4.

Social evaluation
- Appraisal of oneself in relationship to
CHAPTER 39: SELF-CONCEPT
others, events, situations (introspect)

Self-concept Me-centered

● One’s mental image of oneself ● Valuing “how I perceive me” over “how others
● Involves all of the self-perception (appearance, perceive me”
values, beliefs) that influence behavior ● They live up w/ their expectations; compete only
● I or me with themselves
● Positive self-concept
Positive self-concept ● Formed w/ limited reference to others’ opinion

● Are better in developing and maintaining

Other-centered
interpersonal relationships; resist psychologic
and physical illness. ● Have high need for approval from others
● An individual possessing a strong self-concept ● They live up w/ others’ expectations; comparing,
can better accept or adapt to changes that may competing, evaluating themselves in relation to
occur over the lifespan. others
● Nurses’ responsibility: assess clients’
self-concept and identify ways to help them Nurse’s self-concept
develop a more positive view of themselves
● Better able to understand the needs, desires,
Poor self-concept feelings, conflicts of clients
● If positive, they are more likely to help clients
● Expresses feelings of worthlessness, meet their needs
self-dislike, self-hatred
● May feel sad, hopeless; may state lack of Self-awareness
energy to perform even the simplest of tasks
● Relationship b/w an individual’s own and others’
Influences of Self-concept perception of self
● Requires time and energy
- How one thinks, talks and acts
- How one sees and treats another Introspection
individual
- Choices one makes ● Important component of the process of
- Ability to give and receive love self-awareness
- Ability to take action and to change ● Nurses reflect on personal beliefs, attitudes,
things motivations, strengths, limitations
● Gains insight into self through working w/ other
4 DIMENSIONS OF SELF-CONCEPT nurses; taking feedback

1. Self-knowledge When conflicts arises:

- Insight into one’s own abilities, nature,
limitations - Why do I react this way (fear, anger, anxiet,
annoyance, worry)?
2. Self-expectation - Can I change the way I respond to this situation
- What one expects of oneself; realistic or to affect the client’s reaction in a helpful way?
unrealistic expectations
FORMATION OF SELF-CONCEPT
3. Social self – 3 broad steps of self-concept development
- How one is perceived by others and ● The infant learns that the physical self is
society separate and different from the environment.
● The child internalizes others’ attitudes toward
self.
 ● The child and adult internalize the standards of 3. Role Performance
society. - How an individual in a particular role
behaves in comparison to behaviors
Global self expected to the role

● The collective beliefs and images one holds ● Role

about oneself - Set of expectations about how
● Most complete description one can give about the individual occupying a
themselves particular position behaves

Core self-concept ● Role mastery

- Individual’s behaviors meet role
● Most vital beliefs and images to individual’s
expectations
identity
● Role development
Ideal self
- Involves socialization into a
● How we should be/would prefer to be particular role

COMPONENTS OF SELF-CONCEPT ● Role ambiguity

– 4 Components of Self-Concept - Occurs when expectations are
1. Personal Identity unclear
● Conscious sense of individuality and - Individuals do not know what to
uniqueness; continually evolving do or how to do it
● Name, gender, age, race, ethnic origin - Unable to predict the reactions
or culture, occupation or roles, talents, of others to their behavior
other situational characteristics
● Beliefs, values, personality, character ● Role strain
● Encompasses both tangible and - People feel frustrated as they
factual (name, citizenship) and feel inadequate or unsuited to a
intangible (values, beliefs) role
- Associated to sex role
2. Body image stereotypes
● Image of physical self
● How an individual perceives the size, ● Role conflicts
appearance, and functioning of the body - Arise from opposing or
and its parts incompatible expectations
● Aspects of body image: - Can lead to tension, decrease in
○ Cognitive - knowledge of self-esteem, embarrassment
material body
○ Affective - sensations of body 4. Self-Esteem
● Includes clothing, makeup, hairstyle, - One’s judgment of one’s own worth
jewelry - How that individual’s standards and
● Includes body prostheses (artificial performances compare to others’
limbs, dentures, hairpieces) standards and to one’s ideal self
● Understanding that different parts of the ❖ Unmatched self-esteem + Unmatched
body have different values for different ideal self = LOW SELF CONCEPT
individuals
● 2 types of self-esteem:
● The individual who has a body image ○ Global self-esteem
disturbance may hide or not look at or - How much one likes oneself as
touch a body part that is significantly a whole
changed in structure by illness or - Influenced by specific
trauma. self-esteem
 ○ Specific self-esteem
- How much one approves of a ● Body Image Stressors
certain part of oneself - Loss of body parts
- (e.g., amputation,
- Derived from self and others mastectomy,
- The foundation for self-esteem is established hysterectomy)
during early life experiences usually w/in the - Loss of body functions
family structure. - (e.g., from stroke, spinal
**Maslow’s hierarchy of needs cord injury,
neuromuscular disease,
FACTORS THAT AFFECT SELF-CONCEPT arthritis, declining
Stage of Development mental or sensory
● As individuals develop, conditions affecting abilities)
self-concept changes - Disfigurement
➔ Example: - (e.g., through
◆ Infants requires supportive, pregnancy, severe
caring environment burns, facial blemishes,
◆ Child requires freedom to colostomy,
explore and learn tracheostomy)
◆ Older adults self-concept is - Unrealistic body ideal
based on their experiences in - (e.g., a muscular
progressing through life’s stages configuration that
cannot be achieved)
Family and Culture
● Influences the values of a young child ● Role Stressors
● Peers influence the child, affecting the sense of - Loss of parent, spouse, child, or
self close friend
● Child confronted by differing expectations → - Change or loss of job or other
child’s sense of self is often confused significant role
➔ Example: - Divorce
◆ A child may realize that his - Illness of self or others that
parents expect he will not drink affects role performance
alcohol + will attend religious - Ambiguous or conflicting role
services each Saturday; expectations
◆ His peers drink beer and - Inability to meet role
encourage him to spend expectations
Saturdays w/ them

Stressors ● Self-Esteem Stressors

● Can strengthen one’s self-concept as individuals - Lack of positive feedback from
cope successfully w/ their problems significant others
● Overwhelming stressors: can cause maladaptive - Repeated failures
responses - Unrealistic expectations
- Abusive relationship
Types of Stressors: - Loss of financial security
● Identity Stressors
- Change in physical appearance Resources
(e.g., facial wrinkles) ● Internal Resources
- Declining physical, mental, or - Confidence and values
sensory abilities
- Inability to achieve goals ● External Resources
- Relationship concerns - Support network, sufficient finances,
- Sexuality concerns organizations
- Unrealistic ideal self
 ● Greater no. of resources = positive self-concept Development of Sexuality

History of Success and Failure ● Begins with conception and continues

● History of failures: inability to overcome barriers throughout the lifespan.
● History of successes: more positive self-concept
Gender
Illness ● Refers to the psychologic sense of being
● Common reactions: acceptance, denial, feminine or masculine and is related to the terms
withdrawal woman and man.

NURSING INTERVENTIONS Birth to 12 Years

For ALTERED SELF-CONCEPT
Focuses on: ● The ability of the human body to experience a
1. Identifying areas of strength sexual response is present before birth.
2. Enhancing self-esteem ● By the age of 3, more purposeful masturbation
begins, although males do not ejaculate until
– Behaviors reflecting low self-esteem after puberty.
● Avoids eye contact ➔ Masturbation - Excitation of one’s own
● Stoops in posture and moves slowly or another’s genital organs by means
● Has an unkempt appearance other than sexual intercourse.
● Hesitant or halting in speech ● By age 2 1/2 or 3, children have beginning
● Is overly critical of self awareness of genital differences between
● May be overly critical of others males and females.
● Is unable to accept positive remakes about self ● Around age 9 or 10, the first physical changes
● Apologies frequently of puberty begin.
● As the adrenal glands mature, they produce
– Strategies to reinforce strengths: more testosterone and estradiol, which
● Stress positive thinking rather than contributes to the first experiences of sexual
self-negation. attraction to another individual.
● Notice and verbally reinforce client strengths. ● Girls learn about menstruation & self-care.
● Encourage the setting of attainable goals. ➔ Menstruation - Monthly uterine
● Acknowledge goals that have been attained. bleeding.
● Provide honest, positive feedback.
Adolescence

CHAPTER 40: SEXUALITY ● During early adolescence (12 to 13 years),

primary and secondary sex characteristics
● All humans are sexual beings. Regardless of continue to develop.
gender, age, race, socioeconomic status, ● Development of the genitals to adult size takes
religious beliefs, physical and mental health, or about 5 to 6 years.
other demographic factors, we express our ● Teenage girls may have irregular
sexuality in a variety of ways throughout our menstruation initially, which can lead to
lives. embarrassment because of stained clothing.
● Human sexuality is difficult to define. ● Proper feminine hygiene measures, will help to
● Sexuality is an individually expressed and decrease infection, including the risk of “toxic
highly personal phenomenon that evolves shock,” a particular type of Staphylococcus
from life experiences. aureus infection.
● Physiologic, psychosocial, and cultural ● Dysmenorrhea is prevalent among adolescent
factors influence an individual’s sexuality and females.
lead to the wide range of attitudes and behaviors ➔ Dysmenorrhea - Painful menstruation.
seen in humans. Results from powerful uterine
contractions, which cause ischemia and
cramping pain.
 ● Sexually transmitted infections (STIs) are the that involves physical, emotional,
most common bacterial infections among mental, social, and spiritual dimensions.
adolescents. ➔ Sexual health is an inextricable element
➔ Symptoms of STI: Candidiasis, of human health and is based on a
Chlamydial urethritis, genital warts, positive, equitable, and respectful
gonorrhea, gonorrhea, herpes genitalis, approach to sexuality, relationships, and
HIV, AIDS, syphilis, trichomoniasis, and reproduction that is free of coercion,
zika. fear, discrimination, stigma, shame, and
violence. Sexual health includes: the
Young and Middle Adulthood ability to understand the benefits, risks,
and responsibilities of sexual behavior;
● In young adulthood, many individuals form
the prevention and care of disease and
intimate relationships with long-term
other adverse outcomes; and the
implications.
possibility of fulfilling sexual
● Young adults should also know that because
relationships.
sexual needs and responses may change, each
● Sexual health occurs when sexual relationships
partner should listen and respond to the
are respectful, safe, and pleasurable.
needs of the other.
● During middle adulthood both males and
females experience decreased hormone
production, causing the climacteric, usually Sexual Rights
called menopause in women.
1. The right to equality and non-discrimination.
Older Adulthood 2. The right to life, liberty, and security of the
person.
● Older adults may define sexuality far more 3. The right to autonomy and bodily integrity.
broadly. 4. The right to be free from torture and cruel,
● Older women remain capable of multiple inhuman, or degrading treatment or punishment.
orgasms and may experience an increase in 5. The right to be free from all forms of violence
sexual desire after menopause. and coercion.
● Many products are available to assist older 6. The right to privacy.
adults with enhancing their sexual experiences. 7. The right to the highest attainable standard of
➔ Although older adults’ technique may health, including sexual health; with the
require modification, the nurse should possibility of pleasurable, satisfying, and safe
never assume that they are less sexual experiences.
interested in or less motivated to have 8. The right to enjoy the benefits of scientific
an active sex life. progress and its application.
9. The right to information.
10. The right to education and the right to
Sexual Health comprehensive sexuality education.
11. The right to enter, form, and dissolve marriage
● Is an individual and constantly changing and other similar types of relationships based on
phenomenon falling within the wide range of equality and full and free consent.
human sexual thoughts, feelings, needs, and 12. The right to decide whether to have children, the
desires. number and spacing of children, and to have the
● An individual’s degree of sexual health is best information and the means to do so.
determined by that individual, sometimes with 13. The right to the freedom of thought, opinion, and
the assistance of a qualified professional. expression.
● The Centers for Disease Control and 14. The right to freedom of association and peaceful
Prevention (CDC)/Health Resources and assembly.
Services Administration (HRSA) defines 15. The right to participation in public and political
sexual health in the United States as follows: life.
➔ Sexual health is a state of well-being in 16. The right to access to justice, remedies, and
relation to sexuality across the lifespan redress
 femaleness as well as what is perceived
Components of Sexual Health as gender-appropriate behavior

