Grief, Loss and Abuse

Lesson 7: Grief, Anger, and Crisis

• After this session, the learner should be able to: determine the range of emotional responses that individuals experience, discuss loss and grief through its types, the grieving process, various dimensions, and also cultural considerations, explain anger to include aggression, and hostility in terms of expression, its etiology, and cultural considerations, identify crisis based on its varying characteristics, types, and development; and ultimately value the role of the nurse in caring for people undergoing grief, anger issues, and crisis.

Lesson 7A - Emotional Response

• Emotions stem from the Latin verb emoverse, meaning "to stir up" or "to move."
• Emotions are psychophysiological reactions defining a person's mood.
• Emotions have their own innate responses that are automatic and unique and often provoke impulses.
• Intense emotions can disrupt intellectual function; emotions are more likely positive when dealing with the situation as a challenge, while negative emotions are elicited if the event is threatening or harmful based on Boyd, 2017.
• There are four categories of emotions:
  • Negative, positive, borderline and nonemotions

Lesson 7B - Loss and Grief

• Check Unit 3, Chapters 10, Pages 151 - 169 in your textbook.
• Loss pertains to any actual or potential situation where something valued is changed or unavailable
• Grief refers to the total emotional response to loss, manifesting in thoughts, feelings and behaviors associated with distress or sorrow.
• Bereavement is the subjective response of loved survivors after the death of someone with whom they shared a significant relationship.
• Mourning describes the behavioral process of resolving or altering grief, influenced by culture, spiritual beliefs, and custom.
• Types of losses include:
  • Physiologic, Safety, Loss of security and a sense of belonging, Loss of self-esteem, Loss related to self-actualization
• Theories of Grieving:
  • Kubler-Ross Grief Cycle: Denial, Anger, Bargaining, Depression, Acceptance
  • Stages of Grief Process (Bowlby & Parkes, 1960s): Numbness and shock, Yearning and searching, Disorganization and despair, Recovery and reorganization
  • George Engel: Shock and disbelief, Developing awareness, Restitution, Resolution, Recovery
  • Mardi Horowitz: Outcry, Denial and intrusion, Working through, Completion
• Grieving Tasks:
  • Therese Rando: Recognize, React, Recollect and re-experience, Relinquish, Readjust, Reinvest
  • William Warden Tasks that must be completed for healthy grieving: accepting the reality of the loss, working through the pain of grief, adjusting to the environment without the deceased, and emotional relocation the deceased and moving on with life.
• Types of Grieving Include:
  • Uncomplicated (Normal): Abbreviated, Anticipatory
  • Traumatic, Complicated, Inhibited, Delayed, Exaggerated
  • Disenfranchised: grieving over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially, potentially relating to a relationship with no legitimacy, recognition of its absence or grief, even social stigma.
• Dimensions of Grieving Include:
  • Cognitive, emotional, spiritual, behavioral, and physiological responses
• Cultural Considerations:
  • Bereavement rituals that have roots in world religions like Buddhism, Christianity, Hinduism, Islam, and Judaism.
• Application of the Nursing Process:

  • Assessment, Diagnosis, Outcomes

    • Observe all dimensions of human response

  • Explore three critical components:

    • adequate perception regarding the loss
    • adequate support while grieving for the loss
    • adequate coping behaviors during the process

