NOTE: It is now recognized that sometimes what was previously diagnosed as Dysfunctional Grieving might instead be Chronic Sorrow, in which grief lingers and is reactivated at intervals (Eakes, Burke, Hainsworth, 1998). Refer to the nursing diagnosis Chronic Sorrow if appropriate.
Repetitive use of ineffectual behaviors associated with attempts to reinvest in relationships;
reliving of past experiences with little or no reduction (diminishment) of intensity of the grief;
expression of unresolved issues; interference with life functioning;
verbal expression of distress at loss;
idealization of lost object (e.g., people, possessions, job, status, home, ideals, parts and processes of the body);
difficulty in expressing loss;
denial of loss;
alterations in eating habits, sleep patterns, dream patterns, activity level, libido, concentration and/or pursuit of tasks;
expression of guilt;
prolonged interference with life functioning;
onset or exacerbation of somatic or psychosomatic responses
Actual or perceived object loss (e.g., people, possessions, job, status, home, ideals, parts and processes of the body)
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
Psychosocial Adjustment: Life Change
Expresses appropriate feelings of guilt, fear, anger, or sadness
Identifies problems associated with grief (e.g., changes in appetite, insomnia, nightmares, loss of libido, decreased energy, alteration in activity levels)
Seeks help in dealing with grief-associated problems
Plans for future one day at a time
Identifies personal strengths
Functions at a normal developmental level and performs activities of daily living (ADLs) after an appropriate length of time
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
Grief Work Facilitation
Grief Work Facilitation: Perinatal Death
Guilt Work Facilitation
Nursing Interventions and Rationales
1. Assess client's state of grieving. Utilize a tool such as the Hogan Grief Reaction Checklist, or the Grief Experience Inventory.
These are commonly used measures of grief that have shown to effectively measure grief (Hogan, Greenfield, 1988; Gamino, Sewell, Easterling, 2000).
2. Assess for causes of dysfunctional grieving (e.g., sudden bereavement [less than 2 weeks to prepare for the oncoming loss], highly dependent or ambivalent relationship with the deceased, inadequate coping skills, lack of social support, previous physical or mental health problems, death of a child, loss of spouse).
Life circumstances can interfere with normal grieving and be risk factors for dysfunctional grieving (Steele, 1992; Stewart, 1995; Gamino, Sewell, Easterling, 2000).
3. Observe for the following reactions to loss, which predispose a client to dysfunctional grieving:
Delayed grieving: the bereaved exhibits little emotion and continues with a busy life
Inhibited grieving: the bereaved exhibits various physical conditions and does not feel grief
Chronic grieving: the behaviors of the normal grief period continue beyond a reasonable time
These maladaptive grief reactions indicate that the client needs help with grief work (Gifford, Cleary, 1990).
4. Identify problems of eating and sleeping; ensure that basic human needs are being met.
Losses often interrupt appetite and sleep (Bateman et al, 1992; Gifford, Cleary, 1990).
5. Develop a trusting relationship with client by using therapeutic communication techniques.
An accepting, trusting relationship facilitates communication and serves as a foundation for healing.
6. Establish a defined time to meet and discuss feelings about the loss and to perform grief work.
7. Encourage client to "cry out" grief and to talk about feelings of anger, sadness, and guilt.
Grief is work and is best treated as an active process in which the bereaved expresses and feels the grief. Expression of guilt or anger is necessary for progressing through the grieving process and feeling better (Bateman et al, 1992).
8. Assess for spiritual distress, and refer client to appropriate spiritual leader.
Intrinsic spirituality can help the client grieve (Gamino, Sewell, Easterling, 2000); the nurse should approach the client with a nonjudgmental, listening ear and refer client to the appropriate spiritual leader (Brant, 1998).
9. Help client recognize that although sadness will occur at intervals for the rest of his or her life, it will become bearable.
The sadness associated with chronic sorrow is permanent, but as the grief resolves, there can be times of satisfaction and even happiness (Grainger, 1990; Teel, 1991). Grief has a lasting nature; it changes and softens but never ends (Carter, 1989).
10. Help client complete the following "guilt work" exercises:
Identifying "if onlys" and putting them into perspective
Dealing with "I didn't do" by looking at what was accomplished
Forgiving self; say to client, "You are being awfully hard on yourself; try not to hurt yourself over something you could not have controlled"
The client may need to resolve guilt before successfully grieving and moving on with life.
