Assessment - Grief and Loss: Application of the Nursing Process

Assessment

Effective assessment involves observing all dimensions of human response: what the person is thinking (cognitive), how the person is feeling (emotional), what the person’s values and beliefs are (spiritual), how the person is acting (behavioral), and what is happening in the person’s body (physiologic). Effective communication skills during assessment can lead the client toward understanding his or her experience. Thus, assessment facilitates the client’s grief process.

While observing for client responses in the dimensions of grieving, the nurse explores three critical components in assessment:

·    Adequate perception regarding the loss

·    Adequate support while grieving for the loss

·    Adequate coping behaviors during the process.

Perception of the Loss

Assessment begins with exploration of the client’s percep-tion of the loss. What does the loss mean to the client? For the woman who has spontaneously lost her first unborn child and the woman who has elected to abort a pregnancy, this question could have similar or different answers.

Nevertheless, the question is valuable for beginning to facilitate the grief process.

Other questions that assess perception and encourage the client’s movement through the grief process include the following:

·    What does the client think and feel about the loss?

·    How is the loss going to affect the client’s life?

·    What information does the nurse need to clarify or share with the client?

Assessing the client’s “need to know” in plain and simple language invites the client to verbalize perceptions that may need clarification. This is especially true for the person who is anticipating a loss, such as one facing a life-ending illness or the loss of a body part. The nurse uses open-ended ques-tions and helps to clarify any misperceptions.

Consider the following. The doctor has just informed Ms. Morrison that the lump on her breast is cancerous andThree major areas to explore when assessing a grieving client that she can be scheduled for a mastectomy in 2 days. The nurse visits the client after rounds and finds her quietly watching television.

Nurse: “How are you?” (offering presence; giv-ing a broad opening)

Client: “Oh, I’m fine. Really, I am.”

Nurse: “The doctor was just here. Tell me, what is your understanding of what he said?” (using open-ended questions for description of perception)

Client: “Well, I think he said that I will have to have surgery on my breast.”

Nurse: “How do you feel about that news?” (using open-ended question for what it means to the client)

Exploring what the person believes about the grieving pro-cess is another important assessment. Does the client have pre-conceived ideas about when or how grieving should happen? The nurse can help the client realize that grieving is very per-sonal and unique: each person grieves in his or her own way.

Later in the shift, the nurse finds Ms. Morrison hitting her pillow and crying. She has eaten little food and has refused visitors.

Nurse: “Ms. Morrison, I see that you are upset. Tell me, what is happening right now?” (shar-ing observation; encouraging description)

Client: “Oh, I’m so disgusted with myself. I’m sorry you had to see me act this way. I shouldbe able to handle this. Other people have lost their breasts to cancer, and they are doing OK.”

Nurse: “You’re pretty upset with yourself, thinking you should feel differently.” (using reflection)

Client: “Yes, exactly. Don’t you think so?”

Nurse: “You’ve had to deal with quite a shock today. Sounds to me like you are expecting quite a bit of yourself. What do you think?” (using reflection; sharing perceptions; seeking validation)

Client: “I don’t know, maybe. How long is this going to go on? I’m a wreck emotionally.”

Nurse: “You are grieving, and there is no fixed timetable for what you are dealing with. Everyone has a unique time and way of doing this work.” (informing; validating experience)

Support

Purposeful assessment of support systems provides the grieving client with an awareness of those who can meet his or her emotional and spiritual needs for security and love. The nurse can help the client to identify his or her support systems and reach out and accept what they can offer.

Nurse: “Who in your life should or would really want to know what you’ve just heard from the doctor?” (seeking information about situa-tional support)

Client: “Oh, I’m really alone. I’m not married and don’t have any relatives in town.”Nurse: “There’s no one who would care about this news?” (voicing doubt)

Client: “Oh, maybe a friend I talk with on the phone now and then.”

Coping Behaviors

The client’s behavior is likely to give the nurse the easiest and most concrete information about coping skills. The nurse must be careful to observe the client’s behavior throughout the grief process and never assume that a cli-ent is at a particular phase. The nurse must use effective communication skills to assess how the client’s behavior reflects coping as well as emotions and thoughts.

The following day, the nurse has heard in report that Ms. Morrison had a restless night. She enters Ms. Morrison’s room and sees her crying with a full tray of food untouched.

Nurse: “I wonder if you are upset about your upcoming surgery.” (making an observation, assuming client was crying as an expected behavior of loss and grief)

Client: “I’m not having surgery. You have me mistaken for someone else.” (using denial to cope)

The nurse also must consider several other questions when assessing the client’s coping. How has the person dealt with loss previously? How is the person currently impaired? How does the current experience compare with previous experiences? What does the client perceive as a problem? Is it related to unrealistic ideas about what he or she shouldfeel or do?. The interaction of the dimensions of human response is fluid and dynamic. What a person thinks about during grieving affects his or her feelings, and those feelings influence his or her behavior. The critical factors of percep-tion, support, and coping are interrelated as well and pro-vide a framework for assessing and assisting the client.