Loss, Grief and End-of-Life Care

People are complex,

biopsychosocial beings. When they become ill, undergo diagnosis for altered
health states, experience a loss, or progress into the end stage of life, their
responses are the result of the complex interaction of biopsychosocial changes
that occur. Because we live in a culture marked by dramatically different
responses to the experiences of loss and grief, nurses often feel inadequate in
planning interventions to facilitate grief management and the healing process.

A. Loss

The concept of loss can be defined in several ways. The following definitions
have been selected to familiarize the student with the concept of loss:

1. Change in status of a significant object

2. Any change in an individual's situation that reduces the
probability of achieving implicit or explicit goals
3. An actual or potential situation in which a valued object, person,
or other aspect is inaccessible or changed so that it is no longer
perceived as valuable
4. A condition whereby an individual experiences deprivation of, or
complete lack of, something that was previously present

Everyone has experienced some type of major loss at one time or another.
Clients with psychiatric disorders, such as depression or anxiety, commonly
describe the loss of a spouse, relative, friend, job, pet, home, or personal item.

 Types of Loss ;
A loss may occur suddenly (eg, death of a child due to an auto accident) or
gradually (eg, loss of a leg due to the progression of peripheral vascular
disease). It may be predictable or occur unexpectedly. Loss has been referred
to as actual (the loss has occurred or is occurring), perceived (the loss is
recognized only by the client and usually involves an ideal or fantasy),
anticipatory (the client is aware that a loss will occur), temporary, or
permanent.

For example, a 65-year-old married woman with the history of end stage renal
disease is told by her physician that she has approximately 12 months to live.
She may experience several losses that affect not only her, but also her
husband and family members, as her illness gradually progresses. The losses
may include a predictable decline in her physical condition, a perceived
alteration in her relationship with her husband and family, and a permanent
role change within the family unit as she anticipates the progression of her
illness and actual loss of life.

Whether the loss is traumatic or temperate to the client and her family
depends on their past experience with loss; the value the family members
place on the loss of their mother/wife; and the cultural, psychosocial,
economic, and family supports that are available to each of them. Box 6-1
describes losses identified by student nurses during their clinical experiences.

 Examples of Losses Identified by Student Nurses

1. Loss of spouse, friend, and companion. The client was a 67-year-

old woman admitted to the psychiatric hospital for treatment of
depression following the death of her husband. During a group
discussion that focused on losses, the client stated that she had been
married for 47 years and had never been alone. She described her
deceased husband as her best friend and constant companion. The
client told the student and group that she felt better after expressing
her feelings about her losses.
 2. Loss of physiologic function, social role, and independence
because of kidney failure. A 49-year-old woman was admitted to the
hospital for improper functioning of a shunt in her left forearm. She
was depressed and asked that no visitors be permitted in her private
room. She shared feelings of loneliness, helplessness, and hopelessness
with the student nurse as she described the impact of kidney failure
and frequent dialysis treatment on her lifestyle. Once an outgoing,
independent person, she was housebound because of her physical
condition and presented what her kidneys were doing to her.

B. Grief

Grief is a normal, appropriate emotional response to an external and

consciously recognized loss. It is usually time-limited and subsides gradually.
Staudacher (1987, p. 4) refers to grief as a “stranger who has come to stay
in both the heart and mind.â€‌ Mourning is a term used to describe an
individual's outward expression of grief regarding the loss of a love object or
person.

The individual experiences emotional detachment from the object or person,

eventually allowing the individual to find other interests and enjoyments.
Some individuals experience a process of grief known as bereavement (eg,
feelings of sadness, insomnia, poor appetite, deprivation, and desolation). The
grieving person may seek professional help for relief of symptoms if they
interfere with activities of daily living and do not subside within a few months
of the loss.

The grief process is all-consuming, having a physical, social, spiritual, and

psychological impact on an individual that may impair daily functioning.
Feelings vary in intensity, tasks do not necessarily follow a particular pattern,
and the time spent in the grieving process varies considerably from weeks to
years (Schultz & Videbeck, 2002).
 Five Stages of Grief Identified by Kubler-Ross

1. Denial: During this stage the person displays a disbelief in the

prognosis of inevitable death. This stage serves as a temporary escape
from reality. Fewer than 1% of all dying clients remain in this stage.
Typical responses include: No, it can't be true, It isn't possible, and No,
not me. Denial usually subsides when the client realizes that someone
will help him or her to express feelings while facing reality.

2. Anger: Why me? Why now? and it's not fair! are a few of the
comments commonly expressed during this stage. The client may
appear difficult, demanding, and ungrateful during this stage.