1. Sexual self-concept
- How one values oneself as a sexual Sexual Expression
being.
- One’s sexual self concept determines I. Sexual orientation
with whom one will have sex, the gender
● One’s attraction to individuals of the same sex,
and kinds of individuals one is attracted
other sex, or both sexes.
to, and the values about when, where,
● Sexual orientation lies along a continuum with a
with whom, and how one expresses
wide range between extremes of exclusive
sexuality.
attraction.
- A positive sexual self-concept
● LGBTQQ means Lesbian, Gay, Bisexual,
enables individuals to form intimate
Transgender, Queer, and Questioning.
relationships throughout life.
● Homosexuality - same-sex attraction.
- A negative sexual self-concept may
● Lesbians - women attracted only to women
impede the formation of relationships.
● Gay - men attracted to men a (although gay is
2. Body image
also a general term for homosexual).
- Central part of the sense of self, is
● Bisexual - individuals attracted to individuals of
constantly changing.
both genders are referred to as bisexual.
- How an individual feels about their body
● Transgender - someone who identifies with a
is related to the individual’s sexuality.
different gender than their anatomic designation.
- Androgyny, or flexibility in gender roles,
● Queer - someone who rejects gender
is the belief that most characteristics
stereotypes.
and behaviors are human qualities that
● Questioning - those who have not decided on
should not be limited to one specific
their orientation.
gender or the other.
● The nurse should feel comfortable asking for the
❖ Being androgynous does not
client’s definition of a term if unsure of its
mean being sexually neutral or
meaning.
imply anything about one’s
● The origins of sexual orientation are still not
sexual orientation.
well understood.
❖ Rather, it describes the degree
of flexibility an individual has II. Gender identity
regarding gender-stereotypic
behaviors. ● Western culture is deeply committed to the idea
❖ Adults who can behave flexibly that there are only two sexes.
regarding their sexual roles may ● Sometimes gender is clear, in other cases there
adapt better than those who is a blending of both genders within the same
adopt rigid stereotyped gender individual, and in some it is unclear.
roles. ● Intersex
3. Gender identity ➔ An increasing number of babies are
- Is one’s self-image as a female or male. born with an intersex condition in which
- It has a physical component and it also there are contradictions among
includes social and cultural norms. chromosomal sex, gonadal sex,
- Gender identity results from internal organs, and external genital
developmental events that may or may appearance.
not conform to an individual’s apparent ➔ The gender of such an infant is
biological sex. ambiguous.
- Once gender identity is established, it ➔ This means that an intersexed
cannot be easily changed. individual has some parts usually
4. Gender expression associated with males and some
- Is the outward manifestation of an parts usually associated with
individual’s sense of maleness or females.
 ➔ Two of the most common syndromes preference. If you make a
leading to intersex are: mistake, acknowledge it.
❖ Congenital adrenal hyperplasia ❖ Reflect and seek clarification if
❖ Androdrogen-insensitivity the client expresses a concept
syndrome you do not understand.
● Intersex anatomy may not be apparent at ❖ Collaborate with all members of
birth. the healthcare team to create a
● Sometimes it is undetected until puberty, until welcoming and inclusive
the individual is identified as an infertile adult, or environment.
until the individual dies and is autopsied. ❖ Identify community and
● Transgenderism web-based transgender health
➔ For the transgender individual, sexual resources.
anatomy contradicts gender identity. ● Crossdressers
➔ Those who are born physically male but ➔ Cross-dressing (dressing in the
are emotionally and psychologically clothing of the other sex) makes
female are called male-to-female (MtF) individuals’ outward appearance
transgender persons. consistent with their inner identity and
➔ Those who are born female but are gender role and increases their comfort
emotionally and psychologically male with themselves.
are called female-to-male (FtM) ➔ Cross-dressing is a conscious choice
transgender persons. and may occur at home or in public
➔ Transgender - a broader term that settings.
includes all individuals who do not ➔ Cross-dressers may have a different
identify with the gender that name to go with the personality and
corresponds to the sex they were wardrobe.
assigned at birth. ➔ If the social climate is one with rigid
➔ Transsexual - a narrower term that gender roles, some individuals may
includes individuals who desire to need to express their feminine or
physically transition to the gender with masculine identity by creating a
which they identify. separate world and persona within that
➔ Transgender is not considered a social climate.
disorder.
➔ Transgender individuals may be viewed III. Sexual Practices
as having gender dysphoria only if
● Over a lifetime, sexual fantasies and
they have clinically significant distress or
single-partner sex are the most common
impairment in social, school, or other
sexual behaviors.
important areas of functioning.
● Male-to-female or female-to-female oral–genital
❖ Most transgender individuals
sex is known technically as cunnilingus. This
report that they have felt gender
involves kissing, licking, or sucking of the female
dysphoria since early childhood.
genitals including the mons pubis, vulva, clitoris,
❖ They often suffer for many years
labia, and vagina.
and try to hide the situation from
● Fellatio is oral stimulation of the penis by licking
family and friends
and sucking.
➔ Transition - the process of moving from
● The term “sixty-nine” refers to simultaneous
one gender to another.
oral–genital stimulation by two individuals.
➔ The nurse should follow the following
● Anal stimulation can be a source of sexual
guidelines in care of all clients:
pleasure because the anus has a rich nerve
❖ Do not assume the client’s
supply. Stimulation may be applied with fingers,
gender or sexual orientation.
mouth, or sex toys such as vibrators.
❖ Use gender-neutral language as
● A common form of sexual activity for
much as possible. Do not use
heterosexual couples is genital intercourse.
terms such as “sir” or “miss”
● Penile–vaginal intercourse (coitus) can be
without confirming the client’s
both physically and emotionally satisfying.
 ● Anal intercourse, during which the penis is - Religion influences sexual expression.
inserted into the anus and rectum of the partner. - It provides guidelines for sexual
Anal intercourse is commonly practiced by gay behavior and acceptable circumstances
men, but heterosexual couples engage in it as for the behavior, as well as prohibited
well. sexual behavior and the consequences
➔ Because anorectal tissue is not of breaking the sexual rules.
self-lubricating, a lubricant must be used 4. Personal expectation and ethics
on the condom. - Although ethics is integral to religion,
ethical thought and ethical approaches
to sexuality can be viewed separately
Factors Influencing Sexuality from religion.

1. Family
- Family messages about sex range from Sexual Response Cycle
“sex is so shameful it shouldn’t be talked
about” to “sex is a joyful part of adult ● Desire phase - the response cycle starts in the
relationships.” brain, with conscious sexual desires.
- The following are common sexual ● Sexually arousing stimuli, often called erotic
messages children get from their stimuli, may be real or symbolic.
families: ● The excitement phase involves two primary
❖ Sex is dirty. physiologic changes.
❖ Premarital sex is sinful. ➔ Vasocongestion is stimulated.
❖ Good girls don’t do it. ➔ Vasocongestion increases.
❖ Masturbation is disgusting. ● The orgasmic phase is the involuntary climax
❖ Men should be the sexual of sexual tension, accompanied by physiologic
experts. and psychologic release. This phase is the
❖ Sex is mainly for procreating. measurable peak of the sexual experience.
❖ Bodies, including genitals, are ➔ Male orgasms usually last 10 to 30
beautiful. seconds.
❖ Sex should be fun for both ➔ Female orgasms last 10 to 50 seconds.
women and men. ● The resolution phase, the period of return to
❖ Sexual thoughts and feelings the unaroused state, may last 10 to 15 minutes
are natural. after orgasm, or longer if there is no orgasm.
❖ Masturbation is a common, ➔ This phase in females is varied as some
pleasurable activity. women experience multiple successive
❖ There is great variety in sexual orgasms followed by a longer period of
behaviors. resolution.
2. Culture
- Culture influences the sexual nature of Physiologic Changes Associated with the Sexual
dress, rules about marriage, Response Cycle
expectations of role behavior and social
1. Excitement and Plateau
responsibilities, and sex practices.
2. Orgasmic
- Polygamy (several mates or marriage
3. Resolution
partners) or monogamy (one mate or
marriage partner) may be the norm.
- Female circumcision, also known as
female genital mutilation, female ritual
cutting (FRC), or female genital cutting
(FGC).
- Male circumcision is controversial.
Some professional groups support
newborn circumcision believing it will
prevent the spread of HIV and other
infections.
3. Religion
 discomfort or pain during sexual
Altered Sexual Function intercourse.
- The diagnosis of male erectile disorder
1. Past and current factors is usually made when the male has
- Sociocultural factors: erection problems during 25% or more
❖ Very strict upbringing of his sexual interactions.
accompanied by inadequate - Erectile dysfunction (Impotency) -
sex education. when males cannot attain a full erection,
❖ Rigid gender socialization and others lose their erection prior to
❖ Individuals’ religious orgasm.
affiliations lead them to believe 4. Orgasmic disorders
that sex is only for procreation. - The term commonly applied in the past
❖ Parental punishment for to women who did not experience
normally exploring one’s orgasm, frigid, implied that the woman
genitals or for typical childhood was totally incapable of responding
sex play. sexually. The more accurate and
❖ The pressures of family and objective term is female orgasmic
work often leave mature disorder, which simply means that the
couples with too little time and sexual response stops before orgasm
not enough energy to enjoy sex. occurs.
- Psychologic factors: - Preorgasmic - females who have never
❖ Negative feelings experienced an orgasm.
❖ Guilt - Male orgasmic disorder - the male can
❖ Anxiety maintain an erection for long periods (an
❖ Fear hour or more) but has extreme difficulty
- Cognitive factors: ejaculating, referred to as delayed
❖ Internalization of negative ejaculation.
expectations and beliefs. - This disorder is much less common than
❖ Low self-esteem. rapid ejaculation.
❖ Not yet accepted their sexual - Rapid (premature) ejaculation - is one
orientation or gender identity. of the most common sexual
- Sexual problems dysfunctions among males.
- Lack of intimacy ➔ 1 to 2 minutes only.
- Health factors: ➔ Man is concerned about his
❖ Physical changes ejaculatory control, or the
❖ Prescribed medication’s side couple agrees that ejaculation is
effects. too rapid for mutual satisfaction
2. Sexual desire disorder 5. Sexual pain disorders
- Hypoactive sexual desire disorder - Both women and men can experience
❖ Deficiency in or absence of dyspareunia, pain during or
sexual fantasies and immediately after intercourse.
persistently low interest or a ❖ Dyspareunia - recurring pain in
total lack of interest in sexual the genital area or within the
activity. pelvis during sexual intercourse.
3. Sexual arousal disorder - Vaginismus - the involuntary spasm of
- Sexual arousal refers to the physiologic the outer onethird of the vaginal
responses and subjective sense of muscles, making penetration of the
excitement experienced during sexual vagina painful and sometimes
activity. impossible.
- Lack of lubrication and failure to - Vulvodynia - is constant, unremitting
attain or maintain an erection are the burning that is localized to the vulva with
major disorders of the arousal phase. an acute onset.
- Female sexual arousal disorder - the - Vestibulitis - causes severe pain only
lack of vaginal lubrication causes on touch or attempted vaginal entry. Half
 of the women with vestibulitis report ● Transcendent
lifelong dyspareunia. - Higher power, creative force, divine
being, or infinite source of energy

