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Crisis Mgmt

From ANCC Review

Stress is a non specific response to any demand or stressor
Stressor can be physical, psychological, or social and evoke adaptive response
A stimulus leads to a response
Stress is the relationship between the person and environment that is appraised as exceeding the persons resources and endangering a person's well-being.
Person who said stress is a non-specific response Selye
Lazarus proposed a person's cognitive appraisal of situation mediates/moderates its meaning, perceived threat, coping and adaptation Appraisal Stress Coping Adaptation
Coping is process whereby a person manages the demands and emotions that are generated by the cognitive appraisal of the perceived stress. Coping process is deliberate, planned, psychological
The coping process is deliberate, planned and psychological
Adaptation is person's capacity to survive and flourish.
Three areas affected by adaptation Health Psychological Well - Being Social Function (Biopsychosocial)
Crisis is a severely stressful experience for which coping mechanisms fail to provide any adaptation. it is a time limited acute event that can trigger a biopsychosocial response to a developmental, situational or interpersonal experience.
Time limit of a crisis usually 4-6 weeks
Crisis is associated with potential to learn new ways of coping may be associated with dissociative symptoms, re-experiencing and risk of chronic PTSD if unresolved
Types of crisis Developmental Situational Traumatic Psychiatric Emergencies
Types of crisis - Developmental life stage and changes - entering school, having kids etc.
Types of crisis - Situational unpredictable events - job loss, car accident
Types of crisis - Traumatic Catastrophic event - hurricaine, war
Types of crisis - Psychiatric Emergencies functioning impaired by events or incompetency ex) drug overdose, acute psychosis
4 Crisis Theories Phases of Crisis Erikson's developmental crisis Stress Theory General Adaptation Theory
Phases of Crisis was proposed by Lindemann and Caplan
Phases of Crisis states problem arises that creates increased anxiety usual problem solving techniques fail = more anxiety trial and error attempts fail = more anxiety, escalates to panic overwhelmed by anxiety, serious personality disorganzation
Erikson's Developmental Crisis proposed by ERIKSON
E's developmental crisis theory states maturational crises are a normal part of growth/development successful resolution at 1 stage allows child to go to the next child develops positive characteristics after experiencing crisis or less desirable traits if the crisis is not resolved
Erikson's developmental theory gives opportunities for growth and change, developing new coping skills and is a turning point
Stress theory was proposed by Sadock and Sadock
Stress theory states circumstance that disturbs or likely to disturb the psychological or physiological functioning of a person
General Adaptation Theory was proposed by Hans Selye
General Adaptation theory has three stages alarm reaction stage of resistance stage of exhaustion IT CAN BE + OR - negative =distress
During the stage of resistance adaptation is ideally achieved
During the stage of exhaustion adaptation or resistance is lost
The length of crisis intervention usually lasts no more than 4 weeks
Crisis intervention is focused on re-establishing equilibrium and solving immediate problems may prevent serious consequences and allow new coping skills to emerge - resulting in a higher level of functioning than before the crisis may develop new social network to help cope with crisis
Steps in crisis intervention assessment planning intervention resolution
Steps in crisis intervention - assessment determine precipitating event that triggered current crisis assess whether person is suicidal or homicidal and degree of risk (lethality assessment)
Steps in crisis intervention - planning therapeutic intervention how disrupted is pt's life? what are pt's strengths in handling crises in past? available supports?
Steps in crisis intervention - intervention dependent on situation and needs of individual
Steps in crisis intervention - Resolution of crisis and anticipatory planing reinforce adaptive coping skills
NP Crisis Mgmt Principles assist person in dealing w reality encourage expression of feelings within limits encourage person to focus on 1 task at a time avoid giving false reassurance clarify fantasies w facts facilitate problem solving link person/fam w community resources
Crisis Mgmt - Disaster Response therapeutic communication is key assess for biopsychosocial needs basic needs are priority work with local, state, federal disaster response agencies to coordinate response to catastrophic events and mobilize available resources
Individual response to a disaster is best understood by examining the person's usual response to stressful events response to disaster will depend on meaning of the event to the individual/fam/larger community
Phases of bereavement shock, denial disbelief acute mourning resolution
Bereavement is a normal process that may last months or years
Acute morning is intense feelings of crying, guilt, shame, depression, etc. social withdrawal and identification with deceased
Social withdrawal in acute morning is inability to sustain usual work, family , etc.
