Nursing Diagnosis: Dysfunctional Grieving

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)

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, 2000).
·         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).

·         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.
·         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.

Nursing Diagnosis: Disturbed Sleep pattern

Nursing Diagnosis: Disturbed Sleep pattern
Betty J. Ackley

NANDA Definition: Time-limited disruption of sleep (natural periodic suspension of consciousness)

Defining Characteristics: Prolonged awakenings; sleep maintenance insomnia; self-induced impairment of normal pattern; sleep onset >30 minutes; early morning insomnia; awakening earlier or later than desired; verbal complaints of difficulty falling asleep; verbal complaints of not feeling well-rested; increased proportion of Stage 1 sleep; dissatisfaction with sleep; less than age-normed total sleep time; three or more nighttime awakenings; decreased proportion of Stages 3 and 4 sleep (e.g., hyporesponsiveness, excess sleepiness, decreased motivation); decreased proportion of REM sleep (e.g., REM rebound, hyperactivity, emotional lability, agitation and impulsivity, atypical polysomnographic features); decreased ability to function

Related Factors: Ruminative presleep thoughts; daytime activity pattern; thinking about home; body temperature; temperament; dietary; childhood onset; inadequate sleep hygiene; sustained use of antisleep agents; circadian asynchrony; frequently changing sleep-wake schedule; depression; loneliness; frequent travel across time zones; daylight/darkness exposure; grief; anticipation; shift work; delayed or advanced sleep phase syndrome; loss of sleep partner, life change; preoccupation with trying to sleep; periodic gender-related hormonal shifts; biochemical agents; fear; separation from significant others; social schedule inconsistent with chronotype; aging-related sleep shifts; anxiety; medications; fear of insomnia; maladaptive conditioned wakefulness; fatigue; boredom
Noise; unfamiliar sleep furnishings; ambient temperature, humidity; lighting; other-generated awakening; excessive stimulation; physical restraint; lack of sleep privacy/control; interruptions for therapeutics, monitoring, lab tests; sleep partner; noxious odors
Mother's sleep-wake pattern; parent-infant interaction; mother's emotional support
Urinary urgency, incontinence; fever; nausea; stasis of secretions; shortness of breath; position; gastroesophageal reflux