Molestation or Sexual Abuse Religion

● Forced, unwanted sexual activity of any kind.

● Usually applied to ritualistic practices &
Counseling for Altered Sexual Function organized beliefs.
● Spirituality & religion are inherently intertwined.
● PLISSIT model, developed by Annon (1976):
➔ P - Permission giving Agnostic
➔ LI - Limited information
➔ SS - Specific suggestions ● Individual who doubts the existence of God or
➔ IT - Intensive therapy believes the existence of God has not been
proved.
Diagnostic Label for Sexuality
Atheist
1. Inneffective sexual pattern
2. Sexual dysfunction
● One without a belief in a deity.
Nursing Intervention ● They often feel discriminated against or
perceived as angry by those in our culture who
1. Sexual health experience & value spirituality.
2. Responsible sexual behavior
3. Self-examination of the breast and testicles Spiritual Care

● Should not be prescriptive, but should be

descriptive of ways nurses can offer spiritual
CHAPTER 41: SPIRITUALITY support.
● Spiritual nursing care is an intuitive,
Spirituality interpersonal, altruistic, and integrative
expression that is contingent on the nurse’s
● Human tendency to seek meaning & purpose awareness of the transcendent dimension of life
in life, inner peace & acceptance, forgiveness but that reflects the client’s reality.
& harmony, hope, beauty, & so forth. ● Although nursing terminology usually uses
spiritual care, a few nurses use less
Aspects of Spirituality prescriptive, and probably more appropriate,
language such as spiritually sensitive nursing
● Love care or spiritual nursing care.
- In the fabric of relationships
Spiritual Disruption (religious struggle/pain)
● Sacred Reality (unifying interconnectedness)
- Sense of energetic oneness with other ● Inner chaos that can occur when an individual’s
beings in the universe assumptions & beliefs are threatened or
shattered.
● Altruism ● Negative emotions related to God, concerns
- Commitment beyond self with care & about demonic forces, interpersonal conflicts
service; contemplative practice such as with religious individuals or organizations,
meditation, prayer, yoga, religious & struggles to live according to moral values,
spiritual reflection doubts about religious beliefs, guilt, and worry
about not finding meaningfulness in life.
● Commitment
- A life well-examined
Signs & Symptoms of Spiritual Disruption Lifespan Considerations

● Manifest a lack of enthusiasm for life, ● Children

hopelessness, meaninglessness, sense of - Describe their spiritual health and
emptiness, or inadequate acceptance of self. challenges through the stories they tell
● Express feeling abandoned or anger toward a and behaviors.
power greater than self or toward a spiritual
community. ● Adolescents
● Question the credibility of spiritual or - Likely critiquing the religion of their
religious beliefs; question the meaning of life, parents and less likely to be openly
death, or suffering. religious, often will use private religious
● Exhibit sudden changes in spiritual practices. and spiritual coping strategies.
● Request (or refuse) to interact with a spiritual - Time of forming a unique identity,
leader. gaining the ability to think critically,
● Have no interest in religious or spiritually differentiating self from families.
nurturing resources or experiences - Time of risk-taking, susceptibility to
peer pressure, sensation seeking,
impulsivity, and poor future
orientation.
Spiritual Health / Spiritual Wellness or Well-being
● Middle-aged & Older Adults
● Often portrayed as the opposite of spiritual - Most adults realize that materialism
disruption. and social achievements do not meet
● Thought to not occur by chance, but by the requirements of the soul; therefore,
choice. their focus shifts from
● Results when individuals intentionally seek to self-centeredness towards
strengthen their spiritual muscles, as it were, generativity—care and concern for
through various spiritual disciplines (e.g., younger generations.
prayer, meditation, service, fellowship with - Many older adults highly value religious
similar believers, learning from a spiritual coping strategies such as prayer.
mentor, worship, study, fasting).
Spiritual History
Spiritual / Religious Coping
● Important to conduct to gain a basic
● Both positive & negative. understanding of spiritual or religious beliefs &
● The spiritual beliefs or ways of thinking that practices pertinent to client’s health &
help individuals cope with their challenges. healthcare.
● Positive religious coping helps clients adapt to ● Two cautions are important to remember when
illness, whereas negative religious coping is conducting spiritual assessment. First, a
associated with maladaptation for both nurse-conducted spiritual assessment should
adolescents and adults. limit itself to client spirituality as it relates to
● For example, negative religious coping (e.g., health. Second, a nurse should never assume
thinking that illness is a punishment and feeling that a client follows all the practices of the
abandoned by God) were associated with client’s stated religion.
depression and poorer quality of life among
survivors of stem cell transplants.
Faith or beliefs “What spiritual beliefs are
most important to you?”
Spiritual Development
Implications or influence “How is your faith
● Spiritual development results from complex affecting the way you
interactions between “nature and nurture” . cope now?”
● When assessing or supporting client spirituality,
Community “Is there a group of
it is necessary to appreciate how spirituality and likeminded believers with
religiosity evolve with age and life experience.
 - How does the client relate to other
which you regularly
meet?” clients and nursing personnel?

Address “How would you like your Presencing

healthcare team to
support you spiritually?” ● Art of being present, or just being with a client
during his or her suffering.
Cues to spiritual and religious preferences, strengths, ● Nurse must be purposefully attentive.
concerns, or distress may be revealed by one or more of ● Often the best and sometimes the only
the following: intervention to support a client who suffers under
circumstances that medical interventions cannot
● Environment address.
- Does the client have a Bible, Torah,
Koran, other prayer book, devotional Levels of being present for clients
literature, religious medals, a rosary, a
cross, a Star of David, or religious ● Presence
get-well cards in the room? - when a nurse is physically present but
- Does a church send altar flowers or not focused on the client.
Sunday bulletins?
● Behavior ● Partial presence
- Does the client appear to pray before - when a nurse is physically present and
meals or at other times or read religious attending to some task on the client’s
literature? behalf but not relating to the client on
- Does the client express anger at any but the most superficial level.
religious representatives or at a deity?
● Full presence
● Verbalization - when a nurse is mentally, emotionally,
- Does the client mention God or a and physically present; intentionally
higher power, prayer, faith, the focusing on client.
church, synagogue, temple, a
spiritual or religious leader, or ● Transcendent presence
religious topics? - when a nurse is physically, mentally,
- Does the client ask about a visit from emotionally, and spiritually present for a
the clergy? client; involves a transpersonal &
- Does the client express any of the transforming experience.
following: fear of death, concern with the
meaning of life, inner conflict about Dimensions of a Spiritually Healing Response
religious beliefs, concern about a
relationship with the deity, questions HEALING NOT HEALING
about the meaning of existence or the
meaning of suffering, or concern about Client-centered Nurse centered
the moral or ethical implications of
therapy? Neutral Judgmental