3. Bargaining: Statements such as; If I promise to take my

medication, will I get better? or If I get better, I'II never miss church
again? are examples of attempts at bargaining to prolong one's life. The
dying client acknowledges his or her fate but is not quite ready to die at
this time. The client is ready to take care of unfinished business, such
as writing a will, deeding a house over to a spouse or child, or making
funeral arrangements as he or she begins to anticipate various losses,
including death.

4. Depression: This stage is also a very difficult period for the

family and physician because they feel helpless watching the depressed
client mourn present and future losses. The dying patient is about to
lose not just one loved person but everyone he has ever loved and
everything that has been meaningful to him. (Kubler-Ross, 1971, p. 58).

5. Acceptance: At this stage the client has achieved an inner and

outer peace due to a personal victory over fear: “I'm ready to die. I
 have said all the goodbyes and have completed unfinished business.
During this stage, the client may want only one or two significant
people to sit quietly by the client's side, touching and comforting him or
her.

Several authors have described grief as a process that includes various stages,
characteristic feelings, experiences, and tasks. Staudacher (1987) states there
are three major stages of grief: shock, disorganization, and reorganization.

Westberg (1979) describes ten stages of grief work, beginning with the stage of
shock and progressing through the stages of expressing emotion, depression
and loneliness, physical symptoms of distress, panic, guilt feelings, anger and
resentment, resistance, hope, and concluding with the stage of affirming
reality.

Kubler-Ross (1969) identifies five stages of the grieving process including

denial, anger, bargaining, depression, and acceptance; however, progression
through these stages does not necessarily occur in any specific order. Her
basic premise has evolved as a result of her work with dying persons.

C. End-of-Life Care

End-of-life care refers to the nursing care given during the final weeks of
life when death is imminent. The American culture is marked by dramatically
different responses to the experience of death. On one hand, death is denied
or compartmentalized with the use of medical technology that prolongs the
dying process and isolates the dying person from loved ones.

On the other hand, death is embraced as a frantic escape from apparently

meaningless suffering through means such as physician-assisted suicide. Both
require compassionate responses rooted in good medical practice and
personal religious beliefs.

The Patient Self-Determination Act (PSDA), passed in 1990, states that every
competent individual has the right to make decisions about his or her health
care and is encouraged to make known in advance directives (AD; legal
documents specifying care) end-of-life preferences, in case the individual is
unable to speak on his or her own behalf (Allen, 2002; Robinson & Kennedy-
Schwarz, 2001).

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Nursing Diagnosis: Anticipatory Grieving

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

 Caregiver Emotional Health

 Family Coping

 Grief Resolution

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

 Grief Work Facilitation

 Presence

 Emotional Support

NANDA Definition: Intellectual and emotional responses and behaviors by which

individuals, families, communities work through the process of modifying self-
concept based on the perception of potential loss

Anticipatory grieving is a state in which an individual grieves before an actual

loss. It may apply to individuals who have had a perinatal loss or loss of a body
part or to patients who have received a terminal diagnosis for themselves or a
loved one. Intense mental anguish or a sense of deep sadness may be
experienced by patients and their families as they face long-term illness or
disability. Grief is an aspect of the human condition that touches every individual,
but how an individual or a family system responds to loss and how grief is
expressed varies widely. That process is strongly influenced by factors such as
age, gender, and culture, as well as personal and intrafamilial reserves and
strengths. The nurse must recognize that anticipatory grief is real grief and that,
in all likelihood, as the loss actually occurs, it will evolve into grief based on an
accomplished event. The nurse will encounter the patient and family experiencing
anticipatory grief in the hospital setting, but increasingly, with more hospice
services provided in the community, the nurse will find patients struggling with
these issues in their own homes where professional help may be limited or
fragmented. This care plan discusses measures the nurse can use to help patient
and family members begin the process of grieving.

Defining Characteristics:
  Patient and family members express feelings reflecting a sense of
loss
 Patient and family members begin to manifest signs of grief
 Denial of potential loss
 Sorrow
 Crying
 Guilt
 Anger or hostility
 Bargaining
 Depression
 Acceptance
 Changes in eating habits
 Alteration in activity level
 Altered libido
 Altered communication patterns
 Fear
 Hopelessness
 Distortion of reality

Related Factors:

 Perceived potential loss of any sort

 Perceived potential loss of physiopsychosocial well-being
 Perceived potential loss of personal possessions

Expected Outcomes

 Patient or family verbalizes feelings, and establishes and maintains

functional support systems.

Ongoing Assessment

• Identify behaviors suggestive of the grieving process (see

Defining Characteristics). Manifestations of grief are strongly
influenced by factors such as age, gender, and culture. What the
health care provider observes is a product of these feelings after
they have been modified through these layers. The health care
provider can enter dangerous territory when he or she attempts to
categorize grief as appropriate, excessive, or inappropriate. Grief
simply is. If its expression is not dangerous to anyone, then it is
normal and appropriate.

