Nursing
Diagnosis: Dysfunctional Grieving
Betty J. Ackley
NANDA Definition:
Extended unsuccessful use of intellectual and emotional responses by which
individuals, families, and communities attempt to work through the process of
modifying self-concept based on the perception of loss
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.
Defining Characteristics:
Repetitive use of ineffectual behaviors associated with attempts to reinvest in
relationships; crying; sadness; reliving of past experiences with little or no
reduction (diminishment) of intensity of the grief; labile affect; 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; anger; alterations in eating habits, sleep
patterns, dream patterns, activity level, libido, concentration and/or pursuit
of tasks; developmental regression; expression of guilt; prolonged interference
with life functioning; onset or exacerbation of somatic or psychosomatic
responses
Related Factors: Actual or perceived object loss (e.g., people, possessions, job, status, home, ideals, parts and processes of the body)
Related Factors: 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
·
Grief
Resolution
·
Family
Coping
·
Coping
·
Psychosocial
Adjustment: Life Change
Client Outcomes
·
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
·
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).
·
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).
·
Observe
for the following reactions to loss, which predispose a client to dysfunctional
grieving:
o Delayed grieving: the bereaved exhibits little emotion and
continues with a busy life
o Inhibited grieving: the bereaved exhibits various physical
conditions and does not feel grief
o 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).
·
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).
·
Develop
a trusting relationship with client by using therapeutic communication
techniques. An accepting,
trusting relationship facilitates communication and serves as a foundation for
healing.
·
Establish
a defined time to meet and discuss feelings about the loss and to perform grief
work.
·
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).
·
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).
·
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).
·
Help
client complete the following "guilt work" exercises:
o Identifying "if onlys" and putting them into perspective
o Dealing with "I didn't do" by looking at what was
accomplished
o 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.
·
Help
client review past experiences, role changes, and coping skills.
·
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
·
Help
client to identify own strengths for use in dealing with loss; reinforce these
strengths.
·
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).
·
Expect
client to meet responsibilities; give positive reinforcement.
·
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.
·
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).
·
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).
·
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).
Geriatric
·
Use
reminiscence therapy in conjunction with the expression of emotions (Puentes,
1998).
·
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).
·
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.
Multicultural
·
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).
·
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).
·
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).
·
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
·
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.
·
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.
·
Refer
client to or encourage continued interaction with hospice volunteers and
bereavement programs as continuing forms of support.
·
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.
·
Teach
perirectal skin care.
Sleep