Mental Health Chapters 15-20

What is crisis?

•A time-limited event that occurs when an individual is unable to use coping mechanisms effectively when presented with a perceived threat.

•Typically lasts 4-6 weeks and may have positive or negative affects on an individual.

Crisis Positive

Resilient, find out things about yourself, personal growth

Crisis Negative

stress, can’t sleep, health declines, depressed anxious, suicidal.

What brings on a crisis?

A traumatic event… divorce, death, natural disasters, car accidents, shooting, war, COVID. Intrapersonal events. Feel desperate or out of control. The threat is perceived (interpret it) specific to the individual.

Developmental Crisis

Normal part of growth and development. as you mature you go through things

Developmental Crisis Example 

mid life crisis, puberty, going to college (leaving home for the first time)

Situational Crisis

Stressful situation due to lack of coping skills. difficulty if the person lacks good coping skills.

Situational Internal example

disease process like cancer

Situational External Example 

going to college/ moving out, a job promotion, graduation, doing homework assignments. 

Traumatic Crisis

An unexpected event that results in trauma

Traumatic Example 

dangerous situation that results in danger and injury. Car crash, being deployed, COVID, violent crimes

During crisis they present symptoms like those with mental illness.

•They will recognize that they are unable to function. Nursing caring for a person in crisis will need to observe how severe the person in crisis is experiencing it.

Nursing Interventions during crisis

•Safety

•Provide emotional support

•Assist with self-care

•Help with focus

•Administer medications

•Identify coping skills

•Provide resources

•Clarify fact from fiction

•Never give false hope

Grief

a natural reaction to a loss or death of a loved one

Loss

the act of losing something valuable. Can evoke minor to complex thoughts, feelings, and behaviors depending on the perceived relationship of the person with the lost loved object or person. 

Bereavement

The process of healing and learning to cope with the loss.

Uncomplicated Bereavement

usually happens with the expected loss, they have a terminal illness, elderly. Grief that is painful and interrupts their life, but life does not stop. They won’t need assistance. Why did the death happen? Why my loved one? Why me? Why did God allow this to happen? 

Complicated Bereavement

last for more than 1 month up to 6 months after to loss. May have difficulty expecting the death, trusting people, experience bitterness, and life having meaninglessness.

Normal Grief

•Kubler-Ross stages of grief

•Can affect sleep and nutritional habits

•Can affect coping skills

•Will gradually improve

•Different for each person’s experience

Pre death Grief

occurs prior to a death such as when a loved one has a terminal illness. Higher levels of this grief can occur through depressive symptoms, caregiver burden, and less communication within the family about dying. 

acute grief 

occurs immediately after the death of a loved one and normally evolves to a permanent state of integrated grief after a process of adaptation.

Integrated grief

is a long-term process where there continues to be mild yearning and other painful emotions, thoughts, and memories, but they are not intrusive. Even though there may be occasional periods of grief intensity, they do not interfere with ongoing life and the sense of well-being.

prolonged grief disorder

(PGD) (intense longing for or persistent preoccupation with the deceased that lasts more than 6 months)

Traumatic grief

is a term that is used for a more difficult and prolonged grief. In traumatic grieving, external factors influence the reactions and potential long-term outcomes. For example, memories of the traumatic death of the deceased may lead to more traumatic memories including the violent death scene.

Physical Health Grief 

Sleep difficulty, lack of appetite, and weight loss can indicate the severity of the grief. Substance use should be determined. One area to determine is how dependent the bereaved was on the deceased for physical care.Who prepared the meals, shopping, or house cleaning?

Perception Grief 

The thought process should be assessed for negative and maladaptive thoughts. If the person is protesting the death (death should not have happened; it is not fair; could have prevented death) and has a negative view of the world (bad things happen; no one is safe), they are at risk of maladaptive thoughts that complicate bereave-ment. An example of other negative cognitions includes needing the person (i.e., life is unbearable without the person who died) (Skritskaya et al., 2020).

