loss and grief for whose need to subject.pptx

health

1. Mesfin Beharu LOSS AND GRIEF 8/8/2022 1

2. Session objective At the end of this class the students will be able to: Define loss and grief Identify normal grieve function Identify altered grieve function Apply nursing process for loss and grief 8/8/2022 2

3. Brainstorm 8/8/2022 3 Loss?????????? Vs Grief?????? Loss to you? to your culture?? Grief to You? To your Culture??

4. LOSS Is any situation in which a valued object/person is changed or is no longer accessible to the individual A loss can be tangible or intangible For example, when a person is fired from a job, the tangible loss is income , whereas the loss of self-esteem is intangible Loss precipitates anxiety and a feeling of vulnerability — which may lead to crisis 8/8/2022 4

5. Types of Loss Actual loss: Death of a loved one, theft of one’s property. Perceived loss: Occurs when a sense of loss is felt by an individual but is not tangible to others. Physical loss: Loss of an extremity in an accident, scarring from burns, permanent injury . Psychological loss: Such as a woman feeling inadequate after menopause and resultant infertility. 8/8/2022 5

6. GRIEF Grief is a series of intense physical and psychological responses that occur following a loss. It is a normal, natural, necessary, and adaptive response to a loss. Grieving is a mechanism for crisis resolution 8/8/2022 6

7. Grief cont… Loss leads to the adaptive process of mourning/sadness. Mourning : is the period of time during which the grief is expressed and resolution and integration of the loss occur. Bereavement: is the period of grief following the death of a loved one 8/8/2022 7

8. Theories of the Grieving Process LINDEMANN’S THEORY: Reactions to normal grief Somatic Distress: Episodic waves of discomfort in duration of 10–60 minutes ; multiple somatic complaints, fatigue, and extreme physical or emotional pain Preoccupation with the Image of the Deceased/dead: The bereaved experience a sense of unreality, emotional detachment from others, and an overwhelming /irresistible preoccupation with visualizing the deceased. 8/8/2022 8

9. Lindemann’s theory cont… 8/8/2022 9 iii. Guilt: The bereaved consider the death to be a result of their own negligence or lack of attentiveness/care iv. Hostile Reactions: Relationships with others become impaired , irritability, and anger v. Loss of Patterns of Conduct: The bereaved exhibit generalized restlessness and continually search for something to do.

10. Bowlby theory Grief results when an individual experiences a disruption in attachment to a loved object There are four phases that occur during grieving: Numbing Yearning and searching Disorganization and despair Reorganization 8/8/2022 10

11. 8/8/2022 11 Numbing Protects the person from the full impact of the loss. Yearning and Searching Emotional outbursts/eruption of tearful sobbing/crying and acute distress.

12. 8/8/2022 12 Disorganization and Despair Endless examination of how and why the loss occurred or expressions of anger at anyone who seems responsible for the loss. Reorganization Accepts the change, acquire new skills, builds new relationships, and begins to separate himself or herself from the lost relationship.

13. Worden J. William Worden has identified four tasks that an individual must perform in order to successfully deal with a loss: Accept the fact that the loss is real. Experience the emotional pain of grief. Adjust to an environment without the deceased/dead. Reinvest the emotional energy once directed at the deceased into another relationship. 8/8/2022 13

14. Engle’s theory of grief: three stages of mourning Stage I: Shock and Disbelief Denial gives protection until person is able to face reality. Stage I can last from minutes to days Stage II: Developing Awareness Emotional pain occurs with increased reality of loss. Recognition that one is powerless to change the situation. 8/8/2022 14

15. Anger and hostility may be directed at others, Guilt, Sadness, Isolation Stage II may last from 6 to 12 months Stage III: Restitution/back and Resolution Mourner starts to come to terms with the loss. Establishment of new social patterns and relationships . Stage III may take up to several years 8/8/2022 15

16. Types of Grief Uncomplicated Grief Uncomplicated grief runs a fairly predictable course that ends with the relinquishing/turn down of the lost object and resumption/ continuation of the previous life. The bereaved person is able to regain the ability to function. 8/8/2022 16

17. 2. Dysfunctional Grief Persons experiencing dysfunctional grief may fail to demonstrate any behaviors commonly associated with grief. Does not return to a normal sleep pattern or work routine, usually remains isolated, and has altered eating habits. The bereaved may have the need to endlessly tell and retell the story of loss but without subsequent healing. 8/8/2022 17

