Chapter 43 PP Loss, Grieving, and Death Mrs.

Edwards
Lecture Notes
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1.

The are two general types of loss:: actual and perceived

2.

Defined:: Actual loss can be recognized by others.

A perceived loss is experienced by one person but cannot be verified by others.
Psychological losses are often perceived losses in that they are not directly verifiable

3.

Both losses:: Can be anticipatory.

Anticipatory loss is experienced before the loss actually occurs.

4.

Development of circadian rhythm:: Circadian rhythm regularly begins to develop by the sixth week of life and by 3 to 6 months most
infants have a regular sleep-wake cycle.

5.

Examples of situational losses include the:: loss of one's job, the death of a child, or the loss of functional ability because of acute illness or
injury.

6.

Loss can be viewed as:: situational or developmental

7.

Developmental losses: occur in the process of normal development, such as the departure of children from the home, or retirement from a
career.

8.

There are many sources of loss:: (a) loss of an aspect of oneselfa body part, a physiological function, or a psychological attribute
(b) loss of an object external to oneself
(c) separation from an accustomed environment
(d) loss of a loved one or valued person.

9.

Kbler- Ross (1969) described five stages:: denial, anger, bargaining, depression, and acceptance.

10.

Identify clinical symptoms of grief:: Physiologically, the body responds to a current or anticipated loss with a stress reaction. The nurse
can assess the clinical signs of this response

11.

Manifestations of grief that would be considered normal:: include verbalization of the loss, crying, sleep disturbance, loss of appetite,
and difficulty concentrating.

12.

Complicated grieving may be characterized by:: extended time of denial, depression, severe physiological symptoms, or suicidal
thoughts.

13.

A number of factors affect a person's responses to a loss or death:: age, significance of the loss, culture, spiritual beliefs, gender,
socio- economic status, support systems, and the cause of loss or death.

14.

Age: affects a person's understanding of and reaction to loss.

With familiarity, people usually increase their understanding and acceptance of life, loss, and death.

15.

Significance of the loss: depends on the perception of the individual experiencing the loss. A number of factors affect the significance:
importance of the lost person, object, or function; degree of change required because of the loss; and the person's beliefs and values.

16.

Culture influences: an individual's reaction to the loss. How grief is expressed is often determined by the customs of the culture.

17.

Spiritual Beliefs: greatly influence both a person's reaction to loss and subsequent behavior. Most religious groups have practices related to
dying, and these are often important to the client and support people.

18.

Gender Roles: affect reactions at times of loss. Men are frequently expected to "be strong" and show very little emotion during grief, whereas
it is acceptable for women to show grief by crying. Gender role also affects the significance of body image changes to clients.

19.

Socio-economic: often affects the support system available at the time of a loss. A pension plan or insurance can offer a widowed or disabled
person a choice of ways to deal with a loss. A person who is confronted with both severe loss and economic hardship may not be able to cope
with either.

20.

Support Systems: some individuals feel uncomfortable or inexperienced in dealing with losses and may withdraw from the grieving person.
In addition, support may be available when the loss first occurs, but as the support people return to usual activities, the ongoing need for
support may be unmet. Also, the grieving person may be unable or unready to accept support.

21.

Manifestations of impending death include:: loss of muscle tone (relaxation of the facial muscles, difficulty speaking, difficulty
swallowing, gradual loss of the gag reflex, decreased activity of the gastrointestinal tract, possible urinary and rectal incontinence, diminished
body movement); slowing of the circulation (diminished sensation, mottling and cyanosis of the extremities, cold skin, slower and weaker pulse,
decreased blood pressure); changes in respiration (rapid, shallow, irregular or abnormally slow respirations, noisy breathing, mouth
breathing, dry oral mucous membranes); and sensory impairment (blurred vision, impaired sense of taste and smell).

22.

The traditional clinical signs of death:: were cessation of the apical pulse, respirations, and blood pressure, also referred to as heart-lung
death.

23.

In 1968, the World Medical Assembly adopted the following guide- lines for physicians as indications of death:: total lack of
response to external stimuli; no muscular movement, especially during breathing; no reflexes; and a flat encephalogram (brain waves). In instances of artificial support, absence of brain waves for at least 24 hours is an indication of death.

24.

