Loss/Grief Notes PDF

# LOSS/GRIEF ## Introduction Loss is said to occur when an individual does not have access to things that are valuable and important to them. It is a common experience of life. Loss can be either real, potential, or perceived. - Loss can be real e.g., loss of a spouse through death or divorce....

# LOSS/GRIEF ## Introduction Loss is said to occur when an individual does not have access to things that are valuable and important to them. It is a common experience of life. Loss can be either real, potential, or perceived. - Loss can be real e.g., loss of a spouse through death or divorce. - Anticipated; e.g., a person is diagnosed with a terminal illness and has only a short time to live. A loss can be palatable or not palatable e.g., losing a loved one who had been on protracted illness for a long period and no evidence of signs of improvement. Ways by which people respond and express loss differs. This may be attributed to ways by which a widower will express loss of a spouse is different from that of a widow. Men react as if they have lost a part of themselves, while women respond as if they have been deserted or abandoned. ## Types of Loss There are four major categories of loss: **A. Loss of external objects:** This is said to occur when an individual loses something significant to them. The grief he experienced depends on the value he placed on the damaged, or lost object. The valued object maybe a loved one, property, colleague, one's livestock, or pets. **B. Loss of Familiar Environment:** this is said to occur when an individual changes environment. It may be due to a shift in settlement, schools securing a new job, or being hospitalized for the first time. Moving to a new environment brings about different degrees of fear/anxiety. **C. Loss of Aspects of Self:** this may be psychological, physical, or as a result of illness or accidents that bring about loss of any parts of the body. - Example of psychological loss: ambition, a sense of humor or belonging, or enjoyment of life. - Example of physiological loss: loss of physical function as a result of illness or injury (stroke, blindness). Loss also occurs when there is disfigurement or disappearance of a body part, such as having an amputation or mastectomy. **D. Loss of significant other:** this is said to occur when an individual loses a very dear person to them, which is termed a significant loss. This can result from separation (partially due to a change of environments e.g., relocation, job reasons, or it may be a permanent one e.g., divorce, running away, settling down permanently in a different area without the spouse's permission, or death). For example, the death of a spouse is different for men and women (Figure 21-2). “Men who are widowed react as if they have lost a part of themselves, whereas women react as if they have been deserted or abandoned". ## Grief This can be described as a means by which an individual responds and expresses loss. It may be an intense physical and psychological response. It is an expected, normal, natural, necessary, and adaptive response to a loss. Furthermore, it can be described as follows: - Grieving can also be described as a means of walking through an unknown territory at this stage. There would be an influx of thoughts, feelings, and emotions. Familiar internal and external stabilities disappear. - Grief is an adaptive mechanism of mourning, while bereavement is the period of grief following the death of a loved one. - It drains people, both emotionally physically, and psychologically. Prolonging may result in the breaking down of relationships and health status. ## Types of Grief 1. **Uncomplicated Grief:** this is also referred to as normal grief. This is a type of response that usually follows a significant loss. It is fairly predictable, and an individual accepts his/her fate on the lost object and returns to life activities. Though it is obvious that the life of the bereaved person has been changed forever, the person can regain strength and the ability to bounce back to life and start functioning. 2. **Dysfunctional/pathologic:** this is said to occur when a bereaved person Does not go through stages of overwhelming emotions that characterize grief, or they may fail to demonstrate any behaviors commonly associated with grief. Individual exhibits strong emotional reactions continuously, did not return to a normal sleep pattern or work routine, usually remains isolated, and has altered eating habits. The bereaved may need to endlessly tell and retell the story of loss but without subsequent healing. 