• Assess stage of grieving being experienced by patient or

significant others: denial, anger, bargaining, depression, and
acceptance. Although the grief is anticipatory, the patient may
move from stage to stage and back again before acceptance
occurs. This system for categorizing the stages of grief has been
helpful in teaching people about the process of grief.

• Assess the influence of the following factors on coping: past

problem-solving abilities, socioeconomic background, educational
preparation, cultural beliefs, and spiritual beliefs. These factors play a
role in how grief will manifest in this particular patient or family.
The nurse needs to restrain any notion that individuals of a given
 culture or age will always manifest predictable grief behaviors.
Grief is an individual and exquisitely personal experience.

• Assess whether the patient and significant others differ in their

stage of grieving. People within the same family system may
become impatient when others do not reconcile their feelings as
quickly as they do.

• Identify available support systems, such as the following:

family, peer support, primary physician, consulting physician, nursing
staff, clergy, therapist or counselor, and professional or lay support
group. If the patient’s main support is the object of perceived loss,
the patient’s need for help in identifying support is accentuated.

• Identify potential for pathological grieving

response. Anticipatory grief is helpful in preparing an individual to
do actual grief work. Those who do not grieve in anticipation may
be at higher risk for dysfunctional grief.

• Evaluate need for referral to Social Security representatives,

legal consultants, or support groups. It may be helpful to have
patients and family members plugged into these supports as early
as possible so that financial considerations and other special needs
are taken care of before the anticipated loss occurs.

• Observe nonverbal communication. Body language may

communicate a great deal of information, especially if the patient
and his/her family are unable to vocalize their concerns.

Therapeutic Interventions

• Establish rapport with patient and significant others; try to

maintain continuity in care providers. Listen and encourage patient or
significant others to verbalize feelings. This may open lines of
communication and facilitate eventual resolution of grief.

• Recognize stages of grief; apply nursing measures aimed at

that specific stage. Shock and disbelief are initial responses to loss.
The reality may be overwhelming; denial, panic, and anxiety may
be seen.

• Provide safe environment for expression of grief. This

assumes a tolerance for the patient’s expressions of grief (e.g., the
ability to see a man cry, to see mourners make wide gestures with
hands and their bodies, loud vocalizations and crying).

• Minimize environmental stresses or stimuli. Provide the

mourners with a quiet, private environment with no interruptions.

• Remain with patient throughout difficult times. This may

require the presence of the care provider during procedures, difficult
discussions, and conferences with other family members or other
members of the health care team. The patient or family may need a
trusted person present to represent their interest or feelings if
they feel unable to express them. They may require someone to
"witness" with them.

• Accept the patient or the family’s need to deny loss as part of

normal grief process. The nurse needs to see these events as a time
during which the individual or family member consolidates his or
her strength to go on to the next plateau of grief. Other mourners
will need to stop progressing through the process of anticipatory
grief, unable to grieve the loss any further until the loss actually
happens. Realization and acceptance may only occur weeks to
months after loss. Reality may continue to be overwhelming;
sadness, anger, guilt, hostility may be seen.

• Anticipate increased affective behavior. All affective behavior

may seem increased or exaggerated during this time.

• Recognize the patient or family’s need to maintain hope for the

future. They may continue to deny the inevitability of the loss as a
means of maintaining some degree of hope. As the loss begins to
manifest, the mourners start accepting aspects of the loss, piece
by piece, until the whole is actually grasped.

• Provide realistic information about health status without false

reassurances or taking away hope. Defensive retreat can occur weeks
to months after the loss. The patient attempts to maintain what
has been lost; denial, wishful thinking, unwillingness to participate
in self-care, and indifference may be seen.

• Recognize that regression may be an adaptive mechanism. The

sheer volume of emotional reconstituting and reconstruction that
must be accomplished after a loss occurs makes it reasonable to
assume that time to restore energy will be needed at intervals.

• Show support and positively reinforce the patient’s efforts to go

on with his or her life and normal activities of daily living (ADLs), stressing
the strength and the reserves that must be present for the patient and
family to feel enabled to do this.
 Offer encouragement; point out strengths and progress to
date. Patients often lose sight of the achievements while
engaged in the struggle.

This is the same strength and reserve each of them will use to
reconstitute their lives after the loss.

• Discuss possible need for outside support systems (e.g., peer

support, groups, clergy). Acknowledgment occurs months to years
after loss. Patient slowly realizes the impact of loss; depression,
anxiety, and bitterness may be seen. Support groups composed of
persons undergoing similar events may be helpful.

• Help patient prioritize importance of rehabilitation needs. This

allows the health care provider and patient to focus rehabilitative
energy on those things that are of greatest importance to the
patient.

