NURSING PROCESS OF CLIENT WITH LOSS AND GRIEF

A.      DEFINITION

Grief is a painful experience with lifelong consequnces response to real or perceived loss. It is a personalexperience with shared symptoms. Grief is not illness that needs to be cured. It is normal response to loss and must be experienced rather than suppressed so that healing can take place. Grief also menifest myriad physiologic and psychologic response:

1.       Physiologic response to grief

·      Crying or sobbing

·      Signing respiration

·      Shortness of breath, palpitation

·      Fatigue, weakness, exhaution

·      Insomnia

·      Loss of appetite

·      Choking sensation

·      Tightness in chest

·      Gastrointestinal disturbance

2.       Psychologic response to grief

·      Intense loneliness and sadness

·      Anxiety or panic episodes

·      Difficulty concentrating and focusing

·      Disorientation

·      Anger of rage (directed inward or toward others)

·      Ambivalence and low self-esteem (may be warning of possible suicidality and need professional help)

B.      SUMMARY OF THEORIES OF GRIEF

1.       Lindemann

grief is manifestated by predictable psychologic and somatic symptomatology. Acute mourning (feeling or expressing grief or sorrow) is characterized by somatic distress, preoccupation with the deceased person’s image, guilt, hostile reaction, and loss of patterns of conduct. Dysfunctional or “morbid” grief reactions are distortions of some aspect of “normal grief”. The duration of grief and the development of dysfunctional grief depend on the success of grief work.

2.       Bowlby

Grief and loss are characterized first by numbness, during which the loss is recognized but not necessarily felt as real. Numness is followed by yearning and searching, in which  the individual yearns for the loved one and protest the loss. In the third phase, disorganization and despair, the loss is real, and intense emotional pain and cognitive disorganization occur. Reorganization , the final phase, is characterized by a gradual adjusment to life without the deceased person.

3.       Shneidman

Conceptualizing less structure and fewer stages than other theorists of grief, Shneidman vies the expression of grief as dependent primarily on an individual’s personality or style of living. An individual who goes thruogh life feeling depressed and guilty is likely to grieve simiraly. A person who avoids emotional investment with others also tends to try to avoid grief.

4.       Theory Synthesis

Grief tend of occur in several phases. The initial ersponse to loss may be shock, numbness, denial, or others attempt to defend againts the reality and pain of loss. This initial phase is followed by painful pshychologic and physical disequilibrium, which in the case of dysfunctional grief, may last indefinitely. The thirdh phase of resolution or recovery is a gradual process in which the good days begin to outnumber the bad. Ultimately, although not forgotten, the relationship with deceased is resolved and put into perspective.

C.      GRIEF AND LOSS PROCESS

·         Internal or external stressors à annoyed and grief à individual give positive purpose à compensation with positive activities à healing (adaptation and safety)

·         Internal or external stressors à annoyed and grief à individual give positive purpose à feeling weakness à angry and aggresion à expression to our self àfisic illness

·         Internal or external stressors à annoyed and grief àindividual give positive purpose à feeling weakness à angry and aggresion à expression to our self à compensation with constructive behavioral à healing (adaptation and safety)

·         Internal or external stressors à annoyed and grief à individual give positive purpose à feeling weakness à angry and aggresion à expression to our self à compensation with destructive behavioral à very weakness

D.      PHASES OF GRIEF

1.       Phase 1 (1-3 weeks): shock, numbness, denial

·      Well organized, quite, polite, immobilize

·      Flat, isolated effect with intermitten periode of sobbing

·      Person respon with simple statement

    “I have to go home soon and feed the dog”

    “I must pick uc the clothes from the cleaners”

    “I need to water the plants and prepare dinner”

·      Lack of connection between the loss and its full meaning

NURSING INTERVENTION:

·      Acknowledge the grief: give permission to vent.

·      Assure the survivor that she or he won’t be alone at this time

·      Be calm, warm, and caring; accept his or her anguish even if it is difficult

·      Offer to help with family task; kids, meal, phone calls

·      Involve person in brief familiar tasks

·      Engage chaplain or person cleargy as needed or requested

There is a higher than normal death rate in survivors during the first year of loss. Survivors won’t ask for help; they need stimulation, involvement, and company.

2.       Phase 2 (3 weeks to 4 months): yearning and protest, anger, confrontation

·      Intensity of grief hightens

·      Person experience full impact of disstress and has no peace

·      Headaches and restlesness or agitation may occur

·      Person bergains with God or fates: “If only I had another chance” ( may also be part of phase I)

·      Person express feelings of “going crazy” or “losing mind”

·      Somatic complaints (cannot eat/sleep0 are common

·      Person is preoccupied with decreased

·      Person is unable to concentrate or focus on work or school

·      Anger expressed over the loss: “Why did this have to happen?”

·      Self-pity expressed: “Why did this happen to me?”