18. Several factors predispose a person to experience dysfunctional grieving, including: Uncertain/vague, sudden, or over complicated circumstance surrounding the loss. A loss that is socially unspeakable/ horrifying or socially negated (e.g., suicide ) A relationship with the deceased characterized by excessive dependency. 8/8/2022 18

19. 3. Anticipatory Grief Is the occurrence of grief work before an expected loss It may be experienced by the terminally ill person as well as family. Although anticipatory grieving may be helpful in adjusting to the loss , it may also result in some disadvantages. For example, for the dying client, it may lead to family members’ distancing themselves. 8/8/2022 19

20. Factors Affecting Grief The person’s developmental level Religious and cultural beliefs Relationship to the lost object, and The cause of death 8/8/2022 20

21. Nursing Care of the Grieving Person Must be done by clients own way. Nurses can assist by providing support as the client moves through the process of mourning. Assessment A thorough assessment of the grieving client and family begins with a determination of the personal meaning of the loss. Levin (1998) recommends that assessment be done to differentiate the signs of healthy grieving from at-risk behavior. 8/8/2022 21

22. Diagnosis 8/8/2022 22 Diagnosis: dysfunctional grieving Defining characteristics Unsuccessful adaptation to loss Prolonged denial or depression Inability to resume normal living patterns Delayed emotional response Failure to restructure life after the loss Social isolation or withdrawal from others Failure to develop new interests or relationships

23. Related Factors 8/8/2022 23 Loss of physiological function related to disease or trauma Surgery (colostomy, hysterectomy, mastectomy, amputation) Terminal illness Chronic pain Death Developmental life changes Loss of a relationship

24. Diagnosis: Anticipatory grieving 8/8/2022 24 Defining Characteristics Expressed emotional pain over a potential loss Sorrow/sadness Anger Guilt Altered sleep patterns Changes in eating patterns Decreased libido/sexual drive Communication alterations

25. Related Factors 8/8/2022 25 Diagnosis of terminal illness (self or significant other) Upcoming lifestyle change (divorce, child leaving home) Potential job loss Loss associated with aging

26. Outcome Identification and Planning Verbalize feelings of grief Share grief with significant others Accept the loss Renew activities and relationships 8/8/2022 26

27. Implementation To understand the client’s perspective, the nurse must spend time listening. Grieving people need reassurance, counseling, and support. 8/8/2022 27

28. Evaluation It is important to teach grieving individuals that resolution of the loss is generally a process of lifelong adjustment. Therefore, nurses usually do not have an opportunity to be with the bereaved family when grief work is completed. Encouraging the bereaved to share their feelings and continue to verbalize their experience with significant others. 8/8/2022 28

29. Care of the terminally ill patient and post mortem care Terminal illness: is illness that is generally regarded as having no hope of cure . A patient needs intensive physical and emotional support as he /she approaches death. The patient with a terminal illness is expected to die in about six months or less. But, Some patients may live longer and some less. 8/8/2022 29

30. Death/ end of life care Death is a part of every human existence Death:- when all electrical activity in the brain completely and permanently ceases Elizabeth Kübler -Ross identified five possible stages of dying experienced by clients and their families. Stages of Death and Dying 1st stage: Denial:- immediate response to loss Eg . Verbal: “This can’t be happening to me!” Behavioral: Client is diagnosed with terminal lung cancer; client continues to smoke two packs of cigarettes daily. 8/8/2022 30

31. 8/8/2022 31 2 nd stage: Anger:- T he client has no control over the situation and thus becomes angry in response to this powerlessness Eg . Verbal : “Why me?” Behavioral: Client strikes out at caregivers 3rd stage: Bargaining :- client attempts to postpone or reverse the inevitable/unavoidable. The client promises to do something (such as be a better person, change lifestyle) in exchange for a longer life

32. 8/8/2022 32 Eg . Verbal: Client prays, “Please, God, just let me live long enough to see my grandchild graduate.” Behavioral: Client tries to “make deals” with caregivers 4th stage: Depression:- When the realization comes that the loss can no longer be delayed. Verbal: “Go away. I just want to lie here in bed. What’s the use?” Behavioral: Client withdraws and isolates self

33. 8/8/2022 33 Fifth stage: Acceptance:- With acceptance comes growing awareness of peace and contentment/pleasure. The feeling that all that could be done has been done is often expressed during this stage. Reinforcement of the client’s feelings and sense of personal worth/value are important during this stage. Verbal: “I feel ready. At least, I’m more at peace now.” Behavioral: Client gets financial or legal affairs/dealing in order client says goodbye to significant others.

