DIMENSIONS (RESPONSES) AND SYMPTOMS OF THE GRIEVING CLIENT

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DIMENSIONS (RESPONSES) AND SYMPTOMS OF THE GRIEVING CLIENT

DIMENSIONS (RESPONSES) AND SYMPTOMS OF THE GRIEVING CLIENT
DIMENSIONS (RESPONSES) AND SYMPTOMS OF THE GRIEVING CLIENT

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Assessing the client’s “need to know” in plain and simple language invites the client to verbalize perceptions that may need clarification. This is especially true for the person who is anticipating a loss, such as one

facing a life-ending illness or the loss of a body part. The nurse uses open- ended questions and helps to clarify any misperceptions.

Three major areas to explore when assessing a grieving client

Consider the following. The doctor has just informed Ms. Morrison that the lump on her breast is cancerous and that she can be scheduled for a mastectomy in 2 days. The nurse visits the client after rounds and finds her quietly watching television.

Nurse: “How are you?” (offering presence; giving a broad opening) Client: “Oh, I’m fine. Really, I am.” Nurse: “The doctor was just here. Tell me, what is your

understanding of what he said?” (using open-ended questions for

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description of perception) Client: “Well, I think he said that I will have to have surgery on my

breast.” Nurse: “How do you feel about that news?” (using open-ended question

for what it means to the client)

Exploring what the person believes about the grieving process is another important assessment. Does the client have preconceived ideas about when or how grieving should happen? The nurse can help the client realize that grieving is very personal and unique: each person grieves in his or her own way.

Later in the shift, the nurse finds Ms. Morrison hitting her pillow and crying. She has eaten little food and has refused visitors.

Nurse: “Ms. Morrison, I see that you are upset. Tell me, what is happening right now?” (sharing observation; encouraging description)

Client: “Oh, I’m so disgusted with myself. I’m sorry you had to see me act this way. I should be able to handle this. Other people have lost their breasts to cancer, and they are doing OK.”

Nurse: “You’re pretty upset with yourself, thinking you should feel differently.” (using reflection)

Client: “Yes, exactly. Don’t you think so?” Nurse: “You’ve had to deal with quite a shock today. Sounds to me like

you are expecting quite a bit of yourself. What do you think?” (using reflection; sharing perceptions; seeking validation)

Client: “I don’t know, maybe. How long is this going to go on? I’m a wreck emotionally.”

Nurse: “You are grieving, and there is no fixed timetable for what you are dealing with. Everyone has a unique time and way of doing this work.” (informing; validating experience)

Support Purposeful assessment of support systems provides the grieving client with an awareness of those who can meet his or her emotional and spiritual needs for security and love. The nurse can help the client to identify his or her support systems and reach out and accept what they can offer.

Nurse: “Who in your life should or would really want to know what you’ve just heard from the doctor?” (seeking information about situational support)

Client: “Oh, I’m really alone. I’m not married and don’t have any

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relatives in town.” Nurse: “There’s no one who would care about this news?” (voicing

doubt) Client: “Oh, maybe a friend I talk with on the phone now and then.”

Coping Behaviors The client’s behavior is likely to give the nurse the easiest and most concrete information about coping skills. The nurse must be careful to observe the client’s behavior throughout the grief process and never assume that a client is at a particular phase. The nurse must use effective communication skills to assess how the client’s behavior reflects coping as well as emotions and thoughts.

The following day, the nurse has heard in report that Ms. Morrison had a restless night. She enters Ms. Morrison’s room and sees her crying with a full tray of food untouched.

Nurse: “I wonder if you are upset about your upcoming surgery.” (making an observation, assuming client was crying as an expected behavior of loss and grief)

Client: “I’m not having surgery. You have me mistaken for someone else.” (using denial to cope)

The nurse must also consider several other questions when assessing the client’s coping. How has the person dealt with loss previously? 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? The interaction of the dimensions of human response is fluid and dynamic. What a person thinks about during grieving affects his or her feelings, and those feelings influence his or her behavior. The critical factors of perception, support, and coping are interrelated as well and provide a framework for assessing and assisting the client.

Data Analysis and Planning The nurse must base nursing diagnoses for the person experiencing loss on subjective and objective assessment data. Nursing diagnoses used for clients experiencing grief include

• Grieving • Complicated grieving • Risk for complicated grieving

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• Anticipatory grieving

Outcome Identification Examples of outcomes are as follows.

The client will

• Identify the effects of his or her loss. • Identify the meaning of his or her loss. • Seek adequate support while expressing grief. • Develop a plan for coping with the loss. • Apply effective coping strategies while expressing and assimilating all

dimensions of human response to loss in his or her life. • Recognize the negative effects of the loss on his or her life. • Seek or accept professional assistance if needed to promote the grieving

process.

Interventions The nurse’s guidance helps the client examine and make changes. Changes imply movement as the client progresses through the grief process. Sometimes the client takes one painful step at a time. Sometimes he or she may seem to go over the same ground repeatedly.

