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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Grieving, Anticipatory
Mary Leslie Caldwell, RN
Charlotte Razvi, RN, MSN, PhD
Deidra Gradishar, RNC, BS

NANDA: Intellectual and emotional responses and behaviors by which individuals work through the process of modifying self-concept based on the perception of potential loss

Anticipatory grivien 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.

Related Factors

Defining Characteristics

Expected Outcome

Patient or family verbalizes feelings, and establishes and maintains functional support systems.

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) 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.
(i) 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.
(i) 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.
(i) 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.
(i) 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.
(i) 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.
(i) 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.
(i) Observe nonverbal communication.
Body language may communicate a great deal of information, especially if the patient and his or her family is unable to vocalize their concerns.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) 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.
(i) 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.
(i) Provide safe environment for expression of grief.
This assumes a tolerance for the patient's expressions of grief (i.e., the ability to see a man cry, to see mourners make wide gestures with hands and their bodies, loud vocalizations and crying).
(i) Minimize environmental stresses or stimuli. Provide the mourners with a quiet, private environment with no interruptions.
(i) Remain with patient throughout difficult times. This may require the presence of the care provider during procedures, difficult discussions, 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.
(i) 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. Others 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.
(i) Anticipate increased affective behavior.
All affective behavior may seem increased or exaggerated during this time.
(i) 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.
(i) 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.
(i) Recognize that regression may be an adaptive mechanism.
The sheer volume of emotional reconstituting and reconstruction, which must be accomplished after a loss occurs, makes it reasonable to assume that time to restore energy will be needed at intervals.
(i) 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.
This is the same strength and reserve each of them will use to reconstitute their lives after the loss.
Offer encouragement; point out strengths and progress to date.
Patients often lose sight of the achievements while engaged in the struggle.
(i) Discuss possible need for outside support systems (i.e., 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.
(i) 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.
(i) Encourage patient's or significant others' active involvement with rehabilitation team.
(i) 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.
(i) Recognize patient's need to review (relive) the illness experience.
This is one way in which the patient or the family integrate the event into their experience. Telling the event allows them an opportunity to hear it described and gain some perspective on the event.
(i) 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.
(i) 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.
(i) 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:
(i) Provide as much privacy as possible.
(i) Allow use of denial and other defense mechanisms.
(i) Avoid reinforcing denial.
(i) Avoid judgmental and defensive responses to criticisms of health care providers.
(i) Do not encourage use of pharmacological interventions.
(i) Do not force patient to make decisions.
(i) Provide patient with ongoing information, diagnosis, prognosis, progress, and plan of care.
(i) Involve the patient and family in decision making in all issues surrounding care.
This acknowledges their right and responsibility for self-direction and autonomy.
(i) 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.
(i) 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.
(i) 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.
(i) 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.
(i) 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 is 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:
(i) 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.
(i) Promote discussion on what to expect when death occurs.
(i) Encourage significant others and patient to share their wishes about which family members should be present at time of death.
(i) Help significant others to accept that not being present at time of death does not indicate lack of love or caring.
(i) When hospitalized, use a visual method to identify the patient's critical status (i.e., 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.
(i) Initiate process that provides additional support and resources such as clergy or physician.
(i) Provide anticipatory guidance and follow-up as condition continues.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Involve significant others in discussions. This helps reinforce understanding of all individuals involved.
(c) Refer to other resources: counseling, pastoral support, group therapy, and others.
Patient or significant other may need additional help to deal with individual concerns.

NIC

Grief Work Facilitation; Presence; Emotional Support

See also:
Death and dying, Chapter 15, p. 1194

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