Grieving | Nursing Care Plan for Spinal Cord Injury

Nursing diagnosis: Grieving related to Perceived or actual loss of physiopsychosocial well-being

Possibly evidenced by
Altered communication patterns
Expression of distress, choked feelings, such as denial, guilt, fear, sadness; altered affect
Alterations in sleep patterns

Desired Outcomes/Evaluation Criteria—Client Will
Grief Resolution
Express feelings freely and effectively.
Begin to progress through recognized stages of grief, focusing on 1 day at a time.

Nursing intervention with rationale:
1. Identify signs of grieving, such as shock, denial, anger, and depression.
Rationale: Client experiences a wide range of emotional reactions to the injury and its actual and potential impact on life. These stages are not static, and the rate at which client progresses through them is variable.

SHOCK
1. Note lack of communication or emotional response and absence of questions.
Rationale: Shock is the initial reaction associated with overwhelming injury. Primary concern is to maintain life. The client may be too ill to express feelings.

2. Provide simple, accurate information to client and SO regarding diagnosis and care. Be honest; do not give false reassurance while providing emotional support.
Rationale: Client’s awareness of surroundings and activity may be blocked initially, and attention span may be limited. Little is actually known about the outcome of client’s injuries during acute phase, and lack of knowledge may add to frustration and grief of family. Therefore, early focus of emotional support may be directed toward SO.

3. Encourage expressions of sadness, grief, guilt, and fear among client, SO, and friends.
Rationale: Acknowledging client and SO feelings and encouraging expression could provide appropriate support.

4. Incorporate SO into problem-solving and planning for client’s care.
Rationale: Shared clinical decision making with the client and SO establishes therapeutic relationships and provides sense of control of the management of current health situation and the subsequent changes.

DENIAL
1. Assist client and SO to verbalize feelings about situation. Avoid judgment about what is expressed.
Rationale: Important beginning step to deal with what has happened. Helpful in identifying client’s coping mechanisms.

2. Note comments indicating unrealistic outcomes and bargaining with God. Do not confront these comments in early phases of rehabilitation.
Rationale: Denial may be a useful coping mechanism during the early phases of rehabilitation. Client may accept disability but may deny uncertainty and permanency of limitations.

3. Focus on present needs—ROM exercises, skin care, and so on.
Rationale: Attention on “here and now” reduces frustration and hopelessness of uncertain future and may make dealing with today’s problems more manageable.

ANGER
1. Identify use of manipulative behavior and reactions to caregivers.
Rationale: Client may demonstrate manipulative behaviors like spitting, biting, or even pitting caregivers against each other to express anger.

2. Encourage client to take control when possible—establishing care routines, dietary choices, diversional activities, and so forth.
Rationale: Encouraging client participation provides a sense of control and responsibility as well as reduces sense of powerlessness.

3. Accept expressions of anger and hopelessness, such as “let me die.” Avoid arguing. Show concern for client.
Rationale: Nonjudgmental communication of empathy and compassion helps the client regain sense of worth.

4. Set limits on acting out and unacceptable behaviors when necessary, including abusive language, sexually aggressive or suggestive behavior.
Rationale: Although it is important to express negative feelings, client and staff need to be protected from violence and embarrassment. Acting out is traumatic for all involved.

DEPRESSION
1. Note loss of interest in living, sleep disturbance, suicidal thoughts, and hopelessness. Listen to, but do not confront, these expressions. Let client know nurse is available for support.
Rationale: Depression may last for weeks, months, and years. Acceptance and support are critical in facilitating resolution. The client may need psychological counseling.

2. Arrange visit by individual similarly affected, as appropriate.
Rationale: Talking with another person who has shared similar feelings and fears and survived may help client reach acceptance of reality of condition and deal with perceived and actual losses.

3. Consult with and refer to psychiatric nurse, social worker, psychiatrist, and pastor.
Rationale: Client and SO need assistance to work through feelings of alienation, guilt, and resentment concerning lifestyle and role changes. The family required to make adaptive changes to a member who may be permanently “different” benefits from supportive, long-term assistance and counseling in coping with these changes and the future. Client and SO may suffer great spiritual distress, including feelings of guilt, deprivation of peace, and anger at God, which may interfere with progression through, and resolution of, grief process.