Loss of grieving means deeply grief

1. UNIT : X
CONCEPT OF LOSS & GRIEVING
AND DEATH AND DYING.
FUNDAMENTAL OF NURSING-II
ABDUL QUDOOS DAYO
POST RN, BScN,DIP,Card,RN
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2. Objective
 Assess the physiologic signs of death.
 Identify beliefs and attitude about death in relation to age.
 Discuss the various ways of helping the dying patient meet his/her
physiological, spiritual and emotional needs.
 Discuss care of the body after death.
 Discuss the legal implications of death.
 Describe how a nurse meets a dying patient’s needs of comfort.
 Discuss important factors in caring for the body after death.
 List changes that occur in the body after death.
 Define terms related to loss and grieving.
 Identify common manifestations of grief
 Discuss the effects of multiple losses on the grief process.
 Apply the nursing process to grieving clients.
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3. What is loss
 Loss is an actual or potential
situation in which something that is
valued is changed or no longer
available.
 People can experience the loss of
body image, a significant other, a
sense of well-being a job ,personal
possessions, or beliefs.
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4. Types of Loss
 An Actual loss can be recognized by
other.
 A perceived loss is experienced by one
person but cannot be verified by others.
 An Anticipatory loss is experienced
before the loss actually occurs. For
example , a women whose husband is
dying may experience actual loss in
anticipation of his death.
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5. Cont…
 Loss can be viewed as situation or
developmental.
 Losing ones job , the death of a child ,and losing
functional ability because of acute illness or
injury are situational losses.
 Losses that occur in normal development-such
as the departure of grown children from the
home ,retirement from a career, and the death
of aged parents-are developmental losses that
can, to can to some extent, be anticipated and
prepared .
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6. Sources loss
 1. Aspect of self: Losing an aspect of self , changed a
person’s body image, even though the loss may not
be obvious.
 2. External objects Loss of external objects includes
loss of inanimate objects that have importance to the
person.
 3. Familiar Environment separation from an
environment and people who provide security can
cause a sense of loss.
 4. Loved ones Losing a loved one or valued person through
illness, divorce, separation, or death can be very disturbing.
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7. Grief
Grief Total response to emotional experience
related to loss.
Bereavement is the subjective response
experienced by the surviving loved ones.
Mourning: is the behavioral process through
which grief is eventually resolved or altered
: it is often influenced by culture, spiritual
beliefs, and custom.
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8. Types of grief Responses
 A normal grief reaction may be abbreviated or
anticipatory
 Abbreviated grief is brief but genuinely felt. This can
occur when the lost object is not significantly important
to the grieving person or may have been replaced
immediately by another, equally esteemed object.
 Anticipatory grief is experienced in advance of the
event such as the wife who grieves before her ailing
husband dies.
 Disenfranchised grief occur when a person is unable to
acknowledge the loss to other people. Situations in which
this may occur often relate to a socially unacceptable loss
that can not be spoken about, such as suicide, abortion.
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9. Cont…
 Unhealthy grief: that is pathologic or
complicated grief-exists when the
strategies to cope with the loss are
maladaptive. The disorder ,reffered to by
physians as persistent complex
bereavement disorder.
 Complicated grief: may take several
forms. unresolved or chronic grief is
extended in length and severity.
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10. Cont…
 With inhabited grief , many of the normal
symptoms of grief are suppressed and other
effects, including somatic, are experienced
instead.
 Delayed grief Occurs when feeling are
purposely or subconsciously suppressed until a
much later time. A survivor who appears to be
using dangerous activities as a method to
lessen the pain of grieving may experience
exaggerated grief.
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11. 1-Assess the physiologic sign of
death.
 Definition and sign of death
 The traditional clinic sign of death were cessation of the
apical pulse, respiration , and blood pressure, also referred
to as heart-lungs death.
 However, since the advent of artificial means to maintain
respiration and blood circulation , identifying death is move
difficult.
 In 1968 , the world medical assembly (Glider,1968) adopted the following
guidelines for physicians as indications of death.
 Total lack of response to external stimuli.
 No muscular movement ,especially breathing .
 No reflexes
 Flat encephalogram and flat electrocardiogram.
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12. Cont…
 Another definition of death is cerebral death
or higher brain death, Which occur when the
higher brain center, the cerebral cortex, is
irreversibly destroyed.
 In this case, there is a clinical syndrome
characterized by the permanent loss of
cerebral and brainstem function, manifested by
absence of responsiveness to external
stimuli, absence of cephalic reflexes , and
apnea.
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13. Clinical manifestation
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14. 3-Discuss the various ways of helping the dying patient meet
his/her physiological , spiritual and emotional needs.
 The physiological needs of people who are dying are
related to a slowing of body processes and to homeostatic
imbalances.
 Interventions include:
1. Providing personal hygiene measure.
2. Controlling pain.
3. Relieving respiratory difficulties.
4. Assisting with movement nutrition.
5. Hydration
6. Elimination
7. Providing measure related to sensory change .
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15. Discus the various ways of helping the dying patient meet
his/her physiological ,spiritual and emotional needs
 Spiritual support is of great importance in dealing with death.
 The nurse has a responsibility to ensure that the client’s spiritual needs
are attended to, either through direct intervention or by arranging
access to individual who can provide spiritual care.
 Nurses have an ethical and moral responsibility to not impose their
own religious or spiritual beliefs on a client but to respond to the client
in relation to the client’s own background and needs.
 Intervention may include:
I. Facilitating expressions of feeling
II. Prayer
III. Medication
IV. Reading
V. Discussion with a spiritual adviser.
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16. Emotion Support
 1. When nothing can reverse the inevitable dying process, the
nurse can provide an empathetic and caring presence. The nurse
also serves as a teacher, explaining what s happening and what
the family can expect.
 2. Due to the stress of moving through the grieving process,
family members may not absorb what they are told and may
need to have information provide repeatedly.
 3. The dying and the family must be allowed as much privacy.
 4. Those who feel unable to care for or be with the dying
person also require supporting from the nurse and from other
family members. They should be shown an appropriate waiting
area if they wish to remain nearby.
 5. After the client dies, the family should be encouraged to
view the body(with or without a nurse present).
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17. 8-List changes that occur in the body after death
 Rigor mortis: is the stiffing of the body that occurs
about 2 to 4 hours after death. Rigor mortis starts in
the involuntary muscles ( Heart ,Bladder, and so on)
then progresses to the head, Neck, and trunk, and
finally reaches the extremities.
 Algor mortis is the gradual decrease of the body’s
temperature after death. When blood circulation
terminates and the hypothalamus ceases to function,
body temperature falls about 1 C ( 1.8F) Per hours
until it reaches room temperature .Simultaneously
,the skin loses its elasticity and can easily be broken
when removing.
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19. List changes that occur in the body after death
After blood circulation has
ceased, the red blood cells break
down ,releasing hemoglobin,
which discolors the surrounding
tissues. this discoloration ,
reffered to as livor mortis,
appears in the lowermost or
dependent areas of the body.
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20. Identify beliefs and attitude about
death in relation to age:
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Age Beliefs/Attitudes
Infecy-5 Years Does not understand concept of death.
Infant sense of separation forms basis for later under standing of loss and death.
Believes death is reversible , a temporary departure, or sleep .
Emphasize immobility and inactivity as attributes of death.
5-9 Years Understand that death is final.
Believes own death can be avoided.
Associates death with aggression or violence.
Believes wishes or unrelated action can be responsible for death.
9-12 Years Understands death as the inevitable end of life.
Begins to understand own mortality. Expressed as interest in after life or as fear of
death.
12-18 years Fears a ingering death. May fantasize that death can be defed,Acting out defense
through reckless behaviors
e.g: dangerous driving. Substance abuse)
Seldom thinks about death. but views it in religious and philosophic terms. may seen to
reach adult perception of death but be emotionally unable to accept it.
My still hold concepts from previous developmental stages

