Nursing Process for Client with Loss
Loss in actual or potential situation in which something that is valued is changed, no longer available, or gone. People can experience the loss of body image, a significant other, a sense of well-being, a job, personal possessions, beliefs, or a sense of self. Illness and hospitalization often produce losses.
Death is fundamental loss, both for the dying person and for those who survive. Although death is inevitable, it can stimulate people to grow in their understanding of themselves and others. Death can be viewed as the dying person's final opportunity to experience life in ways that bring significance and fulfillment. People experiencing loss often search for the meaning of the event and it is generally accepted that finding meaning is needed in order for healing to occur.
TYPES OF LOSSES
A helpful way to examine different types of losses is to use Abraham Maslow (1954), a hierarchy of needs motivates human actions. These needs begin with physiologic needs (foods, air, water, sleep), then safety needs (a safe place to live and work), then security and belonging needs (satisfying relationships). After those needs comes the need for self-esteem, which leads to feelings of adequacy and confidence. The last and final need is self-actualization, the ability the realizeone’s full innate potential. When these human needs are taken away or not met for some reason, the person experiances loss. Examples of losses related spesicific human needs in Maslow’s hierarchy are as follows:
· Physiologic loss. Examples include amputation and loss of adequate air exchange or pancreatic functioning.
· Safety loss. Loss of a save environment such as following domestic or public violence. A person may perceive a breach of confidentiality in the professional relationship as a loss of psychogical safety secondary to broken trust between client and provider.
· Loss of security and a sense og belonging. The loss of a loved one affects the need to love and be loved. Loss accompanies changes in relationships such as birth, marriage, divorce, illnes, and death: as the meaning of a relationships changes, a person may lose roles within a family or group.
· Loss of self – esteem. Any change in how a person is valued at work or in relationships can threaten his or her need for self – esteem. A change in self – perception can challenge sense of self – worth, which the person may experience as a loss. A loss of role function and the self – perception and worth tied to that role may accompany the death of a loved one.
· Loss related to self – actualization. An external or internal crisis that blocks or inhibits strivings toward fulfillment may threaten personal goals and individual potential (Parkes, 1998). A change in goals or direction will precipitate an inevitable period of grief as the person gives up a creative thought to make room for new ideas and directions. Examples include having to give up plants to attend graduate school or losing the hope of marriage and family.
FACTORS INFLUENCING THE LOSS AND GRIEF RESPONSES :
1. Age
Age effects a persons understanding of and reaction to loss. With familiarity, people usually increase their understanding and acceptance of life, loss, and death.
People do not usually experiences is difficult. Coping with other of life’s losses, such as the loss of a pet, the loss of friend, and the loss of youth or a job, can help people anticipate the more severe loss of death of loved ones by teaching them successful coping strategies.
· Childhood
Children differ from adults not only in their understanding of loss and death but also in how they are affected by the loss of others. The loss of a parent or other significant person can threaten the child’s ability to develop, and regression sometimes results.
Some adults may assume that children do not have the same need as an adult to grieve the loss of others. In situations of crisis and loss, children are sometimes pushed aside or protected from the pain. The can feel afraid, abandoned, and lonely. Careful work with bereaved children is especially necessary because experiencing a loss in childhood can have serious effects later in life.
· Early and Middle Adulthood
The loss of a parent through death seems a more normal occurrence compared to the death of a younger person. The middle-aged adult can experiences losses other than death. For example, losses resulting from impaired health or body function and losses of various role functions can be difficult for the middle-aged adult.
How the middle-aged adult responds to such losses of various role functions can be difficultfor middle-aged adult.
· Late Adulthood
Losses experienced by older adults include loss of helath, mobility, independence, and work role. Limited income and the need to change one’s living accommodations can also lead to feelings of loss and grieving.
2. Significance of the Loss
The significance of a loss depends on the perceptions of the individual experiencing the loss. One person may experience a great sense of loss over a divorce; another may find it only mildly disrupting. A number of factors affect the significance of the loss:
- Importance of the lost person, object, or function
- Degree of change required because of the loss
- The person’s beliefs and values
For older people who have already encountered many losses, an anticipated loss such as their own death may not be viewed as highly negative, and they may be apathetic about it instead of reactive. More than fearing death, some may fear loss of control or becoming a burden.