3. **Anticipatory Grief:** this is said to occur when a person with protracted illness and relatives starts having feelings of loss before the occurrence of loss. This brings about adjustment to grieving and helps to free individual emotional energy. For example, for the dying client, anticipatory grieving may lead to family members' distancing themselves and not being available to provide support. Also, if the family members have separated themselves emotionally from the dying client, they may seem cold and distant, thus, not meeting society's expectations of mourning behavior. This response can prevent the mourners from receiving their much-needed support from others. ## Signs and Symptoms Of Uncomplicated Grief - **Emotions:** Sadness, Anxiety, Guilt, Relief, Emancipation, Fatigue, Numbness, Shock, Helplessness, Yearning, Loneliness. - **Physical Settings:** Increased sensitivity to noise, Constricted feeling in throat and Chest, Hollow feeling in the stomach, Lethargy, Dry mouth, Muscular weakness. - **Behaviors:** Disrupted sleep patterns, social withdrawal, Forgetfulness, avoiding reminders of the deceased, treasuring objects belonging to the deceased. - **Thought process:** Disbelief, preoccupation, confusion, Sense of presence of the deceased, Hallucinations. ## Signs and Symptoms of Dysfunctional Grief - **Physical reaction:** loss of appetite, weight loss, insomnia, fatigue, decreased libido, decreased immune function, susceptibility to illness, restlessness. - **Psychosocial reaction:** profound sadness, helplessness, hopelessness, helplessness, denial, anger, hostility, guilt, nightmares, loneliness. - **Cognitive reaction:** inability to concentrate, forgetfulness, impaired judgment, decreased problem-solving ability. - **Behavioural reaction:** social withdrawal, impulsiveness, indecision. ## Theories Of The Grieving Process 1. **Grief Work Process:** This theory is formulated by Lindemann In 1944. An individual who is bereaved experiences what is called “grief work", at this stage the bereaved started adjusting and adapting to the new environment and gaining freedom from attachment to the deceased or loss objects, in a new environment in which the deceased is no longer present. He tries to establish new relationships and starts life afresh. This theory is the foundation for current crisis and grief resolution theories. 2. **Engle Grief:** This is another form of grief theory formed by George L. Engle. This is a form of typical reaction to the loss of a valued object. This theory states that there are three stages of mourning and each stage is necessary for healing; it cannot be accelerated, and also it takes years for healing to be complete. The three stages of the grieving are: - **Stage I: Shock and Disbelief**, Disorientation, Feeling of helplessness, Denial. This Stage can last from minutes to days. - **Stage II: Developing Awareness**, Emotional pain occurs with the increased reality of loss, Recognition that one is powerless to change the situation, Feelings of helplessness, Anger, and hostility may be directed at others, Guilt, Sadness, Isolation, Loneliness. This Stage may last from 6 to 12 months. - **Stage III: Restitution and Resolution**, Emergence of bodily symptom, Mourner starts to come to terms with the loss and establishment of new social patterns and relationships. This Stage marks the beginning of the healing process and may take up to several years. 3. **Bowlby Theory:** This theory was formulated by in 1982. This theory stated that grief results when an individual experiences a disruption in attachment to a loved object and that grief occurs when attachment bonds are severed. It stated that grief occurs in four phases as follows: - Numbing - Yearning and searching - Disorganization and despair - Reorganization. 4. **Worden Theory:** This theory was formulated by J. William Worden in 1982. This theory identified four tasks that an individual must perform in order to successfully deal with a loss; these are: - Accept the fact that the loss is real. - Experience the emotional pain of grief. - Adjust to an environment without the deceased. - Reinvest the emotional energy once directed at the deceased into another relationship. ## DEATH There are two times in the life of a living being, and we are all expected to go through it: a time to be born and a time to die. At these stages' nurses are present and they play a major role in this critical junction of life. **Death:** is part of every human existence no matter how long a man lives on the surface of the earth; the fact remains that one day transition into heaven will take place. Nurses play a major role in the care of the patients, and they are saddled with the responsibilities of end-of-life care to dying patients so as to ensure a peaceful transition as much as possible. ## Stages of Death and Dying - **Denial:** This is the first stage of dying; this is an immediate response to the loss experienced and expressed by most people. It's been described as a very or manifest for months. - **Anger:** At this stage, the client feels that their security is being threatened by the unknown. There is disruption in daily activities; they lose control of the situation and become angry as a result of this. They may direct their anger towards self, God, and others. Sometimes nurses may be a victim when the dying person reacted. - **Bargaining:** At this stage, the client tries to find means of reversing or postponing the death. They try to do something in exchange for a longer life. - **Depression:** This stage occurs when the reality is to the client that death is inevitable. This stage helps the dying person to accept and adjust to their fate concerning death. - **Acceptance:** This is the final stage, though the majority of dying clients find it difficult at this stage, but they settled down to acceptability of death. At this stage, there is awareness of the reality on ground and there is peace of mind/contentment. 