Module 5
Chapter 20: Crisis and Mass Disaster
Crisis: acute, time-limited occurrence experienced as overwhelming emotional reactions to..
-Stressful situational event
-Developmental event
-Societal event (mass disaster)
-Cultural event
-Perception of event
Intervention: nurse patient reactions, communications, etc. Everyone taxes different interventions
Prevalence and Comorbidity
Grow from crisis, helps do better
If not, can cause regression and health issues
Outcome depends on:
-Perception of the crisis
-Support system (including outside sources)
Factors that limit ability to cope
Mental illness, substance abuse, history of poor coping, physical health problems, limited social support, developmental changes
Theory
Starts with a theory and comes up with an assessment
-Erich Lindemann (1940)
-Gerald Caplan (1964)
-Joint commission on mental illness/health (1961)
-Aguilera/Messnick (1970)
-Roberts (2008_, 7 stages of crisis intervention
*Depression scales, MMSE, etc
“The straw that broke the camels back”
Types of Crisis
Maturational: during developmental stage, requires new coping skills. Example: marriage, new baby
Situational: crisis from any external source. Example: lose a loved one, lose job, move away to new place
Adventitious: not a common part of everyday life. Example: fire, flood, terrorism, crime of violence, shootings
NIMS: National Incident Management System
Keep things organized during chaos
Self-Care for Nurses: monitor thoughts and feelings, learn to recognize when self care is needed
Triage
Separation of those who need rapid med care from those who have minor injuries
Tag patients
Organization in disaster
Phases of a Crisis
increased anxiety confronted by conflict
anxiety escalates, trial and error
if fails, anxiety escalated to severe/panic
if not solved, anxiety can overwhelm, serious illness. Assess for suicidal thoughts
Patient Perception
Whatever is a crisis to them is considered a crisis
Separate your feelings from theirs
What has recently happened to affect reaction
Ask open-ended questions
Things can build up, doesn’t have to occur in the moment
Situational Support
Who can they go to when they have a problem?
Who do you live with, who do you trust?
Foundations of Crisis Intervention
Usually resolved within 4-6 weeks
Goal: return individual to pre-crisis state, or as close to it as possible
Functional levels: Higher, Same, Lower
In Crisis= state of disequilibrium
More vulnerable and open, early interventions=better prognosis
Intervention
Primary: promote mental health, reduce mental illness
Secondary: prevent prolonged anxiety
Tertiary: recovery, provide support
Safety Needs
Always assess MORE THAN ONCE, the potential for suicide and homicide
If yes, do they have a plan???
If plan, major evaluations must be done
CISD: Critical Incident Stress Debriefing
tertiary Intervention directed toward a group that has experienced a crisis. Make sense of tragedy and cope
Used to DEBRIEF
-Staff after patient suicide
-Staff after patient violence
-Crisis Hotline Volunteers
-School children and personnel after shooting
-Rescue and healthcare workers after terrorism/natural disaster
Phases of Debriefing
Introductory, Fact (what actually happened), Thought, Reaction, Symptoms, Teaching, Reentry
-Have to be able to address all of these things
Debriefing: how you cope, handle stress, ask questions, etc.
Everyone deals with crisis differently
Assess Coping SKills
Evaluate level of anxiety first, thoughts of suicide/homicide?
What makes you feel better?
At first, therapists direct the whole thing, but as patient recovers, they become more involved
Evaluation
Performed 4-8 weeks after initial interview
-Are you safe, secure?
-Can you use existing coping skills?
-Rely on support system?
-Current level of functioning
-Need continued therapeutic work?
Terms
-Terrorism: adventitious
-Mass Casualty Incident (MCI): adventitious
-NIMS: organization that controls the aftermath of disaster
-Triage: categorize patients
https://quizlet.com/877741816/ch-20-crisis-and-mass-disaster-flash-cards/
Chapter 21: Child, Partner, and Elder Abuse
Trusted figures are part of the picture of violence in our society
4 Abuse Categories: Emotional, Physical, Sexual, Neglect
Indicators for Family Violence
Recurrent ED visits, “accident prone”
s/s of high anxiety and chronic stress
Insomnia, hair loss, fatigue, etc.
Theory
DV is complex, no single theory
Child learns violence as a behavioral norm
Societal and Cultural Factors
Frustration-Aggression
Patriarchal: men have dominance
Psych Factors
Personality traits, substance abuse, “loss of control", narcissistic, h/o impulsive behavior
Child Abuse
When a child is harmed by someone
Physical, neglect, sexual, emotional
<4 y/o= most vulnerable
*CAPA
Deaths
80% < 4 y/o
Majority= < 1 y/o
Parents or siblings are most common perpetrators
Neglect: 59% of all cases
Sexual: 1 in 4 girls, 1 in 6 boys
Assessing the Child
Reassure that they done nothing wrong, don’t pressure to talk
Don’t react with shock, make child comfortable
Open ended questions
Characteristics of Abusive Parent
History of violence, neglect, etc as a child
Low-self esteem, poor coping, social isolation
Harsh punishments, violent temper, blames child, poor impulse control
Interview w Abuser (or suspected)
DOs
private interview, direct and honest, professional, attentive, inform about making referral to CPS
DONTs
“prove” accusations, display anger or disapproval, place blame, make judgements
Forensics
Provided by Law Enforcement Agencies
Follows state guidelines
Physical evidence of sexual abuse is evident
Keep accurate and detailed records of incident: verbatim statements, body map with descriptions, use of photograph per hospital protocol
Dx
Safety, injury, and risk for injury are all primary
Outcome: “physical abuse, sexual abuse, or neglect has ceased.”