3. Culture
Culture influences an individual’s reaction to loss. How grief is expressed is often determined by the custom of the culture. The death family member in a typical nuclear family leaves a great void because the same few individuals fill most of the roles. Some persons have adopted the belief that grief is a private matter to be endured internally. Therefore, feelings tend to be repressed and may remain unidentified. People who have been socialized to “be strong” and “make the best of the situation” may not express deep feelings or personal concerns when they experience a serious loss.
Some cultural group value social support and the expression of loss. In some groups, the expression of grief through wailing, crying, physical prostration, and other outward demonstration are acceptable and encouraged. Other groups may frown on this demonstration as a loss of control, favoring a more quite and stoic expression of grief.
4. Spiritual Beliefs
Spiritual beliefs and practices greatly influence both a person’s reaction to loss and subsequent behavior. Most religious groups have practices related to dying, and these are often important to the client and support people. To provide support at a time of death, nurses need to understand the client’s particular beliefs and practices.
5. Gender
The gender roles into which many people are socialized in the United States ans Canada affect their reactions at times of loss. Men are frequently expected to be “strong” and show very little emotion during grief, whereas it is acceptable for women to show grief by crying. Often a wife dies, the husband, who is the chief mourner, is expected to repress his own emotions and to comfort sons and daughters in their grieving. Gender roles also affect the significance of body image changes to clients.
6. Socioeconomic Status
The socioeconomic status of an individual often affects the support system available at the time of a loss. A pension plan or insurance, for example, can offer a widowed or disabled person a choice of ways to deal with a loss; a person who is confronted with both severe loss and economic hardship may not be able to cope with either.
7. Support System
The people closest to the grieving individual are often the first to recognize and provide needed emotional, physical, and functional assistance. However, because many people are uncomfortable or inexperienced in dealing with losses, the usual support people may instead withdraw from the grieving individual. Support may be available when the loss is first recognized, but as the support people return to their usual activities, the need for ongoing support may be unmet. Sometimes, the grieving individuals is unable or unready to accept support when its offered.
8. Causes of loss or Death
Individual and societal views on the cause of a loss or death may significantly influence the grief response. A loss or death that is beyond the control of those involved may be more acceptable that one that is preventable, such as a drunk driving accident. Injuries or death occurring during respected activities, such as “in the line of duty,”are considered honorable, whereas those occurring during illicit activities may be considered the individuals just reward.
APPLICATION OF THE NURSING PROCESS
Because the strong emotional attachment created in a significant relationship is not released easily, the loss of that relationship is a major crisis with momentous consequences. Aquilera and Messick (1982) developed a broad approach to assesment and intervention in their work on crisis intervention. The state of disequilibrium that a crisis produces causes great consternation, compelling the person to return to homeostasis, a state of equilibrium or balance.
NURSING MANAGEMENT
1. Assessment
Nursing assessment of the client experiencing a loss includes three major components:
a. Nursing history
b. Assessment of personal coping resources
c. Physical assessment
Assessment Interview
Previous Lossess
· Have you ever lost someone or something very important to you ?
· Have you or family ever moved your home ?
· What was it like for you when you first started school ?
Moved away from home ? Got a job ? Retired ?
· Are you physically able to do all the things you used to do ?
· Has anyone important or close to you died ?
· Do you think there will be any losses in yor life in the near future ?
If there is a current loss :
· What have you been told about (the loss) ? Is ther anything else you would like to know or don’t understand ?
· What changes do you thing this (illness, surgery, problem) will cause in your life? What do you think it will be like without (the lost object) ?
· Have u ever experience a loss like this before ?
· Can you think of anything good that might come out of this ?
· What kind of help do you think you will need ? Who Is going to be helping you with this loss ?
· Are there any people or organizations in your community that might be able to help ?
Effective assessment involves observing all dimensions of human response: what the person is thinking (cognitive), how the person is feeling emotional), what the person’s values and beliefs are (spiritual), how the person is acting (behavioral), and what is happening in the person’s body (physiological). Effective communication skills during assessment can lead the client toward understanding his or her experience. Thus assessment facilitates the client’s grief process.
While observing for client responses in the dimensions of grieving, the nurse explores three critical components in assessment:
· Adequate perception regarding the loss
· Adequate support while grieving for the loss
· Adequate coping behaviors during the process
Perception of the Loss
Assessment begins with exploration of the client’s perception of the loss. What does the loss mean to the client? For the woman who has spontaneously lost her first unborn child and the woman who has elected to abort a pregnancy, this question could have similar or different answers. Nevertheless the question is valuable for beginning ti facilitate the grief process.