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 are important during this stage. ## End of Life Care This can be described as an encompassing care given to patients that are critically ill so as to control pain and ensure the comfortability of the patient as much as possible till the patients dies. This type of care cut across every sphere of life of the affected patient; be it physical, social, spiritual, emotional, psychological, and financial wellbeing of the affected person. This type of care can be carried out in the hospital, at home. It is a means of providing a milieu environment for the patients. It may be inform of palliative care, supportive and hospice care. ## Role of Nurses in End of Life Care - Recognize changes (social, demographic, economic) necessitating improved EOL care. - Ensure activities that promote provision of comfort care to the dying. - Establish a line of communication with patient, family, and colleagues about EOL issues. - Recognize one's own attitudes, feelings, values, and expectations about death; acknowledge diversity (individual, cultural, and spiritual) in beliefs and customs. - Demonstrate respect for the patient's view and wishes during EOL care. - Collaborate with interdisciplinary team members during EOL care. - Use scientifically based standardized tools to assess symptoms experienced by the patient at the end of life. - Use assessment data to plan and intervene using traditional and complementary approaches. - Evaluate the impact of traditional, complementary, and technological therapies on patient-centered outcomes. - Assess and treat multiple dimensions (physical, psychological, social, and spiritual needs) to improve quality at the end of life. - Assist the patient, family, colleagues, and one's self in coping with suffering, grief, loss, and bereavement in EOL care. - Apply legal and ethical principles in the analysis of complex EOL issues. - Identify barriers and facilitators to patients' and caregivers' effective use of resources. - Demonstrate skill at implementing a plan for improved EOL care. - Apply knowledge gained from palliative care research to EOL education and care. ## Strategies Use in EOL Care - **Advance care planning:** This is the phase where all needs of the dying patients are considered in the planning of care ahead so that provision is on the ground before the needs arise. - **Comprehensive care:** This is the phase in which all care has been implemented, and no area of the patient's life is left untouched. - **Terminal phase care management:** This is the last phase in which the patient is given a befitting last respect, and the loved one was accorded all necessary full support needed by them. ## Pain Pain can be defined as a state of uncomfortable experience; it is an unpalatable sensation. It is universal and subjective. It can only be explained by the person going through/experiencing it; it is one of the most prevalent complaints that people present within the hospital. Pain is a stressor that can trigger both physiological and psychological discomfort, and Untreated pain can lead to physical disorders related to undernutrition, immobility, and immune suppression. It can also be described as a response to noxious stimuli which can be a protective mechanism to prevent further injury. Pain sensation serves as a warning sign of potential tissue damage, and it may be absent in people with nerve/spinal cord abnormalities, diabetic neuropathy, multiple sclerosis, and nerve/spinal cord injury. ## Types of Pain Pain can be classified by cause/origin and nature: ### Classification of Pain Based on Cause/Origin - **Cutaneous pain:** This type of pain is said to occur when the cutaneous nerve endings of the skin are stimulated, resulting in a pricking sensation that is well localized. - **Somatic pain:** Is non-localized and originates in support structures such as tendons, ligaments, and nerves; jamming a knee or finger will result in bodily pain. Visceral pain is discomfort in the internal organs and is less localized and more slowly transmitted than cutaneous pain. Visceral pain is often difficult to assess because the location may not be directly related to the cause. - **Viscera pain:** This type of pain occurs at the internal organ; it is not localized, and it's been transmitted slowly to other parts of