21. Cont…
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Age Beliefs/Attitudes
18-45 years Has attitude towards death influenced by
religious and culture beliefs.
45-65 Years Accept own mortality.
Encounters death of parents and some
peers.
Experiences peeks of death anxiety.
Death anxiety diminishes with emotional
well-being.
65+Years Fears prolonged illness.
Encounters Death of family members and
peers.
Sees death as having multiple
meaning(e,g: Freedom of pain ,

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Identify beliefs and attitude about death in relation to age:

23. Discuss care of the body after death:-
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 Because the deceased person’s family often
wants to view the body, and because it is
important that the deceased appear natural and
and comfortable, nurses need to place the body
in an anatomic postion, place dentures in the
month, and close the eyes and mouth before
rigor mortis sets in. Rigor mortis usually leaves
the body about 96 hours after death.
 Tissues after death become soft and eventually
liquefied by bacterial fermentation. The hotter the
temperature,the more rapid the change.

24. Cont...
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 Therefore, bodies are often stored in cool places to delay
this process.
 Nursing personal may be responsible for care of a body
after death.
 Postmortem care should be carried out according to the
policy of the hospital or agency. Because care of the body
may be influenced by religious law, the nurse should check
the clients’s religion and make every attempt to comply.
 If the deceased’s family or friends wish to view the body,
make the environment clean and pleasant and to make the
body appear natural and comfortable.

25. Cont...
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 All equipment, soiled linen, and supplies should be
removed from the bedside.
 Normally the body is placed in a supine position with the
arms either at the sides, palms down, or across the
abdomen.
 One pillow is placed under the head and shoulders to
prevent blood from discoloring the face be setting in it.
 The eyelids are closed and held in place for a few seconds
so they remain closed.
 Dentures are usually interested to help give the face a
natural appearance. The mouth is then closed.