Emotional and Behavioral Response Grief

includes determining current mood and behavior. Poor grooming, disheveled appearance, or blank or tearful facial expressions could indicate depression. A suicide risk assessment should be conducted. By asking the question, "Have you wished that you were dead or wished that you could go to sleep and not wake up?", the nurse can determine if further suicide risk assessment should be completed and the patient referred to a therapist

Social Functioning and Support Grief

Determining the presence of social support is important as well as determining the level of social functioning.

Withdrawal from normal social activities or failure to resume previous activities may indicate the onset of depression.

Interventions of Grief Self Care 

strategies can range from providing or arranging for physical care for the person to suggesting resources.

Adequate nutrition and sleep are critical to support the person through bereavement. Strategies include recommending balanced meals and teaching sleep hygiene techniques.

Interventions of Grief Medications 

Short-term reliance on antidepressants or sleep aids may be useful during acute grief. Careful monitoring of the use of medications is needed to prevent long-term use of these medications.

Interventions of Grief Counseling

to foster adaptive coping and management of painful experiences. The focus of the counseling will be determined by the circumstances of the loss and the relationship of the bereaved to the deceased.

Pre-death grief Counseling

the nurse identifies the changes associated with the disease and fosters acceptance of the loved one's disease and symptoms. The nurse continues to monitor the health and well-being of the caregiver who may be unaware of the extent of their grief or the toll on their own health.

acute grief Counseling

in addition to normalizing the painful, sad feelings, the counseling approaches can encourage engagement with a natural support system or grief support group, and focus on ways to live with the reminders of the loss.

prolonged grief Counseling

is the primary characteristic with impaired functioning and preoccupation with thoughts of the deceased, the person should be referred to a mental health specialist for further evaluation

Offer Support Grief Interventions

Bereavement can be a highly stressful time with increased physical and psychological demands this is a time that the bereaved benefit from the support of family, friends social cultural, and religious communities. Normal life is suspended and a new reality gradually evolves. Social support is especially needed after the busy time of planning a funeral or celebration of life is over and the social community gradually withdraws. Loneliness sets in and the full impact of the loss is realized. During this time, the person is at high risk for suicide. Through social sup-port, the individual can begin thinking about their future and focus on their own self-care and well-being.

Physical Abuse

involves any act of aggression, with or without the use of an object or a weapon, that results in injury, pain, or impairment to another. Examples include striking, kicking, shoving, choking, and burning.

Psychological Abuse

(also referred to as emotional abuse) involves threats, intimidation, or destructive behaviors used as a means of manipulating someone, asserting dominance, or causing tear. Psychological abuse includes behaviors such as criticizing, insulting, humiliating, or ridiculing someone in private or in public. Abusers may destroy property, threaten or harm pets, control or monitor spending and daily activities, or isolate a person from family and friends. Gaslighting is a form of psychological abuse in which the victim is made to question their own judgment and perceptions. Perpetrators downplay the consequences of their behavior, deny abusive intent, or argue that actions are somehow justified.

Intimate Partner Violence (IPV) Risk Factors:

•Women

•LGTBQ+

•Aspects of character

•Stress

Power and Control: using economic abuse 

Preventing her from getting or keeping a job • making her ask for money • giving her an allowance • taking her money • not letting her know about or have access to family income.

Power and Control: Using coercion and threats

Making and/or carrying out threats to do something to hurt her

• threatening to leave her, to commit suicide, to report her to welfare • making her drop charges • making her do illegal things.

Power and Control: Using Intimidation

Making her afraid by using looks, actions, gestures

• smashing things • destroying her property • abusing pets • displaying weapons.

Power and Control: Using Emotional Abuse

Putting her down • making her feel bad about herself • calling her names • making her think she's crazy playing mind games • humiliating her. making her feel guilty.

Power and Control: Using Isolation

Controlling what she does, who she sees and talks to, what she reads, where she goes • limiting her outside involvement • using jealousy to justify actions.