the body. Visceral pain is often difficult to assess because the location may not be directly related to the cause. ### Classification of Pain Based on Nature - **Acute pain:** This type of pain is sudden in onset; it has a short duration is mild in intensity and lasts for a very short period. The intensity of the pain starts reducing once the cause is been attended to. Examples of causes of acute pain were: needle sticks, surgical incisions, burns, and fractures. It may be recurrent acute pain; this is been diagnosed when there is an episode of repeated pain over a long period and there may be an interval of free pain period. Examples of recurrent pain: include migraine headaches, sickle cell pain crises, and the pain of angina pectoris due to myocardial hypoxia. - **Chronic pain:** Is identified as long-term, persistent, nearly constant, or recurrent pain that produces significant negative changes in the client's lifestyle. It may persist for a long period after the pathology has been resolved. This type of pain motivates people to seek help medically because it affects their quality of life. Chronic acute pain: is said to occur nearly every day over a long period, it can last for as much as a year and has a high tendency of ending. Examples are Severe burn injuries, fibroids, and cancer. - **Chronic nonmalignant pain (CNP):** Occurs almost daily and lasts for at least 6 months, with intensity ranging from mild to severe. ## Theory of Pain Control **Gate Control Theory of Pain:** This theory was formulated by Melzack and Wall in 1965. This theory deals with pain transmission, expression, and interpretation. This theory states that the physiological aspects of pain are as important as the psychological aspects. It combines cognitive, sensory, and emotional components in addition to the physiological aspect of an individual and proposes that they can act on a gate control system to block the individual's perception of pain. This theory showed that pain impulses from either large or small diameter nerve cells pass through the same pain control gate in order to block the impulses to the brain. This is possible because the large-diameter cell nerve has the capacity to locked the gate if it is adequately stimulated. **Bezkor and Lee (1997)** describe gate control as a mechanism of “regulation of pain perception through the dorsal horn of the spinal cord. Occurrence of vasoconstriction brings about a decrease in the rate of nerve conduction resulting in reduced transmission of stimuli to the 'gate.” As a result, the level of conscious awareness of painful sensations is altered. ## Factors Affecting Pain Response Pain is subjective, and the degree of response and expression differs in people. This can be attributed to various reasons/factors, varies from person to person and is influenced by several variables. - **Age:** This factor has a great impact on how individual perceive/experience and express pain. Ways by which an adult will respond and express pain differ from that of a toddler or baby. For example, a baby will express pain either by crying or restlessness whereas a toddler can point to the exact place the pain is, an adult can tell you the nature, the intensity, and sometimes the cause of the pain. - **Previous experience with pain:** This factor is a determinants of how an individual will respond to present pain. The strategies he used in the past may influence his conclusion about the present pain and how is going to manage it successfully without much adverse effects on his way of life. - **Cultural factors:** These factors talk about diversity in people's response and expression of pain; this poses a greater challenge to healthcare workers when it comes to pain management. There are no significant differences among groups in the level of intensity at which pain becomes appreciable or perceptible. However, the level of intensity or duration of pain the client is willing to endure is culturally determined. Expression of pain is also governed by cultural values. In some cultures, tolerance to pain, and therefore “suffering in silence,” is expected; in others, full expression of pain may include animated physical and emotional responses. The nurse must be careful not to equate the level of expression of pain with the level of actual pain experienced, but instead consider cultural influences that affect the expression of pain. ## PAIN ASSESSMENT AND MANAGEMENT TIP - Ask about pain regularly. - Assess pain systematically. - Believe the client/family's reports of pain, and what relieves it. - Choose pain control measures appropriate for the client, family, and setting. - Deliver interventions in a timely, logical, and coordinated manner. - Empower clients and families by encouraging them to control their treatment regime as much as possible. - Monitor client responses to pain management strategies - Educate staff and clients about pain management ## PAIN MANAGEMENT This can be achieved through the