Intimate Partner Violence (IPV)
Between current/ former partners
#1 cause of ED visits by women
US women: between 22-39%, worldwide: 69%
Leading cause in homelessness in women
Leading cause of injury related deaths during pregnancy; birth defects and infant deaths are frequent outcomes of abuse
Teen Dating Violence (TDV)
Between 25-33% adolescents report
25% high school and college women have been physically and sexually abused by partner
Instilling fear and wanting to have power, anger may turn physical
Women: 5-8 times more likely to be victimized
Affects children who witness this happen
Battered Partner
Doesn’t ask to be beaten, doesn’t enjoy it. Lives in terror
Powerlessness and Low self esteem
93% of women who kill partners have been beaten by them
Often subject of jealousy, psychologically destroyed
High risk for substance abuse, contemplates suicide and homicide
Characteristics
-Denial and Blame
-Emotional Abuse
-Control through Isolation
-Control through intimidation
-Control through economic abuse
-Control through power
*Violence is learned
*Often has alcohol and drug problem
*Tx isn’t highly effective for the abuser
Safety Plans
Code words with kids, family, and friends
Tell neighbors
Pack bag and hide it, include extra meds, documents, prepaid phone, etc.
Cycle of Violence
Tension Building
Acute Battering (Serious)
Honeymoon
Assessment
x-ray, neuro assessment, physical history
Pregnancy, std, trauma
-Internal Injuries
-Broken Bones
Burns, bruises, scars, PTSD
Document everything
Provide Resources
WHY abused partners stay
-No financial support
-No support system
-Afraid to be alone
-Depressed
-Low self-esteem
-Feels deserving of the abuse
Elder Abuse
6% mistreated annually
70-88% are never reported
*APS: Adult protective Services, deemed unable to care for self
5 kinds of Abuse: Physical, Emotional, Financial, Neglect, Sexual
80 y/o and up: 2-3 times more likely to suffer
Victims 3x more likely to die
Majority: white, female
Abuser
“under extreme stress”
Middle aged child of victim
Financially dependent on victim
Substance abuse
https://quizlet.com/877753560/ch-21-child-partner-and-elder-violence-flash-cards
Chapter 22: Sexual Violence
Sexual Assault: act of violence, power, hate, but NOT SEX
Sexual Violence is related to teen pregnancy, STD, and HIV
Mental Health Issues More prevalent in victims
SV Categories
-Completed/attempted forced penetration, with or without drugs and alcohol
-Completed/attempted acts in which a victim is made to penetrate someone else, with or without drugs and alcohol
-Non-physically forced penetration after pressure
Verbal Pressure, Intimidation, Misuse of authority
-Unwanted sexual contact
-Unwanted non contact sexual experiences
Survivor and Victim
-Survivor: Individual who has experienced a sexual assault, worked through issues
-Victim: Experienced a sexual assault and can become a survivor with time, intervention, and counseling
RAPE
Date rape: form of acquaintance rape, but in the case of date rape, the “victim agreed to spend time with the attacker.”
Still rape
Reporting is not mandated unless involves minor or older adults
Date-Rape Drugs
-Gamma hydroxybutyric acid (GHB): affects CNS
-Rohypnol (flunitrazepam): patent benzo, “forget” drug; roofies
-Ketamine: hallucinogenic agent related to PCP
Manmade: MDMA, MDA, ecstacy, molly, etc.
MDA lasts longer than MDMA
-Most women do not report because they cannot remember everything that happened
Most common to facilitate rape: alcohol
Children: Abuse or Incest
1 in 4 girls and 1 in 6 boys are sexually molested by 18 years old
75% perpetrated by family members
30% between 4 and 7 years old
Also includes:
-Coercing children to touch molester
-Showing children pornographic material
-Initiating inappropriate conversations
Youth
-High school: 8% report being forced to have sex
-Young adults: 20-25% of college women experience attempted/completed rape
90% will know attackers
16-19 years old experience highest rate of SV
Majority is date rape
Alcohol and other drugs are often involved, especially in gang rape (2+ attackers)
*Prisons and Military have the greatest male rapes
Vulnerabilities
-Gender: women have higher vulnerability, both are more vulnerable if handicapped
-Age: 16-19 have higher SV rate, 8-12 in children
-History: raped before 18= 2-3 times more likely to be assaulted as adults
-Drug and Alcohol, High risk sexual behaviors
-Ethnicity: Native Americans = 1 in 3 chance
ED for victims
Do not leave patient alone
Have privacy
Be priority in triage
Thorough exam
Objective, Subjective Data, and Body Map
Forensics
“Rape Kit”
Urine sample if date rape drugs are suspected
Right to refuse exams
Consent forms must be signed
Documentation
Instead of alleged, use reported
Instead of refused, use declined
Instead of intercourse, use penetration
Instead of :in no acute distress” , describe the behavior
Rape-Trauma Syndrome
variant of PTSD.
Acute phase: shock, numbness, disbelief
Long-term phase: prepare patient for this phase
PTSD
Re-experiencing, Avoidance Behaviors, Social Withdrawal, Fears and Phobias, Nightmares, trouble sleeping
Pharmacology
Short term tx with benzos
SSRIs for PTSD
Psychotherapy
Crisis Counseling, Group Therapy, SART, Safe Houses, Assess within 24-48 hours by phone
Emergency Department
Care for physical injuries
Offer emergency contraceptives, 5% result in pregnancy
Prophylactic Tx (prevent diseases)
Test for HIV, Hep B, and Syphilis
Abrasions: immunize for tetanus if 5 years passed
Compassionate Care
*Ability to have comfortable and enjoyable sec will return, make take years to happen
Therapy for Rapists
Most do not acknowledge need for change, No tx or program has bee found totally effective
https://quizlet.com/877762276/ch-22-sexual-violence-flash-cards/