Power and Control: Minimizing Denying and Blaming

Making light of the abuse and not taking her concerns about it seriously • saying the abuse didn't happen • shifting responsibility for abusive behavior • saying she caused it.

Power and Control: Using Children

Making her feel guilty about the children • using the children to relay messages

• using visitation to harass her

• threatening to take the children away.

Power and Control: Using Male Privilege

Treating her like a servant • making all the big decisions • acting like the "master of the castle"• being the one to define men's and women's roles.

Child Neglect

is an act of omission, which occurs when a child's basic physical, emotional, educational, and health care needs are not met. Failure to protect a child from harm, inadequate supervision, or exposure to violence are other forms of neglect. Neglect is the most common form of child abuse.

Human Trafficking

involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act. experience systemic oppression are at particularly high risk. However, victims may be of any age, race, gender, or nationality. Traffickers often prey on people who are psychologically, emotionally, or financially vulnerable. Some are forced into sexual acts or physical labor through violence or manipulation. Others are exploited after being lured by false promises of money, jobs, or romantic relationships. Language barriers, fear of law enforcement or immigration authorities, dependence on the perpetrators) for basic needs, or fear of retribution by traffickers can keep victims from seeking help.

Stalking 

is a pattern of repeated unwanted contact, atten-tion, and harassment that often increases in frequency.

Stalkers harass and terrorize their victims through behavior that causes fear or substantial emotional distress.

Stalking may include such behaviors as following some-one, showing up at the person's home or workplace, vandalizing property, using technology to track or harass someone (cyberstalking), or sending unwanted gifts.

Abuse of Older Adults

who have mental or physical disabilities are vulnerable to abuse. Older individuals may be victims of physical, psychological, or sexual abuse. The most common type of elder abuse is financial abuse, in which older adults may be manipulated by family or caregivers to give up control of their money and are vulnerable to scams and fraud perpetrated by outsiders.

Safety Planning for Abuse

to leave is a dangerous time for people in violent relationships. One of the most important interventions when caring for individuals who are in an ongoing abusive relationship is to help survivors develop a safety plan.

The first step in developing such a plan is

helping the survivor recognize the signs of danger. Changes in tone of voice, substance use, and increased criticism may indicate that the perpetrator is losing control. Detecting early warning signs helps survivors to escape before violence begins.

The next step is to devise the escape

For families at risk for violence, this may involve mapping the house for an escape route. The IPV survivor needs to have a bag packed and hidden but readily accessible that includes what is needed to get away. Important things to pack are clothes, a set of car and house keys, bank account num-bers, birth certificate, insurance policies and numbers, marriage license, valuable jewelry, important telephone numbers, and money. If children are involved, the adult survivor should make arrangements to get them out safely. That might include arranging a signal to indicate when it is safe for them to leave the house and to meet at a prearranged place.

A safety plan for a child or dependent older adult might include

safe places to hide and important telephone numbers, including 911, and those of the police and fire departments and other family members and friends.

Physical Health Interventions for Abuse

may include cleaning and dressing burns or other wounds and assisting with setting and casting broken bones. Malnourished and dehydrated children and older adults may require nursing interventions such as intravenous therapy or nutritional supplements that alleviate the alteration in nutrition and fluid and electrolyte imbalances.

Safety Assessment for Victims of Violence

Once physiologic stability is established, the nurse should determine whether the survivors are in danger for their life, either from homicide or suicide, and, if children or other dependents are in the home, whether they are in danger. Trauma may trigger suicidal ideation or exacerbate pre-existing mental health conditions that place the survivor at risk. Suicide precautions should be initiated if indicated.

Screening For Violence and Abuse Victims of Violence

Psychosocial Assessment Fear

Living with an abusive partner, parent, or caregiver means living with constant fear and uncertainty. Because victims never know what might precipitate an incident of violence, they are constantly hypervigilant and fearful. The back-and-forth nature of the relationship, that is, alternating between love and violence, is confusing, so the survivor may try to do everything possible to please the abuser in an effort to prevent another violent episode.

