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11.psychiatric emergencies

11.psychiatric emergencies






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    11.psychiatric emergencies 11.psychiatric emergencies Presentation Transcript

    • Psychiatric Emer gencies Crisis Management
    • Crisis Management  Define-Crisis- A sudden unexpected event in a person’s life that drastically changes his or her routine.  Also defined as a state in which the body is out of homeostasis.  An acute time limited usually 4-6 weeks event in which client experiences an emotional response that cannot be managed with normal coping mechanisms.  A person in crisis is at risk for physical and emotional harm inflicted by self and by others
    • Crisis .Examples and characteristics of people who may be in crisis:  loss of job suddenly,  divorced recently,  in an abusive relationship,  loss of a loved one due to death,  chemically dependent or otherwise mentally challenged,  those contemplating or attempting suicide.
    • Crisis  Experience a sudden event with little or no time to prepare,  perception of the crisis as life threatening,  loss or decrease in communication with significant others,  an actual or perceived loss.  An important concept to remember is each person is an individual, deal with stress individually, something that may seem minor to one is huge to the next person.
    • Types of crisis  Situational/external – loss of change experienced every day, often unanticipated, life events  Maturational/internal-achieving new developmental stages, which require learning additional coping mechanisms  Adventitious – The occurrence of natural disasters, crimes or national disasters
    • Phases of Crisis  Pre-crisis – person feels “fine” will often deny stress level  Impact – Phase 1 – escalating anxiety from a threat activates increased defense response.  Persons feels anxiety and confusion, may have trouble organizing personal life.  High stress level, will acknowledge feeling stress but may minimize its severity.
    • Phases of Crisis  Crisis-Phase 2 – anxiety continues to escalate as defense mechanisms fail.  Person denies problem is out of control. Withdraws or rationalizes behaviors and stress.  Use defense mechanism projection frequently, and other defense mechanisms as trial and error
    • Phases of Crisis  Phase 3 – trial and error methods continue to fail, and clients anxiety escalates to severe or panic levels, leading to flight or withdrawal behaviors.  Phase 4 – client experiences overwhelming anxiety that can lead to anguish and apprehension, depression, confusion, violence.
    • Crisis  Adaptive  Crisis is perceived in a positive way.  Anxiety decreases, attempts to regain self esteem and is able to start socializing again.  Able to do positive problem solving.
    • Post crisis  Surprisingly, both positive and negative functioning may be seen.  Person may have developed a more positive effective way of coping with stress OR may show ineffective adaptation such as being critical hostile, depressed, or may use food or chemicals such as ETOH to deal with what has happened.
    • What factors affect how an individual copes with stress and crisis?       Accumulation of unresolved losses. Current life stressors Concurrent mental and physical health Excessive fatigue or pain Age and development stage Prior experiences with stress/crisis
    • The basis of intervention crisis includes: Timely intervention Identify current problem and direct resolution Establish trusting nurse-client relationship Assist to regain normal level of functioning Be aware that client in crisis may and probably is usually mentally healthy  Help client set realistic attainable goals  Take active, direct role with client  Short term pharmacological interventions and evaluation     
    • Crisis Intervention  The five steps in crisis intervention.  The steps of crisis intervention are consistent with steps of the nursing process;      assessment diagnosis planning intervention evaluation
    • Assessment  Assess for suicidal or homicidal ideation  Assess for feelings of depression, powerlessness, overwhelmed, or anger  Does client recognize precipitating event?  Identify cultural or religious needs of client.  Assess support systems for the client.  Assess clients coping skills
    • Nursing Interventions  Ensure safety.  Assess situation if you or the patient is in physical danger, signal for help… otherwise DO NOT leave the patient.  Be sure to take care of your own safety first, you will be of no use if you are in danger.
    • Nursing interventions  Diffuse the situation. Do this verbally when at all possible. Physical attempts at restraining or calming are best left until all verbal attempts have been made.  Determine the problem. Attempt to find out from the patients viewpoint the cause of the crisis. Do not push the pt to give you answers, and always remain calm during intervention.
    • Nursing interventions  Decrease the anxiety level.  Make every attempt to reassure the pt that he or she is in a safe place.  Let the person know you are concerned and are here to help.  Develop therapeutic relationships, that include listening, observing, asking questions, make eye contact, ask questions related to patient’s feelings and ask questions related to the event.
