Loss

Homeostasis

• Actual Loss

  • Can be recognized and seen by other people

    • Ex; Death of a spouse/ loss of a family member

    • Can be verified

  • Perceived

    • Experienced by the individual and may be by others/ but cannot be verified

    • Psychosocial loses » nobody else can witness

      • Ex; loss of beauty

      • Ex; losing a job

      • Ex; loss of independence

    • Situational

      • Ex; loss of job, child, losing a home, etc

    • Developmental

      • Ex; loss of hearing

      • Ex; going to college

      • Ex; menopause

      • Ex; retiring

Sources of Loss

• Aspect of self

  • May or may not be obvious to others

    • Ex; scar (obvious)

    • Ex; empty nest syndrome (not obvious)

    • Ex; loss of beauty, strength

    • Ex; loss of job / retirement

    • Ex; puberty

    • Ex; loss of childbearing

• External objects

  • Loss of house in fire

  • Losing a relic / heirloom that has importance

  • Jewelry, clothing (that has meaning)

• Animate objects

  • Ex; pets

• Familiar environment

  • Separation from environment can be devastating

    • Loss in familiarity

    • Older adults relocating

    • Going away to college

    • Ex; hurricane sandy

      • Hundreds lost their homes, churches, communities

• Loved ones

  • Loss through illness, separation, death

  • Can be permanent or temporary

Grieving

• Grief

  • A total response to an emotional feeling of loss

    • Thoughts, feelings, behavior

  • Social process best carried out by the help of others » Grief is a social process

• Bereavement

  • Subjective response to the loss after a death of a person with whom there was a significant relationship

• Mourning

  • Behavioral process where grief is resolved

  • Influenced by culture, spiritual beliefs and customs

Clinical Manifestations

• Physiological

  • Unkept appearance

  • Weight loss/ weight gain

  • People can become sick because of grieving

    • Can cause: stress, anorexia, anxiety, chest tightness, heart palpitations, menstrual cycle disturbances, etc.

• Psycho-socio-cultural

  • Behavioral changes

  • Depression

  • Crying

  • Sleep disturbances

  • Difficulty concentrating

  • Altered libido

  • Excessive dependence

• Developmental

  • Age can influence how someone grieves

Stages of Grieving (Kubler-Ross)

• Denial

  • Refusal to believe in reality

  • “no, not me”

• Anger

  • “Why me?” » Blame God

• Bargaining

  • “If I survive this, I will give up smoking” » “Yes me, but..”

• Depression

  • May be withdrawn

  • “Yes, this is happening”

• Acceptance

  • “Okay, me”

Factors influencing Loss and Grief Responses

• Significance of the loss

  • Important to see the person’s perception that is experiencing

  • Ex; divorce may be a happy or sad depending on the individual

• Age

  • Determines how grief is expressed » Reaction and understanding

    • Ex; an infant vs an adult experiencing loss

• Culture » customs (how grief happen) » greatest impact

• Spiritual Beliefs » Own way to grieve

• Gender

  • Ex; men are socialized to be strong

    • May not cry at funerals

• Socioeconomic status » grief can be delayed » worried about financial status

Developmental Concept of Death

• Infancy (0-5)

  • Don’t understand death

  • Death is reversable

    • Ex; mommy is just sleeping

• Childhood (5-9)

  • Threatens their ability to develop properly

  • May regress

  • It is important to keep their environment as routine as possible

• Older Children (9-12)

  • Believe death is inevitable

  • Begin understanding their own mortality

  • Start to believe what others believe about death

• Adolescence (12-18)

  • Fear lingering death

  • Fantasize that death can be defied

    • Often engage in risky behavior

    • Believe they are invincible

  • Seldom think they can die

• Adulthood (18-65)

  • Loss is influenced by religion and culture

  • At this point — have experienced death at a personal level

  • Accept their death

  • They experience a peak in anxiety regarding death

    • Diminished with spiritual well being

  • Accept that death is a normal part of development

• Maturity (65+)

  • Fear prolonged death / illness

    • Do not want to be sick for long

    • Do not want to drag out their dying process

  • Want to be and go in peace

  • Death has multiple meanings

Nursing Process

Nursing Assessment

• Stages of grief

• Physical status

• Emotional reactions

• Beliefs and rituals

Nursing Diagnosis

• Grieving

• Grieving / Complicated

• Risk for loneliness

• Social Isolation

• Interrupted Family Processes

• Anxiety / Fear

• Hopelessness

Nursing Interventions

• Identify own feelings

  • Can’t impose your feelings on others

• Use therapeutic communication

  • Communicate even if the person is dying

    • Hearing is the last sense to go

    • Be careful and mindful what you say

• Address the physiological needs during the dying processes

  • Does the patient have advanced directives?

• Support process of grieving

• Referral to support services

  • Ex; spiritual services, social work, group therapy, family counseling

Post-Mortem Care

• Consider religious and cultural preferences

• Involve family if appropriate

• Physical preparation of the body

  • Give the patient a full bed bath — clean the body for family viewing

    • Supine position

    • Sleeping position - head at 30 degrees propped with pillow

    • Eyes and mouth closed

    • Remove jewelry except wedding ring

      • Label jewelry and put in bad

    • Tag body and belongings » for identification

  • Remove and secure all tubes / lines

• Identification and disposition of deceased

Dying patients have rights — must treat body / individual with respect and dignity

• Hospice — End of care

• Health literacy — Do people understand