advanced based nursing on grivance m.sc 1st year

Loss is a part of the life cycle, all people experience loss in the form of change, growth and transition.
The experience of loss is painful,

1. PRESENTED BY M s Divya Msc 1 st year S.B.D.S COLLEGE OF NURSING

2. L OSS Introduction Loss is a part of the life cycle, all people experience loss in the form of change, growth and transition. The experience of loss is painful, tri g g ers an fr i g h t eni n g and lo n e l y and it array of emotional responses. Loss is any situation, either actual, potential or perceived in which a valued object is changed i n d i vidua l , becaus e chan g e o r i s n o lo n g er a c c essib l e to is majo r c o n sta n t i n li f e, e v e r y o ne experiences.

3. Definition L o ss is defined as the fact or process of losing something or someone.

4. Types of loss There are 9 types of losses given following. Necessary losses. Actual losses. Perceived losses. Maturational losses. Situational losses. Loss of external objects. Loss of known environment. Loss of an aspect of life. Loss of life or death.

5. 1. Necessary losses:- It is an integral part of each person’s life. Necessary losses are something natural and positive. For example-The growing u p p r o c ess i n de p enden c e w e de v e lo p f r o m o ur parents, start and leave school chan g e fr i end s , beg i n and f orm r elatio n s hi p , discovered ca r ee r the s e and lo s s e s a r e replaced di f f e r ent or b y som e thing be t t er bu t lo s s e s make unbearable change.

6. 2. Actual losses:- Actual losses are any loss of a person or object that can no longer be felt, heard, known or experienced by the individual. For example-The loss of a body part, child relationship or role at work.

7. 3. Perceived losses:- Any loss that is uniquely defined by the grieving client. It may be less obvious to others perceived losses are easily o v e r lo o k ed or misunderstood yet the process of grief follows the same sequence and progression as actual losses. For example -The loss of Confidence or Prestige.

8. 4. Maturational loss: - Any change in the developmental process that is normally expected during a life time. Events as s ocia t ed with maturational loss are part of normal life transition but feeling helps a person cope with change. For example - Mother’s feeling of loss as a child goes to school for the first time.

9. 5. Situational loss: - It includes any sudden unpredictable external event often this t ype of loss includ e s multiple losses r a t her tha n a sin g le loss su c h as automobile a c ci d ent that leaves a driver paralyzed, unable to return to work and grieving over the loss of the passenger in the accident.

10. 6. Loss of external objects: - Extend of grieving depends on objects v alue sen t iment attached to it and its usefulness. L os s , by F or e x amp l e - misplacement, deterioration, destruction natural causes.

11. 7. Loss of known environment: - L o s s o c curs through matu r ational or situational event and th r ou g h inju r y or illnes s . L oneli n ess or new unfamiliar setting threatens self esteem and makes grieving difficulties.

12. C ON T . Loss of significant others: - Loss of family member, friend, trusted nurse acquaintance or animal companion. Loss of an aspect of life: - Illness, injury or developmental changes results in loss of aspect of self that that causes grief and permanent changes in the body image and self concept. For example - Body part, psychological or physiological function. Loss of life :- Loss of life create grief for those left behind person facing death often fears, pain, loss of control and dependency on others. For example: - Death of family members, friend or acquaintance, own death.

13. Categories of loss Category Example Loss related to life experiences Death of a loved one or friend. Separation divorce. B r eak- u p of a f r ie n dshi p . Chan g e of j o b , school. Loss of job. Floo d or other nat u r al d i sas t e r . R ob b e r y assau l t. Loss related to illness Loss of good health. Bodily function. A body part or part of a system body. Self-concept as a whole, integrated person. C o n t r ol o v er o n e ’ s e n v i r o nmen t and schedule. Loss related to death A valued person. Significant support. A defined role. Oppo r tu n it y t o r eso l v e c o n f l i ct. Hope for future with that individual. Goals planned with that person.

