A. Definition
Loss is human experience and a challenge we all must face. Loss requires that we give up something familiar, comfortable, and personal. Loss of person includes death, separation, divorce, moving, and changes in mental or physical status. As we go through our life span we experience developmental losses associated with life transitions, such as grown children leaving the home or retirement from a career (Klebanoff and Smith, 1997). Loss is an actual or potential situation in which something that is valued is changed, no longer available, or gone (Barbara Kozier,2004). People can experience the loss of body, a significant other, a sense of well-being, a job, personal possession, belief, or a sense of self. Illness and hospitalization often produces losses. Death is fundamental loss, both for the dying person an d for those who survive. Although death is inevitable, it can stimulate people to grow in their understanding of themselves and others. Death can be viewed as the dying person’s final opportunity to experience life in ways that bring significance and fulfillment. People experiencing loss often search for the meaning of the event and it is generally accepted that finding meaning is needed in order for healing to occur.
The meaning of loss is subjective, as is the process of responding to a loss. Unresolved losses in the past influence how we manage current losses. Factors such as guilt, financial issues, ambivalence, age, culture, number of current stressors, and available support system determine how we react to loss and express our grief (Gorman, Sultan, and Raines, 1996).

B. Types and Sources of Loss
There are two general types of loss, actual and perceived. Both losses can be anticipatory.
1. An actual loss can be recognized by others.
2. A perceived loss is experienced by one person but cannot be verified by others. Psychologic losses are often perceived losses in that they are not directly verifiable. For example, a woman who leaves her employment to care for her children at home may perceive a loss independence and freedom.
3. An anticipatory loss is experienced before the loss actually occurs. For example, a woman whose husband is dying may experience actual loss in anticipation of his death.
Loss can be viewed as situational or developmental. The loss of one’s job, the death of child, or the loss of functional ability because of acute illness or unjury are situational losses. Losses that occur in the process of normal development-such as the departure of grown children from the home, retirement from a career, and the death of aged parentas are developmental losses.
There are many sources of loss :
1. Loss of an aspect of oneself-a body part, a physiologic function, or a psychologic attribute
2. Loss of an object external to one self
3. Separation from an accustomed environment
4. Loss of a loved or valued person
C. Stages of Grieving and Behavioral Responses
Kubler-Ross’s Stages of Grieving
Stages Behavioral Responses
1. Denial :
-Person refuses to believe that loss is happening.
-With death or trauma, may actually block the memory of the incident or momentarily believe it has not occurred.
-Is unprepared to deal with practical problems, such as prosthesis after loss of leg.
-May assume artificial cheerfulness to prolong denial.
2. Anger :
-Client or family may direct anger at nurse or hospital staff abou matters that normally would not bother them.
-There may be an acute sense of unfairness, fear, anger, and even rage.
-Question may arise, such as “Why me?”or “How could you die and leave me alone?”
3. Bargaining :
-Person seeks ro bargain to avoid loss.
-The bargain may bestruck with Go, with decreased, or one self.
-May express feelings of guilt or fear of punishment for past sins, real or imagined.
4. Depression :
-Person grieves over what cannot be.
-May talk freely (e.g., reviewing past lossess such as money or job)or may withdraw.
-Acknowledge feelings, allows nurturing by self or others, amd moves forward in the process.
5. Acceptance :
-Person comes to term with loss.
-Depression has been lifted; loss is acknowledged.
-May have reduce interest in surroundings and support persons as loss is no longer focal point.
-May wish to begin making plans (e.g., living will, prosthesis, altered living arrangements)
-Is now free to move forward.