Another definition of death is cerebral death or higher brain death:: which occurs when the higher brain center, the cerebral cortex,
is irreversibly destroyed. In this case, there is "a clinical syndrome characterized by the permanent loss of cerebral and brainstem function,
manifested by absence of responsiveness to external stimuli, absence of cephalic reflexes, and apnea. An isoelectric electroencephalogram for at
least 30 in minutes in the absence of hypothermia and poisoning by central nervous system depressants supports the diagnosis" (Stedman's
Medical Dictionary, 2005).

25.

Describe helping clients die with dignity:: Nurses need to ensure that the client is treated with dignity, that is, with honor and respect

26.

Helping clients die with dignity involves:: maintaining their humanity, consistent with their values, beliefs, and culture.

27.

Clients want to be able to manage:: the events preceding death so they can die peacefully

28.

Nurses can help clients to determine:: their own physical, psychological, and social priorities r/t death and dying

29.

The Dying Person's Bill of Rights(see Box 43-1) Page 1110

THIS IS ON TEST PER MRS. EDWARDS, KNOW!: I have the right to be treated as a living human being until I die.
I have the right to maintain a sense of hopefulness however
changing its focus may be.
I have the right to express my feelings and emotions about
my approaching death in my own way.
I have the right to participate in decisions concerning my care.
I have the right to expect continuing medical and nursing
attention even though cure goals must be changed to
comfort goals.
I have the right not to die alone.
I have the right to be free from pain.
I have the right to have my questions answered honestly.
I have the right not to be deceived.
I have the right to have help from and for my family in
accepting my death.
I have the right to die in peace and with dignity.
I have the right to retain my individuality and not be judged for
my decisions which may be contrary to the beliefs of others.
I have the right to be cared for by caring, sensitive,
knowledgeable people who will attempt to understand my
needs and will be able to gain some satisfaction in helping
me face my death.

30.

Some strategies to be taken to make this discussion easier (r/t death topic) include:: the nurse should identify personal feelings
about death and how these may influence interaction with clients

31.

Topics of Focus:: focus on the client's needs; talk to the client and family about how the client usually copes with stress; establish
communication relationship that shows concerns for and commitment to the client; determine what the client knows about the illness and
prognosis; respond with honesty and directness to the client's questions about death; and make time to be available to the client to provide
support and listen and respond.

32.

The most important aspects of providing support to the family members of a dying client involve:: Using therapeutic
communication to facilitate their expression of feelings.
The nurse can provide an empathetic and caring presence. The nurse also serves as teacher, explaining what is happening and what the family
can expect. The nurse must have a calm and patient demeanor.
Family members should be encouraged to participate in the physical care of the dying person as much as they wish to and are able.
Sometimes, it seems as if the client is "holding on" possibly out of concern for the family not being ready. It may be therapeutic for the family to
verbally give permission to the client that they are prepared for the client to "let go," to die when ready.

33.

After the client dies:: the family should be encouraged to view the body because this has been shown to facilitate the grieving process

34.

Describe nursing measures for care of the body after death:: Postmortem care should be carried out according to the policy of the
hospital or agency.
Because care of the body may be influenced by religious law, the nurse should check the client's religion and make every attempt to comply

35.

If the deceased's family or friends wish to view the body:: it is important to make the environment as clean and as pleasant as possible
and make the body appear natural and comfortable.
All equipment, soiled linen, and supplies should be removed from the bedside.
Some agencies require that all tubes remain in place. In other agencies, tubes may be cut to within 2.5 cm (2 inches) of the skin and taped in
place. In others, all tubes are removed.

36.

Body Placement for viewing is normally:: the body is placed in a supine position with the arms either at the sides, palm down, or across
the abdomen. One pillow is placed under the head and shoulders to prevent blood from discoloring the face by settling in it. The eyelids are
closed and held in place for a few seconds so they remain closed. Dentures are usually inserted to help give the face a natural appearance; the
mouth is then closed.

37.

Body prep:: Soiled areas of the body are washed, absorbent pads are placed under the buttocks to take up any feces and urine released because
of relaxation of the sphincter muscles, a clean gown is placed on the client, and the hair is brushed and combed.
All jewelry is removed except a wedding band in some instances, which is taped to the finger.
The top bed linens are adjusted to cover the client to the shoulders, and soft lighting and chairs are provided for the family.

38.

After Body has been viewed by family:: the deceased's wrist identification tag is left on and additional identification tags are applied.
The body is wrapped in a shroud and identification is then applied to the out- side of the shroud.
The body is taken to the morgue if arrangements have not been made to have a mortician pick it up from the client's room.
Nurses have a duty to handle the deceased with dignity and to label the corpse appropriately.