• Encourage patient’s or significant others’ active involvement

with rehabilitation team.

• Continue to reinforce strengths, progress. Adaptation occurs

during the first year or later, after the loss. Patient continues to
reorganize resources, abilities, and self-image. Mourning is a
unique and individual process that occurs over time.
• Recognize patient’s need to review (relive) the illness
experience. This is one way in which the patient or the family
integrates the event into their experience. Telling the event allows
them an opportunity to hear it described and gain some
perspective on the event.

• Facilitate reorganization by reviewing progress. When seen as

a whole, the process of reorganization after a loss seems
enormous, but reviewing the patient’s progress toward that end is
very helpful and provides perspective on the whole process.

• Discuss possible involvement with peers or organizations (e.g.,

stroke support group, arthritis foundation) that work with patient’s medical
condition. Support in the grieving process will come in many forms.
Patients and family members often find the support of others
encountering the same experiences as helpful.

• Recognize that each patient is unique and will progress at own

pace. Time frames vary widely. Cultural, religious, ethnic, and
individual differences affect the manner of grieving.

Carry out the following throughout each stage:

• Provide as much privacy as possible.

• Allow use of denial and other defense mechanisms.

• Avoid reinforcing denial.

• Avoid judgmental and defensive responses to criticisms of

health-care providers.

• Do not encourage use of pharmacological interventions.

• Do not force patient to make decisions.

• Provide patient with ongoing information, diagnosis, prognosis,

progress, and plan of care.

• Involve the patient and family in decision making in all issues

surrounding care. This acknowledges their right and responsibility
for self-direction and autonomy.

• Encourage significant others to assist with patient’s physical

care. The desire to provide care to and for each other does not
disappear with illness; involving the family in care is affirming to
the relationship the patient has with their family.

• When the patient is hospitalized or housed away from home,

facilitate flexible visiting hours and include younger children and extended
family. No individual should be excluded from being with the
patient unless that is the wish of the patient. Hospital guidelines
for visiting serve staff members who organize care more than they
serve patients.

• Help patient and significant others share mutual fears,

concerns, plans, and hopes for each other including the patient. Secrets
are rarely helpful during these times of crisis. An open sharing and
exchange of information makes it easier to address important
issues and facilitates effective family process. These times of
 stress can be used to facilitate growth and family development.
They can be important and sometimes final opportunities for
resolving conflict and issues. They can also be used as times for
potential personal and intrafamilial growth.

• Help the patient and significant others to understand that anger

expressed during this time may be a function of many things and should
not be perceived as personal attacks.

• Encourage significant others to maintain their own self-care

needs for rest, sleep, nutrition, leisure activities, and time away from
patient. Somatic complaints often accompany mourning; changes in
sleep and eating patterns, and interruption of normal routines are
a usual occurrence. Care should be taken to treat these symptoms
so that emotional reconstitution is not complicated by illness.

If the patient’s death is expected:

• Facilitate discussion with patient and significant other on "final

arrangements"; when possible discuss burial, autopsy, organ donation,
funeral, durable power of attorney, and a living will.

• Promote discussion on what to expect when death occurs.

• Encourage significant others and patient to share their wishes

about which family members should be present at time of death.

• Help significant others to accept that not being present at time

of death does not indicate lack of love or caring.

• When hospitalized, use a visual method to identify the patient’s

critical status (e.g., color-coded door marker). This will inform all
personnel of the patient’s status in an effort to ensure that staff do
not act or respond inappropriately to a crisis situation.

• Initiate process that provides additional support and resources

such as clergy or physician.

• Provide anticipatory guidance and follow-up as condition

continues.

Education/Continuity of Care

• Involve significant others in discussions. This helps reinforce

understanding of all individuals involved.

• Refer to other resources (e.g., counseling, pastoral support, or

group therapy). Patient or significant other may need additional
help to deal with individual concerns.

Anxiety
Published on Saturday March 10th , 2007

Anxiety
(_)Actual (_) Potential
Related To:
 [Check those that apply]
(_) Anesthesia
(_) Anticipated/actual pain
(_) Disease
(_) Invasive/noninvasive procedure:_________
_____________________________________
(_) Loss of significant other
(_) Threat to self-concept
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major: [Physiological]
(Must be present) (_) Elevated BP, P, R (_) Insomnia (_) Restlessnes (_) Dry mouth
(_) Dilated pupils (_) Frequent urination (_) Diarrhea
[Emotional]
(_) Patient complains of apprehension, nervousness, tension
[Cognitive]
(_) Inability to concentrate (_) Orientation to past
(_) Blocking of thoughts, hyperattentiveness