11. Help client review past experiences, role changes, and coping skills.
12. Encourage client to keep a journal and write about their bereavement experience.
Writing projects can be helpful for clients who are grieving, especially for those experiencing the unique bereavement of suicidal death (Range, Kovac, Marion, 2000).
13. Help client to identify own strengths for use in dealing with loss; reinforce these strengths.
14. If client or family members are expressing anger, try not to react in anger. Instead, allow feelings to be expressed, listen to the expressions of anger, and accept their right to those feelings. Try lowering the voice and slowing the rate of speech as you respond back to the client/family.
It is not therapeutic to respond to anger with anger. Instead, strive to be therapeutic, helping the client/family express the anger and gain control of themselves by modeling calm behavior (Rueth, Hall, 1999).
15. Expect client to meet responsibilities; give positive reinforcement.
16. Help client to identify areas of hope in life and to determine their purposes if possible.
A significant positive relationship has been found between the level of grief resolution and the level of hope (Herth, 1990). Grieving people who have little purpose in life often experience more anger than individuals with more purpose.
17. Encourage client to make time to talk to family members about the loss with the help of professional support as needed and without criticizing or belittling one another's feelings about the loss.
Once these feelings are shared, family members can begin to accept the unacceptable (Gifford, Cleary, 1990).
18. Identify available community resources, including bereavement groups from local hospitals and hospice.
Support groups can have positive effects on bereavement for both children and adults (Cooley, 1992; Heiney, Dunaway, Webster, 1995; Stewart, 1995).
19. Identify whether client is experiencing depression, suicidal tendencies, or other emotional disorders. Refer client for counseling as appropriate.
Counseling, including use of relaxation therapy, desensitization, and biofeedback in addition to traditional psychotherapy, has been shown to be helpful (Arnette, 1996). Depression syndromes occur in almost one half of all grieving people, and 10% suffer major depression (Steen, 1998). Cognitive behavior therapy can be helpful for traumatic grief (Jacobs, Prigerson, 2000).
1. Use reminiscence therapy in conjunction with the expression of emotions (Puentes, 1998).
2. Identify previous losses and assess client for depression. Signs of depression are often masked by somatic complaints.
Losses and changes associated with older age often occur in rapid succession without adequate recovery time. Having more than two concurrent losses increases the incidence of unresolved grief (Herth, 1990). The elderly often express grief in the form of somatic complaints (Steen, 1998).
3. Evaluate the social support system of the elderly client. If support system is minimal, help client determine how to increase available support.
The elderly who have poor grieving outcomes often do not live with family members and have a minimal support system.
1. Assess for the influence of cultural beliefs, norms, and values on the client's grief and mourning practices. Grieving practices may be based on cultural perceptions (Leininger, 1996).
Great emphasis may be placed on attendance at funerals for some blacks; many Native American tribes may hold long somber wakes during which food and memorial gifts are distributed; Chinese and Japanese families may have specific funeral rituals that must be followed precisely to ensure safe passage of their loved one; Latinos may hold wakes, utilize prayer during a novena, and light candles in honor of the dead; in West Indian/Caribbean cultures death arrangements might be made by a kinsman of the deceased (McQuay, 1995).
2. Assess for the influence of cultural beliefs, norms, and values on the client's expressions of grief.
Blacks may be expected to act "strong" and go about the business of life after a death; Native Americans may not talk about the death because of beliefs that such talk will detract from spirituality and bring bad luck; Latinos may wear black and act subdued during their luto/mourning period; Southeast Asian families may wear white when mourning (McQuay, 1995).
3. Identify whether the client had been notified of health status and was able to be present during death and illness.
Not being present during terminal illness and death can disrupt grief process (McQuay, 1995).
4. Validate the client's feelings regarding the loss.
Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
Home Care Interventions
1. Encourage client to make choices about daily living and the home environment that acknowledge the loss.
Helping with grief work allows client to accept reality of loss and realize that grieving is a healthy response.
2. Evaluate the long-term support system of the bereaved client. Encourage client to interact with the support system at defined intervals.
Regular contact with support systems allows for regular expression of feelings and grief resolution.
3. Refer client to or encourage continued interaction with hospice volunteers and bereavement programs as continuing forms of support.
4. Refer client to medical social services, especially the hospice program social worker, for assistance with grief work.
Consulting with or referring to specialty services is sometimes the best way to provide care.
5. Teach perirectal skin care.
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