Crisis Management and Intervention Notes

Crisis

Marjorie Shragher MSN RN PCCN

Learning Outcomes

  • Define a crisis
  • Distinguish between the four phases of a crisis
  • Differentiate the types of crisis that occur in people's life
  • Assess early signs of anger and aggression in the inpatient unit and apply de-escalation techniques

Learning Outcomes

  • Assess and apply the phases of crisis intervention
  • Identify the nurse's role in crisis and formulate a plan of care
  • Understand the nursing process of a disaster and apply the nursing process to the victims of a disaster
  • Evaluate the effectiveness of interventions for a crisis

What is a Crisis

  • Sudden
  • Disturbs homeostasis
  • Normal coping not working

Characteristics of Crisis

  • Can occur without psychopathy
  • Identifiable event
  • Personal
  • Acute
  • Potential – Grow – Deteriorate
  • Helpless
  • Anxious
  • Overwhelmed
  • Maladaptive

Phase of a Crisis Development

  • Phase 1 – Exposure to a stressor
  • Phase 2 – Previous problem solving not working
  • Phase 3 – Use of all resources
  • Phase 4 – No resolution
  • Panic

Levels of Anxiety

  • Mild
    • Normal
    • Increase perception of reality
    • Identifiable cause
    • Mild symptom
    • Fidget
  • Moderate
    • Mild escalates
    • Slight decrease in reality perception
    • Problem solve hampered
    • Concentration issues
    • Headache
    • Benefits from direction

Levels of Anxiety

  • Severe
    • Distorted perception
    • No learning or problem solving
    • Not functioning
    • Confusion, loud rapid speech, tachy, fast breathing
    • No direction
  • Panic levels
    • Behavior disturbed
    • Can lose touch with reality
    • Extreme fright
    • Hyperactivity of flight
    • ?immobility
    • Shakiness, no sleep delusion, tachy, dilated pupils

Crisis: Finding Balance

  • Perception of event
  • Situational supports
  • Coping mechanisms

Crises: Types

  • Class 1: Dispositional crisis – Acute response to external stressor
  • Class 2: Crises of Anticipated Life Transitions – Normal life cycle transition – Individual feel lack of control
  • Class 3: Crises resulting in traumatic stress – Unexpected external event – No control – overwhelmed

Crises: Types

  • Class 4: Maturational or Developmental Crisis – Failed to master developmental task associated with transition in life cycle
  • Class 5: Crisis reflecting psychopathology – Crisis triggered by a preexisting mental health disorder
  • Class 6: Psychiatric emergencies – Impaired functioning – Incompetent

Crisis: Inpatient Unit

  • Crisis can happen inpatient
  • Anger
    • Secondary emotion
    • Response to grief, depression, anxiety, fear or post trauma stress
  • Aggression
    • Classified mild to severe
    • Intent
    • Goal directed
    • reactive versus proactive

Crisis: Inpatient Unit

  • Anger
    • Clenched fists
    • Low pitched verbalization; clenched teeth
    • Shouting
    • Eye contact: none or intense
    • Easily offended
    • Defensive
    • Passive aggressive
    • No control
    • Tense
    • Flushed
    • Face looks angry
  • Aggression
    • Pacing
    • Body language threatening
    • Threats
    • Loud
    • Overreaction
    • Panic
    • Suspicious
    • Destructive
    • physical

Assessment of Risk factors

  • Prevention is key
    • History of violence
    • Diagnosis
    • Behavior
  • Prodromal syndrome
    • Anxiety and Tension
    • Verbal abuse and profanity
    • Increasing hyperactivity

Assessment/Analyzing Cues

Look for:

  • Confusion
  • Irritability
  • Boisterousness
  • Physical threats
  • Verbal threats

De-escalation Techniques

  • Calm Voice
  • Helpful attitude
  • Identify consequences
  • Non-threatening posture
  • Allow phone call
  • Offer food and drink
  • Decrease waiting time
  • Positive activity e.g. Quiet room or soft music

De-escalation Techniques

  • Walk
  • Reduce demands
  • Group participation
  • Relaxation techniques
  • Express concerns
  • Reduce stimuli
  • Redirect, set limits
  • Time out, quiet time, open seclusion
  • PRN Med

Medication

  • Antianxiety agents
    • Lorazepam (Ativan)
  • Antipsychotics
    • Haloperidol (Haldol), Ziprasidone (Geodon) Olanzapine (Zyprexa)
  • Anticholinergic or antihistamine Benztropine (Cogentin) or Diphenhydramine (Benadryl)
  • The IM or PO combination of choice is Haldol, Benadryl and Ativan

Medication

  • Lorazepam
    • Benzodiazepine
    • Enhance the inhibitory effect of GABA on the CNS
      • CNS depression
        Avoid if pregnant, or sleep apnea, respiratory depression, glaucoma

Medication

  • Haloperidol
    • First generation antipsychotics
    • Pharm class: butyrophenones
    • Alters the effect of dopamine in the CNS, anticholinergic effects, alpha-adrenergic blocking activities