14. Gri e f Introduction Grief is an emotional response to a loss. Grief is a deep emotional and mental anguish that is a response to the subjective experience of loss of something significant.

15. CONT. Definition Grieving is a walk through unknown territory familiar internal and external stabilities disappears in a whirlwind of changing thoughts, feelings and emotional flux. Mourning Mourning is the psychological process through which the individual passes on to the loss of a valued object. Bereavement It includes grief and mourning, the inner feelings and outward reactions of the survivors go through a bereavement period that is not linear, it is the period during which the grief process unfolds.

16. Types of grief The r e a r e 4 type s of grief Normal grief. Anticipatory grief. Complicated grief. Disenf r anchi s ed grief.

17. C ON T . Normal grief: - It consists of normal feelings, behaviors and reaction to a loss. This normal grief response to a loss can prove positive, helping one to mature and develop as a person. It includes resentment, sorrow, anger, crying, loneliness and temporary withdrawal from activities. Anticipatory grief: - The process of disengaging of letting go that occurs before an actual loss or death has occurred is called anticipatory grief. For example- Once a person or family receives a terminal diagnosis, they begin the process of saying good bye and completing life affairs. When the actual process of dying is extended for a long time, persons in the client family may have few syndromes of grief once the death occurs.

18. C ON T . 3. Complicated grief: - When the person has difficulty in progressing through the normal phases or stages of grieving, bereavement appears to go wrong and loss never resolves. This can threaten a person’s relationship with others. Complicated grief includes . Ch r o n i c gr i e f . Del a y ed gr i e f . Exaggerated grief. Masked grief. a) C h r onic gr i e f : - A ct i v e ac u t e m o urn i n g th a t is characterized by normal grief reactions that do not subside and continue over very long periods of time person verbalizes an in ability to “get past” the grief.

19. CONT. Delayed grief: - Characterized by normal grief reactions that are suppressed or postponed and survivor consciously avoids the pain of the loss. For example:- A wife may only bereave a few weeks after the death of her spouse only to became hysterical and sad a year later when she attends a family gathering. The extreme sadness is a delayed response to the death of her husband. Exaggerated grief: - Persons become over whelmed by grief and they cannot function. This may be reflected inform of severe phobias or self-destructive behavior such as al c oh o lism, su b stan c e abuse o r suicid e . Masked grief: - Survivors are not aware that behaviors that interfere with normal functioning are a result of their loss. For example- A person who has lost a pet may develop alterations in eating or sleeping patterns.

20. C ON T . 4 . Disenfranchised grief: - Person experienced and cannot be openly acknowledged, socially sanctioned or publically shared. For example - The loss of a partner from AIDS children experiencing the death of a step parent or the mother whose child dies in-utero or at birth.

21. FACTOR AFFECTING LOSS AND GRIEF Human Development: - Persons of different ages and stages of development will show different and unique symptoms of grief. For example- Toddlers are unable to understand loss or death but they feel great anxiety over loss of object and separation from parents. Psychosocial perspective of loss and grief: - Age, gender, status, race, spirituality religious beliefs, intellect, achievement, self expression and cultural opportunity are the basis for an individual to define and qualify the definition of life or death. Socio-economic status: - Socioeconomic status influences a person’s ability to obtain options and use support mechanism when coping with loss. Generally an individual feels greater burden from a loss when there is lack of financial, educational or occupational resources. For example- A client with limited finances may not be able to replace a home lost in a fire or may not be able to purchase necessary medications to manage a newly diagnosed disease.

22. CONT . Personal relationship: - when the loss involves a loved one, the quality and meaning of relationship are critical in understanding a person’s grief experience. It has been said that to lose your parents is to lose your past to lose your present and to lose your child is to lose your future. Nature of loss: - The ability to resolve grief depends on the situation surrounding the loss. The visibility of the loss influences the support a person receives. For example- The total loss of one’s home from a tornado will bring support from the community; where as a private loss of an important possession may bring less support from others.

