Nursing Dx

Taxonomy II: Coping/Stress Tolerance—Class 2 Coping Response (00147)
[Diagnostic Division: Ego Integrity]
Submitted 1998

Definition: Apprehension, worry, or fear related to death or dying

Related Factors
To be developed

Defining Characteristics
SUBJECTIVE

Fear of: developing a terminal illness; the process of dying; loss of physical and/or mental abilities when dying; premature death because it prevents the accomplishment of important life goals; leaving family alone after death; delayed demise

Negative death images or unpleasant thoughts about any event related to death or dying; anticipated pain related to dying

Powerlessness over issues related to dying; total loss of control over any aspect of one’s own death

Worrying about: the impact of one’s own death on SOs; being the cause of other’s grief and suffering

Concerns of overworking the caregiver as terminal illness incapacitates self; about meeting one’s creator or feeling doubtful about the existence of God or higher being

Denial of one’s own mortality or impending death
OBJECTIVE
Deep sadness
(Refer to ND anticipatory Grieving.)

Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify and express feelings (e.g., sadness, guilt, fear) freely/effectively.
• Look toward/plan for the future one day at a time.
• Formulate a plan dealing with individual concerns and eventualities of dying.

Actions/Interventions
NURSING PRIORITY NO.1. To assess causative/contributing factors:
• Determine how client sees self in usual lifestyle role functioning and perception and meaning of anticipated loss to him or her and SO(s).
• Ascertain current knowledge of situation to identify misconceptions, lack of information, other pertinent issues.
• Determine client’s role in family constellation. Observe patterns of communication in family and response of family/ SO to client’s situation and concerns. In addition to identifying areas of need/concern, also reveals strengths useful in addressing the concerns.
• Assess impact of client reports of subjective experiences and past experience with death (or exposure to death); for example, witnessed violent death or as a child viewed body in casket, and so on.
• Identify cultural factors/expectations and impact on current situation/feelings.
• Note physical/mental condition, complexity of therapeutic regimen.
• Determine ability to manage own self-care, end-of-life and other affairs, awareness/use of available resources.
• Observe behavior indicative of the level of anxiety present (mild to panic)  as it affects client’s/SO’s ability to process information/participate in activities.
• Identify coping skills currently used and how effective they are. Be aware of defense mechanisms being used by the client.
• Note use of drugs (including alcohol), presence of insomnia, excessive sleeping, avoidance of interactions with others.
• Note client’s religious/spiritual orientation, involvement in religious/church activities, presence of conflicts regarding spiritual beliefs.
• Listen to client/SO reports/expressions of anger/concern, alienation from God, belief that impending death is a punishment for wrongdoing, and so on.
• Determine sense of futility, feelings of hopelessness, helplessness, lack of motivation to help self.May indicate presence of depression and need for intervention.
• Active-listen comments regarding sense of isolation.
• Listen for expressions of inability to find meaning in life or suicidal ideation.

NURSING PRIORITY NO.2. To assist client to deal with situation:
• Provide open and trusting relationship.
• Use therapeutic communication skills of Active-listening, silence, acknowledgment. Respect client desire/request not to talk. Provide hope within parameters of the individual situation.
• Encourage expressions of feelings (anger, fear, sadness, etc.). Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Be honest when answering questions/providing information. Enhances trust and therapeutic relationship.
• Provide information about normalcy of feelings and individual grief reaction.
• Make time for nonjudgmental discussion of philosophic issues/questions about spiritual impact of illness/situation.
• Review life experiences of loss and use of coping skills, noting client strengths and successes.
• Provide calm, peaceful setting and privacy as appropriate. Promotes relaxation and ability to deal with situation.
• Assist client to engage in spiritual growth activities, experience prayer/meditation and forgiveness to heal past hurts. Provide information that anger with God is a normal part of the grieving process. Reduces feelings of guilt/conflict, allowing client to move forward toward resolution.
• Refer to therapists, spiritual advisors, counselors to facilitate grief work.
• Refer to community agencies/resources to assist client/SO for planning for eventualities (legal issues, funeral plans, etc.).

NURSING PRIORITY NO.3. To promote independence:
• Support client’s efforts to develop realistic steps to put plans into action.
• Direct client’s thoughts beyond present state to enjoyment of each day and the future when appropriate.
• Provide opportunities for client to make simple decisions. Enhances sense of control.
• Develop individual plan using client’s locus of control  to assist client/family through the process.
• Treat expressed decisions and desires with respect and convey to others as appropriate.
• Assist with completion of Advance Directives and cardiopulmonary resuscitation (CPR) instructions.


Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, including client’s fears and signs/symptoms being exhibited.
• Responses/actions of family/SO(s).
• Availability/use of resources.
PLANNING
• Plan of care and who is involved in planning.
IMPLEMENTATION/EVALUATION
• Client’s response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Identified needs and who is responsible for actions to be taken.
• Specific referrals made.