Date & Plan and Outcome Target Nursing Interventions Date

Sign. [Check those that apply] Date: [Check those that apply] Achieved:
The patient will: (_) Assist patient to reduce
(_) Demonstrate a decrease in present level of anxiety by:
anxiety A.E.B.: • Provide reassurance
• A reduction in and comfort.
presenting physiological, • Stay with person.
emotional, and/or cognitive • Don't make demands
manifestations of anxiety. or request any decisions.
• Verbalization of relief • Speak slowly and
of anxiety. calmly.
(_) Discuss/demonstrate • Attend to physical
effective coping mechanisms for symptoms. Describe
dealing with anxiety. symptoms:
(_) Other:
• Give clear, concise
explanations regarding
impending procedures.
• Focus on present
situation.
• Identify and reinforce
coping strategies patient has
used in the past.
• Discuss advantages
and disadvantages of
existing coping methods.
• Discuss alternate
strategies for handling
anxiety. (Eg.: exercise,
 relaxation techniques and
exercises, stress
management classes,
directed conversation (by
nurse), assertiveness
training)
• Set limits on
manipulation or irrational
demands.
• Help establish short
term goals that can be
attained.
• Reinforce positive
responses.
• Initiate health
teaching and referrals as
indicated:

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

Greiving
Published on Saturday March 10th , 2007

Greiving
(_)Actual (_) Potential
Related To:
[Check those that apply]
(_) Loss of function of body part:__________________________________
(_) Loss of s/o:________________________________________________
(_) Loss of independence/change in lifestyle.
(_) Diagnosis of a terminal illness.
(_) Loss of physical abilities:_____________________________________
(_) Other:____________________________________________________
____________________________________________________________
____________________________________________________________

As evidenced by:
[Check those that apply]
Major: (_) Unsuccessful adaptation to loss (_) Expressed distress of actual or potential
(Must be present) loss
(_) Prolonged denial (_) Depression (_) Delayed emotional reaction
Minor: (_) Social isolation or withdrawl (_) Failure to develop new relationships/interests
(May be present) (_) Failure to restructure life after a loss (_) Denial (_) Guilt (_) Anger (_) Sorrow
 (_) Change in eating habits (_) Change in sleep patterns (_) Decreased libido
(_) Change in communication patterns

Date & Plan and Outcome Target Nursing Interventions Date

Sign. [Check those that apply] Date: [Check those that apply] Achieved:
The patient will: (_) Assess for causative and
(_) Express his/her grief. contributing factors that may
(_) Describe the meaning of the delay the grief process:
death or loss to him/her. _________________________
(_) Share his/her grief with s/o. _________________________
(_) Participate in ADL's as _________________________
tolerated. (_) Reduce or eliminate
(_) Other: causative or contributing factors
if possible.
(_) Encourage to recognize grief
situation.
(_) Give opportunity for
questions.
(_) Encourage expressions of
anger/concerns.
(_) Describe the stages of
anticipatory grieving. (Include
s.o).
(_) Have patient identify support
systems.
(_) Assist with unfinished
business.
(_) Encourage to share
prognosis with s/o.
(_) Encourage s/o to participate
in care.
(_) Encourage problem solving
with help of others.
(_) Encourage planned, "one
day at a time" living.
(_) Allow patient opportunity to
identify own self care
needs:____________
________________________
________________________
(_) Help to set realistic goals -
give realistic
hope:________________
_________________________
_________________________
(_) Encourage patient and s/o to
accept individual responses to
impending loss.
(_) Refer/order consult:
• Pastoral care
• Social services
• Home health care
• Psychiatry
(_) Other:________________
 ________________________
________________________
________________________

__________________________
Patient/Significant other signature

Nursing Diagnosis: Disturbed Sleep Pattern

Insomnia
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

 Anxiety Control

 Sleep

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

 Sleep Enhancement

NANDA Definition: Time-limited disruption of sleep (natural, periodic

suspension of consciousness) amount and quality

Sleep is required to provide energy for physical and mental activities. The sleep-
wake cycle is complex, consisting of different stages of consciousness: rapid eye
movement (REM) sleep, nonrapid eye movement (NREM) sleep, and wakefulness.
As persons age the amount of time spent in REM sleep diminishes. The amount of
sleep that individuals require varies with age and personal characteristics. In
general the demands for sleep decrease with age. Elderly patients sleep less
during the night, but may take more naps during the day to feel rested.
Disruption in the individual’s usual diurnal pattern of sleep and wakefulness may
be temporary or chronic. Such disruptions may result in both subjective distress
and apparent impairment in functional abilities. Sleep patterns can be affected by
environment, especially in hospital critical care units. These patients experience
sleep disturbance secondary to the noisy, bright environment, and frequent
monitoring and treatments. Such sleep disturbance is a significant stressor in the
intensive care unit (ICU) and can affect recovery. Other factors that can affect
sleep patterns include temporary changes in routines such as in traveling, jet lag,
sharing a room with another, use of medications (especially hypnotic and
antianxiety drugs), alcohol ingestion, night-shift rotations that change one’s
circadian rhythms, acute illness, or emotional problems such as depression or
anxiety. This care plan focuses on general disturbances in sleep patterns and
does not address organic problems such as narcolepsy or sleep apnea.

