crisis management, stress and defense mechanisms, anxiety, and violence - quiz 4

crisis

limited and acute

4-6 weeks

triggers a coping response that cannot be managed with pts normal coping mechanisms

crisis risk factors

unresolved loss

life stressors

mental and physical health issues

excess fatigue or pain

age and developmental status

unresolved loss

an unexpected loss

protective factors for crisis

prior personal experience

types of crisis

situational/external

maturational/internal

adventitious

situational/external crisis

unanticipated

ex: kid fell into a pool

maturational/internal crisis

new developmental stages

adaptive: graduating, getting married, having kids, retirement

adventitious crisis

natural disasters

national disasters

ex. fire burning down house, hurricane Katrina

what is our goal as nurses for managing crisis

safety

what is our numeber 1 task for crisis

address pt immediately

strategies to decrease anxiety

offering self, remain with pt

listen and observe

eye contact

ask questions relevant to the event

communicate clearly

avoid false assurances

help pt to develop action plan

primary theraputic interventions for crisis

identify potential problems

- what is causing this crisis?

secondary theraputic interventions for crisis

identify interventions

- what can I do to help this pt through this crisis?

tertiary theraputic interventions for crisis

provide support during recovery from severe crisis

- ex. outpt rehab centers, crisis sstabilization centers, workshops

- debreif what exercises can help pt through this hard situation

fight or flight

increased HR, RR, BP

slowed GI

increased metabolism

pupils dilate

good stress

ex. traveling, new job, exercising at gym

bad stress

ex. school, money

are physiological responses the same for good and bad stress?

yes

can cause anxiety and dysfunctional behavior

stress can lead to

decreased attention span from fatigue

weaker immune system

what do people do with stress

develop adaptive or maladaptive defense mechanisms

acute stress

apprehention

unhappiness

sorrow

decreased appetite

increased HR, RR, BP

increased metabolism

depressed immune system

chronic stress

chronic anxiety or panic attacks

depression

chronic pain

sleep disturbances

wt fluctuations

increased risk for MI, stroke

poor disease management

increased risk for infection

adaptive defense mechanisms

altruism

sublimation

altruism

dealing with anxiety by reaching out to others

ex. you call your mom when you are sad

ATI ex. a nurse who lost a family member in a fire is a volunteer firefighter

sublimation

dealing with unacceptable feelings or impulses by unconsiously substituting acceptable forms

adaptive: going to the gym when you are angry and want to punch someone

adaptive and maladaptive defense mechanisms

suppresion

repression

regression

displacement

reaction formation

undoing

rationalization

dissociation

denile

compensation

identification

intellectualization

suppression

voluntarily denying unpleasant thoughts and feelings

adaptive: student puts off thinking about a fight they had with friend so they can focus on test

maladaptive: someone who lost their job says they will worry about paying bills next week

repression

unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness

adaptive: someone preparing to give a speech unconsciously forgets about the time they were young and kids laughed at them while on stage

maladaptive: someone with a fear of the dentist forgets to go to their dental appointments frequently

regression

sudden use of childlike primative behaviors that dont correlate with the person's current developmental level

adaptive: young child temporarily wets the bed when they learn that their pet died

maladaptive: person who has disagreement with a co workers begins throwing things in their office

displacement

shifting feelings related to an object, person, or situation to another less threating object, person, or situation

adaptive: adolescent angirly punches bad after losing game

maladaptive: person who is angry about losing job destroys their child's favorite toy

reaction formation

unnacceptable feelings or behaviors are controlled or kept out of awareness by overcompensating or demonstrating the opposite behavior of what is felt

adaptive: someone trying to quit smoking repeatedly talks to adolescents the dangers of nicotine

maladaptive: someone who resents having to care for an aging parent becomes overprotective and restricts their freedom

undoing

performing an act to make up for prior behavior (usually seen in children)

adaptive: child completes chores without being prompted to after an argument with their parent

maladaptive: someone buys their girlfriend flowers and gifts after abusing them

rationalization

creating reasonable and acceptable explanations for unacceptable behavior

adaptive: someone says "they must already have a boyfriend" when they get rejected