Exploring the Perception of Loss Cognitive responses are connected significantly with the intense emotional turmoil that accompanies grieving. 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 emotional overload in grieving. The nurse might ask what being alone means to the person and explore the possibility of others being supportive. It is particularly important that the nurse listens to whatever emotions the person expresses, even if the nurse doesn’t “agree” with the feelings. For example, anger at the deceased person or God, or criticism of others who aren’t “there for me” or supportive enough, may seem unjustified to the nurse. But it is essential to accept the person’s feelings without trying to dissuade them from feeling angry or upset. The nurse needs to encourage the person to express any and all feelings without trying to calm or placate them.

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,”

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“It can’t be true,” and “There’s been a mistake.” Adaptive denial, in which the client gradually adjusts to the reality of

the loss, can help the client let go of previous (before the loss) perceptions while creating new ways of thinking about himself or herself, others, and the world. While taking in the loss in its entirety all at once seems overwhelming, gradually dealing it in smaller increments seems much more manageable. The person may have had assumptions about how others should act or respond to the loss—but those assumptions prove incorrect.

Effective communication skills can be useful in helping the client in adaptive denial move toward acceptance. Note the intervention the nurse makes in the scenario with Ms. Morrison. The nurse enters Ms. Morrison’s room and sees her crying and her full tray of food untouched.

Nurse: “You must be quite upset about the news you received from your doctor about your surgery.” (using reflection, assuming the client was crying as an expected response of grief; focusing on the

surgery is an indirect approach regarding the subject of cancer) Client: “I’m not having surgery. You have me mistaken for someone

else.” (using denial) Nurse: “I saw you crying and wonder what is upsetting you. I’m

interested in how you are feeling.” (focusing on behavior and sharing observation while indicating concern and accepting the client’s denial)

Client: “I’m just not hungry. I don’t have an appetite, and I’m not clear about what the doctor said.” (focusing on physiologic response; nonresponsive to nurse’s encouragement to talk about feelings; acknowledging doctor’s visit, but unsure of what he said—beginning to adjust cognitively to reality of condition)

Nurse: “I wonder if not wanting to eat may be related to what you are feeling. Are there times when you don’t have an appetite and you feel upset about something?” (suggesting a connection between physiologic response and feelings; promoting adaptive denial)

Client: “Well, as a matter of fact, yes. But I can’t think what I would be upset about.” (acknowledging a connection between behavior and feeling; continuing to deny reality)

Nurse: “You said you were unclear about what the doctor said. I wonder if things didn’t seem clear because it may have upset you to hear what he had to say. And now, tonight, you don’t have an appetite.” (using client’s experience to make connection between doctor’s news and client’s physiologic response and behavior)

Client: “What did he say, do you know?” (requesting information;

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demonstrating a readiness to hear it again while continuing to adjust to reality)

In this example, the nurse gently but persistently guides the client toward acknowledging the reality of her impending loss.

Obtaining Support The nurse can help the client to reach out and accept what others want to give in support of his or her grieving process. Note the assessment is developed into a plan for support.

Nurse: “Who in your life would really want to know what you’ve just heard from the doctor?” (seeking information about situational support for the client)

Client: “Oh, I’m really alone. I’m not married.” Nurse: “There’s no one who would care about this news?” (voicing

doubt) Client: “Oh, maybe a friend I talk with on the phone now and then.” Nurse: “Why don’t I get the phone book for you, and you can call her

right now?” (continuing to offer presence; suggesting an immediate source of support, developing a plan of action providing further support)

Many Internet resources are available to nurses who want to help a client find information, support groups, and activities related to the grieving process. Using the search words “bereavement” and “hospice,” the nurse can link to numerous organizations that provide support and education throughout the United States. If a client does not have Internet access, most public libraries can help to locate groups and activities that would serve his or her needs. Depending on the state in which a person lives, specific groups exist for those who have lost a child, spouse, or other loved one to suicide, murder, motor vehicle crash, or cancer.

Promoting 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.

Intervention involves giving the client the opportunity to compare and contrast ways in which he or she has coped with significant 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

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situation may lead to experimentation with new methods and self- discovery. Having a 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.

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 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 that 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 skills, these tools include the following:

• Using simple nonjudgmental statements to acknowledge loss: “I want you to know I’m thinking of you.”

• Referring to a loved one or object of loss by name (if acceptable in the client’s culture).

• Remembering words are not always necessary; a light touch on the elbow, shoulder, or hand or just being there indicates caring.

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Nurses’ tools

• Respecting the client’s unique process of grieving. • Respecting the client’s personal beliefs. • Being honest, dependable, consistent, and worthy of the client’s trust.

A welcoming smile and eye contact from the client during intimate conversations usually indicate the nurse’s trustworthiness, but the nurse must be aware that nonverbal behaviors may have different meanings or connotations in other cultures.