Greiving
Greiving
(_)Actual (_) Potential
| (_) Loss
of function of body
part:__________________________________ (_) Loss of s/o:________________________________________________ (_) Loss of independence/change in lifestyle. (_) Diagnosis of a terminal illness. (_) Loss of physical abilities:_____________________________________ (_) Other:____________________________________________________ ____________________________________________________________ ____________________________________________________________ |
| Major:
(Must be present) |
(_)
Unsuccessful adaptation to loss (_) Expressed distress of
actual or potential loss (_) Prolonged denial (_) Depression (_) Delayed emotional reaction |
| Minor:
(May be present) |
(_)
Social isolation or withdrawl (_) Failure to develop new
relationships/interests (_) Failure to restructure life after a loss (_) Denial (_) Guilt (_) Anger (_) Sorrow (_) Change in eating habits (_) Change in sleep patterns (_) Decreased libido (_) Change in communication patterns |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Express his/her grief. (_) Describe the meaning of the death or loss to him/her. (_) Share his/her grief with s/o. (_) Participate in ADL's as tolerated. (_) Other: |
(_)
Assess for causative and contributing factors that may
delay the grief process: _________________________ _________________________ _________________________ (_) Reduce or eliminate causative or contributing factors if possible. (_) Encourage to recognize grief situation. (_) Give opportunity for questions. (_) Encourage expressions of anger/concerns. (_) Describe the stages of anticipatory grieving. (Include s.o). (_) Have patient identify support systems. (_) Assist with unfinished business. (_) Encourage to share prognosis with s/o. (_) Encourage s/o to participate in care. (_) Encourage problem solving with help of others. (_) Encourage planned, "one day at a time" living. (_) Allow patient
opportunity to identify own self care needs:____________ (_) Help to set
realistic goals - give realistic hope:________________ (_) Encourage patient and s/o to accept individual responses to impending loss. (_) Refer/order consult:
(_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature