1. Mental Health Nursing II NURS 2310 Unit 7 Psychiatric Crisis Management

2. Objective 1 Reviewing the concepts associated with stress and stressors

3. Stress = a state of bodily or mental tension resulting from factors that tend to alter an existent equilibrium; stress is necessary for growth and development. Stressors = anything that necessitates an adaptive response on the part of the individual Adaptation = adjustment to or modification of the environment for purposes of survival

4. Objective 2 Examining physical and psychological responses to stress

5. Physical responses to stress: General Adaptation Syndrome Biological responses Psychological responses to stress: Anxiety Grief

6. General Adaptation Syndrome Alarm reaction stage – –physiological responses of the fight-or-flight syndrome are initiated Stage of resistance – –physiological responses used as a defense in attempt to adapt to the stressor Stage of exhaustion – –prolonged exposure to the stressor to which the body has become adjusted – –adaptive energy is depleted, and diseases of adaptation may occur

7. Associated biological responses Immediate response Activation of the sympathetic nervous system – –pupils dilate – –respiration rate increases (dilated bronchioles) – –heart rate and blood pressure increases – –sweat glands increase production Sustained response Stimulation of the pituitary gland – –increases fluid retention and blood pressure – –basal metabolic rate increased

8. Objective 3 Reviewing the levels of anxiety and associated symptoms/behaviors of each

9. Anxiety = a vague, diffuse apprehension that is associated with feelings of uncertainty and helplessness Low levels of anxiety are adaptive and can provide the motivation required for survival Becomes problematic when the symptoms escalate to a level that interferes with the ability to meet basic needs Levels of anxiety – –Mild anxiety – –Moderate anxiety – –Severe anxiety – –Panic anxiety

10. Mild Anxiety Seldom a problem for the individual Associated with the tension experienced in response to the events of day-to-day living Prepares people for action – –sharpens the senses – –increases motivation for productivity – –increases the perceptual field – –results in heightened awareness of the environment Learning is enhanced; individual is able to function at an optimal level

11. Moderate Anxiety Perceptual field diminishes Less alert to events occurring within the environment Attention span and ability to concentrate decrease Needs direction to attend to own needs Requires assistance with problem-solving Increased muscular tension Restlessness

12. Severe Anxiety Perceptual field so greatly diminished that concentration centers on one particular detail only, or on many extraneous details Attention span extremely limited Difficulty completing even the simplest task Physical symptoms (headaches, palpitations, and insomnia) Emotional symptoms (confusion, dread, and horror) All overt behavior aimed at relieving the anxiety due to extent of discomfort

13. Panic Anxiety Most severe form of emotional anxiety Symptoms include a sudden overwhelming feeling of terror or impending doom – –Usually accompanied by behavioral, cognitive, and physiological signs and symptoms that are considered to be outside the expected range of normalcy – –Individual is unable to focus on even one detail within the environment – –Misperceptions are common   Loss of contact with reality   May experience hallucinations or delusions

14. Panic Anxiety (cont’d) Behavior ranges from wild and desperate actions to extreme withdrawal Human functioning and communication with others is ineffective Prolonged panic anxiety can lead to physical and emotional exhaustion – –Life-threatening

15. Objective 4 Exploring various defense mechanisms

16. Defense mechanisms are unconscious coping strategies used to diminish anxiety and that can hinder personality development when used excessively or inappropriately Types of defense mechanisms: Compensation = covering up a real or perceived weakness by emphasizing a trait one considers more desirable Denial = refusing to acknowledge the existence of a real situation or the feelings associated with it

17. Defense mechanisms (cont’d) Displacement = the transfer of feelings from one target to another that is considered less threatening or that is neutral Identification = an attempt to increase self- worth by acquiring certain attributes and characteristics of an individual one admires Intellectualization = an attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis

18. Defense mechanisms (cont’d) Introjection = integrating the beliefs and values of another individual into one’s own ego structure Isolation = separating a thought or memory from the feeling tone or emotion associated with it Projection = attributing feelings or impulses unacceptable to one’s self to another person Rationalization = attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors

19. Defense mechanisms (cont’d) Reaction Formation = preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors Regression = responding to stress by retreating to an earlier level of development and the comfort measures associated with that level of functioning Repression = involuntarily blocking unpleasant feelings and experiences from one’s awareness

20. Defense mechanisms (cont’d) Sublimation = rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive Suppression = the voluntary blocking of unpleasant feelings and experiences from one’s awareness Undoing = symbolically negating or canceling out an experience that one finds intolerable