23. C ON T . Culture and ethnicity: - Interpretation of the loss and the expression of the grief arise from cultural background and family practices. Critical components of culture are their basic core belief systems that they can often do hold on to. For example- in western hemisphere the grieving process is usually personal and private with individual showing restrained emotions. However ceremonies surrounding a person’s death offer time for grief resolution and reminiscing. In eastern nations such as china respect for dead is shown by wailing and physical demonstration of grief f or a spec i f ie d per i od o f tim e. Spiritual beliefs: - Individuals spirituality influences their ability to cope with loss. Clients who have a strong inter connectedness with a single power are able to face death with relatively minimal discomfort.

24. Coping with Loss, Death and Grief:- Just as people feel grief in many different ways, they handle it differently too. Coping can be adaptive or maladaptive. Adaptive coping: - adaptive coping helps the person to deal effectively with event and minimizes distress associated with it. Some people reach out for support from others and find comfort in good memories. Other becomes very busy to take their minds of the loss. For some people, it can help to talk about the loss with others. Some do this naturally and easily with friends and family while others talk to a professional therapist. Maladaptive coping: - it can result in unnecessary distress for the person and other associated with person. Some people become depressed and withdraw from their peers or go out of the way to avoid the places or situations that remind them of the person who has died. This is not really dealing with the pain, only masking it which makes all those feelings build-up inside and only prolong the grief.

25. Strategies of coping:- In coping with the loss and grief, people tend to use one of the three main coping strategies:- Appraisal focused. Problem focused. Emotional focused. 1 st –Appraisal focused coping: - it occur when the persons modify the way they think. For example- Employing denial or distracting themselves from the problem people may alter the way they think about the problem by altering their goals and values, such as by seeing humor in a situation. 2 nd –Problem focused: - People using these strategies try to deal with the cause of their problem. They do this by finding information on the problem and learning new skills to manage the problem men often prefer problem-focused coping problem-focused coping mechanism may allow an individual greater perceiver control over their problem. 3 rd –Emotional focused :- These involve releasing pent up emotions distracting one self, managing hostile feeling, mediating, using simple relaxation procedures etc. women prefer emotional-focused response. Emotional-focused coping may more often lead to a reduction in perceived control.

26. NURSING MANAGEMENT

27. Helping client die with dignity:- Nurse needs to ensure that client is t r ea t ed dignity with that is with honor and respect.

28. CONT. Step can be taken to make such discussion easier for both the nurse and client strategies include following:- ID E NTI F Y Y O U R P E R S O N A L FE EL IN G S A B O U T D E A T H . FOCUS ON CLIENTS NEEDS IT IS IMPORTANT THE NURSE SHOULD NOT IMPOSE FEARS AND BELIEFS ON CLIENT AND FAMILY. TALK TO THE CLIENT OR FAMILY ABOUT HOW CLIENT COPES WITH STRESS. ESTABLISH A COMMUNICATIVE RELATIONSHIP THAT SHOWS CONCERN FOR AND COMMITMENT TO THE CLIENT. DETERMINE WHAT CLIENT KNOWS ABOUT ILLNESS AND PROGNOSIS. RESPOND WITH HONESTY AND DIRECTNESS TO CLIENTS QUESTIONS ABOUT DEATH. MAKE TIME TO BE AVAILABLE TO CLIENT TO PROVIDE SUPPORT, LISLEN AND RESPOND.

29. Hospice and palliative care The hospice movement was founded by physician Saunders in London in 1967. Hospice care focuses on support and care of dying person and family with goal of facilitating a peaceful and dignified death. Hospice care is based on holistic concepts, emphasizes care to improve quality of life rather than cure, support the client and family through the dying process and support the family through bereavement. The principles of hospice care can be carried out in a variety of setting the most common being home and hospital based unit. Services focus on symptom control and pain management.

30. Palliative care:- ca r e is Palliative specialized, interdisciplinary patient with seriou s , ca r e f or li f e o r ch r o n ic i ll n e s s . It limiting debilitati ng involves comprehensive o f the p h y sical, s o cia l and management patient’s ps y cho l o g ical, spiritual needs.