26. Cont...
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 Soiled areas of the body are washed:- however, a
complete bath is not necessary, because the body will be
washed by the mortician (also referred to as an
undertaker), a person trained in care of the dead.
 Absorbent pads are placed under the buttocks to take
up any feces and urine released because of relaxation of
the sphincter muscles.
 A clean gown is placed on the client, and the hair is
arranged.
 All jewellery is removed, except a wedding in some
instances, which is tapped to the finger.

27. Cont...
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 The top bed linens are adjusted neatly to cover the client to
the shoulders. Soft lightining and chairs are provided for the
family.
 In the hospital, after the body has been viewed by the family,
the deceased’s wrist identification tag is left on and
additionalidentification tags are applied.
 The body is wrapped in a shroud, a large piece of plastic or
cotton material used to enclose a body after death.
 Identification is then applied to the outside of the shroud.
 The body is taken to the morgue if arrangements have not
been made to have a mortician pick it up from the client’s
room.

28. Cont...
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 Nurses have a duty to handle the deceased with dignity
and to label the corpse appropriately.
 Mishanding:can emotional distress to survivors.
 Mislabeling:can create legal problems if the body is
inappropriately identified and prepared incorrectly for
burial or a funeral.

29. Discuss the legal implication of death:-
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 The nurse’s role in legal issues related to death is
prescribed by the laws of the region and the policies of the
health care institution.
 Many of these legal issues stimulate strong ethical
concerns.
 It is important for the nurse to have support from other
team members in understanding and providing appropriate
care to clients facing death.

30. Cont...
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 Advance health care directives include a variety of legal
and lay documents that allow persons to specify aspects of
care they which to receive should they become unable to
make or communicate their performances.
 the two types of advance health care directives The living
will provides specific instructions about what medical
treatment the client chooses to omit or refuse (e.g.
Ventilitory support) in the event that the client is unable to
make those decisions.
 The health care proxy, also referred to as a durable power
of attorney for health care, is a witnessed statement
appointing someone else(e.g.A the relative or trusted friend)

31. Cont...
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To manage health care treatment decision when the client
is unable to do so
 Autopsy:an autopsy or postmortem examination is an
examination of the body after death. It is performed only
in certain cases. The law describes uner what
circumstances an autopsy must be performed, for
example, when death is sudden or occurs within 48 hours
of admission to a hospital. The organs and tissues of the
body are examined to establish the exact cause of death.

32. Cont...
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 Certificaation Of Death:- the formal determination
of death, or pronouncement, must be performed by a
primary care provider, a corner, or a nurse. The granting
of the authority to nurse to pronounce death is regulated
by the state.
 Euthanasia: Euthanasia is the act of painlessly putting
to death people suffering from incurable or distressing
disease. It is some times reffered to as “mercy killing”.
Regardless of compassion and good intentions or moral
convictions, euthanasia is legally wrong.

33. cont...
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 Inquest: an inquest is a legal inquiry into the cause or
manner of a death. When a death is the result of an
accident, for example, an inquest is held into the
circumstances of the accident to determine any blame.
 The inquest is conducted under the jurisdiction of a
corner or medical examiner.
 A corner is a public official not necessarily a physician,
appointed or elected to inquire into the cause of death,
when appropriate.
 A medical examiner is a physician and usually has
advanced education in pathology or forensic medicine.

34. Cont...
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 Organ Donation: under the uniform anatomical gift
act and the national organ transplant act, people 18 years
or older and of sound mind may make a gift of all or any
part of their own bodies for the following purposes:
 For medical or dental education,
 Research
 Advancement of medical or dental science
 Therapy of transplantation.
 The donation can be made by a provision in a will or by
signing a card-like form.

35. Identify common manifestations of grief:-
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 Manifestations of grief considered normal include:
• verbalization of the loss
• Crying
• Sleep disturbance
• Loss of appetite
• Difficulty concentrating.
 Complicated grieving may be characterized by:
• Extended time of denial
• Depression
• Severe physiological symptoms
• Suicidal thoughts

36. Disscuss the effects of multiple losses on the grief process:
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 Multiple losses can increase the risk of complicated or
prolonged grief:
1. A perceived need to be brave and in control; fear of
losing control in front of others.
2. Endurance of multiple losses, such as losing in entire
family which the bereaved finds too overwhelming to
contemplate.
3. Extremely high emotional value invested in the dead
person; failure to grieve in this instance helps to
bereaved avoid the reality of the loss.
4. Uncertainly about the loss-for example, when a loved
one is “missing in action”.

37. Cont...
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5. lack of support systems.
 Post-traumatic stress disorder
Post traumatic stress disorder (PTSD) is a disorder that
develops in some people who have experienced a shocking,
scary, or dangerous event. It is natural to feel afraid during
and after a traumatic situation.
 Dipression and other mental distress.
 Harmful behaviors, such as misuse of drugs or alcohol.

38. Apply the nursing process to grieving clients
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