From ANCC Review
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| Stress is | a non specific response to any demand or stressor
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| Stressor can be | physical, psychological, or social and evoke adaptive response
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| A stimulus leads to | a response
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| Stress is the relationship | between the person and environment that is appraised as exceeding the persons resources and endangering a person's well-being.
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| Person who said stress is a non-specific response | Selye
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| Lazarus proposed | a person's cognitive appraisal of situation mediates/moderates its meaning, perceived threat, coping and adaptation
Appraisal
Stress
Coping
Adaptation
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| 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
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| The coping process is | deliberate, planned and psychological
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| Adaptation is | person's capacity to survive and flourish.
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| Three areas affected by adaptation | Health
Psychological Well - Being
Social Function
(Biopsychosocial)
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| 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.
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| Time limit of a crisis | usually 4-6 weeks
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| 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
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| Types of crisis | Developmental
Situational
Traumatic
Psychiatric Emergencies
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| Types of crisis - Developmental | life stage and changes - entering school, having kids etc.
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| Types of crisis - Situational | unpredictable events - job loss, car accident
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| Types of crisis - Traumatic | Catastrophic event - hurricaine, war
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| Types of crisis - Psychiatric Emergencies | functioning impaired by events or incompetency
ex) drug overdose, acute psychosis
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| 4 Crisis Theories | Phases of Crisis
Erikson's developmental crisis
Stress Theory
General Adaptation Theory
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| Phases of Crisis was proposed by | Lindemann and Caplan
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| 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
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| Erikson's Developmental Crisis proposed by | ERIKSON
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| 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
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| Erikson's developmental theory gives opportunities for | growth and change, developing new coping skills and is a turning point
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| Stress theory was proposed by | Sadock and Sadock
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| Stress theory states | circumstance that disturbs or likely to disturb the psychological or physiological functioning of a person
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| General Adaptation Theory was proposed by | Hans Selye
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| General Adaptation theory has three stages | alarm reaction
stage of resistance
stage of exhaustion
IT CAN BE + OR -
negative =distress
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| During the stage of resistance | adaptation is ideally achieved
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| During the stage of exhaustion | adaptation or resistance is lost
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| The length of crisis intervention | usually lasts no more than 4 weeks
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| 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
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| Steps in crisis intervention | assessment
planning
intervention
resolution
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| 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)
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| 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?
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| Steps in crisis intervention - intervention | dependent on situation and needs of individual
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| Steps in crisis intervention - Resolution of crisis and anticipatory planing | reinforce adaptive coping skills
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| 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
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| 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
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| 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
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| Phases of bereavement | shock, denial disbelief
acute mourning
resolution
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| Bereavement is | a normal process that may last months or years
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| Acute morning is | intense feelings of crying, guilt, shame, depression, etc.
social withdrawal and identification with deceased
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| Social withdrawal in acute morning is | inability to sustain usual work, family , etc.
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| identification with the deceased is | transient adoption of habits, mannerisms, somatic symptoms of the deceased.
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| resolution is | acceptance of loss, awareness of grieving, ability to recall deceased without subjective pain
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| dysfunctional grieving is | when pt gets stuck in one phase, becomes chronic mourner, fixated on deceased
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| dysfunctional grieving often leads to | depression
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| MH needs of military | need timely screening, ID and Tx of
PTSD
Depression/suicide risk
TBI
ETOH/drug addictions
domestic violence/abuse
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| if symptoms of PTSD occur for less than this amount, you should diagnose stress disorder | <30 days
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| Emergency psychiatric evaluations - goal | timely assessment of pt in crisis
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| 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
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| 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
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| 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
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| Suicide Assessment -NP needs to identify | protective factors/obstacles to suicide
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| 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
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| depressive pts can be treated as outpatient if | family can supervise closely, otherwise hospitalize
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| Suicidal ideation in schizophrenia pts should be | taken seriously because of potential to be violent and highly lethal
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| pts with personality d/o can benefit from | empathic confrontation and assistance in solving their problems that led to the suicide attempt
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| D/O associated with violence | psych diagnoses
intoxication
withdrawal
catatonic excitement
personality disorders
cognitive disorders (frontal lobe involvement)
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| 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
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| If pt is armed | never interview, must surrender
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| 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
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| Presenting symptom - grief/bereavement | extreme reaction to loss and excessive use of medication
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| Presenting symptom - Hyperventilation | can be a sign of anxiety
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| Presenting symptom - Phobias | assess for onset/severity
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| Presenting symptom - PTSD | identify symptoms that disrupt normal functioning and assess onset of symptoms
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| Presenting symptom - severe behavioral disturbance | vast range of presentations. symptoms include screaming, shouting, aggressive outbursts
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| 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
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| 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
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| Adult Seclusion and Restraints Guidelines from JCAHO - licensed provider must evaluate pt after application of restraint | within an hour
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| Adult Seclusion and Restraints Guidelines from JCAHO - pt must be re-evaluated for need to continue restraint/seclusion | after first 4 hour order expires
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| 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
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| 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
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| 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
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| Restraint of patient may be | physical or pharmacological and needs to be a last resort
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