Defining Characteristics:

 Verbal complaints of difficulty falling asleep

 Awakening earlier or later than desired
  Interrupted sleep
 Verbal complaints of not feeling rested
 Restlessness
 Irritability
 Dozing
 Yawning
 Altered mental status
 Difficulty in arousal
 Change in activity level
 Altered facial expression (e.g., blank look, fatigued appearance)

Related Factors:

 Pain/discomfort
 Environmental changes
 Anxiety/fear
 Depression
 Medications
 Excessive or inadequate stimulation
 Abnormal physiological status or symptoms (e.g., dyspnea,
hypoxia, or neurological dysfunction)
 Normal changes associated with aging

Expected Outcomes

 Patient achieves optimal amounts of sleep as evidenced by rested

appearance, verbalization of feeling rested, and improvement in sleep
pattern.

Ongoing Assessment

• Assess past patterns of sleep in normal environment: amount,

bedtime rituals, depth, length, positions, aids, and interfering
agents. Sleep patterns are unique to each individual.

• Assess patient’s perception of cause of sleep difficulty and

possible relief measures to facilitate treatment. For short-term
problems, patients may have insight into the etiological factors of
the problem (e.g., fear over results of a diagnostic test, concern
over a daughter getting divorced, depression over the loss of a
loved one). Knowing the specific etiological factor will guide
appropriate therapy.

• Document nursing or caregiver observations of sleeping and

wakeful behaviors. Record number of sleep hours. Note physical (e.g.,
noise, pain or discomfort, urinary frequency) and/or psychological (e.g.,
fear, anxiety) circumstances that interrupt sleep. Often, the patient’s
perception of the problem may differ from objective evaluation.

• Identify factors that may facilitate or interfere with normal

patterns. Considerable confusion and myths about sleep exist.
Knowledge of its role in health/wellness and the wide variation
among individuals may allay anxiety, thereby promoting rest and
sleep.
 • Evaluate timing or effects of medications that can disrupt
sleep. In both the hospital and home care settings, patients may be
following medication schedules that require awakening in the early
morning hours. Attention to changes in the schedule or changes to
once-a-day medication may solve the problem.

Therapeutic Interventions

• Instruct patient to follow as consistent a daily schedule for

retiring and arising as possible. This promotes regulation of the
circadian rhythm, and reduces the energy required for adaptation
to changes.

• Instruct to avoid heavy meals, alcohol, caffeine, or smoking

before retiring. Though hunger can also keep one awake, gastric
digestion and stimulation from caffeine and nicotine can disturb
sleep.

• Instruct to avoid large fluid intake before bedtime. This helps

patients who otherwise may need to void during the night.

• Increase daytime physical activities as indicated. This reduces

stress and promotes sleep.

Instruct to avoid strenuous activity before bedtime. Overfatigue may

cause insomnia.

• Discourage pattern of daytime naps unless deemed necessary

to meet sleep requirements or if part of one’s usual pattern. Napping can
disrupt normal sleep patterns; however, elderly patients do better
with frequent naps during the day to counter their shorter
nighttime sleep schedules.

• Suggest use of soporifics such as milk. Milk contains L-

tryptophan, which facilitates sleep.

• Recommend an environment conducive to sleep or rest (e.g.,

quiet, comfortable temperature, ventilation, darkness, closed door).
Suggest use of earplugs or eye shades as appropriate.

• Suggest engaging in a relaxing activity before retiring (e.g.,

warm bath, calm music, reading an enjoyable book, relaxation exercises).

• Explain the need to avoid concentrating on the next day’s

activities or on one’s problems at bedtime. Obviously, this will interfere
with inducing a restful state. Planning a designated time during
the next day to address these concerns may provide permission to
"let go" of the worries at bedtime.

• Suggest using hypnotics or sedatives as ordered; evaluate

effectiveness. Because of their potential for cumulative effects and
generally limited period of benefit, use of hypnotic medications
should be thoughtfully considered and avoided if less aggressive
means are effective. Different drugs are prescribed depending on
whether the patient has trouble falling asleep or staying asleep.
Medications that suppress REM sleep should be avoided.
 • If unable to fall asleep after about 30 to 45 minutes, suggest
getting out of bed and engaging in a relaxing activity. The bed should
not be associated with wakefulness.