Lesson 7C - Anger, Aggression, & Hostility

• For further information, refer to Unit 3, Chapters 11, Pages 127 - 183.
• Anger: a natural, manageable emotion and a strong, uncomfortable emotional response to a provocation that is unwanted and incongruent with one's values, beliefs, or rights
• Hostility: verbal aggression, lack of cooperation or expressed through verbal abuse, violation of rules or norms, or threatening behavior
• Physical Aggression: behavior in which a person attacks or injures another person or destroys property
• Anger Expression:
  • Anger Suppression: (maladaptive) includes feeling anxious, acting as though nothing happened, withdrawing from angry people, conveying anger nonverbally by body language, or sulking, pout, or ruminating.
  • Unhealthy Outward Anger Expression:(maladaptive) includes flying off the handle, expressing anger in an attacking or blaming way, yelling, saying nasty things, calling the other person names or using profanity, or using fists rather than words to express angry feelings.
  • Constructive Anger Discussion: Discussing the anger with a reliable friend or family member and approaching the person with whom one is angry and discussing the concern directly using "I" language to describe feelings and request changes in another's behavior.
• Etiology of Anger/Hostility:
  • Neurobiologic causes include damage to the cerebral cortex; an aggression-related gene (monoamine oxidase A); low serotonin levels; or higher testosterone in males or low progesterone during menstruation.
  • Psychoanalytic Theory: includes suppression of emotions; a limitation: studies suggest that suppressing emotions does not actually reduce aggression
  • Behavioral Theories: include the frustration-aggression hypothesis; Not all situations in which one's goal is blocked lead to anger or violence
  • Social learning occurs when children's observations of aggressive behaviors among family members and violence in their communities foster a context for learning that aggressive behavior is an acceptable way of getting what they want
  • GAM (General Aggression Model), accounts for the interaction of cognition, affect and arousal during an aggressive episode.
    • Distal, devlopmental factors & processes, Biological modifiers + Environmental modifiers --> personality -->proximate, episodic factors & processes where person + situation --> present internal state (Affect and cognition and arousal) --> Appraisal and decision processes --> Thoughtful action or Impulsive Action --> Social Encounter, etc..
• Cultural Considerations:
  • Native American and Asian cultures see expressing anger as rude or disrespectful and avoid it at all costs
  • People of color are overrepresented in interpersonal violence episodes, race is not a factor but rather socioeconomic factors
  • Terminologies of culture-bound anger syndrome:
    • Hwabyeong- Korea; Bouffee delirante- West Africa and Haiti; Amok- Philippines, Malaysia, and Laos; Cafard- Polynesia; Mal de Pelea- Puerto Rico; Iich'aa- Navajo
  • Application of Nursing Process:
    • Assessment:
      • Predictors: involuntary hospitalization, suspiciousness, impulsivity, agitation, and unwillingness to follow unit rules
      • Observable precursors: staring and eye-contact, tone and volume of voice, as well as anxiety, mumbling, and pacing
      • Impaired communication, physical condition, social factors, milieu, and environmental factor
    • Diagnosis:
      • Risk for Self-Directed Violence and Risk for Other-Directed Violence
    • Intervention: -Communication and development of therapeutic nurse-patient relationship includes listening to the patient's illness experience and concerns -Validating -Providing choices -Cognitive interventions focus on -patient education -Developing prevention strategies
      • Milieu and environmental interventions involves -Reducing stimulation -Creating a culture of nonviolence -Managing imminent aggression and violence:
      • de-escalation techniques
      • administer and monitor PRN medications
      • avoiding the use of seclusion and restraint -Evaluation for the patient regains or maintains aggressive or potentially aggressive thoughts, feelings, and actions, evidence for a reduction in risk factors, and an examination of the interactions of the aggressor, victim, and environments.

Crisis

• Refer to Unit 1, Chapters 3, Pages 52 - 53.
• Crisis is a time-limited event triggering adaptive or non-adaptive responses to maturational, situational, or traumatic experiences when coping mechanisms cannot address a challenge or threat.
• This is considered a state of temporary disequilibrium.
• The effect is self-limiting which can last 24-36 hours or up to 4-6 weeks.
• Types of Crisis include:
  • Maturational or developmental, Situational, Adventitious, Traumatic, or Social
  • Maturational ex: Quarter-life, midlife, or later life crises
  • Situational ex: Death of a loved one, loss of a job, illness
  • Adventitious ex: Man-made or natural disasters, and other violence.
• Phases of Crisis:
  • A problem contributes to increase in anxiety levels leading to initiate common problem-solving.
  • Those techniques are ineffective causing Trial-and-error to resore balance.
  • Escalation to automatic relief due to trial-and error failures
  • Overwhelmed with serious personality disorganization
• Crisis Intervention
  • Goal: Return client to a pre-crisis level
  • Reestablish optimum level of functioning (OLOF)
  • Approaches: directive/supportive intervention
• Balance by:
  • Assessing situation perceptions/coping/support system (how may people offer help + sizing all to assess their overall avaliability)

Lesson 8A - Overview.