maladaptive: someone says they have to drive home drunk because they have to feed their dog

dissociation

disruption in consciousness, memory, identity or perception of the environment that results in compartmentalization of uncomfortable or unpleasant aspects to oneself

adaptive: parent blocks out distracting noise in order to focus while driving

maladaptive: someone forgets who they are after a sexual assult

denile

pretending the truth is not reality to manage unpleasant anxiety-causing thoughts or feelings

adaptive: someone initially says "no that can't be true" when told they have cancer

maladaptive: parent who is told their child was killed in combat tells everyone a month later their child is coming home for the holidays

compensation

emphasizing strengths to make up for weakness

adaptive: someone who is unable to play contact sports excels in academic competitions

maladaptive: someone who is shy learns computer skills to avoid socialization

identification

conscious or unconscious assumption of characteristics of another individual or group

adaptive: child who has a chronic illness pretends to be a nurse for their dolls

maladaptive: child who observes their parents abuse and becomes a school bully

intellectualization

separation of emotions and logical facts when analyzing or coping with a situation or event

adaptive: a law enforcement officer blocks out the emotional aspect of a crime so they can objectively focus on the investigation

maladaptive: someone who learns they have a terminal illness focuses on creating a will and financial matters rather than acknowledging their grief

maladaptive defence mechanisms

conversion

splitting

projection

conversion

responding to stress through the unconscious development of physical manifestations not caused by a physical illness

maladaptive: someone experiences deafness after their partner tells them they want a divorce

splitting

demonstrating an inability to reconcile negative and positive attributes of self or others in a cohesive image

maladaptive: pt tells nurse that the nurse is the only one who cares about them but the next day the pt refuses to talk to the nurse

projection

attributing one's unacceptable thoughts and feelings to another who does not have them

maladaptive: a married client who is attracted to another person accuses their partner of having an affiar

nursing care for stress

cognitive reframing

journal writing

cognitive reframing

helps pt look at irrational thoughts in a more realistic light

restructure the thought in a more positive way

ex. "im a bad father" to "ive made some mistakes as a parent but ive learned from them and improved my parenting skills"

journal writing

helps ease anxiety

increases confidence and hope

relxation techniques

meditation

guided imagery

breathing exercise

progressive muscle relaxation

physical exercise

guided imagery

close eyes and imagine a calming place

breathing exercises

goal is to increase O2 to brain

- helps pt calm down and increases their ability to think and recall things

progressive muscle relaxation

tighten muscle groups then relax them

physical exercise

NON weight lifting exercises to ease anxiety

levels of anxiety

mild

moderate

severe

pani

mild anxiety

every day living

headache

mild discomfort

mild restlessness/irritability

moderate anxiety

DO NOT leave pt at this point

decreased ability to think and problem solve

insomnia

pacing

voice tremors

increased vital signs

keep directions brief

problem-solving and learning can still occur at this stage

severe anxiety

field of view greatly reduced

learning and problem solving does not occcur

function is effective and behaviors are automatic

increased HR, RR, BP

confusion

impending doom

keep direction simple

usually unable to take directions from others

panic

pt not able to process things

lost touch with reality

extreme fright and horror

hyperactivity or immobility

hallucinations

dilated pupils

dysfunction in speech

who is at higher risk for anxiety

females

environment for anxiety

must keep the physical safety of the pt

quiet and low stimulation

when would we need to put them in restraints

if they get violent

use therapeutic communication first

anxiety nursing considerations

encourage exercise

- stress relief

set limits, talk slow and low

what levels of anxiety is theraputic communication useful for

mild and moderate ONLY

* severe anxiety and panicing pts do not have the cognitive abilities for theraputic communications or questions/education to be helpful, you must bring them down to mild/moderate anxiety in order to start asking questions and educate them

anxiety disorders

anxiety

OCD

anxiety

separation anxiety

specific phobias

agoraphobia

social anxiety

panic disorder

generalized anxiety disorder (GAD)