D. Factors Influencing the Loss and Grief Responses
1. Age
Age effects a persons understanding of and reaction to loss. With familiarity, people usually increase their understanding and acceptance of life, loss, and death.
People do not usually experiences is difficult. Coping with other of life’s losses, such as the loss of a pet, the loss of friend, and the loss of youth or a job, can help people anticipate the more severe loss of death of loved ones by teaching them successful coping strategies.
a. Childhood
Children differ from adults not only in their understanding of loss and death but also in how they are affected by the loss of others. The loss of a parent or other significant person can threaten the child’s ability to develop, and regression sometimes results.
Some adults may assume that children do not have the same need as an adult to grieve the loss of others. In situations of crisis and loss, children are sometimes pushed aside or protected from the pain. The can feel afraid, abandoned, and lonely. Careful work with bereaved children is especially necessary because experiencing a loss in childhood can have serious effects later in life.
b. Early and Middle Adulthood
The loss of a parent through death seems a more normal occurrence compared to the death of a younger person. The middle-aged adult can experiences losses other than death. For example, losses resulting from impaired health or body function and losses of various role functions can be difficult for the middle-aged adult. How the middle-aged adult responds to such losses of various role functions can be difficultfor middle-aged adult.
c. Late Adulthood
Losses experienced by older adults include loss of helath, mobility, independence, and work role. Limited income and the need to change one’s living accommodations can also lead to feelings of loss and grieving.
2. Significance of the Loss
The significance of a loss depends on the perceptions of the individual experiencing the loss. One person may experience a great sense of loss over a divorce; another may find it only mildly disrupting. For older people who have already encountered many losses, an anticipated loss such as their own death may not be viewed as highly negative, and they may be apathetic about it instead of reactive. More than fearing death, some may fear loss of control or becoming a burden.
3. Culture
Culture influences an individual’s reaction to loss. How grief is expressed is often determined by the custom of the culture. Some cultural group value social support and the expression of loss. In some groups, the expression of grief through wailing, crying, physical prostration, and other outward demonstration are acceptable and encourages. Other groups may frown on this demonstration as a loss of control, favoring a more quite and stoic expression of grief.
4. Spiritual Beliefs
Spiritual beliefs and practices greatly influence both a person’s reaction to loss and subsequent behavior. Most religious groups have practices related to dying, and these are often important to the client and support people. To provide support at a time of death, nurses need to understand the client’s particular beliefs and practices.
5. Gender
Men are frequently expected to be “strong” and show very little emotion during grief, whereas it is acceptable for women to show grief by crying. Often a wife dies, the husband, who is the chief mourner, is expected to repress his own emotions and to comfort sons and daughters in their grieving. Gender roles also affect the significance of body image changes to clients. A man might consider his facial .

6. Socioeconomic Status
The socioeconomic status of an individual often affects the support system available at the time of a loss. A pension plan or insurance, for example, can offer a widowed or disabled person a choice of ways to deal with a loss; a person who is confronted with both severe loss and economic hardship may not be able to cope with either.
7. Support System
The people closest to the grieving individual are often the first to recognize and provide needed emotional, physical, and functional assistance. However, because many people are uncomfortable or inexperienced in dealing with losses, the usual support people may instead withdraw from the grieving individual. Support may be available when the loss is first recognized, but as the support people return to their usual activities, the need for ongoing support may be unmet. Sometimes, the grieving individuals is unable or unready to accept support when its offered.
8. Causes of loss or Death
Individual and societal views on the cause of a loss or death may significantly influence the grief response. A loss or death that is beyond the control of those involved may be more acceptable that one that is preventable, such as a drunk driving accident. Injuries or death occurring during respected activities, such as “in the line of duty,”are considered honorable, whereas those occurring during illicit activities may be considered the individuals just reward.
E. Life Transition as Loss
When considering life transition that include loss, often the older population is the first that comes to mind. People move through developmental states they encounter a number losses. Examples have been selected to illustrate loss during major developmental stages.
a. Childhood
Separation and divorce may be the childs first significant loss. Children’s adaptation to divorce varies on a continuum from healthy to unhealthy. Change from a nuclear to a binuclear family produces situational stress. The formation of binuclear families demand psychological, social,and economic reorganization by all family members. If parental conflict was high prior to the divorce, the children may experience relief from strss with the new family structure. When parents cope well by living in the present and designing a new future, children are ableto adapt and cope better.
b. Adolescence
One of the major tasks of adolescence is individuation and separation from the family. Adolescents must give up their dependence on their parents, develop more independence, and from interdependent relationship with their peer group.
c. Middle Adulthood
The middle adulthood period presents unique challenges to each person. This is the period when one is to be most productive in the work setting. The person begins to recognize the limits of physical and psychological abilities and realizes that achievement of life goals may not possible.
The middle adult may also be in the middle in other ways. At a time when they are being freed from parental responsibility and expect greater independence and more social mobility, middle adults may find that their dependent parents restrict their leisure time. Although most older adult children, it is primarily their offspring, especially female adult children, to whom they turn the time of need.
d. Late Adulthood
The developmental stage that most reflects change and transition is late adulthood. Loss of work roles with retirement, loss of body image, loss associated with mortality are both expected and unexpected event for older adult. Death is frequently viewed as the ultimate loss. Other losses include loss of control and competence, loss of some life experiences, loss of material possessions, and loss of dreams. The goal for the older adult who has confronted loss is to use adaptive mechanisms to understand and accept the inevitability of the losses an dlive the remaining years to the maximum potential.
F. Psychiatric Disability As a Loss
a. Individual Loss
These losses are often in the following areas: activities of daily living, social interactions, school, employment, housing, and community participation. People with severe mental disorders also experience losses in their relationship with others. Often they have few relationship with people who are not connected to the mental health system. Their small networks may be restricted to family members and other mental health clients. Thus, many live very isolated lives.
b. Family Loss
Caregiver burden may lead to loss of independence and increased responsibility as families try to cope with day to day living. Deficit behaviors such as lack of motivation, difficulty in completing task, isolation from others, inability to manage money, poor grooming and personal care, and poor eating and sleeping behavior can be great concern to families. Intrusive or acting out behaviors such as lack of consideration for others, excessive arguing, conflict with neighbors and friends, damaging material possessions, inappropriate sexual behavior, suicide attempts, and substance abuse very disturbing to family members. Some families cope fairly well while others are easily exhausted and give up.
Badger (1996) describes the process of family transformation when living with a person experiencing a mental disorder. Three stages have been identified : acknowledging the strangers within, fighting the battle, and gaining a new perspective.
G. The Nursing Process
1. Assessment
a. Nursing history
b. Assessment of personal coping resources
c. Physical assessment
Assessment Interview
Previous Lossess
• Have you ever lost someone or something very important to you?
• Have you or family ever moved your home?
• What was it like for you when you first started school?
Moved away from home?got a job?retired?
• Are you physically able to do all the things you used to do?
• Has anyone important or close to you died?
• Do you think there will be any losses in yor life in the near future?
If there is a current loss :
• What have you been told about (the loss)? Is ther anything else you would like to know or don’t understand?
• What changes do you thing this (illness, surgery, problem) will cause in your life? What do you think it will be like without (the lost object)?
• Have u ever experience a loss like this before?
• Can you think of anything good that might come out of this?
• What kind of help do you think you will need? Who Is going to be helping you with this loss?
• Are there any people or organizations in your community that might be able to help?
2. Diagnosing
Nursing diagnoses (NANDA, International, 2003) relating specifically to grieving include the following :
• Anticipatory Grieving: Intellectual and emotional responses and behaviors by which individuals, families, communities work through the process of modifying self concepts based on the perception of potential of loss
• Dysfunctional Grieving : Extended, unsuccessful use of intellectual and emotional responses and behaviors by which individuals, families, communities attempt to work through the process of modifiying self concept based on the perception of loss.