following ways: - **General overview of pain management:** These involved knowing what causes pain, risk factors, pain assessment, preventive measures, and family involvement. - **Pharmacologic pain management:** This involves the use of drugs such as different types of analgesics. - **Nonpharmacologic pain management:** This involves a review of experience with nonpharmacologic methods and a demonstration of specific techniques. Others includes: Psychotherapy, family support, Transcutaneous electrical nerve (TENS), application of heat or cold, Acupuncture or acupressure, Focused breathing, Herbal remedies, Hypnosis, Imagery, Massage, Music, Progressive muscle relaxation, Therapeutic touch, Yoga, Encourage Exercise, good nutrition. ## Nutrition and Therapeutic Outcomes | FOOD | THERAPEUTIC OUTCOME | |---|---| | Cherries and berries with black or red-blue skins (raspberries, blackberries) | Rich in bioflavonoids (anti-inflammatory substances) | | Amino acids (found in whole grains, starchy vegetables, dairy products, turkey) | Used in pain associated with arthritis and gout | | Fatty acid eicosapentaenoic acid (EPA), a component of certain fish oils (Found in cold-water fish) | Produces mild analgesia | | | Inhibits formation of substances associated with inflammation | ## Sleep and Rest Rest and sleep are very critical to wellbeing. The body of an individual require certain periods of rest and sleep so as to allow the body to regain strength and staminal for optimal body function. There are various factors that brings about variation in the needs of an individual when it comes to rest and sleep. These includes: age, developmental level, health status, activity level, and cultural norms. Also pain and impaired sleep are closely related in most people. It is of notes that 50–70% of clients experiencing pain also suffer sleep disturbance and sleep deprivation can decrease pain tolerance and, thus, may exacerbate pain (especially headaches) ## Definition Rest can be referred to as a state of relaxation and calmness. It's a state in which an individual experience a form of calmness both mentally and physically. During this stage activities ranges from lying down to reading a book, taking a quiet walk, listening to light music, etc Sleep this can be referred to a state of altered consciousness during which an individual experiences minimal physical activity and a general slowing of the body's physiological processes. It does occur in cycle periodically and lasts for several hours per time. Any alteration in the normal sleep pattern can be distressing to clients and impaired further sleep. sleep is very essential for physiological and psychological healing process. ## Stages of Sleep The cycles of been awake and sleep were been controlled by the brain. Electroencephalograph (EEG) patterns, eye movements, and muscle activity are used to identify stages of sleep. The stages of sleep are classified into two categories: - non-rapid eye movement (NREM) and rapid eye movement (REM) sleep ## Non-Rapid Eye Movement (NREM) Sleep Once sleep set in both the respiratory and heart rate gradually become slightly reduced and regular. NREM sleep consists of four different stages. - **Stage 1:** This stage is characterized by: * general slowing of EEG frequency * an appearance of wave spikes * the eyes tend to roll slowly from side to side * muscle tension remains absent except in the facial and neck muscles. This stage usually lasts only for 10 minutes or there about in an adult and also at this stage it is easier to awakening the sleeper. Stage. - **Stage 2:** At this stage sleep is still fairly light sleep, with a further slowing of EEG patterns and loss of slow rolling eye movements. After an initial 20 minutes or so of stage 2 sleep, a deep form of sleep called stage 3 to 4 is entered. - **Stage 3:** refers to medium-depth sleep - **Stage 4:** signals the deepest sleep. During these stages, all cortical brain cells appear to be firing at the same time, resulting in large slow waves on the EEG. * When roused from stage 3 to 4 sleep, an adult can take 15 seconds or so to become fully awake. REM sleep periods become longer as the night progresses, and the individual becomes more rested. ## Rapid Eye Movement (REM) Sleep After the initial 90 minutes or so of NREM sleep in adults. The individual enters rapid eye movement, or REM, sleep. The EEG pattern resembles that of the awake state; there are rapid conjugate eye movements. Heart rate and respiratory rate are irregular and often higher than when awake; and muscles, including those of the face and neck, are flaccid, leaving the body immobilized. Dreams occur 80% of the time when clients are in REM sleep. ## Factors Affecting Rest and Sleep There are so many factors that influence the quality and quantity of rest and sleep, this includes: - **Degree of Comfort:** Assessment of patients' physical and psychological needs and meeting such is very crucial, however if the