Immediate contributors Distant, tangential, or

● Affect and attitude
to spiritual pain abstract contributors of
- Does the client appear lonely, spiritual pain
depressed, angry, anxious, agitated,
apathetic, or preoccupied? Accurately names Inaccurately or never
feelings, engages names feelings,
● Interpersonal relationships emotions engages thinking
- Who visits?
- How does the client respond to visitors?
- Does a minister come?
Prayer Types of Beliefs:

● Allow individuals to connect with each other & ● Affecting Diet

with the divine. ● Illness & Healing
● Some would describe prayer as an inner ● Dress & Modesty
experience for gaining awareness of self. ● Birth
● Others may view it as a conversation with the ● Death
divine.
● To pray for another is also a way for loving Nursing Interventions
individuals to express care.
● Many nurses pray with clients when they request ● Offering one’s presence
it. ● Conversing about spirituality
● Supporting client’s religious practices
Meditation ● Empathic communication
● Assisting clients with prayer
● Buddhist origin yet pervades Western societies. ● Referring client to a spiritual care expert
● Mindfulness meditation techniques have
been adapted for Christian prayer and as a
nonreligious lifestyle strategy for improving CHAPTER 42: STRESS AND COPING
health and overall well-being.

Holy Days
CONCEPT OF STRESS

● Solemn religious observances and feast days STRESS

throughout the year. ● A universal phenomenon
● Include fasting or special foods, reflection, ● All individuals experience it
rituals, and prayer. ● Can result from both positive and negative
experiences
● Its concept is important because it provides a
Sacred Texts way of understanding the individual as a being
who responds in totality (mind, body, and spirit)
● Individuals often gain strength and hope from to a variety of changes that take place in daily
reading religious writings when they are ill or in life.
crisis. ● Is a condition in which an individual experiences
● Frequently tell instructive stories of the changes in the normal balanced state.
● “Refers to any event in which environmental
religion’s leaders, kings, and heroes.
demands, internal demands, or both tax or
● In most religions, these scriptures are thought to exceed the adaptive resources of an individual,
be the word of the Supreme Being as written social system, or tissue system” (Monat &
down by prophets or other human Lazarus, 1991, p. 3).
representatives.
STRESSOR
Sacred Symbols ● Any event or stimulus that causes an individual
to experience stress.
● When an individual faces stressors responses
● Include jewelry, medals, amulets, icons, are referred to as:
totems, or body ornamentation (e.g., tattoos) - coping strategies
that carry religious or spiritual significance. - coping responses
● May be worn to pronounce one’s faith, to remind - or coping mechanisms.
the practitioner of the faith, to provide spiritual
SOURCES OF STRESS (S.I.D.E)
protection, or to be a source of comfort or
strength. 1. INTERNAL STRESSORS
● Clients may wear religious symbols at all 2. EXTERNAL STRESSORS
times, and they may wish to wear them when 3. DEVELOPMENTAL STRESSORS
they are undergoing diagnostic studies, medical 4. SITUATIONAL STRESSORS
treatment, or surgery
INTERNAL STRESSORS
- Peer competition
● Originate within an individual, for example,
infection or feelings of depression.
EXTERNAL STRESSORS ADOLESCENT - Changing physique
● Originate outside the individual, for example, a
move to another city, a death in the family, or - Relationships
pressure from peers. involving sexual
DEVELOPMENTAL STRESSORS attraction
● Occur at predictable times throughout an
individual’s life - Exploring
SITUATIONAL STRESSORS independence
● Are unpredictable and may occur at any time
during life. - Choosing a career
● Situational stress may be positive or negative.
Examples of situational Stress:
- Death of a family member YOUNG ADULT - Marriage Leaving
- Marriage or divorce home
- Birth of a child
- New job - Managing a home
- Illness.
- Getting started in an
* The degree to which any of these events has positive occupation
or negative effects depends to some extent on an
- Continuing one’s
individual’s developmental stage
education

- Children
EFFECTS OF STRESS

● Stress can have: MIDDLE ADULT - Physical changes of

- Physical aging
- Emotional
- Intellectual - Maintaining social
- Social status and standard
- And spiritual consequences of living

● Usually the effects are mixed because stress - Helping teenage

affects the whole individual. children to become
independent
● Physically, stress can threaten an individual’s
physiologic homeostasis. - Aging parents
● Emotionally, stress can produce negative or
nonconstructive feelings about the self.
● Intellectually, stress can influence an OLDER ADULT - Decreasing physical
individual’s perceptual and problem-solving abilities and health
abilities.
- Changes in
● Socially, stress can alter an individual’s
residence
relationships with others.
● Spiritually, stress can challenge one’s beliefs - Retirement and
and values. reduced income
* Many health conditions have been linked to stress - Death of spouse and
friends
TABLE 42.1
SELECTED STRESSORS ASSOCIATED WITH
DEVELOPMENTAL STAGES
MODELS OF STRESS
CHILD - Beginning school - assist nurses to predict stressors in a particular
situation and to understand the individual’s
- Establishing peer
responses.
relationships
THREE MAIN MODELS OF STRESS: STAGES OF GAS AND LAS:
1. STIMULUS-BASED MODES ● ALARM REACTION
2. RESPONSE-BASED MODELS ● RESISTANCE
3. TRANSACTION-BASED MODELS ● EXHAUSTION

