Loss

Actual or potential situation in

which something that is valued is
changed, no longer available or
gone
Ex. Loss of body image, significant
others, job, personal possession
Actual loss – woman has a
mastectomy.
Perceived loss – less obvious; loss
of confidence
Maturational loss – resulting from
normal life’s transition ex. Loss
felt by an adolescent when
romance fails
Situational loss – occurring
suddenly in response to a specific
external event. Ex. sudden death
of a loved one
Grieving
• Subjective response of emotional
pain to loss
• Normal response to loss; essential
for good mental & physical health
• Permits the individual to cope
gradually & eventually accept the
situation as part of reality
“The goal of the grieving
process is the resolution of the
hurt & the reestablishment of
one’s life.”
Bereavement – common depressed
reaction to the death of a loved
one. Ex. Disturbed sleep, excessive
crying, withdrawn behavior
Mourning – reaction activated by a
person to assist in overcoming a
great personal loss. Ex. Black dress,
defined time of social withdrawal
Kubler-Ross’s Stages of Grieving

Denial – refusal to believe that loss

is happening
Anger – client/family may direct
anger at nurse or hospital staff,
about matters that normally do
not bother them
Elizabeth Kubler-Ross
Bargaining – seeks to bargain to avoid
loss; may express feelings of guilt for
past sins; an effort to prolong
inevitable loss
Depression – grieves over what has
happened
Acceptance – may wish to begin making
plans
Denial – “ No – not me.”
Anger – “Why me?”
Bargaining – “Yes, but…”
Depression – “Yes, me.”
Acceptance – “I am ready.”
“Care of dying patient’s &
their families can be one of
the most neglected &
challenging aspects of
nursing care.”
Bereavement overload – initial
loss was compounded with an
additional loss before the
resolution of the initial loss
“Burnout” – when the stresses
exceed the rewards of the job
& the individual nurse lacks the
support of peers.
Issues related to Dying & Death

Euthanasia – “easy death” an

action deliberately taken with
the purpose of shortening life
to end suffering or to carry out
the wishes of a terminally ill
patient.
Do not Resuscitate – joint
decision of the patient, family
& health care providers
Does not mean to withhold
hygiene, nutrition, fluids or
medications
Advance directives – signed &
witnessed documents providing
specific instructions for health
care treatment in the event that
person is unable to make those
decisions
personally at the time they are
needed.
• Based on the right to self
determination
• Has the right to accept or
refuse recommended medical
treatment
Needs of a Dying Patient

•Physical Needs
•Emotional Needs
•Spiritual Needs
Nurse’s Goal

Should be not only to allay the

physical sufferings of patients
as best as possible but also to
prepare them for recognition &
acceptance of death.
“ One of the worst fears of
any individual is to be left to
die alone.”
Physical Needs

• Personal hygiene measures

- Dying patients experience
excessive diaphoresis. Secretions
may gather in the eyes and due
to an elevated temperature, the
patient’s mouth may become dry.
Physical Needs
• Pain Control
- Pain is an unpleasant sensory
and emotional experience. There are
3 major techniques of managing pain:
a. Pharmacologic
b. Non-invasive
c. Neurologic
Physical Needs
• Relief of Respiratory difficulty
- It can be relieved by the following
measures:
a. For conscious patient’s – Fowler’s
position and throat suctioning are
indicated
b. For unconscious patient’s – semi
prone position facilitates drainage of
mucus from the mouth and throat
Physical Needs
c. Oxygen therapy – Cannula or mask may
be necessary for both conscious and
unconscious patient’s.

• Movement
- Regular changing of positions, patient
should be in lateral position so that saliva
which cannot be swallowed will drain from
the mouth.
Physical Needs

• Nutrition and hydration

- The digestive system of dying
patients slows down; peristalsis is
reduced, there is accumulation of
flatus. The nurse must assess
patient’s gag reflex. This is to ensure
effective swallowing.
Physical Needs

• Elimination
- Patient’s may develop
constipation, incontinence (fecal
and urinary), or urinary retention
brought by loss of muscle tone
Physical Needs
• Measures related to sensory changes
- As death nears, the patient’s vision
becomes blurred. Many patients prefer
a lighted room. A dying patient may
hear what people are saying after he or
she can no longer see or respond.
When talking to a dying patient we
need to speak clearly and avoid
whispering since patients tend to
become disturbed when unable to hear
Care of the Dying Client

Clinical Signs of death:

Cessation of apical pulse,

respiration & blood pressure
Signs of Impending Death:

• Slow, thready & weaker pulse

• Lowered blood pressure
• Rapid, shallow, irregular or
abnormally slow breathing
• Mottling of lower extremities
“ Generally respirations cease
first then followed by cardiac
arrest a few moments later.”
Indications of death:

• Total lack of response to external

stimuli
• No muscular movement especially
breathing
• No reflexes
• Flat ECG
• Hearing is the last sense thought
to be loss
• Only a physician can pronounce
death; after the pronouncement
the life-support systems be shut
off
Cerebral death

Cerebral cortex is irreversibly

destroyed; patient may still be
able to breath but irreversibly
unconscious
Major goals for a dying patient:

• Maintaining physiologic &

psychologic comfort
• Achieving a dignified & peaceful
death
Meeting Physiologic Needs of a
dying patient:

• Provide personal hygiene

measures
• Controlling pain & relieving
respiratory difficulties
Spiritual Support
• Important in dealing with death
• Nurse’s responsibility that the
patient’s spiritual needs are
attended to
• Nurse’s have a responsibility to
not to impose their own religious
or spiritual beliefs on a client
Care of the body after death:
Body Changes:
Rigor mortis – Stiffening of the body
2-4 hrs. after death
Algor mortis – Gradual decrease of
the body’s temperature after death;
1 degree centigrade decrease/hr.
until it reaches room temperature
Livor mortis – Discoloration of the
surrounding tissues due to the
release of hemoglobin; appears in
the lowermost parts or dependent
areas of the body
Death must be certified by a
physician.
Nurses have a responsibility to be
aware regarding the legal
concerns in a particular institution
Nursing Interventions:
• Must be responsible for the care
of the body after death (position
the body, place dentures in the
mouth, close the eyes & mouth
before rigor mortis sets in)
• All equipments & supplies must
be removed from the bedside
• The nurse should check the client’s
religion & make every attempt to
comply.
• Applies identification bands (in the
ankle & 1 in the wrist. Wraps the
body in a shroud then another ID
band is applied outside the shroud.
• Prepares the body by making
it look as natural &
comfortable as possible.
• The nurse places a small pillow
or folded towel under the head
to prevent discoloration from
blood pooling.
• Apply a moistened cotton ball
to hold eyelids in place
• Inserts the patient’s dentures
to maintain normal facial
features.
• A rolled-up towel under the
chin keeps the mouth closed
• All valuables & their disposition
must be documented in the
patient’s medical record
Emotional Support
• If a significant other is alone at
the time of death of a loved
one, contact the family, clergy
or friends to be with the
grieving individual.
• Words that convey sympathy
must be expressed
• Provide comforting gesture if
appropriate (hand on the arm,
embrace can be used as a
comforting gesture)
• Be non-judgmental as the
family expressed feelings of
anger, guilt or unfairness
Resolution of Grief
• Requires support &
understanding
• 6 months – 2 years may elapse
before an individual can
complete grief work & begin the
full process of resolution