34. Ethical Implications 8/8/2022 34 One of the most difficult dilemmas is determining the difference between killing and allowing someone to die by withholding life-sustaining treatment methods ANA distinguishes relieving pain and mercy killing ( euthanasia or assisted suicide ) Pain relief is a central value in nursing, whereas euthanasia is unethical

35. Nursing care for patients who are dying 8/8/2022 35 Assessment Information needed:- Client’s awareness of the terminal nature of illness Availability of support systems Physical condition Emotional status Presence of advance directives for HC decisions History of previous positive coping skills Unfinished business expressed by client or family.

36. Diagnosis 8/8/2022 36 Powerlessness Helplessness Outcome Identification and Planning Planning focuses on meeting the holistic needs of the client and family. Essential elements to consider when planning care of the dying person, include : Offer to contact clergy, Balance the client’s need for independence and need for assistance, Respect the client’s confidentiality, Answer all questions and provide factual information to client and family .

37. I mplementation 8/8/2022 37 Areas that are often problematic for the terminally ill client are nutrition, respiration, elimination, comfort, and mobility Promoting Comfort (pain relief, keeping the client clean and dry, and providing a safe, nonthreatening environment ) Psychosocial Needs Spiritual Needs

38. Common elements of a good death:- Adequate pain and symptom management Clear communication about decisions by patient, family and physician Adequate preparation for death, for both patient and loved ones Finding a spiritual or emotional sense of completion Affirming the patient as a unique and worthy person Strengthening relationships with loved ones Not being alone 8/8/2022 38

39. Post mortem care Definition: Post-mortem care involves the physical caring for the body after death. Purpose To show respect for the dead To prepare the body for morgue To prevent spread of infection To show kindness to the family To preserve the natural appearance of the body for the family and relatives. 8/8/2022 39

40. Purpose cont… 8/8/2022 40 Ensuring proper identification of the patient prior to transportation to the morgue or funeral home Providing appropriate disposition/outlook of patient's belongings Maintaining vital organs, if donation is planned

41. Sign of approaching death Circulatory system- circulation slow gradually pulse become weak, irregular & fast, Decreased B/P Facial appearance- sagging/dropping of jaws takes place, checks become flaccid and checks are sucked in Skin - skin becomes cold and clammy/moist Central nervous system - reflexes gradually disappear ,sign of anxiety or distress may be shown by restlessness, tossing/throw movement occur, pulling or pricking of bed clothing, crying, and talking incoherently take place. 8/8/2022 41

42. Sign of approaching death cont… Gastrointestinal system - hiccoughs/grasping, vomiting, abdominal distension are seen. Respiratory system - respiration becomes irregular, cheyne -stokes , rapid or very slow. Breathing takes place through mouth. Sight ,speech and hearing - eyes have a sunken appearance, they don’t react to light, Speech becomes mumbled and confused , hearing become dulled/ boring,. Genito -urinary system - retention of urine, distension of bladder 8/8/2022 42

43. Changes that occur in the Body after Death Post-mortem Cooling ( Algor Mortis) Change is cooling of the body Occurs when no further heat is produced by metabolism.  Body temperature falls gradually after death (approximately 1.0 to 1.5 degrees F/hr.) 8/8/2022 43

44. Body after Death cont… Muscular Rigidity (Rigor Mortis) Begins about 6 hours after death First evident in the muscles of the jaw, then extends to involve all the muscles in the body 2 to 4 hours after death. The muscles become rigid, the body is fixed in the position in which it lies. 8/8/2022 44

45. Body after Death cont… 8/8/2022 45 Purple Discoloration ( Livor Mortis) Decomposition of the tissues begins almost as soon as blood supply stops . Reddish-purple discoloration that develops in the dependent parts of a dead body. First evident about 30 minutes after death and fully developed in 6-10 hours.