needs is un- met the patient experience discomfort which can leads to physiological tension, resultant anxiety, and potential impairments in sleep/rest. - **Anxiety:** Whenever or wherever there is anxiety the patient becomes restless which brings about interference with the sleeping pattern of an individual. Anxiety related to work pressures, family demands, and other stressors does not automatically cease when an individual attempts to go to sleep. It often results in difficulty falling or staying asleep. - **Environment:** This can either promote or impaired sleep. Lighting, temperature, odors, ventilation, and noise level can all interrupt the sleep process when they differ from the norms of the client's usual sleep environment. - **Lifestyle:** A fast-paced life filled with multiple stressors can result in individual inability to relax easily or to fall asleep quickly. Relaxation precedes healthy sleep. Also having a tight work schedule interferes with sleep. Individuals who frequently change work shifts have a real challenge in trying to stabilize biological rhythms and rest. - **Diet:** The type of food consumed has an impact on the quality and quantity of sleep. Foods that were high in caffeine, such as coffee, colas, and chocolate, serve as stimulants and often disrupt the normal sleep cycle. Also, consuming a large, heavy, or spicy meal just before bedtime may cause indigestion, which will likely interfere with sleep, furthermore, going to bed hungry can result in altered sleeping pattern because the individual will be preoccupied with food and hunger pangs instead of concentrating on sleep. - **Drugs and Other Substances:** Alcohol and nicotine use can impair sleep. Alcohol may interfere with REM sleep, causing very restless and non-refreshing sleep. Nicotine, which is a stimulant, can also impair the sleep cycle by stimulating the body, resulting in difficulty falling and staying asleep. Many medications (both prescribed and over-the-counter) cause fatigue, sleepiness, restlessness, agitation, or insomnia, thus affecting the quality and quantity of rest and sleep. - **Cultural Norms :** Cultural and societal expectations also affect sleep. Some people perceive sleep as a luxury to be indulged in when they are not too busy with “important” activities. While Others view sleep as an absolute necessity. The amount of sleep that a person considers to be necessary is partially determined by the attitudes of family and culture. ## Alteration in Sleep Patterns Sleep pattern disturbance can be defined as: The state in which an individual experiences or is at risk of experiencing a change in the quantity or quality of his or her rest/ sleep pattern as related to the person's biological and emotional needs. Alterations in sleep patterns are generally viewed as either primary sleep disorders (those in which the sleep alteration is the fundamental problem) or secondary sleep disorders (those in which the alteration has a medical or clinical cause that results in or contributes to the sleep alteration). The most common sleep alterations include insomnia, hypersomnia or narcolepsy, sleep apnea, sleep deprivation, and parasomnias. ## Definition of Terms - **Insomnia:** Refers to the chronic inability to sleep or inadequate quality of sleep due to sleep prematurely ended or interrupted by periods of wakefulness. Insomnia is not a disease, but it may be a manifestation of many illnesses. - **Hypersomnia:** is an alteration in sleep pattern characterized by excessive sleep, especially in the daytime. Persons suffering from hypersomnia often feel that they cannot get enough sleep at night, and therefore they sleep very late into the morning and nap several times. - **Parasomnias:** This refers to sleep alterations resulting from “an activation of physiological systems at inappropriate times during the sleep-wake cycle" - **Sleep deprivation:** Is a term used to describe prolonged inadequate quality and quantity of sleep, either of the REM or the NREM type. Sleep deprivation can result from age, prolonged hospitalization, drug and substance use, illness, and frequent changes in lifestyle patterns - **Sleep apnea:** Refers to periods of sleep during which airflow stops for 10 seconds or more. - **Narcolepsy:** This is another form of sleep alteration that manifests as sudden uncontrollable urges to fall asleep during the daytime. Individuals often achieve adequate sleep at night but are overwhelmed by sleepiness at unexpected and unpredictable periods during the day ## Role of Nurses - Establish a Trusting Nurse-Client Relationship - Ensure Appropriate Nutrition - Create a Relaxing Environment - Initiate Relaxation Techniques - Provide Client Education - Initiate Pharmacologic Interventions - Ensure Appropriate Nutrition ## Alternative methods that promote sleep - Massage - Imagery - Meditation Herbal: Chamomile Hops Lavender Kava Passion flower Skullcap - Aromatherapy: Chamomile oil Lavender oil ==End of OCR==