    • Nursing interventions      Demonstrate genuineness and caring Communicate clearly Avoid false reassurance Teach relaxation techniques Identify and teach coping skills, assertiveness training
    • Nursing interventions  Return client to pre-crisis or better level of functioning.  The ultimate goal is for him or her to learn skills necessary to cope with stress in a more positive way than was used before the crisis.  Much of this learning will come from role modeling behaviors from nurses, always remember “actions speak louder than words”
    • Nursing interventions  Assist patient with development of an action plan including short term goals focused on the crisis that are realistic and manageable  Identify and coordinate with support agencies and other resources  Plan for and provide follow up care
    • Remember  With crisis intervention there is the common rule of thumb as with CPR….once you start and make that commitment to help, you cannot quit until you are physically no longer able to continue.  We as nurses may very easily be the one who walks into a room during the suicide attempt or who may take the call at the nursing station of a distraught person who is about to hurt himself or others.  Crisis is a form of mental illness that if treated in an appropriate and timely way, is usually temporary.
    • Suicide  Define: Suicide is the intentional act of killing oneself. People may elect to make this choice for many reasons, depression is a major cause.  Who is at highest risk?  Adolescent, young adult, and older adult males.  People who are unemployed and people who belong to minority groups are also at risk.
    • Co morbidities       Major depression Bipolar disorder Schizophrenia Alcohol and substance abuse Borderline and antisocial disorders Panic disorder
    • Definitions  Suicidal ideation – having thoughts about committing suicide  Para suicide- inflicting a non lethal injury to oneself with the intent to die or commit bodily harm  Self injurious behavior -purposeful intent to inflict harm on one’s body without obvious intent to actually commit suicide. May not be able to resist the impulse to injure themselves
    • Definitions cont ’d  Suicide pacts -copycat suicides, agreement made among a group of people often adolescents and some religious groups to kill themselves together.  Throughout all these groups runs the possibility of alcohol and chemical abuse in addition to other problems that seem insurmountable to the person considering suicide.
    • Suicide  Suicide contract -contract between patient and nurse or significant other in which the patient will call the designated person when the patient has thoughts of suicide.  Who contemplates suicide? The person that believes the problem is insurmountable and the act of suicide is the end of his/her problems.  Little concern is given to the aftermath and ramifications of those left behind.  Long term therapy is need to survivors.
    • S&S of Suicide  Noticeable improvement in mood occurs.  This often happens when pt has made the decision to commit suicide, the pain that is being experienced will soon be over.  Person starts giving away personal items. Items will be given away for reasons other than, “because I am going to kill myself”.  May even write or change a will when contemplating suicide.
    • S&S of Suicide  Person starts talking about death and suicide or becomes preoccupied with learning about these things.  Person has difficulty sleeping or awakens frequently very early in the morning, especially true for adolescents.  Myths and truths about suicide
    • Key factors about suicide Biological  Genetics, suggest suicide behaviors within families is common  Physical disorders: AIDS, cancer, stroke, cirrhosis, dementia, head injury multiple sclerosis.  Think of terminal illnesses.
    • Key factors about suicide Psychosocial       Sense of hopelessness Motivations, revenge, reunion with loved ones Anger turned inward History of aggression or violence Developmental stressors In adolescents interpersonal conflicts precipitating suicide attempts
    • Key factors about suicide Cultural    Religion Family values Attitudes Environmental  Peak times during spring and October Comorbidities  As discussed before, depression, substance abuse, etc.
    • Protective factors       Responsibility feelings Current pregnancy Religious beliefs Overall satisfaction with life Presence of social support Effective coping and problem solving skills
    • Nursing assessment and care for the patients who are suicidal  The goal is to prevent the suicide. Excellent observational skills and communication skills is mandatory.  Assess for lacerations, scratches and scars that may indicate previous attempts  Safety.      Wear paper gowns, paper bedding, no scissors, razors etc. Some may even break a light bulb and use glass to hurt self. Does person have access to guns or medications? Need to ask what their plan is how lethal is their plan? And what is access to method of plan?
    • Nursing assessment and care for the patients who are suicidal  Medications.  Always make sure pt has swallowed their meds when giving them. As they may pocket and save them.  Communication.  Ask outright if the person is considering suicide and, if so how and when.  Ask about any specific plan the individual may have, and if they have attempted suicide in the past.
    • Nursing assessment and care for the patients who are suicidal  Contract.  Develop suicide contract. Helps the patient to feel responsible and respected.  Crisis intervention as suicide is certainly a crisis situation.  Assessment tools SAD PERSONS ATI
    • Medical and therapeutic interventions  Depends on the individual and extenuating circumstances  Primary intervention include activities that provide support information and education to prevent suicide, such as speaking at a high school health class  Secondary treats the actual suicide crisis  Tertiary includes interventions with family and friends of victim who committed suicide to reduce traumatic aftereffects.