31. Purposes of palliative care:- P r o vi d es r elief f r om p a i n and other de t err i ng symptoms. Affirms life and regards dying as a normal process. Intends neither to hasten or nor postpone death. In t eg r a t e s ps y chologica l and spi r i t ua l aspects of client care. Of f ers a support s y s t em t o help th e clien t l i v e as actively as possible until death. Of f ers support s y s t em t o help f a m i l y c ope duri n g client’s illness. Uses a team approach to address the needs of client. Will enhance the quality of life.

32. Principles of palliative care:- Palliative care respects the goals likes and choices of the dying person and his or her loved ones. Palliative care looks after the medical emotional, social and spiritual needs of dying person, with a focus on making sure he or she is comfortable, not left alone and able to look back on his or her life and find peace. Palliative care supports the needs of family members helping them with the responsibilities of care giving and even supporting them as they grieve. Palliative care helps to gain access to needed health care providers and appropriate care settings. Palliative care builds ways to provide excellent care at the end life, through education of care providers appropriate health policies and adequate funding from insurance and government.

33. Meeting the physiological needs of dying client:- The physiological needs of people who are dying are related to slowing of body process and to homeostatic imbalances, intervention include providing personal hygiene measures, controlling pain, relieving respiratory difficulties, assisting with movements, nutrition, hydration, elimination and providing measures related to sensory changes.

34. C ON T . Following are given dying clients problems and nursing care that should be given. Providing spiritual support:- Spiritual support is of great importance in dealing with death. The nurse has a responsibility to ensure that client’s spiritual needs are attended. Facilitate mourning:- Help client accept that loss is real. Support efforts to live without deceased person or in face of disability. En c ou r a g e establishment o f n ew r elationshi p . A l l o w t i m e t o grie v e. Interpret normal behavior. Provide continuing support. B e alert f or signs of i n ef fe ct i v e c opin g . Supporting the family:- The most important aspect of providing support to the family members of dying client involves using therapeutic communication to facilitate their expressions of feelings.

35. Care of body after death:- Caring for the deceased body and meeting the needs of grieving family are nursing responsibilities. The body of deceased needs to be treated in a way that respect the sanctity of human body nursing care includes maintaining privacy and preventing damage to the body.

36. Physiological changes:- Several physical changes occur after death. The body temperature decreases with a resultant lack of elasticity. Therefore the nurse must use caution when removing tapes from the body to avoid skin breakdown.

37. C ON T . equipment ( o r gani z es Steps:- Gather P r o c edu r e ) :- Disposable g l o v e s , g o wns and other p r o t ect i v e cl o thin g . P l astic ba g f or haza r dou s w as t e disposable. w ashcloth, w arm, w a t e r , W ash basin, bath towel. Clean gown.

38. C ON T . Absorbent pads. Bo d y ba g o r sh r oud ki t . P a p er tap e and gau z e d r essin g . Suitable receptacle for patient’s belongings. V aluable e n v elo p e. Identification tags. Wash hand (reduced spread of microorganisms). Don clean gloves (protect nurse from contamination). Close patient’s eyes and mouth if needed (provide a normal appearance). Remove all tubing’s and other devices from patient’s body (make patient look more peaceful). Place patient in supine position (allows access for procedure) elevate head, prevent discoloration and do not place one hand o n t op o f other thi s ca n lead t o dis c ol o r atio n .

39. CONT. Replace soiled dressing with clean ones (avoid odor). Bathe patient as necessary (reduces odor). Br u sh o r c omb hairs ( g i v e mo r e n o rma l a p pea r an c e). A p p l y clea n g o wn (p r epa r e bo d y f or viewi n g ) . Care for valuables and personal belongings (for legal issues). Allow family to view body and remain in room (provide emotional support). A sheet or light blanket placed over body with only head and upper shoulder exposed will maintain dignity and respect for deceased. After family has left the room, attach a special label if patient has contagious disease (protect those who handle the body). Await arrival of ambulance or transfer to morgue. Document procedure and disposition of patient’s body as well as belongings and valuables (for legal purposes).

