NURSING PROCESS FOR CLIENT WITH LOSS

Life is a series of experiences and challenges. Loss is a human experience and a challenge we all must face. Loss requires that we give up something familiar, comfortable, and personal. The more intense the attachment, the more deeply felt the sense of loss. Loss of a person includes death, separation, divorce, moving, and changes in mental or physical status.
Loss of attachment: the lost may be real or imagined and may include the loss of love, a person, physical functioning, status or self esteem. Many losses take on importance because of their symbolic meaning. May involve the loss of old friends, warm memories, and neighborhood associations. The ability to sustain, integrate and recover from loss, however is a sign of personal maturity and growth. (S. Sundeen 1995:426).


The nursing process
1. Assessment
Assessment of clients in the grieving or mourning process includes an accurate perception of the loss from their viewpoint. You begin by identifying the loss, be it a person or a relationship or a change in health status, roles in life, or dreams and aspirations for the future. Seek to understand the nature of the attachment to the lost person, object, or expectation. Assess past experiences with loss and the impact those have on the present experience. Assess cultural rituals and rules about mourning to understand the unique experience of grieving individuals.

2. Diagnosis
Possible nursing diagnoses for survivors of family member who has died include Anticipatory grieving, Dysfunctional grieving, Social isolation, altered role performance, risk for altered parenting, ineffective family coping: compromised, and family coping: potential for growth. Nursing diagnosis for children of divorce include Altered family process, Risk for caregiver role strain, and family coping: potential for growth. For adolescent who lack a peer group, nursing diagnosis might be impaired social interaction and self-esteem disturbance. Nursing diagnoses for middle adults experiencing loss might be impaired adjustment, self-esteem disturbance, and health-seeking behaviors. Nursing diagnoses in late adulthood include spiritual distress, Social isolation, and Hopelessness. Nursing diagnoses for families experiencing loss through mental illness include impaired social interaction, Social isolation, Caregiver role strain, ineffective family coping: compromised, family coping: potential for growth, and ineffective community coping

3. Nursing Interventions
Behavioral: Coping Assistance
Grief work facilitation
Assisting individuals and families to progress through the grief process in an important nursing intervention. Encourage people to express their feelings about the loss and help them identify their greatest fears concerning the loss. Help them recognize that all these feelings are a normal part of grieving. Discuss the active process of grieving as they meet new challenges in coping. Let them know that you understand grieving takes a great deal of time and energy.
As new skills are identified and implemented, support those which are most effective. If appropriated, suggest alternative ways of dealing with challenges while supporting them in following their own choices. An important aspect of grieving is establishing autonomy and direction in their own lives (Attig, 1996; McClosky and Bulechek, 1996).
Discuss potentially difficult times such as holiday seasons or anniversary dates. Role playing may be helpful as they anticipate these painful events. Assist survivors to identify goals that are unattainable because of the loss while encouraging realistic goal setting. Explore the ways in which social support systems have changed as a result of the loss or death. Refer to appropriate self-help groups for survivors of death, families of mentally ill person, and individuals who are psychiatrically disable (Klebanoff and Smith, 1997).
Spiritual care includes helping grieving persons to seek new meanings in both life and death. Encourage them to implement religious beliefs and rituals surrounding death. Guide them through the process of self-reflection as they think about what has happened to them. As grieving progresses, you can provide a listening ear while they recover old and discover new goals and purposes in life (Attig, 1996; McCloskey and Bulechek, 1996).
If children are involved in the grieving process, answer their questions associated with the loss. Use clear words, such as dead or died, rather than euphemisms, such as passing on or gone to sleep. Clear up any misunderstanding the children may have. Use play, art, or journal therapy to help children identify and work through their feelings. Refer to community resources designed to help children identify and work through their feelings. Refer to community resources designed to help children cope with the loss of a family member (McCloskey and Bulechek, 1996).
Families have specific needs as they address losses associated with having a member who is psychiatrically disabled. Assist them in redefining roles, responsibilities, and functions within the family. Teach them how to navigate the mental health system to obtain treatment and locate sources of emotional and financial support. If necessary, help them locate respite care to prevent caregiver burnout. Teach them ways to cope with deficit behaviors and intrusive or acting out behaviors by their loved one. Discuss stigma and ways to respond to prejudice from individuals, from communities, and from states and federal legislative branches as health care resources are allocated. Act as an advocate in preventing family exclusion and fostering family inclusion as a member of the team, all of whom work together to support the individual in living the fullest life possible.

4. Evaluation
Living with losses is normal but very stressful part of life. When coping with loss through grieving or mourning, people may respond in adaptive or maladaptive ways. Some never lose their sense of despair. In the face of this overwhelming negativism, family and friends often avoid the despairing person. Others are able to move through the process and focus on positive achievements and celebrate the relationship that was or is now. Family and friends find delight in sharing this positive process.
Some nurses have difficulty dealing with loss and death since they view the essence of caring as supporting life process. To accept death as a process of life enables other nurses to support people through this final stage of growth. To be effective caregivers, nurses must be willing to talk openly about death as well as accept their own mortality.

References:
Fontane, Karen Lee. 1999. Essential of Mental Health Psychiatric Nursing. California: Addison Wesley Longman, Inc.

Kozier, Barbara. 1979. Fundamental of Nursing. California: Wesley Publishing Company.

Stuart, G.W. & Sundeen S.J. 1995. Principle and Practice of Psychiatric Nursing. St. Louis, Missiouri: Mosby Year Book.

Yosep, Iyus. 2009. Keperawatan Jiwa edisi Revisi. Bandung: Refika Aditama.