46.   Decomposition (Putrefaction) The destruction of a dead body by bacteria. The rate at which changes develop depends on the environment.  Hot, moist conditions favor putrefaction, but cold, dry air delays or prevent it. The body should be placed in refrigeration in the morgue as soon as possible. It is best not to keep the body on the nursing unit/ward more than one hour. 8/8/2022 46

47. Equipment Gloves Pads Cotton balls Adhesive bandages to cover  wounds  or punctures Plastic bag for belongings bath basin with water soap towels washcloths clean sheets stretcher or morgue cart 8/8/2022 47

48. Post-mortem Care Procedure Note the exact time of death and chart it Check the chart for the physician’s certification of the death Ask the relatives if they wish to stay while doing the procedure Place “NO VISITOR-CHECK AT NURSE’S STATION” – sign to door. Provide privacy 8/8/2022 48

49. Procedure cont… 5. Wash hands and apply gloves and other protective equipment 6. Place body in a supine position in bed flat (Align body in natural anatomical position with body on back, arms along side and palms turned toward thighs) 7. Place pillow under head to prevent deep, reddish-purple discoloration around sides of the face, earlobes and neck. 8/8/2022 49

50. Procedure cont… 8/8/2022 50 8 . Remove jewelries and personal items. Return these to the family in the presence of a witness. Document the name of the person who received the items. 9. Follow the institution’s policy about removing or inserting dentures, dental plates, artificial eyes, limbs and hair, and removing contact lenses 10. Close patient’s eyelids by applying light pressure downward with the fingertips

51. Procedure cont… 11. If eyelids will not remain closed on their own, initially, you can place wet gauze pads over closed eyes until it remain closed on their own 11. Remove all equipments, tubes or clamp all drains according to hospital policy. (or leave tubes in place for autopsy according to the institution’s policy). 12. Bathe the body using a circular strokes, wet forehead, eyes, cheeks, nose, mouth and ears. Using same technique to other body parts. 8/8/2022 51

52. Post-mortem Care Procedure cont’d 13. Get cotton balls and put them on patient’s closed eyes, nares and outer ear. 14. Place a small rolled towel into chin to prevent the lower jaw from sagging 15. Remove bath blanket 16. Give time to the family to view the patient, encouraging them to say goodbye. 8/8/2022 52

53. Procedure cont… 17. Then, secure ankles and wrists. 18. Attach two body tags. Tie death tag to the great toe and left wrist . Each tag should include the deceased patient's name, room and bed numbers, date and time of death, and physician's name 19. Wrap/drape the body in a sheet 20. Transfer the body to the stretcher or morgue cart 21. Transport patient to the morgue. 8/8/2022 53

54. Procedure cont… 22. If death is caused by accident ,suicide, homicide poisoning etc. notice the legal authorities and the body should not be handed over the relative without the written permission of the legal authorities 23.When death occurs due to communicable diseases ,special care must be taken to prevent the spread of disease. 8/8/2022 54

55. Post-mortem Care Procedure cont’d 24. After the dead body is taken from the room, the room should be cleaned The utensil are washed and disinfected Linen and blanket are sent to the laundry Bedding should be exposed to sunlight 8/8/2022 55

56. Hospice Care 8/8/2022 56 Is a type of care for the terminally ill Is founded on the concept of allowing individuals to die with dignity and be surrounded by those who love them The emphasis is on palliative care (control of the symptoms (care) rather than cure )

57. Home Care 8/8/2022 57 Is an alternative for the dying client, if the family members are physically and emotionally able to provide care. Ideally, HCPs should share the responsibility of home care of the dying with the family.

58. Legal Aspects 8/8/2022 58 It is important for nurses to know their legal responsibilities, which are defined by their state or provincial board of nursing Autopsy Postmortem examination to determine the cause of death. Is mandated in situations in which an unusual (unexpected or violent) death has occurred

59. 8/8/2022 59 Families must give consent for an autopsy to be performed Organ Donation At the time the family gives consent for donation, the nurse notifies the donor team that an organ is available for transplant

60. Care of the Family 8/8/2022 60 At the time of death, the nurse provides invaluable support to the family of the deceased. When an individual dies, family members’ anxiety is increased due to their uncertainties about what to do. Informing the family of the type and circumstances surrounding the death is extremely important.

61. Care of the Family cont… 8/8/2022 61 The nurse provides information about viewing the body, asks the family about donating organs, and offers to contact support people (e.g., other relatives, clergy) Using sensitive and compassionate interpersonal skills is essential in providing information and support to families.

62. Nurse’s self-care 8/8/2022 62 Because many nurses are confronted with death and loss daily, grief is a common experience for nurses. Nurses are at particular risk for experiencing negative effects from caring for the dying. Often, the nurse’s fears and doubts about death and its meaning surface, causing anxiety related to feelings about mortality.

63. Nurse’s self-care cont… 8/8/2022 63 Set away/aside some time for your own grieving: Know when to ask for help. Use support from within your agency— counselors, clergy, support groups. Find a way to say goodbye to the deceased client—rituals bring closure, which is a necessary part of grieving.

64. 8/8/2022 64 Thank you!!!