    • Medical and therapeutic interventions  Establish trusting therapeutic relationship  Limit amount of time an at risk patient stays alone, q 10-15 min watch  Assess risk factors, SAD PERSONS  Patient history of attempt
    • Med and Therapeutic interventions  When patients go from sad and depressed to happy and peaceful-be watchful as now they have the energy to carry out the act.  Involve significant others in the care plan  Assess for other diagnosis and problems, such as substance abuse.
    • Survivor assistance  Encourage to talk about suicide  Therapeutic communication active listening and silence  Listen to feelings of guilt and self persecution  Encourage discussion of individual relationships with the victim both positive and negative  Allow grieving in their own way  Inform and introduce resources in community for support
    • Interesting Facts  Suicide is 4 times higher in males than in females  10th leading cause of death in 2010  There is 1 suicide for every 25 attempts in adults.  There were 38,364 suicides in 2010 in the United States-an average of 105 each day  Among young adults 15-24 years old, there is aprox 100-200 attempts for every committed suicide.
    • Interesting Facts  Most common methods of suicide is shooting oneself with a gun-men and women equally use this method  Overdosing with medications-usually women  Hanging-usually men  Men tend to choose more violent types  Women tend to choose overdose methods
    • Interesting Facts  People who have overdosed have a better chance of being found alive which makes intervention possible.  Something about nurses.  We are trained to help and “take care” of others, however nurses are not exempt from tragedies…we are still parents, friends, siblings, and humans who experience the same pain and fear as everyone else. We need to utilize EAP as most facilities provide assistance.
    • Anger management  Define and discuss anger.  Anger is a normal feeling, an emotional response to frustration of desires or needs as perceived by the individual.  Can be positive.  Becomes negative when it is denied, suppressed or expressed inappropriately. (aggressively)
    • Physical signs that may be symptoms of suppressed or denied anger  Headaches  Coronary artery disease  Hypertension  Gastric ulcers  Depression  Low self esteem
    • Anger Management  Discuss aggression.  Includes physical or verbal responses that indicate rage and potential harm to self or others or property.  Aggression can be cathartic if used appropriately like punching a punching bag.  However, sometimes this just increases the anger.  Aggression can be sudden and can quickly escalate.
    • Anger management Factors influencing expression of anger and aggression:  Impulsivity can cause pt to form anger to aggressive behavior to violence without any warning.  Paranoid delusions may cause pt to believe he is being stalked or attacked  Auditory hallucinations may command pt to commit acts of hostility or aggression
    • Anger management  Dementia, delirium, head injury, drugs, alcohol, antisocial, and borderline personality disorders can all cause violent anger reactions  Depression  Inability to handle feelings and emotions
    • Impulse Control Disorder Pt who is aggressive is often impulsive and unable to control impulses. Criteria characterizing impulse control disorder:  Inability to control impulse that could be harmful  Buildup of feelings of tension or pressure before acting on impulse
    • Impulse control disorder  Sense of excitement and release of tension when acting on impulse  Followed by some degree of remorse after acting on impulse, but quickly rationalizing action
    • Stages of Anger  Pre assaultive -begins to become angry. Intervention is important to prevent more aggressive behaviors  Assaultive- active stage, may need physical restraint  Post assaultive- review incident with patient
    • Assessing Pt for aggressive and violent behavior  Who? Males in late teens to early 20 ’s with limited education  History of aggressiveness, violence and poor impulse control  Antisocial personality disorder, psychotic illness, substance abusers  History of traumatic brain injury  Living in violent environment
    • Assessment cont ’d  Assess facial expressions frowning grimacing  Body language, clenching fists waving arms  Rapid breathing  Aggressive posture  Verbal clues, loud rapid talking
    • Nursing interventions  Remain calm and in control  Encourage verbal expression of feelings  Attempt to move pt to quiet area away from others  Set limits-calm matter of fact statements  Encourage therapeutic physical activity, walking  Inform pt of consequences of behavior
    • Nursing Interventions May need to medicate Strength in numbers—use 4-6 staff members May need seclusion and physical restraints but only use after all other efforts have been exhausted  Once aggressive state is over discuss how to avoid situation and more therapeutic responses with pt.   
    • Nursing Interventions  Have them tell you in their own words how they felt and what led up to the event  Debriefing staff afterwards to see what worked and what didn’t  Documentation is necessary in all aspects
    • Pharmacological interventions     Sedative and hypnotic meds Antidepressants Antipsychotic meds (haldol) Mood stabilizers (lithium)
    • Preventative measures  Behavior therapy  Cognitive behavioral therapy, anger management classes  Group therapy  Family therapy
    • Sexual assault Define and discuss sexual abuse  Sexual abuse is violent or nonviolent sexual contact or sexual activity that is not wanted by the receiver.  Can also be defined as pressured or forced sexual contact including sexually stimulated talk or actions inappropriate touching or intercourse incest and rape.