Other questions that assess perception as well as encourage the client’s movement through the grief process include the following:
· What does the client think and feel about the loss?
· How is the loss going to affect the client’s life?
· What information does the nurse need to clarify or share with the client?
Assessing the client’s “need to know” in plain and simple languange invites the client to verbalize perceptions that may need clarification. This is especially true for the person who is anticipating a loss such as in a life-ending illness on the loss of a body part. The nurse uses open-ended questions and helps to clarify any misperceptions.
Support
Purposeful assesment of support system provides the grieving client with an awereness of those who can meet his or her emotional and spiritual need for security and love. The nurse can help the client to identify his or her support systems and reach out and accept whta they can offer.
Coping Behaviors
The client’s behavior is likely to give the nurse the easist and most conerete information about coping skills. The nurse must be careful to observe the client’s behaviors throughout the giref process and never assume that a client is at a particular phase. The nurse must use effective communication skills to well as emotions and thoughts.
The nurse also must cinsider several other questiuons when assesing the client’s coping. How has the person dealt with loss previosly? How is the person currently impaired? How does the current experience compare with previous experiences? What does the client perceive as a problem? Is it related to unrealistic ideas about what he or she should feel or do? (McBride, 2001)
The interaction of the dimensions of human response is fluid and dynamic. What a person thinks about during griefing affects his or her behavior. The critical factors of perception, support, and coping are interrelated as well and provide a framework for assesing and assisting the client.
2. Diagnosing
Nursing diagnoses (NANDA, International, 2003) relating specifically to grieving include the following :
a. Anticipatory Grieving: Intellectual and emotional responses and behaviors by which individuals, families, communities work through the process of modifying self concepts based on the perception of potential of loss.
b. Dysfunctional Grieving : Extended, unsuccessful use of intellectual and emotional responses and behaviors by which individuals, families, communities attempt to work through the process of modifiying self concept based on the perception of loss.
Other diagnoses may include:
a. Interrupted family processe if the loss has such impact on the individual and family that ususal effective roles and interactions are negatively affected.
b. Impaired adjustment if the client has great difficulty placing the loss in appropriate to his or her other life activities.
c. Risk for loneliness related to the loss of relationships with others.
3. Intervention
Interventions Regarding The Perception of Loss
Cognitive responses are connected significantly with the intense emotional turmoil that accompanies grieving. For example in the vignette, Margaret’s disillusionment with those friends unavailable after her husband’s death added great pain to her loss. She had counted on them to be there as she dealt with James’ death. A cognitive shift occurred when she realized they would not be there, meaning she was alone and they no longer cared. She felt abandoned. She then had two immediate losses: Jammes’ death and realizing that people she had counted on were unavailable.
Exploring the client’s perception and meaning of the loss is a first step that can help alleviate the pain of what some would call the initial emotioonal overload in grieving. Using the example of Margaret, the nurse could ask what being alone means to her and explore the possibility of others being supportive. Further exploration could focus on her perception that those who had abandoned her no longer cared. Perhaps Margaret would then discover that others could meet her need to be cared for. She begin to think that it was fear or discomfort about death that kept farmer friends away. In fact, it was in just this way that she could accept the caring of some friends and release the importance of those who would not or could not be there for her. In this situation, exploring perceptions and the meaning of the loss helped the bereaved to make cognitive shifts that valuably influenced her emotional experience.
When loss occurs, especially if it is sudden and without warning, the cognitive defense mechanism of denial acts as a cushion to soften the effects. Typical verbal responses are,”I can’t believe this has happened. It can’t be true. There’s been a mistake.
Interventions Regarding Coping Behaviors
When attempting to focus Ms. Morrison on the reality of her surgery, the nurse was helping her shift from an unconscious mechanism of denial to conscious coping with reality. The nurse used communication skills to encourage ms. Morrison to examine her experience and behavior as possible ways in which she might be coping with the news of loss. Margaret and James’s logical approach to life allowed them to cope by continuing to have fun together while attending to medical regimens as they faced the reality of this impending death.