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Sleep
·         Rest
·         Well-Being
·         Psychosocial Adjustment: Life Change
·         Quality of Life
·         Pain Level
·         Comfort Level
Client Outcomes
·         Wakes up less frequently during night
·         Awakens refreshed and is not fatigued during day
·         Falls asleep without difficulty
·         Verbalizes plan to implement bedtime routines
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Sleep Enhancement
Nursing Interventions and Rationales
·         Assess client's sleep patterns and usual bedtime rituals and incorporate these into the plan of care. Usual sleep patterns are individual; data collected through a comprehensive and holistic assessment are needed to determine the etiology of the disturbance (Spenceley, 1993). Staff nurses' evaluation of client's sleep states are usually valid (Edwards, Schuring, 1993).
·         Determine current level of anxiety, if client is anxious, see Nursing Interventions and Rationales for Anxiety. Anxiety interferes with sleep. Interventions such as relaxation training can help clients reduce anxiety (Pagel, Zafralotfi, Zammit, 1998). Many clients with insomnia display hyperarousal during the day in addition to the nighttime (Sateia et al, 2000).
·         Assess for signs of new onset of depression: depressed mood state, statements of hopelessness, poor appetite. Refer for counseling as appropriate. Sleep deprivation in normal subjects did not result in the usual complaints of people with insomnia. Many symptoms associated with sleep deprivation probably arise from central nervous system hyperarousal (Bonnett, Arand, 1998).
·         Observe client's medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over-the-counter medications. Difficulty sleeping can be a side effect of medications such as bronchodilators; caffeine can also interfere with sleep.
·         Provide measures to take before bedtime to assist with sleep (e.g., quiet time to allow the mind to slow down, carbohydrates such as crackers, or a back massage). Simple measures can increase quality of sleep. Carbohydrates cause release of the neurotransmitter serotonin, which helps induce and maintain sleep (Somer, 1999). Research has shown back massage to effectively promote sleep (Richards, 1994).
·         Provide pain relief shortly before bedtime and position client comfortably for sleep. Clients have reported that uncomfortable positions and pain are common factors of sleep disturbance (Sateia et al, 2000).
·         Keep environment quiet (e.g., avoid use of intercoms, lower volume on radio and television, keep beepers on nonaudio mode, anticipate alarms on IV pumps, talk quietly on unit). Excessive noise causes sleep deprivation that can result in ICU psychosis (Barr, 1993). Health volunteers exposed to recorded critical care noise levels experienced poor sleep (Topf, 1992). More than half of the noises in ICUs were caused by human behavior such as talking and TV watching (Kahn, Cook, 1998).
·         Use soothing sound generators with sounds of the ocean, rainfall, or waterfall to induce sleep, or use "white noise" such as a fan to block out other sounds. Ocean sounds promoted sleep for a group of postoperative open-heart surgery clients (Williamson, 1992).
·         For hospitalized stable clients, consider instituting the following sleep protocol to foster sleep:
o Night shift: Give client the opportunity for uninterrupted sleep from 1 AM to 5 AM. Keep environmental noise to a minimum.
o Evening shift: Limit napping between 4 PM and 9 PM. At 10 PM turn lights off, provide sleep medication according to individual assessment, and keep noise and conversation on the unit to a minimum.
o Day shift: Encourage short naps before 11 AM. Enforce a physical activity regimen as appropriate. Schedule newly ordered medications to avoid waking client between 1 AM and 5 AM.
Critical care nurses can take effective actions to promote sleep (Edwards, Schuring, 1993).
·         Determine if client has a physiological problem that could result in insomnia such as pain, cardiovascular disease, pulmonary disease, neurological problems such as dementia, or urinary problems. Sleep disturbances in the elderly may represent a complex interaction of age-related changes and pathological causes (Sateia et al, 2000).
·         Observe elimination patterns. Have client decrease fluid intake in the evening, and ensure that diuretics are taken early in the morning. Many elderly people void during the night. Increasing water intake at night or taking diuretics late in the day increases nocturia, which results in disrupted sleep.
·         Do a careful history of all medications including over-the-counter medications and alcohol intake. Alcohol intake and medication effects are common causes of insomnia in the elderly. Rebound insomnia associated with the use of shorter-acting hypnotics may perpetuate a cycle of sleep disturbance and chronic hypnotic use (Sateia et al, 2000).
·         If client is waking frequently during the night, consider the presence of sleep apnea problems and refer to a sleep clinic for evaluation. Sleep apnea in the elderly may be caused by changes in the respiratory drive of the central nervous system or may be obstructive and associated with obesity (Foyt, 1992).
·         Evaluate client for presence of depression or anxiety, which can result in insomnia. Refer for treatment as appropriate. Anxiety and depression are common in the elderly and can result in insomnia (Sateia et al, 2000).
·         Encourage social activities. Help elderly get outside for increased light exposure and to enjoy nature. Exposure to light and social interactions influence the circadian rhythms that control sleep (Elmore, Betrus, Burr, 1994; Sateia et al, 2000).
·         Suggest light reading or TV viewing that does not excite as an evening activity. Soothing activities decrease stimulation of the reticular activating system and help sleep come naturally.
·         Increase daytime physical activity. Encourage walking as client is able.
·         Avoid use of hypnotics and alcohol to sleep. Long-term use of hypnotics can induce a drug-related insomnia. Alcohol also disrupts sleep and can exacerbate sleep apnea (Evans, Rogers, 1994).
·         Reduce daytime napping in the late afternoon; limit naps to short intervals as early in the day as possible. The majority of elderly nap during the day (Evans, Rogers, 1994). Avoiding naps in the late afternoon makes it easier to fall asleep at night.
·         Help client recognize that there are changes in length of sleep. Client may not be able to sleep for 8 hours as when younger, and more frequent awakening is part of the aging process (Floyd et al, 2000).
·         If client continues to have insomnia despite developing good sleep hygiene habits, refer to a sleep clinic for further evaluation (Pagel, Zafralotfi, Zammit, 1997).
Nursing Interventions and Rationales
·         Provide support to the family of client with chronic sleep pattern disturbance. Ongoing sleep pattern disturbances can disrupt family patterns and cause sleep deprivation in the client or family members, which creates increased stress on the family.
Client/Family Teaching
·         Encourage client to avoid coffee and other caffeinated foods and liquids and also to avoid eating large high-protein or high-fat meals close to bedtime. Caffeine intake increases the time it takes to fall asleep and increases awake time during the night (Evans, Rogers, 1994). A full stomach interferes with sleep.
·         Advise the client that research on use of melatonin is still equivocal. While it may help the client to fall asleep faster, it does not improve the quality or length of time in the sleep interval, and long-term results are unknown (Hughes, Sack, Lewy, 1998; Defrance, Quera-Salva, 1998; Walsh et al, 1999).
·         Advise client to avoid use of alcohol or hypnotics to induce sleep. Sleep induced by alcohol is often disrupted later in the night (Walsh et al, 1999). Use of benzodiazapines, while they are effective in inducing and maintaining sleep, have major side effects including daytime drowsiness, dizziness or light-headedness, and memory loss (Holbrook et al, 2000).
·         Ask client to keep a sleep diary for several weeks. Often the client can find the cause of the sleep deprivation when the pattern of sleeping is examined (Pagel, Zafralotfi, Zammit, 1998).
·         Teach relaxation techniques, pain relief measures, or the use of imagery before sleep.
·         Teach client need for increased exercise. Encourage to take a daily walk 5 to 6 hours before retiring. Moderate activity such as walking can increase the quality of sleep (King et al, 1997).
·         Encourage client to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts.
·         Teach the following guidelines for good sleep hygiene to improve sleep habits:
o Go to bed only when sleepy.
o When awake in the middle of the night, go to another room, do quiet activities, and go back to bed only when sleepy.
o Use the bed only for sleeping—not for reading or snoozing in front of the television.
o Avoid afternoon and evening naps.
o Get up at the same time every morning.
o Recognize that not everyone needs 8 hours of sleep.
o Move the alarm clock away from the bed if it is a source of distraction.
o Do not associate lulls in performance with sleeplessness; sleeplessness should not be blamed for everything that goes wrong during the day.
These guidelines on sleep hygiene have been shown to effectively improve quality of sleep (Morin, 1993; Pagel 1997; Walsh et al, 1999).