    • Sexual assault  Sexual abuse is generally inflicted on someone the abuser considers less powerful both physically or emotionally.  The abuser is usually a close, significant figure in the abused persons life and knows how to manipulate the potential victim into submission.
    • Sexual assault Discuss and define sexual harassment Involves physical or verbal sexual innuendo. It may or may not include actual sexual activity but serves to leave the recipient uncomfortable and the workplace if that is where it occurs, unfriendly to that person or group of people.
    • Incest  Define and discuss incest-Incest is defined as sexual intercourse between persons so closely related that they are forbidden by law to marry.  It can include foreplay, touching, kissing, and mutual masturbation as well as oral sex and intercourse.  Most frequently occurs in very young children ages 5-8.
    • Rape  Discuss and define rape- Rape is forcible, degrading, nonconsensual and intimidation.  It is a crime of violence, aggression, anger and power.  The majority of rapists are known to the person who is raped.  Rape is not always about the sexual aspect as it is about power.  Most people who are raped suffer long term and severe emotional trauma.
    • Rape  It is important for the nurse to discourage the survivor to not clean up before going to the emergency department.  What they wash away is evidence.  As a nurse, it is very important to follow strict policy and procedures during collection of evidence as it may be used as evidence in court.
    • Date Rape  Discuss and define date rape- Date rape or “acquaintance” rape is increasing in recent years, often with drugs and alcohol involved to facilitate sexual assault.  Seen frequently among high school and college students and young adults within that age group.
    • Rape  Something alarming to be aware of in caring for the elderly, is rape happens to the elderly as well.  That population is being assaulted in their private residences and in long term care and assisted living facilities.  Rape trauma syndrome is similar to posttraumatic stress disorder.  Occurs in 2 phases, acute, and long term reorganization phase.
    • Rape trauma syndrome  Rape trauma syndrome is similar to posttraumatic stress disorder.  Occurs in 2 phases, acute, and long term reorganization phase.
    • Acute Phase Acute phase  Occurs immediately following the rape and lasts for about 2 weeks  Consists of emotional reaction expressed which consists of emotional outbursts including crying, laughing hysteria, anger and incoherence
    • Acute Phase cont ’d  Could consist of emotional reaction that is controlled, which is ambiguous, when the survivor may appear calm but also my be confused, having difficulty making decisions and feel numb.  A somatic reaction occurs later and lasts about 2 weeks with variety of symptoms.  Bruising and soreness from attack
    • Acute Phase cont ’d  Muscle tension, headaches, sleep disturbances, GI symptoms, GU symptoms and a variety of emotional reactions including embarrassment, desire for revenge, guilt, anger, fear, anxiety and denial
    • Long term reorganization phase  Long Term Phase-Occurs 2 weeks or more after the attack. Long term psychological effects include, flashbacks, increased activity such as visiting friends, moving around to avoid reoccurrence, increased emotional responses, crying, anxiety, rapid mood swings, fears, phobias  Difficulty daily functioning  Low self esteem
    • Long Term Phase cont ’d  Depression  Sexual dysfunction, somatic reports such as headaches and fatigue Other responses and reactions include reliance on alcohol or drugs or an inability to communicate any information about the rape experience.
    • Nursing Assessment  As a nurse, be empathetic, objective and nonjudgmental  Provide private environment for exam  Alert specially trained nursing personal to perform examination  Assess for s/s of psychological trauma  Assess pt’s level of anxiety, coping mechanisms, support systems
    • Nursing assessment  Follow facility protocols as far as obtaining lab values, and collecting legal evidence.
    • Nursing Interventions   Provide nonjudgmental and empathetic care Obtained informed consent for pictures and evidence collection
    • Nursing Interventions  Perform rapid physical assessment of injuries  Treat injuries and document care given  Support pt while evidence is being collected  Evaluate for STD’s, pregnancy risk and provide for prevention  Call pts support system if they allow
    • Nursing Interventions  Prepare them for thoughts, symptoms, and emotions that may occur  Encourage pt to verbalize her story and emotions  Listen and let survivor talk  Counseling begins at emergency dept.  Provide numbers for 24 hr hotline
    • Nursing Interventions  Promotion of self care activities  Referrals for resources and support services  Nursing case management schedule for follow up calls or visits