Nursing Implications: Crisis/PTSD

Crisis

An overwhelming amount of stress which the person is unable to deal with by means of existing coping skills

Crisis Defining Characteristics

• Acute, not chronic. Self limiting 4-6 weeks

• Occurs in all individuals at one time or another

• Not necessarily equated with psychopathology

• Precipitated by identifiable events

• Personal in nature

• Contains the potential for psychological growth or deterioration

Crisis

An overwhelming amount of stress which the person is unable to deal with by means of existing coping skills

Crisis Defining Characteristics

• Acute, not chronic. Self limiting 4-6 weeks

• Occurs in all individuals at one time or another

• Not necessarily equated with psychopathology

• Precipitated by identifiable events

• Personal in nature

• Contains the potential for psychological growth or deterioration

Crisis Overview

• Overwhelming stress increases vulnerability and causes anxiety and physical discomfort (review anxiety content)

• Inability to cope threatens the person’ self-esteem and integrity

• Stressful event can be real, potential or imagined

• Availability of support systems and resources will also impact the development and resolution of a crisis

• Crises resolved as person learns new coping and grows or becomes increasingly maladaptive and ill

Life Crisis Units & Probability of Illness

300 LCU = 80%

200-299 = 50%

150-199 = 33%

Crisis Risk Factors

• Maturational/Developmental crises: transitions in development require new behaviors & skills (basis of Erikson’s theory); considered normal and often are predictable so can do prevention

• Situational crises: specific external events not experienced by everyone (ex. Rape) unpredictable

• Adventitious crises: disaster type events that effect groups; unpredictable

Maturational/Developmental Crises:

Transitions in development require new behaviors & skills (basis of Erikson’s theory); considered normal and often are predictable so can do prevention

Situational Crises

Specific external events not experienced by everyone (ex. Rape) unpredictable

Adventitious Crises

Disaster type events that effect groups; unpredictable

Phase 1 of Crisis Development

The individual is exposed to a precipitating stressor

Phase 2 of Crisis Development

When previous problem-solving techniques do not relieve the stressor, anxiety increases further

Phase 3 of Crisis Development

All possible resources, both internal and external, are called upon to resolve the problem and relieve the discomfort (people often seek help at this point)

Phase 4 of Crisis Development

Tension mounts and, over time, increases to the breaking point. The individual experiences major disorganization

Crisis Intervention: Behaviors

• Anxiety

• Inadequate coping(withdrawal, overeating, substance abuse, violence)

• Feelings of detachment/ shock, numbness

• Feelings of confusion/ being overwhelmed

• Difficulty with decision making/suggestibility

• Denial

• Suicidal ideation/behavior

Can lead to post traumatic stress disorder

Crisis: Assessment

• Precipitating event

  (if multiple events, summarize situation)

• Patient’s perception of event and patient’s response

• Social supports

• Pre-crisis functioning

• Previous strengths and coping skills

• Presence of substance abuse

• Physical adaptations (insomnia, pain)

Crisis: Nursing diagnosis/Problems

• Ineffective coping individual (family)

• Family process altered

• Anxiety/ fear

• Hopelessness/powerlessness

• Social interaction impaired

• Spiritual distress

• Potential for injury/Risk for violence: self or other

• Self-care deficit

• Dx for adaptations such as sleep pattern disturbance

Crisis: Goals

The Patient will:

• return to previous or improved level of functioning.

• utilize appropriate social supports.

• utilize more effective coping skills.

• make changes in current situation to reduce stress.

• utilize cognitive strategies to reduce stress.

• identify methods of coping with expected life changes to prevent crisis.

• verbalize decreased stress and anxiety.

Crisis Interventions

• Short term goal directed therapy

• Initially the patient may be so overwhelmed the nurse must be more directive

• As patient gets stronger encourage more independence

• Provide opportunity to express feelings and concerns

• Exhibit calm, respectful, supportive demeanor

• Assist patient to identify key issues

• Focus on realistic problem solving of major current issues

• Refer to needed agencies for support (social services, safe houses)

• Education about new skills & reinforce positive coping

• Cognitive restructuring & relaxation techniques

• Help utilize positive social supports

Crisis: Evaluation

• Patient returned to previous (or higher) level of functioning.

• Patient utilized appropriate social supports.

• Patient utilized more effective coping skills.

• Patient made changes to reduce stress.

• Patient utilized cognitive strategies to reduce stress.

• Patient utilized effective coping with expected life changes and no crisis occurred.

• Patient verbalized decreased stress and anxiety

PTSD: Overview

• Occurs following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape

• Marked by clear biological changes as well as psychological symptoms

• Often underdiagnosed or misdiagnosed

• Traumatic event breaks the denial of vulnerability needed to carry on daily activities

PTSD: Epidemiology

• Most people who are exposed to a traumatic, stressful event experience some of the symptoms of PTSD in the days and weeks following exposure.

• About 8% of men and 20% of women go on to develop PTSD (manifestations lasting greater than 1 month)

• 2-7% develop chronic PTSD

• 3-5% of U.S. adults aged 18 to 54 (5.2 million people) have PTSD at any given time

• 8% of Americans will experience PTSD

• Women (10.4%) twice as likely as men (5%)

PTSD: Risk Factors

• Severe stressful event

• Stressful event has long duration

• Inability to process responses after event

• Prior history of stressful events (including abuse)

• Poor coping skills

• Limited social support network

• Pre-existing pathology

• Lack of control of over reoccurrence of event

• Similarity between current situation & stressful event

PTSD: Assessment/Clinical Manifestations

• History of exposure to traumatic event: can be one time occurrence or longer event such as combat experience or bullying

• Re-experiencing the traumatic event: flashbacks, nightmares, intrusive memories

• Perceptual distortions: illusions and hallucinations

• Emotional arousal as if event was currently occurring: fear, anger, horror, helplessness

• Difficulty sleeping, hypervigilence and paranoia

• Exaggerated startle response, irritability and easily angered

• Memory of event blocked or preoccupation with event

• Feelings of detachment and restricted affect

• Impairment in social and occupational performance

• Somatic complaints

• Avoidance of situations that are reminder of event

• Substance abuse (self-medicate) and depression are common co-morbidities

Re-experiencing the traumatic event

Flashbacks, nightmares, intrusive memories

Perceptual Distortions

Illusions and Hallucinations

Emotional arousal as if event was currently occurring

Fear, anger, horror, helplessness

PTSD: Nursing Diagnosis/Problems

• Post-trauma syndrome

• Anxiety; Fear; Ineffective coping: individual

• Impaired social interaction

• Ineffective role performance

• Spiritual distress

• Interrupted family process

• Disturbed sleep pattern

• Disturbed sensory-perceptual

• Disturbed thought process; Impaired memory

• Dysfunctional grieving

PTSD: Goals

• Patient will verbalize impact of traumatic event on current situation

• Patient will utilize healthier coping skills for dealing with flashbacks and other emotional triggers.

• Patient will have improved sleep patterns.

• Patient will show improved social and occupational functioning.

• Patient will not abuse substances

PTSD: Interventions

• Antidepressant/Mood stabilizer/antipsychotic medications

• 12-step programs & support groups

• Cognitive behavioral therapy

• Behavioral therapies (as in phobias)

• Anger management

• Family therapy

• Bereavement counseling

PTSD: Evaluations

• Patient verbalized impact of traumatic event on current situation

• Patient utilized healthier coping skills for dealing with flashbacks and other emotional triggers.

• Patient has improved sleep patterns.

• Patient has improved social and occupational functioning.

• Patient does not abuse substances