loss, grieving & death

8/9/2019 Loss, Grieving & Death

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LossLoss

Actual or potential situation inActual or potential situation in

which something that is valued iswhich something that is valued ischanged, no longer available orchanged, no longer available orgonegone

Ex. Loss of body image, significantEx. Loss of body image, significantothers, job, personal possessionothers, job, personal possession


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Actual lossActual loss woman has awoman has amastectomy.mastectomy.

Perceived lossPerceived loss less obvious; lossless obvious; lossof confidenceof confidence


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Maturational lossMaturational loss resulting fromresulting from

normal lifes transition ex. Lossnormal lifes transition ex. Lossfelt by an adolescent whenfelt by an adolescent whenromance failsromance fails

Situational lossSituational loss occurringoccurringsuddenly in response to a specificsuddenly in response to a specific

external event. Ex. sudden deathexternal event. Ex. sudden deathof a loved oneof a loved one


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GrievingGrievingSubjective response of emotionalSubjective response of emotional

pain to losspain to loss

Normal response to loss; essentialNormal response to loss; essentialfor good mental & physical healthfor good mental & physical health

Permits the individual to copePermits the individual to copegradually & eventually accept thegradually & eventually accept thesituation as part of realitysituation as part of reality


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The goal of the grievingThe goal of the grievingprocess is the resolution of theprocess is the resolution of the

hurt & the reestablishment ofhurt & the reestablishment ofones life.ones life.


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BereavementBereavement common depressedcommon depressed

reaction to the death of a lovedreaction to the death of a lovedone. Ex. Disturbed sleep,one. Ex. Disturbed sleep,excessive crying, withdrawnexcessive crying, withdrawn

behaviorbehaviorMourningMourning reaction activated by areaction activated by a

person to assist in overcoming aperson to assist in overcoming agreat personal loss. Ex. Blackgreat personal loss. Ex. Blackdress, defined time of socialdress, defined time of social

withdrawalwithdrawal


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KublerKubler--Rosss Stages of GrievingRosss Stages of Grieving

DenialDenial refusal to believe that lossrefusal to believe that loss

is happeningis happeningAngerAnger client/family may directclient/family may direct

anger at nurse or hospital staff,anger at nurse or hospital staff,

about matters that normally doabout matters that normally donot bother themnot bother them


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Elizabeth KublerElizabeth Kubler--RossRoss


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BargainingBargaining seeks to bargain toseeks to bargain toavoid loss; may express feelingsavoid loss; may express feelingsof guilt for past sins; an effort toof guilt for past sins; an effort to

prolong inevitable lossprolong inevitable lossDepressionDepression grieves over what hasgrieves over what has

happenedhappened

AcceptanceAcceptance may wish to beginmay wish to beginmaking plansmaking plans


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DenialDenial NoNo not me.not me.AngerAnger Why me?Why me?

BargainingBargaining Yes, butYes, butDepressionDepression Yes, me.Yes, me.

AcceptanceAcceptance I

am ready.I

am ready.


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Care of dying patients &Care of dying patients &their families can be one oftheir families can be one of

the most neglected &the most neglected &challenging aspects ofchallenging aspects ofnursing care.nursing care.


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Bereavement overloadBereavement overload initialinitial

loss was compounded with anloss was compounded with anadditional loss before theadditional loss before the

resolution of the initial lossresolution of the initial lossBurnoutBurnout when the stresseswhen the stresses

exceed the rewards of the jobexceed the rewards of the job& the individual nurse lacks& the individual nurse lacksthe support of peers.the support of peers.


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Issues related to Dying & DeathIssues related to Dying & Death

EuthanasiaEuthanasia easy death aneasy death an

action deliberately taken withaction deliberately taken withthe purpose of shortening lifethe purpose of shortening lifeto end suffering or to carry outto end suffering or to carry out

the wishes of a terminally illthe wishes of a terminally illpatient.patient.


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Do not ResuscitateDo not Resuscitate jointjointdecision of the patient, familydecision of the patient, family& health care providers& health care providers

Does not mean to withholdDoes not mean to withholdhygiene, nutrition, fluids orhygiene, nutrition, fluids or

medicationsmedications


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Advance directivesAdvance directives signed &signed &witnessed documentswitnessed documentsproviding specific instructionsproviding specific instructions

for health care treatment infor health care treatment inthe event that person is unablethe event that person is unableto make those decisionsto make those decisions

personally at the time theypersonally at the time theyare needed.are needed.