Medication

  • Diphenhydramine (Benadryl)
    • Antagonizes the effects of histamines at H1 receptor sites,
    • CNS Depression
    • anticholinergic effects

Time Out

  • After De-escalation
  • Unlocked seclusion
  • Locked seclusion
  • Observation
  • Assessment
  • Debrief Staff

Client Problems

  • Ineffective coping – negative role modeling and dysfunctional family system aeb client’s behavior
  • Risk for violence – inadequate anger management

Outcomes

  • Client
    • Recognizes anger and talk about feeling
    • Takes responsibility for feelings
    • Demonstrates self control
    • Demonstrates ability to diffuse anger
    • Uses tension in a constructive manner
    • Does not harm self or others
    • Problems solves instead of resorting to violence

Nursing Interventions/Implementation

  • Rapid Assessment
  • Safety a priority
  • Use techniques to deal with anxiety
  • Coping mechanisms
  • Relaxation techniques
  • Support Services
  • Follow up

Crisis Intervention

  • Therapeutic goal
    • Psychological resolution of the individual’s immediate crisis
    • Restoration to at least the level of functioning that existed before the crisis period

Crisis intervention: Phases 1: Assessment

  • Trigger
  • When it occurred
  • Assess physical and mental status
  • Any previous history with stressors
  • How they coped in the past
  • What was results of coping methods
  • Assess suicidal/homicidal
  • Assess support systems
  • Assess problem solving abilities
  • Self-evaluation of individual
  • Substance abuse

Crisis intervention: Phase 2: Planning Therapeutic Intervention

  • The nurses
  • Nursing actions
  • Type of crisis
  • Individual strength and support
  • Choices
  • Resources
  • Goals related to crisis resolution

Crisis intervention: Phase 3 Intervention

  • Reality-oriented approach – Here and now
  • Remain with the individual in panic anxiety
  • Establish a relationship
    • Active listening
    • Attend to immediate needs
  • Promote verbalization of feelings
  • Set limits on behaviors
  • Clarify problem
  • Trigger to event
  • Acknowledge feelings

Crisis intervention: Phase 3 Intervention

  • Guide with problem solving
    • Confront factors causing crisis
    • Encourage discussion of change
    • Discuss if change is realistic
    • If change is unrealistic, encourage exploring feelings
    • Discuss alternative coping mechanism
    • Weigh the risk and benefits of alternatives

Crisis intervention: Phase 3 Intervention

  • Assist with coping strategies that would be helpful in the future
  • Identify external support systems

Crisis intervention: Phase 4: Evaluation of Crisis Resolution and Anticipatory Planning

  • Look at:
    • Positive behavioral changes?
    • Adaptive coping mechanisms/effectiveness?
    • Grown from the experience
    • Plan of action for the future

Disaster

  • Event
  • Overwhelms local resources
  • Threatens function and safety of the community
  • Violent disaster
  • Property/life devastation
  • Feelings:
    • Damaged feeling of safety/wellbeing
    • Degrees of emotional trauma

Disaster

  • Assessment
  • Large scale trauma, natural disasters
  • Individuals respond differently
  • Grieving is natural
  • More extreme if
    • directly experienced
    • witnessed

Response to Disaster

  • Adults/ Adolescents
    • Anger
    • Disbelief
    • Sadness
    • Anxiety
    • Fear
    • Irritability
    • Arousal
    • Numbing
    • Increase in substance use
  • Children
    • Separation anxiety
    • Regressive behavior
    • Nightmares
    • Withdrawn/hyperactive
  • Older children
    • Difficulty concentrating
    • Somatic complaints
    • Sleep disturbances
    • Safety concerns

Client Problems

  • Risk for injury
  • Risk for Infection
  • Anxiety (Panic)
  • Fear
  • Spiritual Distress
  • Risk for post trauma syndrome
  • Ineffective community coping

Outcomes

  • Demonstrates behavior to protect self from further injury
  • Identifies interventions to prevent/reduce risk of infection
  • Is free of infection/physical injury
  • Expresses beliefs & values about spiritual issues
  • Demonstrates ability to deal with emotional reactions in an appropriate manner

Outcomes

Demonstrates an increase in activities to
improve community functioning

Interventions/Implementation

  • Maintaining anxiety at a manageable level
  • Encouraging free expression of beliefs and values about spiritual issues
  • Assistance to deal with emotional reactions in an individually appropriate manner
  • Promotion of activities to improve community functioning
  • Safety
  • Support Services

References

  • ATI. (2023). Content Mastery Series Review Module: RN Pharmacology for Nursing (9th ed.). Assessment Technology Institute.
  • ATI . (2023). RN Mental Health Nursing: Content Mastery Series Review Module (12th ed.). Assessment Technologies Institute .
  • Townsend, M. C. (2023). Essentials of Psychiatric Mental Health Nursing, Concepts of Care in Evidence Based Practice (9th ed.). Philadelphia, PA: F.A. Davis.