For patients who are hospitalized:

• Provide nursing aids (e.g., back rub, bedtime care, pain relief,
comfortable position, relaxation techniques). These aids promote rest.

• Organize nursing care:

 Eliminate nonessential nursing activities.
 Prepare patient for necessary anticipated
interruptions/disruptions.

This promotes minimal interruption in sleep or rest.

• Attempt to allow for sleep cycles of at least 90

minutes. Experimental studies have indicated that 60 to 90 minutes
are needed to complete one sleep cycle, and the completion of an
entire cycle is necessary to benefit from sleep.

• Move patient to room farther from the nursing station if noise is

a contributing factor.

• Post a "Do not disturb" sign on the door.

Education/Continuity of Care

• Teach about possible causes of sleeping difficulties and optimal

ways to treat them.

• Instruct on nonpharmacological sleep enhancement techniques.

neffective Coping

Inability to form a valid

appraisal of the stressors,
inadequate choices of
practiced responses, and/or
inability to use available
resources
................
‫التأقلم غير الفعال‬

، ‫عدم القدرة على تشكيل تقييم صالح من الضغوطات‬

‫ أو‬/ ‫ و‬، ‫والخياراته عدم كفاية الستجابات التي تمارس‬
‫عدم القدرة على استخدام الموارد المتاحة‬
ASSESSMENT DATA

• Suicidal ideas or behavior

• Slowed mental processes
• Disordered thoughts
• Feelings of despair,
hopelessness, and
worthlessness
• Guilt
• Anhedonia (inability to
experience pleasure)
• Disorientation
• Generalized restlessness or
agitation
• Sleep disturbances: early
awakening, insomnia, or
excessive sleeping
• Anger or hostility (may not
be overt)
• Rumination
‫‪• Delusions, hallucinations, or‬‬
‫‪other psychotic symptoms‬‬
‫‪• Diminished interest in‬‬
‫‪sexual activity‬‬
‫‪• Fear of intensity of feelings‬‬
‫‪• Anxiety‬‬
‫‪................................‬‬
‫الفكار أو السلوك النتحاري‬
‫تباطؤ العمليات العقلية •‬
‫أفكار المختلين •‬
‫مشاعر اليأس ‪ ،‬واليأس ‪ ،‬والتفاهه •‬
‫الشعور بالذنب •‬
‫)انعدام التلذذ )عدم القدرة على تجربة متعة •‬
‫توهان •‬
‫الرق أو التحريض المعمم •‬
‫اضطرابات النوم ‪ :‬النوم في وقت مبكر الصحوة ‪• ،‬‬
‫والرق ‪ ،‬أو المفرط‬
‫)الغضب أو العداوة )قد ل يكون سافرا •‬
‫التأمل •‬
‫الوهام ‪ ،‬الهلوسة ‪ ،‬أو أعراض ذهانية أخرى •‬
‫تضاؤل الهتمام في النشاط الجنسي •‬
‫الخوف من شدة المشاعر •‬
‫القلق •‬
EXPECTED OUTCOMES

Immediate

The client will:

• Be free from self-inflicted

harm
• Engage in reality-based
interactions
• Be oriented to person,
place, and time
• Express anger or hostility
outwardly in a safe manner,
eg, talking with staff
members

Stabilization
The client will:

• Express feelings directly

with congruent verbal and
nonverbal messages
• Be free from psychotic
symptoms
• Demonstrate functional
level of psychomotor activity

Community

The client will:

• Demonstrate compliance
with and knowledge of
medications, if any
• Demonstrate an increased
ability to cope with anxiety,
stress, or frustration
• Verbalize or demonstrate
acceptance of loss or change,
if any
‫‪• Identify a support system in‬‬
‫‪the community‬‬

‫‪................‬‬

‫فوري‬

‫‪ :‬العميل سوف‬

‫تكون خالية من الضرر ذاتيا •‬

‫المشاركة في تفاعلت الواقع القائم على •‬
‫تكون موجهة إلى شخص ‪ ،‬والمكان ‪ ،‬والوقت •‬
‫التعبير عن الغضب أو العداء ظاهريا بطريقة آمنة ‪• ،‬‬
‫على سبيل المثال ‪ ،‬يتحدث مع الموظفين‬

‫استقرار‬

‫‪ :‬العميل سوف‬

‫التعبير عن المشاعر بصورة مباشرة مع رسائل •‬

‫متطابقة اللفظي وغير اللفظي‬
‫تكون خالية من أعراض ذهانية •‬
‫إثبات المستوى الوظيفي للنشاط النفسي •‬
‫المجتمع‬

‫‪ :‬العميل سوف‬

‫إثبات المتثال للوالمعرفة من الدوية ‪ ،‬إن وجدت •‬

‫إثبات زيادة القدرة على التعامل مع الجهاد ‪ ،‬والقلق •‬
‫‪ ،‬أو الحباط‬
‫باللفاظ أو إثبات قبول الخسارة أو تغيير ‪ ،‬إن وجدت •‬
‫التعرف على نظام الدعم في المجتمع •‬

‫‪IMPLEMENTATION‬‬

‫‪NURSING INTERVENTIONS‬‬
‫‪* denotes collaborative‬‬
‫‪interventions‬‬
‫‪RATIONALE‬‬

‫‪Provide a safe environment‬‬

‫‪for the client.‬‬
‫‪Physical safety of the client is‬‬
a priority. Many common
items may be used in a self-
destructive manner.