• Refer to Unit 3, Chapters 10, Pages 151 - 169.
• Abuse defined as wrongful use or maltreatment of another person.
• Violence defined as extreme aggression involves with strong force or weapons.
• It can inflict bodily harm to death while often suggesting destructiveness beyond aggression

Lesson 8B - Family Violence.

• Involves spouse batterying, neglect and physical, emotional, or sexual abuse as well as elder abuse, including martial rape.
• The most dangerous place can become the home setting.
• These are usually shown in families who display social isolation and drug abuse, abuse of power and control, and even generational transmission.
• Intimate partner violence involves the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship that is either marital or partnered.
• Republic Act 9262 is the "Anti-Violence Against Women and Their Children Act of 2004." -The state values the dignity of women and children, recognizing the need to protect them from violence and threats to personal safety and security.
  • Child abuse encompasses intentional injury, neglect, failure to provide care, sexual assault, emotional neglect, abandonment, or overt torture.
• Republic Act 7610 relates to "Special Protection of Children Against Abuse, Exploitation and Discrimination Act." while mandating state intervention when a guardian, parent, teacher, fails, or is incapable of shielding the child from the exploitation and discriminatory abuse.
• Elder Abuse:
  • Happens when maltreatment of older adults from family or others in a professional care giving
  • Includes includes physical/sexual/psychological abuse, self/neglect as well financial exploitation and general inadequacy when providing adequare medical aid -House Bill 7030 or the "Anti-Elder Abuse Act" provides penalties for abuses committed against the elderly. Approved on the third and final reading last February 2019 with proposed laws which penalize by jailing but also implementing fines.

Lesson 8C - Rape and Sexual Assault

• Unit 3, Chapters 12, Pages 196-198
• Republic Act 8353: The Anti-Rape Law of 1997.
• Rape is committed:"

-““1) By a man who shall have carnal knowledge of a woman under any of the following circumstances:

• a) Through force, threat, or intimidation

• b) When the offended party is deprived of reason or otherwise unconscious

• ( c) By means of fraudulent machination or grave abuse of authority; and

• ( d) When the offended party is under twelve (12) years of age or is demented, even though none of the circumstances mentioned above be present.” By any person who, under any of the circumstances mentioned in paragraph 1 hereof,

• ““2) shall commit an act of sexual assault by inserting his penis into another person's mouth or anal orifice, or any instrument or object, into the genital or anal orifice of another person.”

Lesson 8D - Community Violence

• To further clarify the lesson check, the following, Unit 3, Chapters 12, Pages 198 - 199.
• It involves terrorist attacks but can often range from less serious bullying, including cyberbullying as well as ostracism or even hazing rites

Lesson 8E - the nurse´s obligations during an abuse

-A report in 2017 indicated that there were low routine screening with intimate partners showing violence. -Development guidelines are regulated with clearly defined parameters, including documentation with screenings when necessary. It's important to always properly document, never forget to preserve the evidence provided.

Notes on self-awareness

-There are myths that often revolve around or concern abuse and it's important to never fall for the trap -Questions should include an appropriate level of respect for clients or in fear will be worsen the situation. --A woman who has stayed in a abusive relationship might deserve a relationship or it has become private.

-Important considerations for nurses. -As their role as a supportive element of the client is to listen and convey the level of acceptation is for their clients.

• Their clients are going to have many stress as they might never realize and it's important for nurses be prepared to listen to their client's, no matter how disturbing. -A good example of help that should can help them move from victims being survivors and nurses should ask all women about abuse.

-It's important to not dwell on the horrific and client focus on helping on the present. -It's usually recommended for nurses that work with either both parties, but is often difficult with emotionally.

Neurodevelopmental Disorders (Lesson 9)

• Learning Outcome: -Identify formerly diagnosed Neurodevelopmental disorders. -Distinguish key symptoms of neurodevelopmental Disorders like intellectual disability, attention deficit. -Discussion of etiology. Check Unit 4, Chapters 22, Pages 419 - 435

NEURODEVELOPMENTAL DELAY

"The child's development in attention, cognition, language, affect, and social or moral behavior is outside the norm and is manifested by delayed socialization, communication, peculiar mannerisms, and idiosyncratic interests.