·      Regret expressed: “Ishould have been a better sister”

·      Person searches for the decreased and revisits places often visited by decreased

NURSING INTERVENTION:

·      Be direct “How are you sleeping?”focus on person’s feeling; show acceptance

·      Determine person’s ability to function, eat, and perform activities of daily living

·      Assses’s person’s ambivalent; suicide ideation

·      Establish your availability

·      Make appointment to visit person on a regular basis

3.       Phase 3 (4-14 months): apathy, aimlessness, disorganization, despair

·      Difficulty “getting back into the swing of things”

·      Preoccupation, dreams, or hallucinations may prevail

Normal

·      Survivor perceives the deceased person as dead (reinforcing reality and finality of death)

·      Smells perfume or shaving lotion of deceased

·      Discusses deceased as being both good and bad

·      Talks about good and bad times together

·      Laughs about the good times shared

·      Sleeps and eats better

·      Displays more energy andinterest in usual activity

Dysfuntional

·      Survivors sees or hears the deceased person as still living; unable to “let go”

·      Experience scary, vivid, threatening hallucinations

·      Idealizes deceased as perfect, not deserving to die

·      Has sleep disturbances with nightmares about deceased

·      Suggest he or she should have died instead of deceased

·      Expresses desire to join deceased because “life is not worth living” (suicidal ideation)

·      Demonstrates significant weight loss (6 to 10 lb)

·      States has no energy or interest in usual activities

·      Exhibits symptons of depression (refers to DSM-IV-TR criteria)

Nearly two thirds in a major study continue to experience phase III a year after the death or other loss.

4.       Phase 4 (14 months to throughout rest of life): recovery, resolution, acceptance

·      Survivor is slowly but surely becoming more involved in life

·      Reorganization of of life ovoles out of the chaos of grief

·      Affect still reverts to sadness with talk of the deceased person, but there are moments of tenderness as well

·      Energy is more plentifull and directed toward life

·      Scents of deceased are gone; survivor may wish for them back on occasion

·      Life seems tolerable, althought it may never reach the heights of joy before the loss

·      There may still be bouts of immens sadness and even panic, but they will go away

·      Dreams are more peasent andmay occasionally include deceased, but there are no more dreams of seeing deceased as dead or threatening

·      Memories are warm (if relationship was positive), with intelectual integration integration of the loss

·      Reestablishment of the survivor’s previous life is evident.

NURSING INTERVENTION:

·      Contact the survivor, especially at key times

·      Share memories of the deceased

·      Acknowledge the long, painful process of grieving

·      Continue to asses for signs hidden depression or suicidality

·      Asses for ambivalence, low self-esteem, and internalized rage

E.       KUBLER-ROSS’S STAGES OF GRIEVING

Elisabeth Kubler-Ross’s stages of dying (denial, anger, bargaining, depression, and acceptance) are often applied to grief. The initial response to loss may include denial, anger, and bargaining. Denial is caracterized by refusal to accept loss. Anger may innityally be directed at health care staff and later at the person who died. Bargaining and denial are often mixed in a futile attempt to reverse reality. Depression tends to be the longest phase and, in dysfunctional grief, may become chronic meet criteria for major depression. Acceptance of the loss is a gradual process that includes aspects of previous stages. Grieving individuals may not reach acceptance.

Kubler-Ross’s Stages of Grieving

1.    Denial

Behavioral Response

·      Person refuse to believe that loss is happening

·      With death or trauma, may actually block the memory of the incident or momentarilly it has not occured

·      Is unprepared to deal with practical problems, such as prosthesis after loss of legg

·      May assume artificial cheerfulness to prolong denial.

Nursing Implication

·       Verbally support client’ denial for its protective function

·       Examine own behavior to ensure not sharing in client’s denial

2.    Anger

Behavioral Response

·      Client or family may direct anger at nurse or hospital staff about matters that normally would not brother them

·      There may be an acute sense of unfairness, fear, anger, and even rage. Questions may arise, such as “Why me?” or “How could you die and leave me alone?”

Nursing Implication

·      Help client understand that anger is a normal response to feeling of loss and powerlesness

·      Avoid withdrawl or retaliation with anger; do not take anger personally

·      Deal with needs underlying any angry reaction

·      Provid structure and continuity to promote feeling of security

·      Allow client as much control as possible over life

3.    Bargainning

              Behavioral Response

·       Persons seek to bargain to avoid loss

·       The bargain may be struck with God, with deceased, or oneself

·       May express feling of guilt or fear of punishment for past sins, real or imagined

Nursing Implication

·       Listen attentivelly, and encourage client to talk to relieve guilt and irrational fears

·       If appropiate, offer spiritual supprot

4.    Depression

Behavioral Response

·       Persons grieves over what has happened and what cannot be

·       May talk freely (e.g., reviewing past losses such as money or job) or may withdrawl

Nursing Implication

·        Allow client to express sadness

·       Communicate nonverbally by sitting quitely without expecting conversation