identification with the deceased is transient adoption of habits, mannerisms, somatic symptoms of the deceased.
resolution is acceptance of loss, awareness of grieving, ability to recall deceased without subjective pain
dysfunctional grieving is when pt gets stuck in one phase, becomes chronic mourner, fixated on deceased
dysfunctional grieving often leads to depression
MH needs of military need timely screening, ID and Tx of PTSD Depression/suicide risk TBI ETOH/drug addictions domestic violence/abuse
if symptoms of PTSD occur for less than this amount, you should diagnose stress disorder <30 days
Emergency psychiatric evaluations - goal timely assessment of pt in crisis
During psychiatric triage VS Request old records Determine if psychiatric or medical evaluation takes priority Gather brief hx, precipitating event, MSE, brief PE, labs, UDS
General strategy for Emergency Psych Evals protect self/others have others present during eval be alert to impending violence let those trained in physical restraint procedure implement - PRN prevent pt self injury/suicide, prevent violence to others R/O Organic mental d/o R/O poss psychosis
Suicide risk assessment - High Risk Individuals Divorced, Single, Separated >45 yo m >55 yo f white male living alone physical illness mental illness substance use fam hx of suicide previous suicide attempt recent loss
Suicide Assessment -NP needs to identify protective factors/obstacles to suicide
Management of suicidal patient Do not leave pt alone and remove any potentially dangerous objects from the room assess whether attempt was planned/impulsive determine lethality/reaction to being rescued (disappointed/relieved) what factors leading to attempt have changed
depressive pts can be treated as outpatient if family can supervise closely, otherwise hospitalize
Suicidal ideation in schizophrenia pts should be taken seriously because of potential to be violent and highly lethal
pts with personality d/o can benefit from empathic confrontation and assistance in solving their problems that led to the suicide attempt
D/O associated with violence psych diagnoses intoxication withdrawal catatonic excitement personality disorders cognitive disorders (frontal lobe involvement)
Signs of impending violence recent act of violence verbal/physical threats carrying weapons (fork or knife) progressive psychomotor agitation ETOH or substance paranoid features catatonic excitement manic episode command violent auditory hallucinations
If pt is armed never interview, must surrender
Interviewing always ensure safety, make full assessment possible, obtain collateral information, act quickly if sitch requires immediate action do not close door provide non stimulating environment consider benzo or AP if appropriate or necessary
Presenting symptom - grief/bereavement extreme reaction to loss and excessive use of medication
Presenting symptom - Hyperventilation can be a sign of anxiety
Presenting symptom - Phobias assess for onset/severity
Presenting symptom - PTSD identify symptoms that disrupt normal functioning and assess onset of symptoms
Presenting symptom - severe behavioral disturbance vast range of presentations. symptoms include screaming, shouting, aggressive outbursts
Indications for seclusion and restraints prevent imminent harm to pt or others prevent significant disruption to tx program or physical surroundings assist in tx as part of onging behavior therapy at pts voluntary reasonable request
Contraindication for seclusion and restraints extremely unstable medical psychiatric condition delirious or demented pt unable to tolerate decreased stimulation pts with severe drug reactions, ODsor requiring close monitoring of drug dosages for punishment or convenience of staff
Adult Seclusion and Restraints Guidelines from JCAHO - licensed provider must evaluate pt after application of restraint within an hour
Adult Seclusion and Restraints Guidelines from JCAHO - pt must be re-evaluated for need to continue restraint/seclusion after first 4 hour order expires
Adult Seclusion and Restraints Guidelines from JCAHO - if restraint and seclusion still needed after 4 hours licensed professional must give written/verbal order for 4 hours
Adult Seclusion and Restraints Guidelines from JCAHO - evaluate by licensed professional for continued need after 8 hrs should be done face to face. if needed another 4 hr order is written
Adult Seclusion and Restraints Guidelines from JCAHO - this is repeated as long as restraints/sec. is necessary 4 hour order, 8 hr face to face evaluation
Restraint of patient may be physical or pharmacological and needs to be a last resort
Created by: jonquil