21. Objective 5 Identifying behaviors associated with maladaptive coping

22. Coping = the process of responding to stress or a potential stressor Adaptive coping mechanisms = effective, therapeutic ways of dealing with stress Maladaptive coping mechanisms = detrimental behaviors that decrease the ability to cope with illness – –use of defensive mechanisms – –substance abuse – –eating disorders – –addiction (i.e. gambling) – –exacerbation of mental disorder

23. Objective 6 Describing effective coping strategies to decrease psychological/ emotional discomfort

24. Conscious coping strategies are purposeful behaviors used to make an unfamiliar situation controllable and predictable Relaxation techniques are the most commonly used conscious coping strategies Relaxation techniques include: imagery relaxation strategies – –deep breathing exercises, meditation – –yoga, zen practices therapeutic touch music therapy

25. Objective 7 Defining psychiatric crisis

26. Crisis = a sudden event in one’s life that disturbs homeostasis and during which usual coping mechanisms cannot resolve the problem Types of emotional crisis include: Dispositional crises Crises of anticipated life transitions Crises resulting from traumatic stress Maturational/developmental crises Crises reflecting psychopathology Psychiatric emergencies

27. Characteristics of a crisis: Crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology Crises are precipitated by specific identifiable events Crises are personal by nature; what may be considered a crisis situation by one individual may not be so for another Crises are acute, not chronic, and will be resolved in one way or another within a brief period A crisis situation contains the potential for psychological growth or deterioration

28. Phases in the development of a crisis: Phase I – Exposure to a precipitating stressor anxiety increases; previous problem-solving skills are employed Phase II – Previous problem-solving techniques fail anxiety increases further; discomfort exists; feelings of confusion prevail as coping skills are exhausted Phase III – Internal and external resources used use of new problem-solving techniques Phase IV – Tension mounts to the breaking point anxiety may reach panic levels; cognitive functions are disordered; emotions are labile; behavior may reflect the presence of psychotic thinking; major disorganization of the individual with drastic results often occurs

29. Objective 8 Identifying types of psychiatric crisis

30. Suicidal thinking or behaviors Homicidal thinking or behaviors Acute psychotic symptoms Sudden change in mental status Violence resulting from a mental disorder

31. Objective 9 Exploring components of crisis intervention

32. Crisis intervention = the provision of emergency psychological care to clients in order to restore their level of functioning and to prevent or decrease potential negative effects of the crisis – –requires problem-solving skills that are often lacking in the client due to the level of anxiety accompanying disequilibrium – –assistance with problem-solving during the crisis period preserves self-esteem and promotes growth with resolution – –provide guidance and support to help mobilize the resources needed to resolve the crisis

33. Crisis intervention consists of: Preventing clients in crisis from harming themselves or others Administering medications Providing a supportive, therapeutic environment

34. Objective 10 Identifying clients at risk for suicide

35. Diagnosed mental disorder – –Depressive disorder Previous suicide attempt Family history of suicide Gender – –Females more likely to attempt suicide – –Males more likely to complete suicide Age – –Adolescents more likely to attempt suicide – –Individuals age 65 or older more likely to complete suicide Caucasians Substance abuse

36. Socioeconomic status – –Highest socioeconomic class – –Lowest socioeconomic class Occupational – –Professional health care personnel – –Business executives Single, divorced, or widowed individuals – –Isolation Any type of loss Physical illness Hopelessness Impulsive and/or aggressive tendencies

37. Objective 11 Identifying warning symptoms and preventative nursing interventions for individuals who are at risk for suicide

38. Warning Symptoms 8 out of 10 people who kill themselves have given definite warnings about their intentions – –Approach all suicidal behavior with the gravity of the potential act in mind – –Attention should be given to the possibility that the individual is issuing a cry for help – –Between 50% and 80% of all people who ultimately kill themselves have a history of a previous attempt People who want to kill themselves are typically suicidal only for a limited time – –Most suicidal people are ambivalent about their feelings regarding living or dying

39. Warning Symptoms (cont’d) Suicidal persons are not necessarily psychotic or otherwise mentally ill – –Unable to see an alternative solution to what is considered an unbearable problem – –Most suicides occur within 3 months after the beginning of “improvement”   Individual has gained the energy to carry out suicidal intentions

40. Preventative Nursing Interventions Provide effective and appropriate clinical care Encourage use of family support and community resources Assist in restricting access to highly lethal methods of suicide Provide education with regards to problem- solving, conflict resolution, and nonviolent handling of disputes Ensure arrangement are in place so that suicidal individual is not left alone Establish therapeutic rapport