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Based on the right to self

B

ased on the right to selfdeterminationdetermination

Has the right to accept orHas the right to accept or

refuse recommended medicalrefuse recommended medicaltreatmenttreatment


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Needs of a Dying PatientNeeds of a Dying Patient

Physical NeedsPhysical Needs

Emotional NeedsEmotional NeedsSpiritual NeedsSpiritual Needs


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Nurses GoalNurses Goal

Should be not only to allay theShould be not only to allay the

physical sufferings of patientsphysical sufferings of patientsas best as possible but also toas best as possible but also toprepare them for recognition &prepare them for recognition &

acceptance of death.acceptance of death.


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One of the worst fears of One of the worst fears of

any individual is to be left toany individual is to be left todie alone.die alone.


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Pain ControlPain Control

-- Pain is an unpleasant sensoryPain is an unpleasant sensory

and emotional experience. There areand emotional experience. There are3 major techniques of managing pain:3 major techniques of managing pain:

a. Pharmacologica. Pharmacologic

b. Nonb. Non--invasiveinvasive

c. Neurologicc. Neurologic


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Relief of Respiratory difficultyRelief of Respiratory difficulty

-- It can be relieved by the followingIt can be relieved by the followingmeasures:measures:

a.a. For conscious patientsFor conscious patients FowlersFowlersposition and throat suctioning areposition and throat suctioning areindicatedindicated

b.b. For unconscious patientsFor unconscious patients semisemiprone position facilitates drainage ofprone position facilitates drainage ofmucus from the mouth and throatmucus from the mouth and throat


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c. Oxygen therapyc. Oxygen therapy Cannula or maskCannula or maskmay be necessary for both conscious andmay be necessary for both conscious and

unconscious patients.unconscious patients.

MovementMovement

-- Regular changing of positions, patientRegular changing of positions, patientshould be in lateral position so that salivashould be in lateral position so that salivawhich cannot be swallowed will drain fromwhich cannot be swallowed will drain fromthe mouth.the mouth.


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Nutrition and hydrationNutrition and hydration

--The digestive system of dying

The digestive system of dyingpatients slows down; peristalsis ispatients slows down; peristalsis is

reduced, there is accumulation ofreduced, there is accumulation offlatus. The nurse must assessflatus. The nurse must assesspatients gag reflex. This is to ensurepatients gag reflex. This is to ensureeffective swallowing.effective swallowing.


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EliminationElimination

-- Patients may developPatients may developconstipation, incontinence (fecalconstipation, incontinence (fecaland urinary), or urinary retentionand urinary), or urinary retention

brought by loss of muscle tonebrought by loss of muscle tone


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Measures related to sensory changesMeasures related to sensory changes-- As death nears, the patients visionAs death nears, the patients vision

becomes blurred. Many patients preferbecomes blurred. Many patients prefer

a lighted room. A dying patient maya lighted room. A dying patient mayhear what people are saying after he orhear what people are saying after he orshe can no longer see or respond.she can no longer see or respond.

When talking to a dying patient weWhen talking to a dying patient weneed to speak clearly and avoidneed to speak clearly and avoidwhispering since patients tend towhispering since patients tend tobecome disturbed when unable to hearbecome disturbed when unable to hear


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Care of the Dying ClientCare of the Dying Client

Clinical Signs of death:Clinical Signs of death:

Cessation of apical pulse,Cessation of apical pulse,

respiration & blood pressurerespiration & blood pressure


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Signs ofImpending Death:Signs ofImpending Death:

Slow, thready & weaker pulseSlow, thready & weaker pulse

Lowered blood pressureLowered blood pressureRapid, shallow, irregular orRapid, shallow, irregular or

abnormally slow breathingabnormally slow breathingMottling of lower extremitiesMottling of lower extremities


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Generally respirations ceaseGenerally respirations cease

first then followed by cardiacfirst then followed by cardiacarrest a few moments later.arrest a few moments later.


