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Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 9


Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 9 LOSS, GRIEF, AND DEATH Loss Any situation actual, potential, or perceived wherein a valued object ... – PowerPoint PPT presentation

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Title: Medical-Surgical Nursing: An Integrated Approach, 2E Chapter 9

Medical-Surgical Nursing An Integrated Approach,
2E Chapter 9

  • Any situation actual, potential, or perceived
    wherein a valued object or person is changed or
    is no longer accessible to the individual.

Types of Loss
  • Actual (loss of someone or some thing).
  • Perceived (felt by an individual but not tangible
    to others, e.g. loss of self-esteem).
  • Physical (loss of part or aspect of the body).
  • Psychological (emotional loss, e.g. a womans
    feelings after menopause).

Categories of Loss
  • Loss of External Object.
  • Loss of Familiar Environment.
  • Loss of Aspect of Self (Physiological or
  • Loss of Significant Other.

  • A series of intense physical and psychological
    responses that occur following a loss.
  • A normal, necessary, and adaptive response to a

Mourning Bereavement
  • Mourning is the period of time during which
    grief is expressed and resolution and integration
    of loss occur.
  • Bereavement is the period of grief following the
    death of a loved one.

Theories of the Grieving Process
Leading theoretical models describing grieving
have been devised by
  • Erich Lindemann
  • George L. Engle
  • John Bowlby
  • William Worden

Lindemann Theory
Erich Lindemann coined the phrase grief work and
described typical grief reactions
  • Somatic distress.
  • Preoccupation with the image of the deceased.
  • Guilt.
  • Hostile reactions.
  • Loss of patterns of conduct.

Engle Theory
  • Three Stages of Mourning
  • Stage I Shock and Disbelief (disorientation,
    helplessness, denial).
  • Stage II Developing Awareness (guilt, sadness,
    isolation, anger and hostility).
  • Stage III Restitution and Resolution (bodily
    symptoms, idealization of the deceased, beginning
    of coming to terms with loss, establishment of
    new social patterns and relationships).

Bowlby Theory
  • Four Stages of Mourning
  • Numbness.
  • Yearning and searching.
  • Disorganization and despair.
  • Reorganization.

Worden Theory
  • Four Tasks to Deal with Loss Successfully
  • Accept the fact that the loss is real.
  • Experience the emotional pain of grief.
  • Adjust to an environment without the deceased.
  • Reinvest the emotional energy once directed at
    the deceased into another relationship.

Types of Grief
  • Uncomplicated (a grief reaction that normally
    follows a significant loss).
  • Dysfunctional (intense grief that does not
    result in reconciliation of feelings).
  • Anticipatory (occurrence of grief work before
    loss actually occurs).
  • Disenfranchised (grief that is not openly
    acknowledged, socially sanctioned, or publicly
    shared, e.g. grief over the loss of a pet).

Factors Affecting Loss and Grief
  • Developmental Stage.
  • Religious and cultural beliefs.
  • Relationship with the lost object.
  • Cause of death.

Nursing Care of the Grieving Client
  • Nursing care for the grieving follows the
    standard five-part model
  • Assessment.
  • Nursing Diagnosis.
  • Planning/Outcome Identification.
  • Implementation.
  • Evaluation.

Death Legal Considerations
  • The Patient Self-Determination Act (PSDA, 1990)
    was intended to provide individuals with legal
    means to determine the circumstances under which
    life-sustaining treatment should or should not be
    provided to them.
  • Many states also have a Health Care Surrogate
    Law, implemented in the absence of advance

Death Ethical Considerations
  • Death is often fraught with ethical dilemmas.
  • Many health care agencies have ethics committees
    to develop and implement policies to deal with
    end-of-life issues.
  • Important distinctions must be made between pain
    relief and euthanasia.

Stages of Dying and Death
  • Denial.
  • Anger.
  • Bargaining.
  • Depression.
  • Acceptance.

Assessment of the Dying Client
  • Client and family goals and expectations.
  • Clients awareness of terminal nature of the
  • Availability of support systems.
  • Current stage of dying.
  • History of previous positive coping skills.
  • Client perception of unfinished business to be

Physiological Needs of the Dying Client
  • Respirations.
  • Fluids and nutrition.
  • Mouth, eyes, and nose.
  • Mobility.
  • Skin care.
  • Elimination.
  • Comfort.
  • Physical environment.

  • A type of care for the terminally ill, founded on
    the concept of allowing individuals to die with
    dignity, surrounded by those who love them.
  • Clients enter hospice care when aggressive
    medical treatment is no longer an option or when
    client refuses further medical intervention.

Signs of Impending Death
  • Lungs become unable to provide adequate gas
  • Heart and blood vessels become unable to maintain
    adequate tissue perfusion.
  • The brain ceases to regulate vital centers.
  • Cheyne-Stokes respirations (irregular breathing)
    and death rattle (noisy respirations caused by
    secretions accumulating in larynx and trachea)
    signal imminence of death.

Care After Death
  • Treat the body with respect and dignity.
  • Bathe and put a clean gown on the body.
  • Remove dressings and tubes.
  • Place the client in body alignment with
    extremities straight.
  • Place dentures in the mouth, if client normally
    wore them.
  • Comb clients hair.

Legal Aspects Following Death
  • Autopsy (examination of the body after death by
    pathologist to ascertain cause of death).
  • Organ Donation.

Care of the Family
  • Informing the family as to the circumstances of
    the death.
  • Providing information about viewing the body.
  • Offering to contact support people.
  • Sometimes assisting in decision making regarding
    a funeral home and removal of the dead persons

Nurses Self-Care
  • Dealing with dying clients is stressful. Nurses
    must face their grief.
  • Unresolved grief is called shadow grief. Nurses
    often carry shadow grief which, if not released,
    can cause illness and burnout.

Signs of Shadow Grief
  • Loss of energy, spark, joy, and meaning in life.
  • A feeling of being powerless to make a
  • Increased smoking or drinking.
  • Unusual forgetfulness.
  • Constant criticism directed at others.
  • Constant inability to get work done.
  • Uncontrolled outbursts of anger.
  • Perception of clients and their families as
  • Surrender of hobbies or interests.

Coping with Shadow Grief
  • Take time to cry with and for clients.
  • Get physical run, walk, bicycle, play tennis.
  • Ask colleagues to help with tasks avoid being
  • Connect to place of worship pray.
  • Look for joy in work. Laughter is a great healer.
  • Create a caring circle of friends.
  • Listen to music.