Mental Health Mental Health Nursing IINursing II

NURS 2310NURS 2310

Unit 7Unit 7

Psychiatric Crisis Psychiatric Crisis ManagementManagement

Objective 1Objective 1

Reviewing the concepts associated with stress and

stressors

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

Objective 2Objective 2

Examining physical and psychological responses to

stress

Physical responses to stress:

General Adaptation Syndrome Biological responses

Psychological responses to stress:

Anxiety Grief

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

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 responseStimulation of the pituitary gland– increases fluid retention and blood

pressure– basal metabolic rate increased

Objective 3Objective 3

Reviewing the levels of anxiety and

associated symptoms/behaviors

of each

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

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

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

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

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

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

Objective 4Objective 4

Exploring various defense mechanisms

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

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

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

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

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

Objective 5Objective 5

Identifying behaviors associated with maladaptive coping

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

Objective 6Objective 6

Describing effective coping strategies to decrease psychological/emotional discomfort

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

Objective 7Objective 7

Defining psychiatric crisis

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

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

Phases in the development of a crisis:Phase I – Exposure to a precipitating stressor anxiety increases; previous problem-solving

skills are employedPhase 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 techniquesPhase 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

Objective 8Objective 8

Identifying types of psychiatric crisis

Suicidal thinking or behaviors

Homicidal thinking or behaviors

Acute psychotic symptoms

Sudden change in mental status

Violence resulting from a mental disorder

Objective 9Objective 9

Exploring components of crisis intervention

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

Crisis intervention consists of:

Preventing clients in crisis from harming themselves or others

Administering medications

Providing a supportive, therapeutic environment

Objective 10Objective 10

Identifying clients at risk for suicide

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

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

Objective 11Objective 11

Identifying warning symptoms and preventative nursing

interventions for individuals who are at risk for suicide

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

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

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