Other diagnoses may include:
• Interrupted family processes
• Impaired adjustment
• Risk for loneliness
3. Plannig
The overall goals:
• To adjust to the changed ability
• To direct both physical and emotional energy into rehabilitation
• To remember that person without feeling intense pain
• To direct emotional energy into one’s own life and adjust to the actual or impending loss
Planning Home Care
- The determination of how much and what type of home care follow-up is needed is based in great part on the nurse’s knowledge of how the clinet and family have coped with previous losses
- In preparation, the nurse reassesses the client’s abilities and needs
4. Implemneting
Stages Nursing Implication
1. Denial :
- Verbally support client’s denial for its protective function.
- Examine own behavior to ensure not sharing in client’s denial
2. Anger :
- Help client understand that anger is a normal response to feelings of loss and powerlessness.
- Avoid withdrawal or retaliation with anger; do not take anger personality.
- Deal with needs underlying any angry reaction.
- Provide structure and continuity to promote feelings of security.
- Allow client as much control as possible over life.
3. Bargaining :
- Listen attentively, and encourage client to talk to relieve guilt and irrational fears.
- If appropriate, offer spiritual support.
4. Depression :
- Allow client to express sadness.
- Communicate noverbally by sitting quietly without expecting conversation.
- Convery caring by touch, if appropriate.
- Help persons understand importance of being with client in silence.
5. Acceptance :
- Help family and friends understand client’s reduced need to socialize and need for short, quite visits.
- Encourage client to participate as much as possible in the treatment program.
5. Evaluating
• Did the client has been spontaneously express his/her feelings?
• Did the client can explained the loss meaning of his/her life?
• Did the clinet had a support system to expressed the feeling (friends,families,groups, and other communities)?
• Did the client have had acceptance signs?
• Did the client can respected a new relationship with pther person?

References
Kozier,Barbara,et all. Fundamental Of Nursing Concepts, Process and Practise. Seventh Edition. Pearson Prentice Hall

Yosep, Iyus. 20009.Keperawatan Jiwa Edisi Revisi. Bandung : Refika Aditama

Kaplan, Sadock, B. 1995. Comprehensive Text Book of Psychiatry. 6th ed,vol 1. Maryland: William & Wilkins

Haladay W, Fortinash. 2007. Psychiatric Nursing Care Plans. 5th ed. Philadelphia: Mosby Elsevier

Patricia D. Barry. 1998. Mental Health and Mental illnesss six edition. Lippincott: Philadelphia.