Psychosocial Assessment Low self Esteem

Being the victim of abuse is devastating to healthy self-esteem, or feelings of self-acceptance, self-worth, self-love, and self-nurturing. Emotional abuse may be particularly devastating. Victims are criticized, rejected, devaluated, and ignored. Over time, people begin to internalize the negative messages and may come to believe the abuse is deserved. Low self-esteem has been linked to physical and mental health problems, problems with relationships, and may affect survivors' ability to achieve financial independence.

Psychosocial Assessment Guilt and Shame 

Survivors are ashamed of being manipulated and violated and for having put themselves in such a situation. Abusive partners tell the survivors that the abuse is their fault and many victims believe them. Feelings of humiliation and shame prevent survivors from seeking medical care and other forms of support and reporting abuse to authorities. The experience of being battered is so degrading and humiliating that survivors are often afraid to disclose it to anyone. Many fear that they will not be taken seriously or will be blamed for inciting the abuse or for staying with their abusers. Keeping their circumstances secret and maintaining a front of normality places enormous tension and pressure on survivors.

Psychosocial Assessment Problems with Intimacy

Abused children, especially those who have experienced child sexual abuse, experience intrusion, abandonment, devaluation, or pain in the relationship with the abuser instead of the closeness and nurturing that are normal for intimate relationships (AACAP, 2020). Consequently, intimacy is associated with shame and fear rather than warmth and caring and with concerns about dominance and submission rather than mutuality. Shame, in turn, is associated with being submissive, feeling devalued, and the desire to retaliate against a person who is seen as the source of humiliation. In adulthood, unresolved feelings of shame, as well as symptoms of PTSD or depression, may disrupt the development of intimacy and interfere with the ability to develop and sustain healthy relationships.

Psychosocial Assessment Revictimization

including symptoms of PTSD, dissociation, boundary issues, and feelings of self-blame and shame. Internalized stigma, victim-blaming statements, and past negative social reactions from others affect survivors self perception and willingness to disclose subsequent abuse. People with abuse histories frequently have difficulty with boundaries. During childhood abuse, they experienced frequent boundary violations and associate those violations with intimate relationships. Excessive use of alcohol and other drugs by survivors makes them less able to defend themselves and more vulnerable to revictimization.

Psychosocial Assessment Social Networks

provides additional clues of psychological abuse and controlling behavior. Having supportive family or friends is crucial in short-term planning for developing a safety plan and is also important to long-term recovery. A survivor cannot leave an abusive situation with nowhere to go. Supportive family and friends may be willing to provide shelter and safety, as well as emotional support. As part of safety planning, survivors can set up code words to make contacts aware that help is needed, or ask friends to keep belongings or documents that they may require if they leave home quickly.

Psychosocial Assessment Social Isolation 

Many perpetrators isolate their family from all social contacts, including other relatives. Some survivors isolate themselves because they are ashamed of the abuse or fear non supportive responses. Nurses can assess restrictions on freedom that may suggest abuse and control by asking such questions as "Are you free to go where you want?" "Is staying home your choice?" and "Is there anything you would like to do that you cannot?"

Psychosocial Assessment Economic and Emotional Dependency

Women who have young children and depend on the perpetrator financially may believe that they cannot leave the abusive relationship. Those who are emotionally dependent on the perpetrator may experience an intense grief reaction that further complicates their leaving. Older adults and children often depend on the abuser and cannot leave the abusive situation without workable alternatives.

Mandatory Reporting

•Nurses are mandatory reporters

⚬It is not your job to investigate,  only report if suspicion is there

•State laws require of known or suspected abuse

•Collaboration with other HCP for client safety

Anxiety

is an unavoidable human condition that takes many forms and serves different purposes. can be positive and can motivate one to act, or it can produce paralyzing fear, causing inaction.