RETT'S DISORDER

• A pervasive developmental disorder characterized by the development of multiple deficits after a period of normal functioning • It occurs almost exclusively in girls, is rare, and persists throughout life • Develops between birth and 5 months of age • The child looses motor skills and begins stereotyping the movement"

Other diagnostic factors

• She loses interest in the social environment and severe impairment of expressive and receptive language becomes evident as she grows older"Childhood Disintegrative Disorder"

• “A pervasive developmental disorder, characterized by marked regression after at least 2 years of normal growth and development” • Typical age of onset is between 3 and 4, more often in boys • NonSpecific Anxiety or Agitation is Common"

-Asperger's Disorder”

• “A pervasive developmental disorder characterized by impairments of social interaction and restricted interests or behaviors” • There is no language or cognitive delays. Motor clumsiness is common • Occurs more often in boys and the effects are generally life long • Can be from heredity, environment, medication of child or conditions

Intellectual Disabilities

• Is a total score derived from the process a or subtest in testing, is design for humans • For function of human or activity but the disability will have the adaptive in many skills, not before the ago of 18 years child • From 1 and up higher increase from population of the population or income • The child may have most effect to help or genes in his/hers system, to defect the syndrome • Chromosomal change and down syndrome • It also come from conditions of the mind system • There are also genetic theories

Assisting Children with Assessment

• A child that needs assistance, you should always test the general level of functioning social interactions" • Potential diagnoses, interrupted family • Planning and evaluation social environment

Implementation should have all actions

"A child that needs assistance, you should always test the general level of functioning social interactions" “ A that the is safe and effective for children

How to support their families.

"Have the power to change with the child and what make the child have better feelings" • "Offer the parents the opportunity to express their frustrations to there child's feeling"

Autism and spectrum

“The social interactions of the child as well there stereotypical” • If the have contact can make all types of connection" • (Symptoms not responsive is from the child) ""May be the first years can show a risk with this but and no • If the child had autism

• Most common cause: genetic syndromes

– • chromosomal changes or defects (e.g., Down syndrome) – • exposure to toxins during pregnancy (e.g., fetal alcohol syndrome) – • heredity – • medication conditions – •environmental influences

Medication for patients: ""Therapy: – • special education and language therapy – • cognitive behavioral therapy (for anxiety and agitation "Pharmacologic: No approved treatment – • antipsychotics—for specific target symptoms – • naltrexone, clomipramine, clonidine, and stimulants—to diminish" • Medical or nursing Assessment • Child's reaction- assessment: - family

A child the is a and always has different social reaction! • “Physical health • Family reaction • Planning and evaluation”

•"Interventions – • developing a list o (effective for some) – • drawings or symbo • buildOn their strengths and use positive reinforcement • If you always need ' to cooperate and learn" ""How to promote the correct interactions. • social interactions may be more useful than those based on speech • action child: with all simple games •""How too make there environment and predictable •"The Milieu must be with structured routine and activities to help give secure fillings" “If there routine change “You may provoke disorganization” •"Always remember you may have •Behavioral and the child needs to get attention"

• How to comfort the family? • Offer the patients to have opportunity to express their feelings"

Attention hyperactivity and deficit (disorders)

• Learning Outcome ""Attention: involves concentrating with all skills, •""Hyperactivity (excessive): to all to concentrate or to hear people! •""Diagnoses ""The power to have this disorder is with most child and

• The child needs to have treatment with six month's" ""Medical and is all by • Diet: You make give diet the Prevent • ""Activity: is needed for children ADHD (activity is needed for child)"" ""For assessment for is the child"

• "Have a great family can and is important how the support her or him.

• A child need be with people ""mood disorder"" and have been verbal"

• "All time need assessment you The child may have difficulty """The and need to have more focus or better feeling"""•

These questions cover anticipatory and complicated grief, maladaptive coping strategies, and traumatic distress due to unexpected death. Additionally, the quiz covers assessing immediate needs and evaluating resources for clients experiencing abuse.