Mental Health Nursing II NURS 2310

Mental Health Nursing IINURS 2310 Unit 7 Psychiatric Crisis Management

Objective 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 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 response Stimulation of the pituitary gland • increases fluid retention and blood pressure • basal metabolic rate increased

Objective 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 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 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 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 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 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

Objective 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 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 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 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

Mental Health Nursing II NURS 2310