  • Cold and mottled extremities.
  • Changes in vital signs.
  • Changes in breathing patterns.
• Signs and Symptoms of Death:
  • Absence of heartbeat and respirations.
  • Involuntary release of stool and/or urine.
  • Lack of any response to verbal or tactile stimuli.
  • Drop in body temperature as the body begins to cool.

Nursing Diagnosis and Planning

• Nursing Diagnosis Examples:
  • Grief: Supported by data such as the anticipated death of a spouse and crying when told a spouse will live only a few more days.
  • Chronic Sadness: Supported by continued sadness and depression after the amputation of a left leg due to a motorcycle accident; includes statements of fear, helplessness, hopelessness, low self-esteem, and continued self-blame.
  • Death Anxiety: Supported by an understanding of a terminal diagnosis (prognosis of less than $6\,\text{months}$); includes statements of fear of dying, fear of suffering, fear of leaving family, and powerlessness over the process.
• Planning and Outcome Statements:
  • Husband will express feelings toward the anticipated loss of his wife during her last few days.
  • Client will identify personal strengths within $1\,\text{month}$ of amputation.
  • Client will accept assistance from friends, family, and significant others within $2\,\text{weeks}$ of diagnosis.

Implementation: Care and Symptom Management

• General Care Strategies:
  • Provide education regarding the stages of grief.
  • Encourage healthy behaviors.
  • Listen to clients and families tell the story of their loss.
  • Include the entire family/significant others in assessment and planning.
  • Use community resources and appropriate referrals.
• Symptom Management at End of Life: Focus on managing pain, dyspnea, anorexia, cachexia, constipation, diarrhea, nausea, vomiting, fatigue, anxiety, and depression.
• Care Environment:
  • Include favorite belongings and allow pets to visit.
  • Allow unrestricted visiting hours for family, ensuring privacy and space for intimacy.
  • Do not change the setting unless requested by the client or family.
  • Only conduct tests if treatment measures will actually be implemented.
• Specific Nearing Death Concerns:
  • Nearing Death Awareness: Clients may appear confused and report speaking to or seeing deceased persons.
  • Basic Care: High level of compassion in bathing, oral care, turning, and repositioning.

End-of-Life Planning and Collaborative Care

• Advance care planning: An ongoing process of making decisions about future health care.
• Advance directives: Legal documents informing providers of a client’s goals and the designated contact for care decisions.
• Palliative Care:
  • Can begin at the time of diagnosis.
  • Includes curative measures.
  • Relief from pain and symptoms.
  • Regards dying as a normal process; intends neither to hasten nor postpone death.
  • Integrates psychological and spiritual aspects and offers a support system.
• Hospice Care:
  • Program for clients with a life expectancy of $6\,\text{months}$ or less.
  • Client decides to forego curative treatment.
  • Note: Palliative care includes hospice, but not all palliative care is hospice.

Postmortem Care and Preparing the Body

• Background and Policies:
  • Follow facility and state policies; verify if an autopsy is required before removing tubes/paraphernalia.
  • Use Personal Protective Equipment (PPE) if an infectious disease was present.
  • Treat the body with respect and dignity; delegation to Unlicensed Assistive Personnel (UAP) is permissible.
• Positioning and Preparation:
  • Place the body supine with arms at the sides.
  • Elevate head and shoulders.
  • Insert dentures or prosthetics; close eyes gently.
  • Remove jewelry and remove extra equipment.
• Washing and Linens:
  • Honor family wishes; some religions forbid washing the body (mortician may handle it).
  • Clean soiled areas, place absorbent pads, apply a clean gown, and brush hair.
  • Replace soiled linens with clean, straightened linens.
• Religious and Legal Concerns:
  • Some religions require a specific person for care.
  • Wrap the body in a shroud for transport.
  • Notify or obtain a signature from the provider for the death certificate.
  • Follow up on organ donation.
• Documentation and Identification:
  • Keep hospital ID band in place and add ID tags per policy.
  • Label and document all personal belongings and their distribution.
  • Document time of body transfer and special circumstances in a final chart note.

The Nurse's Experience and Role

• Nurses and Loss: Frequent experience with death can lead to unresolved, chronic grief. Nurses must explore personal feelings regarding death to provide effective care.
• Nurse Self-Care: Essential for handling the stressors of working with the dying. Includes proper diet, exercise, sleep, relaxation, and vacations.
• Organ Donation Role: Recognize potential situations for donation and work collaboratively with the family and interprofessional team.

Questions & Discussion

• Knowledge Check: Defining Bereavement:
  • Question: Which of the following best defines bereavement?
  • Options: 1. Outward social expression. 2. Inner feelings and outward expressions. 3. Symptoms lasting $6\,\text{months}$. 4. Non-validated loss.
  • Answer: The inner feelings and outward expressions of people experiencing loss.
• NGN NCLEX-RN Practice: Nursing Diagnosis Match:
  • Supporting Data 1: Crying after being told spouse will live only a few more days. -> Grief.
  • Supporting Data 2: Statements of fear and helplessness after amputation. -> Chronic Sadness.
  • Supporting Data 3: Continued sadness and depression after a motorcycle accident. -> Chronic Sadness.
• Knowledge Check: Family Support:
  • Question: Which action is best when a family is emotional at the bedside of a dying client?
  • Best Action: Assess the family's grief reactions. (Incorrect actions: encouraging them to leave, discouraging crying, or saying "everything will be fine").