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1. Bekalu Assefa (BSc N)
LOSS AND GRIEF
10/25/2023
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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
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3. Brainstorm
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 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 10/25/2023
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5. Types of Loss
Actualloss:Deathofalovedone,theftofone’sproperty.
Perceived loss: Occurs when a sense of loss is felt by an
individual but is not tangible to others. Example;- loss of youth,
loneliness andfeelingofemptiness.
Physical loss: Loss of an extremity in an accident, scarring from
burns,permanentinjury.
Psychological loss: Such as change in self esteem due to
harassment at work, change in sense of control and safety due to
crimeandchangeinidentityduetowidowhood. 10/25/2023
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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
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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 of the loss occur.
Bereavement: is the period of grief following the
death of a loved one
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8. Theories of the Grieving Process
 LINDEMANN’S THEORY: Reactions to normal grief
i. Somatic Distress: Episodic waves of discomfort in duration of
10–60 minutes; multiple somatic complaints .i.e. fatigue,
weakness, difficulty breathing, an extreme physical or
emotional pain.
ii. 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.
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9. Lindemann’s theory cont…
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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
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Numbing
It is common in grieving become emotionally blank and
disconnected from the world around you.
Peoples are not processing their emotion, or they feel
guilty because they are un able to cry.
Yearning and Searching
Emotional outbursts/eruption of tearful sobbing/crying
and acute distress.

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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:
1) Accept the fact that the loss is real.
2) Experience the emotional pain of grief.
3) Adjust to an environment without the deceased/dead.
4) Reinvest the emotional energy once directed at the
deceased into another relationship.
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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. 10/25/2023
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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 accept the loss.
 Establishment of new social patterns and
relationships .
Stage III may take up to several years
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16. Types of Grief
1. 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.
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17. 2. Dysfunctional Grief
 Failure to follow the predictable course of normal
grieving to resolution of loss.
 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.
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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.
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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, anger, guilty, irritability, sadness and
decreased ability to perform task.
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20. Factors Affecting Grief
 The person’s developmental level
Religious and cultural beliefs
Relationship to the lost object, and
The cause of death
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21. 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.
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22. Death/ end of life care
Deathisapartofeveryhumanexistence
Death:-permanently/irreversible cessation of vital physiology of the body. i.e.
Irreversible cessation of circulation and respiration and entire function of
brain,includingbrainstemisdead.
Elizabeth Kübler-Ross identified five possible stages of dying
experiencedbyclients andtheirfamilies.
StagesofDeathandDying
1ststage:Denial:-immediate responsetoloss
E.g.Verbal:“Thiscan’tbehappeningtome!”
Behavioral: Client is diagnosed with terminal lung cancer; client
continuestosmoketwopacksofcigarettes daily. 10/25/2023
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2nd stage: Anger:- The 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

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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

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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.

26. 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
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27. Post mortem care
Definition: a caring for deceased patient’s body with
sensitivity and with patient’s religious or cultural beliefs
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
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28. Purpose cont…
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Ensuring proper identification of the patient prior
to transportation to the morgue or funeral home
Maintaining vital organs, if donation is planned

29. 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.
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30. 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 10/25/2023
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31. 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.)
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32. 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.
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33. Body after Death cont…
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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.

34. 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.
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35. 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
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36. Post-mortem Care Procedure
1. Note the exact time of death and chart it
2. Check the chart for the physician’s certification of
the death
3. Ask the relatives if they wish to stay while doing
the procedure
4. Place “NO VISITOR-CHECK AT NURSE’S
STATION” – sign to door. Provide privacy
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37. 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.
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38. Procedure cont…
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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

39. 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.
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40. 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.
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41. 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.
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42. 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.
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43. 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
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44. Hospice Care
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Is a type of care for the terminally ill
 Is comfort care without curative intent; the patient
no longer has curative options.
The emphasis is on palliative care (control of the
symptoms (care) rather than cure)

45. Home Care
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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.

46. Legal Aspects
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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

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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

48. Care of the Family
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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.

49. Care of the Family cont…
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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.

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Thank you!!!