40. CONT. Applying of shroud:- The body is in dorsal recumbent position, arms are straight at sides. There is pillow under head and shoulders. Pla c e bo d y o n sh r ou d . Brin g t op o f sh r o u d d o wn o v er hea d . F old th e bo t t om o v er f eet. F old th e s i d es o v er bo d y , ta p e o r p i n th e s i de s t o g e the r an d a t ta c h identification tags. Documentation:- Time of death and actions taken to prevent the death if applicable. Who pronounced the death of the client? Any special preparation and any type of donation, including time and staffs. Who was called and who came to the hospital-donor organization, morgue funeral home and individual family members making may decision. Personal articles left on the body and taped to skin or tubes left in. Personal items given to family specific names and description of items. T i m e o f disc ha r g e an d de s tin a ti o n o f bo d y . Location of name tags on the body. Special request by the family. Any other personal statement that might be needed to clarify the situation.

41. CONT. The grieving nurse:- When a nurse cares for the client for a long period of time, it is possible to have deep personal feelings of loss and sadness when the client dies. The bond formed between the client and the nurse places the nurse in similar relationship with the client as that of family; thus the nurse must go through the grieving process also. Burnout:- Burnout is the special term used when grief/stress exceeds the reward of the job and individuals nurse lacks the support of peers. It is a syndrome of emotional exhaustion, depersonalization of others, and perception of reduced personal accomplishment. There are many ways in which a nurse can attempt to cope with loss of a dying client.

42. Ethical and legal dimensions:- Multiple treatment opinions and sophisticated life support technologies may make it difficult to draw a line between promoting life and need prolonging the dying process. In these cases, health care decision-making is complicated for patients and healthcare professional alike. The increased popularity of “managed death” concept and all call to legalize physician assisted suicide and physician assisted suicide and physician administered lethal injections pose new ethical challenges. As patient and family struggle with end of life treatment decision, they are increasing looking to nurses for information, advice and support. Patients have legally and morally protected right to consent to and refuse any and all indicated medical therapies. Other legal perspectives:- Death certificate. Organ donation. Autopsy.

43. The dying person’s bill of rights:- 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 particular decision concerning my care. I have the right to expect continuing medical and nursing attention e v en thou g h ca r e g oals mus t b e chan g ed t o c omfort g oal s . I have the right not to die alone. I have the right to be free from pain. I have the right to have my question & answered honestly. 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 dignity. I have the right to retain my individuality and not to be judged for my decisions when may be contrary to belief of others. I have the right to be caring, sensitive knowledgeable people who will be able to understand my needs and will be able to gain some satisfaction in helping me face my death.

44. The topic is summarized by introduction, definition, types of loss, categories of loss, grief-introduction, definition, types of grief, factor affecting loss and grief, coping with loss, death and grief, strategies of coping, coping skills and coping resources, goals of grief counseling, approaches used, nursing management, planning, implementing, hospice and palliative care, documentation, ethical and legal dimensions, the dying person is bill of rights.

45. The nurse is the consistent link in promoting understanding of the patients disease of the dying process and in making the event more manageable for the patient for the patient and family who will require assistance to resolve problems and proceed through the grief work.

46. Basheer Shebeer.P., Khan S. Yaseen.(2012), A Concise text book of Advanced Nursing Practice; 2 nd edition: Publish by Emmess Medical Publishers, Bangalore; 2017,PP-603- 607. Brar Navdeep Kaur, Rawat HC.(2015), Textbook of advance Nursing Practice; 1 st editition: publish by Jaypee Brothers & M.P(P) LTD. New Delhi;2015, PP-886-907. http://www.mentalhealthamerica.net/conditions/copin g-loss-bereavement-and-grief http://en.m.wikipedia.org/wiki/grief