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

 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

o Restraints

 Must do neurovascular checks every 2 hours

Family Violence

• Types

o Spousal abuse

 Afraid spouse will find them and kill them

o Child abuse-must report, call social work

 It is important to be very detailed in your documentation

o 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 Anti-anxieties-benzodiaphenes

 Ativan-fast acting

 Valium-fast acting

 Xanax –fast acting

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

o Anti-depressants

 SSRI

• Celexa
 • Lexapro

• Prozac

• Zoloft

• Paxil

 Tricyclic

• Elavil

• Anafranil

 MOA inhibitor

• Nardil

o Beta Blockers

 Inderal

• Help these clients learn new coping strategies