Continually assess the client’s

potential for suicide. Remain
aware of this suicide potential
at all times.
Clients with depression may
have a potential for suicide
that may or may not be
expressed and that may
change with time.

Observe the client closely,

especially under the following
circumstances:
• After antidepressant
medication begins to raise the
client’s mood.
• During unstructured time on
the unit or times when the
number of staff on the unit is
limited.
• After any dramatic
behavioral change (sudden
cheerfulness, relief, or giving
away personal belongings).
Suicidal Behavior. You must
be aware of the client’s
activities at all times when
there is a potential for suicide
or self-injury. Risk of suicide
increases as the client’s
energy level is increased by
medication, when the client’s
time is unstructured, and
when observation of the client
decreases. These changes
may indicate that the client
has come to a decision to
commit suicide.

Reorient the client to person,

place, and time as indicated
(call the client by name, tell
the client your name, tell the
client where he or she is, and
‫‪so forth).‬‬
‫‪Repeated presentation of‬‬
‫‪reality is concrete‬‬
‫‪reinforcement for the client.‬‬

‫‪Spend time with the client.‬‬

‫‪Your physical presence is‬‬
‫‪reality.‬‬

‫‪.............................‬‬

‫التدخلت التمريضية‬

‫يدل على التدخلت التعاونية *‬

‫الساس المنطقي‬

‫‪.‬توفير بيئة آمنة للعميل‬

‫السلمة الجسدية للعميل هو أولوية‪ .‬ويمكن استخدام‬
‫‪.‬العديد من العناصر المشتركة بطريقة التدمير الذاتي‬

‫باستمرار بتقييم إمكانات العميل للنتحار‪ .‬تبقى على‬

‫‪.‬علم بهذه المحتملة النتحارية في جميع الوقات‬
‫يمكن للعملء مع بالكتئاب لديهم إمكانية للنتحارية‬
‫التي قد تكون أو ل يمكن التعبير عنها والتي قد تتغير‬
‫‪.‬مع مرور الوقت‬
‫مراقبة العميل عن كثب ‪ ،‬خاصة في ظل الظروف التالية‬
‫‪:‬‬
‫بعد الدوية المضادة للكتئاب تبدأ لرفع المزاج •‬
‫‪.‬العميل‬
‫خلل الوقت غير منظم في وحدة أو أوقات عندما •‬
‫‪.‬يقتصر عدد الموظفين في الوحدة‬
‫بعد تغيير أي السلوكية التمثيلية )مرح المفاجئ ‪• ،‬‬
‫‪).‬والغاثة ‪ ،‬أو التخلي عن ممتلكاتهم الشخصية‬
‫السلوك النتحاري‪ .‬يجب أن تكون على علم بالنشطة ‪:‬‬
‫العميل في جميع الوقات عندما يكون هناك احتمال‬
‫للنتحار أو إصابة النفس‪ .‬وزيادة خطر النتحار وزيادة‬
‫مستوى الطاقة العميل من الدوية ‪ ،‬وعند الساعة‬
‫العميل غير منظم ‪ ،‬وعندما رصد النقصان العميل‪ .‬هذه‬
‫التغيرات قد تشير إلى أن العميل قد حان لتخاذ قرار‬
‫‪.‬النتحار‬

‫إعادة توجيه العميل إلى شخص ‪ ،‬والمكان ‪ ،‬والوقت‬

‫كما هو مبين )الدعوة العميل حسب السم وأخبر العميل‬
‫اسمك ‪ ،‬أخبر العميل حيث كان هو أو هي ‪ ،‬وهكذا‬
‫‪).‬دواليك‬
‫‪.‬وكرر عرض الواقع هو تعزيز ملموسة للعميل‬

‫‪.‬قضاء بعض الوقت مع العميل‬

‫وجودكم هو الواقع المادي لتخلصة من الشعور القاتل‬
‫بالوحدة‬

‫هذا واتمنى اكون اعطيت هذا الموضوع حقه و‬

‫تستفيدون‬
‫‪ .....‬ودمتم برعاية المولى‬