Nursing Level I

• unfamiliar environments
• focus on prolonging life and avoiding death
• strangers caring for the dying
• nurses uncomfortable with emotions of self/family of dying
• viewed as personal/professional failure
• talking about death discouraged
• terminally ill folks remind us of our mortality
• nurses grieve when we see others grieving

• removal, change, or reduction in value of something valued or held dear and the feelings that result
• responses vary per person
• Concrete-tangible
• Psychologica-intangible

• Part of life/natural
• recoverable or replaceable
• maturational
• -form of necessary loss, occurs during normal life transitions, help develop coping skills for unplanned/unwanted/unexpected

• Tangible
• person can no longer feel, hear, or know a person or object

• Intangible
• Subjective-defined per individual
• not easily identified by others
• easily overlooked by others
• individual interpretation of menaing affects the intensity of the grief

• not part of expected maturation experiences
• seems unnecessary
• sudden, unpredictable external events
• may result in multiple losses

• Inner emotional response to a loss, exhibited in ways unique to each individual
• Coping process
• Affected by-past experiences, culture, spiritual beliefs

• natural response to loss-physical, emotional, cognitive, behavioral
• lead to personal growth for the bereaved
• resolution of mental trauma of loss through a series of stages
• grief work-effort to acknowledge the pain associated with loss and integrate the loss into the future

• inability to accept the loss and move on with life
• unresolved grief, not able to reconcile new life with the way life was before the loss
• chronic/disruptive yearning
• do not rush to this diagnosis
• grief and time to grieve is very variable

• unconscious process
• may feel relief after the loss
• intellectual and emotional responses and behaviors to help a person move on to a healthier emotional state
• stressors may outweigh the benefits

• Marginal or Unsupported grief
• unable to openly acknowledge or publicly share grief

• Cultural background
• Developmental Factors - Age/Gender
• Situation or circumstances surrounding dying
• Psychosocial factors
• Previous experiences with grief
• Individual's physical condition

• Internal experience of grief and its expression outside of oneself
• Rituals of cultural/social  acts to express thoughts and feelings of sorrow
• psychological stages occurring as one adapts to loss

• both grief and mourning
• inner feelings, emotional responses, and outward behaviors of a person experiencing loss
• acute state of intense psychological sadness/suffering experienced after tragic loss of loved one
• Traditionally defined as being deprived through death
• Familial experience even communal ie 9/11

• Death-accepting/Death-denying
• may be seen as end of existence or transition to another state of being/consciousness

• Kubler-Ross first described process of dying in 1960's
• Traditionally viewed as preserved for the elderly
• 2000 focus on active/healthy life, youth-oriented
• Death gets in the way of Happy

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

• Developmental stages
• Personal relationship
• Nature of Loss
• Coping Strategies
• Socioeconomic Status
• Culture/Ethnicity
• Spiritual/Religious Beliefs
• Hope

• Trust/Mistrust
• Autonomy/Shame-Doubt
• Intiative/Guilt
• Industry/Inferiority
• Identity/Role Confusion
• Intimacy/Isolation
• Generativity/Self-absorption-Stagnation
• Integrity/Despair

no concept of death

Death is reversible such as sleep

• Can accept finality of death
• associated with skeleton
• able to hide from it

more aware of own aging and physical changes

• begin to experience anticipatory grief: physical changes, loss of independence/employment/relationships
• High risk for complicated grieving

• quality and meaning of relationship lost
• availability of famliy, friends, health care workers

• meaning of loss
• impact on patient's behavior, health, well-being
• visible loss = support
• private losses may mean less support
• sudden loss vs. expected loss
• violent deaths, suicides, multiple losses complicate the grief process

• May use usual
• May need new strategy
• Adaptive/maladaptive
• Ego defense mechanisms
• Emotional disclosure-venting
• Focus on positive
• Negative focus may indicate higher degree of distress

• Influences access to support systems & Resources
• Affects financial, educational, and occupational resources
• Money unable to replace tangible losses
• Money unably to control issues of loss

• background affects understanding and approach to grief process
• some cultures have specific times for grieving through rituals
• dictates acceptable expressions of grief
• provides stability where there is chaos and loss
• work/task oriented cultures
• no public displays of emotion vs wailing, ripping of clothing, body mutilation
• America - Individualism

• Spiritual Resources: their faith, sources of hope, meaning of life, religious rituals
• Spiritual well-being: higher power, connectedness to others and purpose of life - even in the end

• Energizes, comforts
• Provides meaning & purpose
• Determine sources of hope - spirtiuality, relationships, positive emotuions, anticipating the future, availability of resources, providing service for others

• Physical
• Psychological
• Resources Available

• Sleep pattern/fatigue
• weight
• nutrition
• activity level
• pain & discomfort
• S/S of Illness

• Emotional state
• Decision making process
• Confidence level
• Coping Strategies
• Spirituality

• relationships
• social life
• support system
• financial situation

• behaviors that interfere with functioning
• inadequate coping skills, poor relationships, substance abuse, loss of support systems, multiple unresolved losses

• Therapeutic Communication
• Support
• Educate
• References for other resources

• Identify/Express feelings freely
• FInish unfinished business
• Acknowledge impact of grieving process
• Dying with Dignity

• symptom management, not curative
• Good Death
• Pain/Symptom Control
• Psychological/Spiritual Care
• Enhance Quality of Life

patient's individual wishes are the focus and every attempt to meet those expectations is made

• DNR
• Full Code
• via POLST form
• Doctor's signature

Patient requests assistance in death coming sooner

• Act of Omission
• Pulling the Plug

• Emotional Signs
• Psycosocial/Spiritual
• Physiological Phases

• Comfort Care
• Positioning, cleansing
• Nutrition
• Communication
• Manage Pain