● STIMULUS-BASED MODES ALARM REACTION

- stress is defined as a stimulus, a life event, or a - The body can also react locally; that is, one
set of circumstances that arouses physiologic organ or a part of the body reacts alone.
and psychologic reactions that may increase the - Alerts the body’s defenses
individual’s vulnerability to illness. - 2 PHASE OF ALARM REACTION:
(1) Shock phase
HOLMES AND RAHE (1967) (2) Countershock phase
- assigned a numerical value to 43 life changes or
events. The scale has been modified and ➔ SHOCK PHASE (1st Part)
shortened many times. The scale of stressful life - the stressor may be perceived
events is used to document an individual’s consciously or unconsciously by the
relatively assigned numerical value to 43 life individual.
changes or events. Recent experiences, such as - stimulate the sympathetic nervous
divorce, pregnancy, and retirement. system, which stimulates the
- In this view, both positive and negative events hypothalamus. The hypothalamus
are stressful. releases corticotropin-releasing
hormone, which stimulates the anterior
pituitary gland to release
● RESPONSE-BASED MODELS adrenocorticotropic hormone.
- All of these adrenal hormonal effects
SELYE (1956, 1976) permit the individual to perform far more
- Stress may also be considered as a response strenuous physical activity than would
- as “the nonspecific response of the body to any otherwise be possible. The individual is
kind of demand made upon it” then ready for “fight or flight.” This
- (Selye’s Stress Response) characterized by a primary response is short-lived, lasting
chain or pattern of physiologic events called the from 1 minute to 24 hours.
general adaptation syndrome (GAS) or stress
syndrome. ➔ COUNTERSHOCK PHASE (2nd Part)
- Used the term stressor to denote any factor that - During this time, the changes produced
produces stress and disturbs the body’s in the body during the shock phase are
equilibrium. reversed.
- Stress can be observed only by the changes it
produces in the body. STAGE OF RESISTANCE
- Focuses on physiologic responses - When the body’s adaptation takes place.
- In other words, the body attempts to cope with
STRESS SYNDROME / GENERAL ADAPTATION the stressor and to limit the stressor to the
SYNDROME (GAS) smallest area of the body that can deal with it.
● Occurs with the release of certain adaptive
hormones and subsequent changes in the STAGE OF EXHAUSTION
structure and chemical composition of the body. - The adaptation that the body made during the
● Parts of the body affected by stress are the: second stage cannot be maintained.
- Gastrointestinal tract - This means that the ways used to cope with the
- Adrenal glands stressor have been exhausted.
- Lymphatic structures - The end of this stage depends largely on the
adaptive energy resources of the individual, the
LOCAL ADAPTATION SYNDROME (LAS) severity of the stressor, and the external
● The body can also react locally; that is, one adaptive resources provided, such as oxygen.
organ or a part of the body reacts alone.
● TRANSACTION-BASED MODELS
INDICATORS OF STRESS
LAZARUS (1966)
● PHYSIOLOGIC INDICATORS
- Stated that the stimulus theory and the response
● PSYCHOLOGIC INDICATORS
theory do not consider individual differences.
● COGNITIVE INDICATORS
Neither theory explains which factors cause
some individuals and not others to respond
PHYSIOLOGIC INDICATORS
effectively nor interprets why some individuals
- Responses to stress vary depending on the
adapt for longer periods than others.
individual’s perception of events.
- Recognizes that certain environmental demands
- Physiologic signs and symptoms of stress result
and pressures produce stress in substantial
from activation of the sympathetic and
numbers of individuals, he emphasizes that
neuroendocrine systems of the body.
individuals and groups differ in their sensitivity
and vulnerability to certain types of events, as
PYSCHOLOGIC INDICATORS
well as in their interpretations and reactions.
- Include anxiety, fear, anger, depression, and
- He includes mental and psychologic
unconscious ego defense mechanisms.
components or responses as part of his concept
of stress
a. ANXIETY AND FEAR
TRANSACTIONAL STRESS THEORY
ANXIETY
- By Lazarus
- A common reaction to stress
- Encompasses a set of cognitive, affective, and
- a state of mental uneasiness, apprehension,
adaptive (coping) responses that arise out of
dread, or foreboding or a feeling of helplessness
individual–environment transactions.
related to an impending or anticipated
- The individual and the environment are
unidentified threat to self or significant
inseparable; each affects and is affected by the
relationships.
other.
- Experienced at the conscious, subconscious, or
unconscious level.

Anxiety may be manifested on four levels:

● MILD ANXIETY
- A slight arousal that enhances
perception, learning, and productive
abilities.
● MODERATE ANXIETY
- Increases the arousal to a point where
the individual expresses feelings of
tension, nervousness, or concern.
- Attention is focused more on a particular
aspect of a situation than on peripheral
activities.
● SEVERE ANXIETY
- Consumes most of the individual’s
energies and requires intervention.
Perception is further decreased.
- The individual, is unable to focus on
what is really happening
● PANIC
- An overpowering, frightening level of
anxiety causing the individual to lose
control.
* Mild or moderate anxiety motivates goal-directed
behavior. In this sense, anxiety is an effective coping ● FANTASY
strategy. - likened to make-believe
- Unfulfilled wishes and desires are imagined as
FEAR fulfilled, or a threatening experience is reworked
- is an emotion or feeling of apprehension or replayed so it ends differently from reality.
aroused by impending or seeming danger, pain, - Can be helpful if they lead to problem-solving.
or another perceived threat.

b. ANGER COPING
- An emotional state consisting of a
subjective feeling of animosity or strong COPING
displeasure. ● may be described as dealing with change—
- Verbally expressed anger differs from: successfully or unsuccessfully
● Hostility
● Aggression COPING STRATEGY
- unprovoked attack ● Is a natural or learned way of responding to a
● Violence changing environment or specific problem or
- exertion of physical situation.
force to injure or abuse ● Vary among individuals and are often related to
the individual’s perception of the stressful event.
c. DEPRESSION ● Are also viewed as long-term or short term
- A common reaction to events that seem ➔ LONG-TERM COPING STRATEGIES
overwhelming or negative. - Can be constructive and
- An extreme feeling of sadness, despair, practical.
dejection, lack of worth, or emptiness,
affects millions of Americans a year. ➔ SHORT-TERM COPING STRATEGIES
- Can reduce stress to a tolerable
d. EGO DEFENSE MECHANISMS limit temporarily but are
- Are unconscious psychologic adaptive ineffective ways to permanently
mechanisms or, according to Anna deal with reality
Freud (1967)

TWO TYPES OF COPING STRATEGIES:

COGNITIVE INDICATORS (1) PROBLEM-FOCUSED COPING
- Thinking responses that include (2) EMOTIONAL-FOCUSED COPING
● PROBLEM-SOLVING
- Involves thinking through the threatening PROBLEM-FOCUSED COPING
situation, using specific steps to arrive at a - Refers to efforts to improve a situation by
solution making changes or taking action
EMOTIONAL-FOCUSED COPING
● STRUCTURING - Includes thoughts and actions that relieve
- Is the arrangement or manipulation of a situation emotional distress.
so threatening events do not occur. - Does not improve the situation, but the individual
often feels better.
● SELF-CONTROL OR SELF-DISCIPLE
- Is assuming a manner and facial expression that
convey a sense of being in control or in charge. THREE APPROACHES TO COPING WITH STRESS
1. ALTER STRESSORS
● SUPPRESSION 2. ADAPT STRESSORS
- Is consciously and willfully putting a thought or 3. AVOID STRESSORS
feeling out of mind: “I won’t deal with that today.
I’ll do it tomorrow.” This response relieves stress
temporarily but does not solve the problem.
 ● ADAPTIVE COPING
CHAPTER 43: LOSS, GRIEVING, AND DEATH
- Helps the individual to deal effectively
with stressful events and minimizes
distress associated with them LOSS
- Effective coping results in adaptation ● is an actual or potential situation in which
something that is valued is changed or no longer
● MALADAPTIVE COPING available.
- Can cause unnecessary distress for the ● Illness and hospitalization often produce losses
individual and others associated with the ● finding meaning is needed in order for healing to
individual or stressful event. occur.
- Ineffective coping results in
maladaptation. 2 TYPES OF LOSS
(1) ACTUAL LOSS
● can be recognized by others
CAREGIVER BURDEN (2) PERCEIVED LOSS
● Reaction to long-term stress is seen in family ● is experienced by an individual but
members who undertake the care of an cannot be verified by others.
individual in the home for a long period.
★ Psychologic losses are often perceived losses
CRISIS INTERVENTION because they are not directly verifiable.
● Is a short-term helping process of assisting
clients to (a) work through a crisis to its ★ Both losses can be ANTICIPATORY
resolution and (b) restore their pre-crisis level of ○ ANTICIPATORY LOSS is experienced
functioning. It is a process that includes not only before the loss actually occurs
the client in crisis but also various members of
the client’s support network. ★ can be viewed as SITUATIONAL or
DEVELOPMENTAL.
BURNOUT ○ SITUATIONAL: Losing one’s job, the
● A complex syndrome of behaviors that can be death of a child, and losing functional
likened to the exhaustion stage of the general ability because of acute illness or injury
adaptation syndrome.
○ DEVELOPMENTAL: departure of grown
NURSING INTERVENTION FOR STRESS children from the home, retirement from
Focuses on teaching the clients about: a career, and the death of aged parents.
● Exercise
● Nutrition DEATH
● Sleep ● Death is a loss both for the dying individual and
● Time Management for those who survive.
● Relaxation Techniques