Normal anxiety

is described as being of realistic intensity and duration for the situation and is followed by relief behaviors intended to reduce or prevent more anxiety. A normal anxiety response" is appropriate to the situation

Exaggerated Response Anxiety 

•When the anxiety is not proportional to the threat

•Interferes with a person’s ability to meet their needs

Mild Anxiety

Perceptual field widens slightly. Able to observe more than before and to see relationships (make connection among data). Learning is possible.

•Increased awareness

•More alert

•Widened perceptual field

•Able to recognize & identify anxiety

•Still able to learn/problem solve

Mild Anxiety

Is aware, alert, sees, hears, and grasps more than before. Usually able to recognize and identify anxiety easily.

Moderate Anxiety 

Perceptual field narrows slightly. Selective inatten-tion: does not notice what goes on peripheral to the immediate focus but can do so if attention is directed there by another observer.

Moderate Observable behavior

Sees, hears, and grasps less than previously. Can attend to more if directed to do so. Able to sustain attention on a particular focus; selectively inattentive to contents outside the focal area. Usually able to state, "I am anxious now."

Severe Anxiety

Perceptual field is greatly reduced. Tendency toward dissociation: to not notice what is going on outside the current reduced focus of attention; largely unable to do so when another observer suggests it.

Severe Observable behavior

Sees, hears, and grasps far less than previously.

Attention is focused on a small area of a given event. Inferences drawn may be distorted because of inadequacy of observed data. May be unaware of and unable to name anxiety. Relief behaviors generally used.

Panic Anxiety

Perceptual field is reduced to a detail, which is usually "blown up," that is, elaborated by distortion (exaggeration), or the focus is on scattered details; the speed of the scattering tends to increase. Massive dissociation, especially of contents of self-system. Felt as an enormous threat to survival. Learning is impossible.

Panic Observable behavior

Says, "I'm in a million pieces," "I'm gone," or "What is happening to me?" Perplexity, self-absorption.

Feelings of unreality. Flights of ideas or confusion. Says, "I'm in a million pieces," "I'm gone," or "What is happening to me?" Perplexity, self-absorption.

Feelings of unreality. Flights of ideas or confusion.

Fear. Repeats a detail. Many relief behaviors used automatically (without thought). The enormous energy produced by panic must be used and may be mobilized as rage. May pace, run, or fight vio-lently. With dissociation of contents of self-system, there may be a very rapid reorganization of the self, usually going along pathologic lines (e.g. a psychotic break" is usually preceded by panic).

Phobias

is an irrational fear of an object, person, or situation that leads to a compelling avoidance.

Panic Disorder

is an extreme, overwhelming form of anxiety often experienced when an individual is placed in a real or perceived life-threatening situation. Panic is normal during periods of threat but is abnormal when it is continuously experienced in situations that pose no real physical or psychological threat. Some people experience heightened anxiety because they fear experiencing another panic attack. This type of panic interferes with the individual's ability to function in everyday life and is characteristic of panic disorder.

Serotonin And Norepinephrine

are both implicated in panic disorders. Norepinephrine effects act on those systems most affected by a panic attack—the cardiovascular, respiratory, and gastrointestinal systems. Serotonergic neurons are distributed in central autonomic and emotional motor control systems regulating anxiety states and anxiety-related physiologic and behavioral responses

Gamma-Aminobutyric Acid

is the most abundant inhibitory neurotransmitter in the brain. GABA receptor stimulation causes several effects, including neurocognitive effects, reduction of anxiety, and sedation. GABA stimulation also results in increased seizure threshold.

Abnormalities in the benzodiazepine-GABA-chloride ion channel complex have been implicated in panic disorder

Benzodiazepine Therapy

have produced anti-panic effects; their therapeutic onset is much faster than that of antidepressants. Therefore, benzodiazepines are tremendously useful in treating intensely distressed patients. Alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin) are widely used for panic disorder. They are well tolerated but carry the risk for withdrawal symptoms upon discontinuation of use. The benzodiazepines are still used for panic disorder even though the SSRIs are recommended for first-line treatment of panic disorder

Distraction

After patients can identify the early symptoms of panic, they may learn to implement distraction behaviors that take the focus off the physical sensations. Some activities include initiating conversation with a nearby person or engaging in physical activity (e.g., walking, gardening, or housecleaning). Performing simple repetitive activities such as snapping a rubber band against the wrist, counting backward from 100 by 3s, or counting objects along the roadway might also deter an attack.