Intervention involves giving the client the oportunity to compare and contrast ways in which he or she has coped witg signifinicant loss in the past and helping him or her to review strengths and renew a sense of personal power. Remembering and practicing old behaviors in a new situation may lead to experimentation with new methods and self – discovery. Having an historical perspective helps the person’s grief work by allowing shifts in thinking about himself or herself, the loss, and perhaps the meaning of the loss. Margaret’s religious practices of prayer and spiritual reading helped her to discover new depths of meaning and purpose in her life.
Encouraging the client to care for himself or herself is another intervention that helps the client cope. The nurse can offer food without pressuring the client to eat. Being careful to eat, sleep well, exercise, and to take time for comforting activities are ways that the client can nourish himself or herself. Just as the tired hiker needs to stop, rest, and replenish himself or herself, so must the bereaved person take a break from the exhausting process of grieving. Going back to a routine of work or focusing on other members of the family may provide the respite. Volunteer activities — volunteering at a hospice or botanical garden, taking part in church activities, or speaking to bereavement education groups, for example — can affirm the client’s talents and abilities and can renew feelings of self – worth.
Communication and interpersonal skills are tools of the effective nurse, just like a stethoscope, scissors, and gloves. The client trusts that the nurse will have what it takes to assist him or her in grieving. In addition to previously mentioned sills, these tools include the following:
- Use simple, nonjudgmental statements to acknowledge loss: “I want you to know I’m thinking of you.”
- Refer to a loved one or object of loss by name (if acceptable in the client’s culture).
- Words are not always necessary; a light touch on the elbow, shoulder, or hand or just being there indicates caring.
- Respect the client’s unique process of grieving.
- Respect the client’s personal beliefs.
- Be honest, dependable, consistent, and worthy of the client’s trust.
4. Planning
The overall goals for clients:
a. To adjust to the changed ability
b. To redirect both physical and emotional energy into rehabilitation
c. To remember that person without feeling intense pain
d. To redirect emotional energy into one’s own life and adjust to the actual or impending loss.
Planning Home Care
Clients who have sustained or anticipate a loss may require ongoing nursing care to assist them in adapting to the loss:
· The determination of how much and what type of home care follow-up is needed is based in great part on the nurse’s knowledge of how the client and family have coped with previous losses.
· In preparation, the nurse reassesses the client’s abilities and needs.
5. Implementing
Stages Nursing Implication :
1. Denial
a. Verbally support client’s denial for its protective function.
b. Examine own behavior to ensure not sharing in client’s denial.
2. Anger
a. Help client understand that anger is a normal response to feelings of loss and powerlessness.
b. Avoid withdrawal or retaliation with anger; do not take anger personality.
c. Deal with needs underlying any angry reaction.
d. Provide structure and continuity to promote feelings of security.
e. Allow client as much control as possible over life.
3. Bargaining
a. Listen attentively, and encourage client to talk to relieve guilt and irrational fears.
b. If appropriate, offer spiritual support.
4. Depression :
a. Allow client to express sadness.
b. Communicate noverbally by sitting quietly without expecting conversation.
c. Convery caring by touch, if appropriate.
d. Help persons understand importance of being with client in silence.
5. Acceptance :
a. Help family and friends understand client’s reduced need to socialize and need for short, quite visits.
b. Encourage client to participate as much as possible in the treatment program.
6. Evaluating
• Did the client has been spontaneously express his/her feelings?
• Did the client can explained the loss meaning of his/her life?
• Did the clinet had a support system to expressed the feeling (friends,families,groups, and other communities)?
• Did the client have had acceptance signs?
• Did the client can respected a new relationship with pther person?
References :
Kozier,Barbara,et all. Fundamental Of Nursing Concepts, Process and Practise. Seventh Edition. Pearson Prentice Hall.
Stuart, G.W. & Sundeen S.J. 1995. Principle and Practice of Psychiatric Nursing. St. Louis, Missiouri: Mosby Year Book.
Varcarolis, Elizabeth M. 1999. Foundations of Psychiatric-Mental Health Nursing. 2nd ed. Philadelphia: W.B.Saunder Company.
Videbeck, Sheila L. 2004. Psychiatric Mental Health Nursing. Second Edition. Philadelphia: Lippincot Williams & Wilkins.
Yosep, Iyus. 2009.Keperawatan Jiwa Edisi Revisi. Bandung : Refika Aditama.
