Crisis 2-08-07

Crisis •

Crisis is generally self limiting, want to get back to where the person was before (pre-crisis level)

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During a crisis people are more open to outside help

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These people are not considered mentally unhealthy, they are just off their equilibrium

Phase 1 •

Person faced with conflict

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Start experiencing anxiety

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How you make it through this phase is going to depend on how you cope

Phase 2 •

After usual defensive response fails

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Anxiety increases

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Becomes disorganized, hard to think

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Trial and error

Phase 3 •

Panic mode

Phase 4 •

Anxiety overwhelms person, serious disorganization

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Depression, confusion, may result in violence, suicide

Nursing Care •

Focus on the crisis only, what is happening at that moment

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Be active and directive with the patient

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Early intervention

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Set realistic and mutual goals

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Assess for suicidal or homicidal thoughts

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Help them to feel safe

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Help lower anxiety level

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Listen

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Help them to identify social support

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Identify coping skills o

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How have you handled things in the past?

Regular follow up

Suicide •

Do they have a plan?

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Do they have what they need to carry out this plan?

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Try to form a trust relationship with them to try to get them to a mental health facility

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When they come into the health facility, search them for any harmful objects

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Do they have a history of suicide attempts? They will be more likely to carry it out.

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Is there a family history of suicide?

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Must inspect gifts from visitors for harmful objects that could be used for suicides

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Must have plastic utensils, no glass products

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Females-underwire in bras

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Belts/ shoestrings need to be taken away

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May break windows, use window screens

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No tweezers

Don’t put these patients in a private room o

Will be on 1:1 observation or in an observation room

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They should be on 15 minute checks

Anger and Aggression •

Find out if they have a history of violence

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Always observe for changes with your patients between other patients or staff o

Be alert for signs of violence 

Restlessness

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Hyperactivity

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Profanity

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Argumentative

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Getting louder

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Stony silence (Glare in eyes, jaw clenched)

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Intoxication

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Carrying a dangerous object

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Have there been any recent acts of violence

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Look at the milieu for signs conductive to violence: •

Are there too many patients in the dayroom

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Too much stimulus can increase anxiety

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Inexperienced staff

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Provocative or controlling staff o

Don’t talk down to patients

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Poor limit settings

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Arbitrary revocation of privileges

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Tornado warnings etc. may trigger anger or violence

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How to de-escalate the situation o

Try to distract them into focusing on something else

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Maintain calmness (yours and the clients)

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Use a calm, clear tone of voice

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If they still don’t calm down, try to give ativan or haldol

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If that doesn’t work they will probably go to seclusion or restraints

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You have 55 minutes to get order to cover that

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Must have very detailed documentation of what patient has done and what you tried to do to de-escalate the situation.

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Must offer food, water, and bathroom breaks

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In most instances people will eventually calm down

Restraints 

Must do neurovascular checks every 2 hours

Family Violence •

Types o

Spousal abuse 

o

Child abuse-must report, call social work 

o

Afraid spouse will find them and kill them

It is important to be very detailed in your documentation

Elder abuse

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All you can do is help through the crisis at that moment

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Always about control, people don’t know how to cope

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Important not to be judgmental towards the person being abused

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Find out if they have an exit plan when something does happen

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Important to offer truthful information

Sexual Assault

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Most important thing is to make them feel safe

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Perform rape exam and conduct it in a very respectful way

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Get community resources

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Inform the on the ways to cope

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Don’t be judgmental

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Be very detailed in your documentation

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Person may feel very guilty, emphasize that it is not their fault

Anxiety •

Can go from mild to severe

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Person has anxiety, then has maladaptive behavior that relieves the anxiety, however this interferes with normal function

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Maladaptive signs and symptoms o

Anxiety

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Memory disturbance

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These patients generally don’t seek out help unless symptoms interfere with their life

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All receive primary gain from their symptoms

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Some experiencing secondary gain

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Such as attention

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Not accepting responsibility

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Getting their way

Generalized anxiety disorders o

Excessive anxiety or worry more than days

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6 months or longer

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Increased motor tension

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Autonomic hyperactivity

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Apprehension

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May have mild depression

Panic Disorder o

With or without agoraphobia

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Feeling of impending doom

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Intense apprehension, fear, or terror

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Can last for minutes or hours

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Depression is common

o

Intense physical discomfort 

Muscle tension

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SOB

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Chest pain

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palpitations

Panic Disorders with Agoraphobia o

More prevalent in women

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Afraid of places that are difficult to escape from 

Crowds

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Trains

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Buses

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Will severely restrict what they do in their lives

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Generally have a support person

Social Phobia

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o

Afraid to speak or eat in public

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Afraid of public restrooms

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Only experience anxiety when they are in that situation

Specific phobias o

Fear of specific objects or situations

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Anxiety in presence of those objects or situation

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Causes them to have overwhelming symptoms of panic

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May panic just thinking about the phobia

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Phobias can be a learned behavior from parents

Obsessive Compulsive Disorders o

Obsession-unwanted intrusive thought

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Compulsion-unwanted repetitive act

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They recognize that it is unreasonable, but still have to do it.

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Will interfere with person’s normal routine

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Occurs when the person is not able to perform the act

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Could interfere with someone’s job

Post Traumatic Stress disorders o

Have flashbacks-relive experience

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Causes high anxiety

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Some have survival guilt

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Causes depression

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Will have difficulty with interpersonal relationships

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Have to learn new coping skills, go to support groups

Managing anxiety o

Relaxation techniques

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o

Good nutrition

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Sleep

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Cognitive restructuring-replace negative self taught with positive self taught

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Behavior modification

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Systematic desensitization –graduated exposure to the phobia or situation

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Flooding-faced with the object until the anxiety decreases

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Response prevention-don’t permit client to perform the ritual

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Thought Stopping-rubber band on arm, when they have the thought of OCD behavior, pop themselves with rubber band

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Cognitive-behavioral therapy includes: 

Restructuring

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Psycho education

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Breathing restraining

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Muscle relaxation

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Teaching of self monitoring for panic and other symptoms

Medications o

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Anti-anxieties-benzodiaphenes 

Ativan-fast acting

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Valium-fast acting

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Xanax –fast acting

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Buspar-non-addicting, non-narcotic, not fast acting

Anti-depressants 

SSRI •

Celexa

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Lexapro

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Prozac

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Zoloft

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Paxil

Tricyclic •

Elavil

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Anafranil

MOA inhibitor •

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Beta Blockers 

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Nardil

Inderal

Help these clients learn new coping strategies