Reframing

is a cognitive technique that can change the way a situation, event, or person is viewed and reduce the impact of anxiety-provoking thoughts. People with anxiety disorders often view themselves negatively and use "should statements" and "negative labels." Should statements lead to rigid rules and unrealistic expectations? By encouraging patients to avoid the use of should statements and reframe their views, they can change their beliefs to be more realistic. For example, if a patient says, "I should be a better parent" or "I'm a useless failure," the nurse could ask the person to identify the positive aspects of parenting and other successes.

Positive Self-Talk

involves planning and rehearsing positive coping statements "This is only anxiety, and it will pass," "I can handle these symptoms," and "I'll get through this" are examples of positive self-talk. These types of positive statements can give the individual a focal point and reduce fear when panic symptoms begin. Handheld cards that offer positive statements can be carried in a purse or wallet so the person can retrieve them quickly when panic symptoms are felt

Panic control treatment

Exposure to panic-invoking sensations

Systemic desensitization

Gradual exposure to fear in a controlled environment

Implosive therapy

Images of anxiety-producing stimuli are shown and discussed in great detail

Flooding

Desensitizing of feared object by presenting it repeatedly until anxiety subsides

Exposure therapy

repeated exposure to actual or simulated anxiety inducing situation until anxiety subsides

Psychological trauma

is an emotional injury caused by an overwhelmingly stressful event that threatens one's survival and sense of security.

Resilience

is the capacity to withstand stress and catastrophe. It develops over time and is the culmination of multiple internal and external factors.

Posttraumatic stress disorder

occurs following exposure to an actual or threatened by traumatic event such as death, serious injury, and or sexual violence. Traumatic events include those that are directly experienced, witnessed, learned about from others, or repeated exposure to aversive events. Examples of traumatic events are violent personal assault, rape, military combat, natural disasters, terrorist attacks, being taken hostage, incarceration as a prisoner of war, torture, an automobile accident, or being diagnosed with a life-threatening illness.

Traumatic events

include those that are directly experienced, witnessed, learned about from others, or repeated exposure to adverse events.

emotional reaction

(strong agitation of feelings), and another resilient individual is hardly aware of a traumatic event. Although most stressful events do not lead to mental disorders, sometimes, emotional problems and mental disorders develop as the response to trauma.

intrusion

is defined as involuntary appearance of thoughts, memories, or dreams of traumatic events that cause psychological and sometimes physiologic distress.

Often the intrusive thoughts are associated with cues that symbolize or resemble the original event. Sometimes, the traumatic images, thoughts, or perceptions are reexperi-enced, known as flashbacks. Nightmares are common.

Intrusive symptoms also include dissociative reactions i.e., feeling or acting as if the event is reoccurring).

Sleeping is difficult. Terrifying flashbacks and nightmares often include fragments of traumatic events exactly as they happened. Many stimuli (e.g., loud noises, odors) associated with the trauma cause flashbacks and dreams.

Consequently, affected individuals avoid such stimuli

Dissociation

Mood and Cognition PTSD

often become more irritable with episodes of explosive anger, fear, guilt, or shame. Individuals with PTSD often have difficulty experiencing positive emotions such as happiness or love. Consequently, they become estranged from loved ones who become frustrated with their family member's unpredictable moods and lack of emotional connection. In PTSD, the thought process becomes distorted with exaggerated negative beliefs or expectations about oneself, others, and the world. They may believe that no one can be trusted or that they are terrible people

Physical Health Assessment PTSD

The assessment should focus not only on the physical problems but also on healthy aspects. For example, nutrition, exercise, and self-care, such as hobbies and leisure activities, may be the individual's strengths.