Greiving

Greiving

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_) 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:____________________________________________________
____________________________________________________________
____________________________________________________________

 

As
evidenced by:
[Check
those that apply]
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:

  • Pastoral care
  • Social services
  • Home health care
  • Psychiatry

(_)
Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature