Crisis 2-08-07
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Crisis •
Crisis is generally self limiting, want to get back to where the person was before (pre-crisis level)
•
During a crisis people are more open to outside help
•
These people are not considered mentally unhealthy, they are just off their equilibrium
Phase 1 •
Person faced with conflict
•
Start experiencing anxiety
•
How you make it through this phase is going to depend on how you cope
Phase 2 •
After usual defensive response fails
•
Anxiety increases
•
Becomes disorganized, hard to think
•
Trial and error
Phase 3 •
Panic mode
Phase 4 •
Anxiety overwhelms person, serious disorganization
•
Depression, confusion, may result in violence, suicide
Nursing Care •
Focus on the crisis only, what is happening at that moment
•
Be active and directive with the patient
•
Early intervention
•
Set realistic and mutual goals
•
Assess for suicidal or homicidal thoughts
•
Help them to feel safe
•
Help lower anxiety level
•
Listen
•
Help them to identify social support
•
Identify coping skills o
•
How have you handled things in the past?
Regular follow up
Suicide •
Do they have a plan?
•
Do they have what they need to carry out this plan?
•
Try to form a trust relationship with them to try to get them to a mental health facility
•
When they come into the health facility, search them for any harmful objects
•
Do they have a history of suicide attempts? They will be more likely to carry it out.
•
Is there a family history of suicide?
•
Must inspect gifts from visitors for harmful objects that could be used for suicides
•
Must have plastic utensils, no glass products
•
o
Females-underwire in bras
o
Belts/ shoestrings need to be taken away
o
May break windows, use window screens
o
No tweezers
Don’t put these patients in a private room o
Will be on 1:1 observation or in an observation room
o
They should be on 15 minute checks
Anger and Aggression •
Find out if they have a history of violence
•
Always observe for changes with your patients between other patients or staff o
Be alert for signs of violence
Restlessness
Hyperactivity
Profanity
Argumentative
Getting louder
Stony silence (Glare in eyes, jaw clenched)
Intoxication
Carrying a dangerous object
Have there been any recent acts of violence
Look at the milieu for signs conductive to violence: •
Are there too many patients in the dayroom
•
Too much stimulus can increase anxiety
•
Inexperienced staff
•
Provocative or controlling staff o
Don’t talk down to patients
•
Poor limit settings
•
Arbitrary revocation of privileges
•
Tornado warnings etc. may trigger anger or violence
•
How to de-escalate the situation o
Try to distract them into focusing on something else
o
Maintain calmness (yours and the clients)
o
Use a calm, clear tone of voice
o
If they still don’t calm down, try to give ativan or haldol
o
If that doesn’t work they will probably go to seclusion or restraints
o
You have 55 minutes to get order to cover that
Must have very detailed documentation of what patient has done and what you tried to do to de-escalate the situation.
Must offer food, water, and bathroom breaks
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
•
All you can do is help through the crisis at that moment
•
Always about control, people don’t know how to cope
•
Important not to be judgmental towards the person being abused
•
Find out if they have an exit plan when something does happen
•
Important to offer truthful information
Sexual Assault
•
Most important thing is to make them feel safe
•
Perform rape exam and conduct it in a very respectful way
•
Get community resources
•
Inform the on the ways to cope
•
Don’t be judgmental
•
Be very detailed in your documentation
•
Person may feel very guilty, emphasize that it is not their fault
Anxiety •
Can go from mild to severe
•
Person has anxiety, then has maladaptive behavior that relieves the anxiety, however this interferes with normal function
•
Maladaptive signs and symptoms o
Anxiety
o
Memory disturbance
•
These patients generally don’t seek out help unless symptoms interfere with their life
•
All receive primary gain from their symptoms
•
Some experiencing secondary gain
•
o
Such as attention
o
Not accepting responsibility
o
Getting their way
Generalized anxiety disorders o
Excessive anxiety or worry more than days
•
•
•
o
6 months or longer
o
Increased motor tension
o
Autonomic hyperactivity
o
Apprehension
o
May have mild depression
Panic Disorder o
With or without agoraphobia
o
Feeling of impending doom
o
Intense apprehension, fear, or terror
o
Can last for minutes or hours
o
Depression is common
o
Intense physical discomfort
Muscle tension
SOB
Chest pain
palpitations
Panic Disorders with Agoraphobia o
More prevalent in women
o
Afraid of places that are difficult to escape from
Crowds
Trains
Buses
o
Will severely restrict what they do in their lives
o
Generally have a support person
Social Phobia
•
•
•
•
o
Afraid to speak or eat in public
o
Afraid of public restrooms
o
Only experience anxiety when they are in that situation
Specific phobias o
Fear of specific objects or situations
o
Anxiety in presence of those objects or situation
o
Causes them to have overwhelming symptoms of panic
o
May panic just thinking about the phobia
o
Phobias can be a learned behavior from parents
Obsessive Compulsive Disorders o
Obsession-unwanted intrusive thought
o
Compulsion-unwanted repetitive act
o
They recognize that it is unreasonable, but still have to do it.
o
Will interfere with person’s normal routine
o
Occurs when the person is not able to perform the act
o
Could interfere with someone’s job
Post Traumatic Stress disorders o
Have flashbacks-relive experience
o
Causes high anxiety
o
Some have survival guilt
o
Causes depression
o
Will have difficulty with interpersonal relationships
o
Have to learn new coping skills, go to support groups
Managing anxiety o
Relaxation techniques
•
o
Good nutrition
o
Sleep
o
Cognitive restructuring-replace negative self taught with positive self taught
o
Behavior modification
o
Systematic desensitization –graduated exposure to the phobia or situation
o
Flooding-faced with the object until the anxiety decreases
o
Response prevention-don’t permit client to perform the ritual
o
Thought Stopping-rubber band on arm, when they have the thought of OCD behavior, pop themselves with rubber band
o
Cognitive-behavioral therapy includes:
Restructuring
Psycho education
Breathing restraining
Muscle relaxation
Teaching of self monitoring for panic and other symptoms
Medications o
o
Anti-anxieties-benzodiaphenes
Ativan-fast acting
Valium-fast acting
Xanax –fast acting
Buspar-non-addicting, non-narcotic, not fast acting
Anti-depressants
SSRI •
Celexa
•
Lexapro
•
Prozac
•
Zoloft
•
Paxil
Tricyclic •
Elavil
•
Anafranil
MOA inhibitor •
o
Beta Blockers
•
Nardil
Inderal
Help these clients learn new coping strategies
Crisis is generally self limiting, want to get back to where the person was before (pre-crisis level)
•
During a crisis people are more open to outside help
•
These people are not considered mentally unhealthy, they are just off their equilibrium
Phase 1 •
Person faced with conflict
•
Start experiencing anxiety
•
How you make it through this phase is going to depend on how you cope
Phase 2 •
After usual defensive response fails
•
Anxiety increases
•
Becomes disorganized, hard to think
•
Trial and error
Phase 3 •
Panic mode
Phase 4 •
Anxiety overwhelms person, serious disorganization
•
Depression, confusion, may result in violence, suicide
Nursing Care •
Focus on the crisis only, what is happening at that moment
•
Be active and directive with the patient
•
Early intervention
•
Set realistic and mutual goals
•
Assess for suicidal or homicidal thoughts
•
Help them to feel safe
•
Help lower anxiety level
•
Listen
•
Help them to identify social support
•
Identify coping skills o
•
How have you handled things in the past?
Regular follow up
Suicide •
Do they have a plan?
•
Do they have what they need to carry out this plan?
•
Try to form a trust relationship with them to try to get them to a mental health facility
•
When they come into the health facility, search them for any harmful objects
•
Do they have a history of suicide attempts? They will be more likely to carry it out.
•
Is there a family history of suicide?
•
Must inspect gifts from visitors for harmful objects that could be used for suicides
•
Must have plastic utensils, no glass products
•
o
Females-underwire in bras
o
Belts/ shoestrings need to be taken away
o
May break windows, use window screens
o
No tweezers
Don’t put these patients in a private room o
Will be on 1:1 observation or in an observation room
o
They should be on 15 minute checks
Anger and Aggression •
Find out if they have a history of violence
•
Always observe for changes with your patients between other patients or staff o
Be alert for signs of violence
Restlessness
Hyperactivity
Profanity
Argumentative
Getting louder
Stony silence (Glare in eyes, jaw clenched)
Intoxication
Carrying a dangerous object
Have there been any recent acts of violence
Look at the milieu for signs conductive to violence: •
Are there too many patients in the dayroom
•
Too much stimulus can increase anxiety
•
Inexperienced staff
•
Provocative or controlling staff o
Don’t talk down to patients
•
Poor limit settings
•
Arbitrary revocation of privileges
•
Tornado warnings etc. may trigger anger or violence
•
How to de-escalate the situation o
Try to distract them into focusing on something else
o
Maintain calmness (yours and the clients)
o
Use a calm, clear tone of voice
o
If they still don’t calm down, try to give ativan or haldol
o
If that doesn’t work they will probably go to seclusion or restraints
o
You have 55 minutes to get order to cover that
Must have very detailed documentation of what patient has done and what you tried to do to de-escalate the situation.
Must offer food, water, and bathroom breaks
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
•
All you can do is help through the crisis at that moment
•
Always about control, people don’t know how to cope
•
Important not to be judgmental towards the person being abused
•
Find out if they have an exit plan when something does happen
•
Important to offer truthful information
Sexual Assault
•
Most important thing is to make them feel safe
•
Perform rape exam and conduct it in a very respectful way
•
Get community resources
•
Inform the on the ways to cope
•
Don’t be judgmental
•
Be very detailed in your documentation
•
Person may feel very guilty, emphasize that it is not their fault
Anxiety •
Can go from mild to severe
•
Person has anxiety, then has maladaptive behavior that relieves the anxiety, however this interferes with normal function
•
Maladaptive signs and symptoms o
Anxiety
o
Memory disturbance
•
These patients generally don’t seek out help unless symptoms interfere with their life
•
All receive primary gain from their symptoms
•
Some experiencing secondary gain
•
o
Such as attention
o
Not accepting responsibility
o
Getting their way
Generalized anxiety disorders o
Excessive anxiety or worry more than days
•
•
•
o
6 months or longer
o
Increased motor tension
o
Autonomic hyperactivity
o
Apprehension
o
May have mild depression
Panic Disorder o
With or without agoraphobia
o
Feeling of impending doom
o
Intense apprehension, fear, or terror
o
Can last for minutes or hours
o
Depression is common
o
Intense physical discomfort
Muscle tension
SOB
Chest pain
palpitations
Panic Disorders with Agoraphobia o
More prevalent in women
o
Afraid of places that are difficult to escape from
Crowds
Trains
Buses
o
Will severely restrict what they do in their lives
o
Generally have a support person
Social Phobia
•
•
•
•
o
Afraid to speak or eat in public
o
Afraid of public restrooms
o
Only experience anxiety when they are in that situation
Specific phobias o
Fear of specific objects or situations
o
Anxiety in presence of those objects or situation
o
Causes them to have overwhelming symptoms of panic
o
May panic just thinking about the phobia
o
Phobias can be a learned behavior from parents
Obsessive Compulsive Disorders o
Obsession-unwanted intrusive thought
o
Compulsion-unwanted repetitive act
o
They recognize that it is unreasonable, but still have to do it.
o
Will interfere with person’s normal routine
o
Occurs when the person is not able to perform the act
o
Could interfere with someone’s job
Post Traumatic Stress disorders o
Have flashbacks-relive experience
o
Causes high anxiety
o
Some have survival guilt
o
Causes depression
o
Will have difficulty with interpersonal relationships
o
Have to learn new coping skills, go to support groups
Managing anxiety o
Relaxation techniques
•
o
Good nutrition
o
Sleep
o
Cognitive restructuring-replace negative self taught with positive self taught
o
Behavior modification
o
Systematic desensitization –graduated exposure to the phobia or situation
o
Flooding-faced with the object until the anxiety decreases
o
Response prevention-don’t permit client to perform the ritual
o
Thought Stopping-rubber band on arm, when they have the thought of OCD behavior, pop themselves with rubber band
o
Cognitive-behavioral therapy includes:
Restructuring
Psycho education
Breathing restraining
Muscle relaxation
Teaching of self monitoring for panic and other symptoms
Medications o
o
Anti-anxieties-benzodiaphenes
Ativan-fast acting
Valium-fast acting
Xanax –fast acting
Buspar-non-addicting, non-narcotic, not fast acting
Anti-depressants
SSRI •
Celexa
•
Lexapro
•
Prozac
•
Zoloft
•
Paxil
Tricyclic •
Elavil
•
Anafranil
MOA inhibitor •
o
Beta Blockers
•
Nardil
Inderal
Help these clients learn new coping strategies
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