·       Convey caring by touch, if appropiate

·       Help persons understand importance of being with client in silence

5.    Acceptance

Behavioral Response

·      Person comes to terms with loss

·      Depression has been lifted; loss is acknowledged

·      May have reduce interest in surroundings and support persons as loss is no longer focal point

·      May wish to begins making plans (e.g., living will, prosthesis, altered living arrangements)

·      Is now free to move forward

Nursing Implication

·      Help family and friends understand client’s reduced need to socialize and need for short, quite visits

·      Encourage client to participate as much as possible in the treatment program

F.       ENGEL’S STAGES OF GRIEVING

The initial response to loss is shock and disbelief. Awarness and meaning of yhe loss develop during the first year of mourning. Eventually the relationship is resolved and put into perspective.

Engel’s Stages of Grieving

1.    Shock and Disbelief

Behavioral response

·      Refusal to accept loss

·      Stunned feelings

·      Intellectual acceptance but emotional denial

2.    Developing Awarness

              Behavioral response

·      Reality of loss begins to penetrate consciousness

·      Anger may be directed at hospital/nurses

·      Crying and self-blame

3.    Restitution

Behavioral response

·      Rituals of mourning (funeral)

4.    Resolving the Loss

Behavioral response

·      Attempt to deal with painful vold

·      Still unable to accept new love object to replace loss person

·      May accept more dependent relationship with support person

·      Thinks over and talks about memories of dead person

5.    Idealization

Behavioral response

·      Produced images of dead person that are almost devoid of undesirable features

·      Represses all negative and hostile feelings toward deceased

·      May feel guilty and remorseful about past inconsiderate or unkind acts to deceased

·      Unconciously internalizes admired qualities of deceased

·      Reminders of deceased evoke fewer feelings of sadness

·      Reinvest feelings in others

6.    Outcome

Behavioral response

·      Behavioral influenced by several factors, such as importance of lost object as source of support, degree of dependence on relationship, degree of ambivalence toward deceased, number and nature of other relationships, and number and nature of previuos grief experience 9which tend to be cumulative)

G.     ANTICIPATORY GRIEF: PREMOURNING, PREDETH

Anticipatory grief is associated with the anticipation of a predicted death or loss. Example include grieving for person with a long term or life-threatening illness and grieving for elderly relayives whose life functions are deteriorating.

Positive aspect of anticipatory grief include the oppurtunity to resolve relationships, to prepare survivors for the loss, and to work on spiritual reconciliation.

Negative aspect of anticipatory grief include increased stress n caregivers, resentment and anger caused by ambivalent relationship, hopelessness or powerlessness, ang depression.

H.     INTERVENTION IN ANTICIPATORY GRIEF

·      Allow caregiver time to come to term with inevitable loss

·      Offer emphaty and information about the ilness when the client is ready

·      Identify source suport, such as grief groups

·      Be available to listen and asses sign of depression

The anguish that caregivers feel during anticipatory grief does not subtitute for postdeath grief.

I.        NURSING PROSES

·      ASSESMENT

1.       Predisposition factor’s

Genetic

The body health

The mental health

Past experienced grief

Personality structure

2.       Presipitation factor’s

Behavioral

Coping mechanisme

·      DIAGNOSE

1.       Potential grief process isn’t finishing with connection the mother’s of death

2.       Grieving of depression phase with connection fracture of left leg

3.       Potential grieving response whom longer with connection before grieving process wasn’t finished.

J.        TIPS FOR HELPING SURVIVOR

1.       Listen; say little

2.       Avoid cliches such as, “Everything will be fine”, “I know how you must feel”, or “She lived a long life

3.       Be there for the long term, not just for the funeral or memorial service

4.       Include the survivors in the first holiday after the loss

5.       Remember the anniversary of the death in special way (a call, card, flower)

6.       Love the survivor and accept them.

REFFERENSI:

Fortinash, Katherine M. 1991. Psychiatric Nursing Care Plans. Philadelpia: Mosby Year Book.

Kaplan & Saddock. 1995. Comprehensive Textbook of Psychiatric/IV. Sixth Edition. USA: Baltimore Maryland.

Louis, tt. Principle and Practice if Psychiatric Nursing. St. Louis, Missiori; Mosby Year Book.

Rosdahl, Caroline Bunker. 1999. Textbook of Basic Nursing. Philadelpia, New York, Baltimore; Lippincott.

Stuart, G.W. & Sundeen SJ. 1995. Principle and Practice of Psychiatric Nursing. St Louis, Missiouri: Mosby Year Book.

Varcolis, Carson, Shoemaker. 2006. Foundation of Psychiatric Mental Health Nursing a clinical Approach. St Louis, Missiouri: Mosby Year Book.

Yosep, Iyus. 2009. Keperawatan Jiwa. Edisi Revisi. Bandung: Refika Aditama.