DIAGNOSTIC LABELS FOR STRESS SOURCES OF LOSSES:

● ANXIETY (1) Aspect of self
● CAREGIVER ROLE STRAIN (2) External object
● COMPROMISED FAMILY COPING (3) Familiar environment
● DEFENSIVE COPING (4) Loved ones
● DISABLED FAMILY COPING
● INEFFECTIVE COPING 1. ASPECT OF SELF
● INEFFECTIVE DENIAL ● Losing an aspect of self changes an
● POST-TRAUMA & RELOCATION STRESS individual’s body image, even though
SYNDROME the loss may not be obvious.
● The degree of how losses affect an
individual largely depends on the
integrity of the individual’s body image
 2. EXTERNAL OBJECTS MOURNING
● This includes: ● process through which grief is eventually
- loss of inanimate objects that have resolved or altered;
importance to the individual ● often influenced by culture, spiritual beliefs, and
➔ EG. loss of money custom
➔ burning of home

-loss of animate (live) objects TYPES OF GRIEF RESPONSES

➔ Loss of pets 1. Abbreviated
3. FAMILIAR ENVIRONMENT 2. Anticipatory
● Separation from an environment and 3. Disenfranchised grief
individuals who provide security 4. Complicated grief
➔ OFWs
➔ 6yr old leaving home to go to NORMAL GRIEF REACTION:
school. 1. Abbreviated Grief
4. LOVED ONES ● is brief but genuinely felt.
● Losing a loved one or valued individual ● occur when the lost object is not
through illness, divorce, separation, or significantly important.
death can be very disturbing. ● or may have been replaced immediately
by another, equally esteemed object.
GRIEF
● total response to the emotional experience 2. Anticipatory Grief
related to loss. ● experienced in advance of the event
● manifested in thoughts, feelings, and behaviors such as the wife who grieves before her
associated with overwhelming distress or ailing husband dies.
sorrow.
● social process; it is best shared and carried out 3. Disenfranchised Grief:
with the assistance of others ● occurs when an individual is unable to
★ Grieving permits the individual to cope with the acknowledge the loss to others.
loss gradually. ● may occur often relate to a socially
★ symptoms that can accompany grief are: unacceptable loss:
➔ anxiety, depression, ➔ Suicide
➔ weight loss, ➔ Abortion
➔ difficulties in swallowing, vomiting, ➔ Giving child up for adoption
➔ fatigue, headaches, dizziness,
➔ fainting, blurred vision, COMPLICATED GRIEF
➔ skin rashes, excessive sweating, ● Unhealthy grief—that is, pathologic
➔ menstrual disturbances, ● when the strategies to cope with the loss are
➔ palpitations, chest pain, and dyspnea. maladaptive;
● And out of proportion or inconsistent with
BEREAVEMENT cultural, religious, or age-appropriate norms.
● subjective response experienced by the
surviving loved one PERSISTENT COMPLEX BEREAVEMENT DISORDER
● Although bereavement can threaten health, a - medical diagnosis for preoccupation lasts for
positive resolution of the grieving process can more than 12 months and leads to reduced
enrich the individual. ability to function normally
★ Grieving and bereaved may experience
altercations in: ★ Inhibited grief
➔ libido, ○ normal symptoms of grief are
➔ Concentration suppressed and other effects, including
➔ patterns of eating, sleeping, activity, and physiologic, are experienced instead
communication ★ Delayed grief
○ occurs when feelings are purposely or
subconsciously suppressed
 ★ Exaggerated grief ● ADULTHOOD iin which death is accepted as
○ survivor using dangerous activities as a very real but also very frightening.
method to lessen the pain of grieving ● OLDER ADULTHOOD in which death may be
viewed as more desirable than living with a poor
STAGES OF GRIEVING quality of life.
Kübler-Ross (1969), who described FIVE stages:
➔ denial, ● Hopelessness occurs when the individual
➔ anger, perceives no solutions to a problem
➔ bargaining,
➔ Depression, ● loss of control may be manifested by anger,
➔ Acceptance violence, acting out, or depression and passive
behavior
Engel (1964) identified SIX stages of grieving:
➔ shock and disbelief DEVELOPMENT OF THE CONCEPT OF DEATH:
➔ developing awareness
➔ restitution,
AGE BELIEFS / ATTITUDES
➔ resolving the loss,
➔ Idealization, Infancy–5 + Don’t understand concept of death
➔ outcome years + death = reversible, temporary, sleep
+ death = immobility / inactivity
MANIFESTATIONS OF GRIEF
● nurse can assess the clinical signs of this 5–9 yrs + understand death is final
+ own death can be avoided
response: + assoc. Death with aggression or violence
● GRIEF CONSIDERED NORMAL include:
➔ verbalization of the loss, 9-12 yrs + death as the inevitable end of life
➔ crying, + understands own mortality; interest in
➔ sleep disturbance, afterlife or as fear of death
➔ loss of appetite,
12-18 yrs + Fears a lingering death
➔ difficulty concentrating
+ fantasize that death can be defied
+ Seldom thinks about death, but views it in
● COMPLICATED GRIEVING religious and philosophic terms
➔ Extended time of denial
➔ Depression 18-45 yrs + attitude toward death influenced by
➔ Severe physiologic symptoms religious and cultural beliefs
➔ Suicidal thoughts
45-65 yrs + accepts mortality; death anxiety lowers
with emotional well-being.
FACTORS INFLUENCING THE LOSS AND GRIEF + encounters of death;
RESPONSES + peak of death anxiety.
● Age
● Significance of the Loss 65+ yrs + fears prolonged illness
● Culture + sees death w/ multiple meanings (free
from pain, reunion, etc.)
● Spiritual Beliefs
● Gender
● Socioeconomic Status Good to know bullshit:
● Support System Many of the characteristics seen in a fearful individual
● Cause of Loss of Death are similar to those of grieving and include crying,
immobility, increased pulse and respirations, dry mouth,
RESPONSES OF DYING AND DEATH anorexia, difficulty sleeping, and nightmares
Depends on:
- all the factors regarding loss DEFINITION OF DEATH
- the development of the concept of death ● for death to occur, a person must have a
permanent loss of the ability to use all brainstem
● CHILDHOOD belief in death as a temporary function and permanent incapacity for
state consciousness
DEATH-RELATED RELIGIOUS AND CULTURAL ORGAN DONATION
PRACTICES ● two main approaches to organ donation:

1. Explicit Consent
RELIGION THEY ARE PROHIBITED
- No one is considered a donor unless
Autopsy - Eastern Orthodox religions, they voluntarily ‘opt-in’ to become one.
- Muslims,
- Jehovah’s Witnesses, 2. Presumed Consent
- Orthodox Jews - Everyone is considered a donor unless
- Hindus (may oppose based on not they officially ‘opt-out’ of the system.
wanting non-Hindus to touch the body)