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Indications of death:Indications of death:

Total lack of response to externalTotal lack of response to external

stimulistimuliNo muscular movement especiallyNo muscular movement especially

breathingbreathing

No reflexesNo reflexes

Flat ECGFlat ECG


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Hearing is the last sense thoughtHearing is the last sense thoughtto be lossto be loss

Only a physician can pronounceOnly a physician can pronouncedeath; after the pronouncementdeath; after the pronouncementthe lifethe life--support systems be shutsupport systems be shut

offoff


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Cerebral deathCerebral death

Cerebral cortex is irreversiblyCerebral cortex is irreversibly

destroyed; patient may still bedestroyed; patient may still beable to breath but irreversiblyable to breath but irreversiblyunconsciousunconscious


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Major goals for a dying patient:Major goals for a dying patient:

Maintaining physiologic &Maintaining physiologic &psychologic comfortpsychologic comfort

Achieving a dignified & peacefulAchieving a dignified & peacefuldeathdeath


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Meeting Physiologic Needs of aMeeting Physiologic Needs of a

dying patient:dying patient:

Provide personal hygieneProvide personal hygiene

measuresmeasuresControlling pain & relievingControlling pain & relieving

respiratory difficultiesrespiratory difficulties


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Spiritual SupportSpiritual Support

Important in dealing with deathImportant in dealing with death

Nurses responsibility that theNurses responsibility that the

patients spiritual needs arepatients spiritual needs areattended toattended to

Nurses have a responsibility toNurses have a responsibility tonot to impose their own religiousnot to impose their own religiousor spiritual beliefs on a clientor spiritual beliefs on a client


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Care of the body after death:Care of the body after death:

Body Changes:Body Changes:Rigor mortisRigor mortis Stiffening of theStiffening of thebody 2body 2--4 hrs. after death4 hrs. after death

Algor mortisAlgor mortis Gradual decrease ofGradual decrease ofthe bodys temperature afterthe bodys temperature after

death; 1 degree centigradedeath; 1 degree centigradedecrease/hr. until it reaches roomdecrease/hr. until it reaches roomtemperaturetemperature


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Livor mortisLivor mortis Discoloration of theDiscoloration of thesurrounding tissues due to thesurrounding tissues due to therelease of hemoglobin; appears inrelease of hemoglobin; appears in

the lowermost parts or dependentthe lowermost parts or dependentareas of the bodyareas of the body


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Death must be certified by aDeath must be certified by aphysician.physician.

Nurses have a responsibility to beNurses have a responsibility to beaware regarding the legalaware regarding the legalconcerns in a particular institutionconcerns in a particular institution


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Nursing Interventions:Nursing Interventions:

Must be responsible for the careMust be responsible for the careof the body after death (positionof the body after death (position

the body, place dentures in thethe body, place dentures in themouth, close the eyes & mouthmouth, close the eyes & mouthbefore rigor mortis sets in)before rigor mortis sets in)

All equipments & supplies mustAll equipments & supplies mustbe removed from the bedsidebe removed from the bedside


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The nurse should check theThe nurse should check the

clients religion & make everyclients religion & make everyattempt to comply.attempt to comply.

Applies identification bands (inApplies identification bands (inthe ankle & 1 in the wrist. Wrapsthe ankle & 1 in the wrist. Wrapsthe body in a shroud then anotherthe body in a shroud then another

ID band is applied outside theID band is applied outside theshroud.shroud.


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Prepares the body by makingPrepares the body by making

it look as natural &it look as natural &comfortable as possible.comfortable as possible.

The nurse places a small pillowThe nurse places a small pillowor folded towel under the heador folded towel under the headto prevent discoloration fromto prevent discoloration fromblood pooling.blood pooling.


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Apply a moistened cotton ballApply a moistened cotton ball

to hold eyelids in placeto hold eyelids in placeInserts the patients denturesInserts the patients dentures

to maintain normal facialto maintain normal facialfeatures.features.

A rolledA rolled--up towel under theup towel under thechin keeps the mouth closedchin keeps the mouth closed


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All valuables & their dispositionAll valuables & their dispositionmust be documented in themust be documented in the

patients medical recordpatients medical record


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Emotional SupportEmotional Support

If a significant other is alone atIf a significant other is alone atthe time of death of a lovedthe time of death of a loved

one, contact the family, clergyone, contact the family, clergyor friends to be with theor friends to be with thegrieving individual.grieving individual.

Words that convey sympathyWords that convey sympathymust be expressedmust be expressed


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Provide comforting gesture ifProvide comforting gesture if

appropriate (hand on the arm,appropriate (hand on the arm,embrace can be used as aembrace can be used as a

comforting gesture)comforting gesture)Be nonBe non--judgmental as thejudgmental as thefamily expressed feelings offamily expressed feelings of

anger, guilt or unfairnessanger, guilt or unfairness


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Resolution of GriefResolution of Grief

Requires support &Requires support &understandingunderstanding

6 months6 months 2 years may2 years mayelapse before an individual canelapse before an individual can

complete grief work & begincomplete grief work & beginthe full process of resolutionthe full process of resolution


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