OCD

obsessive compulsive disorder

- obsessive: hyper-focused on ONE thing

- compulsive: has to perform some action or else their anxiety will increase

- compulsion will decrease anxiety

hoarding

body dysmorphia

1st line med for OCD and anxiety

SSRI: sertaline (zoloft)

benzodiazepines for OCD and anxiety

lorazepam (ativan)

diazepam (valium)

benzodiazepines for anxiety and OCD considerations

not long term meds or first line because they are very adictive

causes respiratory depression and sedation

cannot take with ETOH

may cause paradoxical response

paradoxical reponse

opposite response than what is expected

- insomnia, anxiery, restless, agitation

atypical anxiolytic meds for OCD and anxiety

buspirone

buspirone considerations

cant have

- st johns wort

- grapefruit

- erythromycin

- ketoconazole

these will increase buspirone in the body

non benzo meds for OCD and anxiety

betablockers: propanolol

antihistamines

antiepileptic: lamotrigine, valproic acid (VPA)

* these are used for those with a history of drug use/addiction

antihistamines for OCD and anxiety considerations

causes anticholinergic effects

also affects antipsychotic use (it is the antidote for EPS symptoms)

- cant use antihistamines with antipsychotics

beta blockers for OCD and anxiety considerations

decreases BP

take BP before giving

cognitive behavioral therapy for OCD and anxiety

relaxation training

modeling

systematic desensitization

flooding

response prevention

thought stopping

systematic desensitization

progressive exposure to someone's fear

ex. showing them a picture of a spider, then having them hold a spinder stuffed animal, then having them hold a real spider

flooding

putting them in an environment filled with their fear

ex. putting them in a room with a bunch of spiders

relaxation training

a treatment procedure that teaches pt to relax at will so they can calm themselves in stressful situations

modeling

learning by imitating others; copying behavior

response prevention

focuses on preventing the pt from performing a compulsive behavior with the intent that anxiety will diminish

thought stopping

teaches pt to say "stop" when negative thoughts or compulsive behaviors begin, and substitute a positive thought

the goal of therapy is that with time, the client uses the command silently

cycle of violence

tension building stage

acute battering stage

honeymoon stage

tension bulding stage

minor episodes of anger

- verbal and some minor physical violence ex. pushing, shoving

- victim is usually tense during this stage and accepts blame

acute battering stage

serious abuse takes place

- victum may provoke perp due to unbearable tension

- victim will try to hide bruises

- shortest stage

honeymoon stage

they fall in love again and perp tells victim they will not hurt them again

perp love bombs victim

how to as suspected victim of violence about bruising/injuries

"how did you get these buises/injuries?"

types of violence

physical

emotional (mental/verbal)

sexual

financial

neglect

most common type of violence

emotional

perpetrator common characteristics

poor impulse control

poor coping skills

lacking knowledge in role

low self esteem

likely to have experienced violence as a kid

possible history of substance abuse

victim common characteristics

low self esteem

helpless, hopeless, powerless, guilt, shame

may consider the abuse as warranted

suspicious injuries in children that may indicate abuse

spiral fracture

bruising inconsistent with age

- ex. bruises on knees when they no longer crawl

patterned burn marks

what to do when you encounter suspected child abuse

report it to the non emergency hot line

- do not go to charge nurse or anyone else before doing this

how much proof is needed to report suspected abuse

none, just a suspicion

elder abuse findings

malnutrition

clothing not matching weather

bad hygiene

financial abuse: no water/utilities/gas/electricity in home

the child's perpetrators are most often who

their parents

unwanted sexual advances and sexual harassment

stranger rape

marital rape

date rape

drug facilitated sexual assault

incest

human sex trafficking

* all perps are usually acquaintances of the victim

who are the main victims of rape

anyone can be a victim of rape

main reason perpetrators commit rape

so they can have control

rape-trauma syndrome

PTSD like

- flashbacks, nightmares, hyperarousal, avoidance, emotional instability, may appear detached or confused

pt may develop a depressive or anxiety disorder