Cremation - Baha’i NURSING INTERVENTIONS

- Mormon, FOR LOSS, GRIEF AND DEATH
- Eastern Orthodox,
- Islamic, Assessing
- Roman Catholic faiths. ● The nurse first needs to recognize the states of
awareness manifested by the client and family
Organ - Jehovah’s Witnesses
donation members
○ Cases of terminal illness
- the state of awareness shared
DEATH- RELATED LEGAL ISSUES by dying clients and their
- Advance derivatives families affects the nurse's
- Do-Not-Resuscutate Orders ability to communicate freely
- Organ Donation with clients and other healthcare
- Euthanasia; Aid in dying team members, as well as to
assist in the grieving process.
ADVANCE DERIVATIVES
● This document describes preferences for future 3 TYPES OF AWARENESS
treatment, whether or not the client is currently 1. Closed Awareness
unwell. - The client is not made aware of
● specifies one or more individuals who will serve impending death
as their proxy (substitute) in making healthcare - The family does not completely
decisions should they be unable to do so. understand why the client is ill
or they believe the client will
GOOD TO KNOW BULLSHIT: recover
★ Another doc: POLST (Physician Orders for 2. Mutual pretense
Life-Sustaining Treatment) is signed by both the - The client, family, and
client or healthcare decision maker and the healthcare personnel know that
primary care provider. the prognosis is terminal but do
★ specifies current preferences for resuscitation; not talk about it and make an
medical interventions such as comfort effort not to raise the subject.
measures, intravenous medications, and - Permits the client a degree of
noninvasive airway support; and artificial privacy and dignity, but it places
nutrition and hydration. a heavy burden on the dying
client, who then has no one in
DO NOT RESUSCITATE ORDERS whom to confide.
● referred to as DNR, no code blue, no code, 3. Open awareness
allow natural death (AND). - The client and others know
● documentation of the decision to refrain from about the impending death and
cardiopulmonary resuscitation (CPR) feel comfortable discussing it,
● “do nothing” and decisions to withhold or even though it is difficult.
withdraw treatment are separate from DNR
decisions.
 (b) Achieving a dignified and peaceful death, which
SIGNS OF IMPENDING DEATH includes maintaining personal control and
accepting declining health status.
Loss of ● Relaxation of the facial
muscle muscles (e.g., the jaw may
Planning for Home Care
tone sag)
● Clients facing death may need help accepting
● Difficulty speaking
that they have to depend on others.
● Difficulty swallowing and
● Clients need help, well in advance of death, in
gradual loss of the gag reflex
planning for the period of dependence. They
● Decreased activity of the
need to consider what will happen and how and
gastrointestinal tract, with
where they would like to die.
subsequent nausea,
accumulation of flatus,
abdominal distention, and
IMPLEMENTING
retention of feces, especially if
● The major responsibility is to assist the client
narcotics or tranquilizers are
to a peaceful death if the client is dying. The
being administered
following are the responsibilities:
● Possible urinary and rectal
○ Minimize the client’s loneliness, fear,
incontinence due to decreased
and depression.
sphincter control
○ Maintain the client’s sense of security,
● Diminished body movement
self-confidence, dignity, and self-worth.
Slowing of ● Diminished sensation ○ Help the client accept losses.
the ● Mottling and cyanosis of the ○ Provide physical comfort
circulation extremities ● The client must be treated with dignity, honor
● Cold skin, first in the feet and and respect. This involves maintaining their
latter in the hands, ears, and humanity, to be consistent with their values,
nose (the client, may feel beliefs and culture.
warm if there is a fever) ● Help clients to determine their own physical,
● Slower and weaker pulse psychologic, and social priorities.
● Decreased blood pressure ● Support the client’s will and hope since most
dying individuals strive for self-fulfillment; the
Changes in ● Rapid, shallow, irregular, or need to find meaning in continuing to live while
respiration abnormally slow respirations suffering:
s ● Noisy breathing, referred to as ○ Personal feelings about death must be
the death rattle, due to identified and how they may influence
collecting of mucus in the interactions with clients, it must be
throat discussed with a friend or colleague.
● Mouth breathing, dry oral ○ Focus on the client’s needs, and avoid
mucous membranes imposing personal fears and beliefs on
the client or family.
Sensory ● Blurred vision ○ Talk to the client or family about how the
impairment ● Impaired senses of taste and client copes with stress since clients
smell typically use their coping strategies in
dealing with impending death.
○ Establish a communication relationship
DIAGNOSIS
that shows concern for and
● Diagnoses that may be particularly appropriate
commitment to the client.
for the dying client are fear, hopelessness, and
○ Determine what the client knows about
powerlessness
the illness.
○ Respond with honesty and directness to
PLANNING
questions about death, don’t sugarcoat
Major goals for dying clients are:
anything.
(a) Maintaining physiologic and psychologic comfort
○ Make time to be available to the client to
provide support, listen and respond.
Hospice and Palliative Care ● Meeting the Physiologic Needs of the Dying
● Cecily Saunders founded the hospice Client
movement. ○ Slowing of body processes.
● Hospice Care ■ Personal hygiene measures.
○ Support and care of the dying client with ■ Controlling pain - essential to
a life expectancy of 6 months or less. enable clients to maintain some
○ Improve the quality of life rather than quality in their life and daily
cure. activities such as eating, moving
○ The goal is to facilitate a peaceful and and sleeping. Drugs can be
dignified death of a dying client. used to control it such as
○ Physical needs are usually more morphine, heroin, methadone
apparent than emotional and behavioral and alcohol. The client’s opinion
signs. must be considered since the
○ Good assessment and ongoing client is the one that’s aware of
evaluation is essential as it indicates their personal pain tolerance.
when modifications or changes are ■ Relieving respiratory difficulties.
needed. ■ Assisting with movement.
○ Principles of hospice are: ■ Nutrition, hydration and
■ Home - most common. elimination.
■ Hospital ■ Provide measures related to
■ Nursing home-based unit sensory changes.
○ Care is provided by both healthcare
professionals and nonprofessionals to ● Supporting the family
ensure that a full range of care services ○ provide an empathetic and caring
is delivered. presence
○ More than 1.43 million Medicare ○ Family members should be encouraged
beneficiaries access hospice services to participate in the physical care of the
yearly, in 48% of all Medicare deaths; dying client as much as they wish to and
only 28% are diagnosed with cancer are able.
(The National Hospice and Palliative ○ After the client dies, the family should be
Care Organization, 2018).. encouraged to view the body (with or
○ Clients who have dementia, respiratory, without a nurse present or after
cardiac, and circulatory diseases are the preparation by the funeral home),
top noncancer diagnosis. because this has been shown to
facilitate the grieving process.
● Palliative care
○ Improves quality of life of the clients that ● POSTMORTEM CARE
may influence the course of illness and ○ Rigor mortis = stiffening of the body
their families who face problems that are that occurs about 2 to 4 hours after
associated with life-threatening illness. death.
○ Provide relief from pain and other ○ Algor mortis = gradual decrease of the
distressing symptoms. body’s temperature after death.
○ Offers a support system to help patients ○ Liver mortis = discoloration
live actively and families to cope during
the patient’s illness. EVALUATING
○ Use a team approach to address the Evaluation activities may include the ff:
needs of patients such as bereavement ● Listening to the client’s reports of feeling in
counseling. control of the environment surrounding death,
○ Applicable early in the course of illness such as control over pain relief, visitation of
in conjunction with other therapies. family and support people, or treatment plans
● Observing the client’s relationship with
significant others
● Listening to the client’s thoughts and feelings
related to hopelessness or powerlessness.