Chapter 17: Trauma and stress are related disorders, crisis and response to disaster Flashcards

1
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The evolution of the concept of stress

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From the Latin word meaning to draw tight. It was used to denote force pressure or strain. The earliest 20th century had a shift away from the view of the body as machine.

Stress as a physiological response
Stress as a response to changing environment conditions. Homeostasis with used to describe the body’s ability to maintain stable internal Environment. Environmental changes are perceived as threats to the personal integrity or safety and signal a compensatory response mediated by the sympathic branch of the autonomic nervous system. Strong emotions like fear and anger or fundamental to the stress response. Leader dubbed the fight or flight response. The General adaption syndrome theory differentiate stress which is a nonspecific response of the body to any demand placed on it, from stressors which are events that initiate the response. Stressors can be physical like infection, physiological like trauma, or social like lack of social support, and can be short or long term. First is the alarm reaction stage during which all body systems respond in a coordinated effort to mediate the stressor, then stage of resistance were efforts to adopt continue then stage of exhaustion where the individuals resources deplete and exhaustion or death in ensue.
Criticism included that many norepinephrine responses are not general but very specific. That stressors do not necessarily produce the same response in every individual. That a stressor for one person may not be a stressor for another.

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2
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The evolution of stress, stress as a stimulus

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Researchers became interested in the physiological and emotional aspects of stress. Life changes or events where the stimuli, i.e. stressors, that evoked the stress response. Explored associations between significant life events such as marriage birth divorce and death, and stress.
Major problem is that stress provoking stimuli can be identified only in retrospect. It does not take into consideration the meaning the individual assigned to an item, individual coping abilities, or the implication of chronic or recurrent events.

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3
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The evolution of stress, stress as a person environment transaction

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Stress is the appraisal of an event (the subjective evaluation of an event or situation) that is critical to the stress experience. Stress resulted from a perceived in balance between individuals resources and the demands placed on them. Depends on how a stressor is appraised in relation to the persons resources for coping with it. It is neither an environmental stimulus, a characteristic of the person, nor response, but a relationship between demands and the power to deal with them without unreasonable or destructive costs.

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4
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The evolution of stress, cognitive appraisal

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Cognitive appraisal describes the process by which individuals examined the demands and constraints of a situation in relation to their own personal and network resources. Two levels primary where individuals evaluate the situation and determine whether they are in danger or under threat. If yes they go to the secondary appraisal where the individual considers the options for dealing with the situation. Stress is the perception of threat or harm (1st appraisal) for which an individual has no effective response. (2nd appraisal)

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5
Q

New understandings of the stress and the stress response

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Concept of stress criticized for his lack of Percision and specificity. Stress is probably best thought of as a generic, non-technical term, analogous to disease or to addiction.

Allostasis
Means maintaining stability through change. It reflects the notion that different environmental circumstances or conditions require different set points. Example ideal blood pressure is different when asleep versus exercising. Allostatic load Refers to the cumulative negative effects on the body of continuously having to adapt to changing environmental conditions and psychosocial challenges. It is the sum total of the where in tear on the body that accumulates from the constant effort required to maintain normal body rhythms in the face of changing environmental conditions, the challenges of life and adverse psychological consequences of harmful lifestyle choices such as inactivity alcohol and smoking

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6
Q

New views on responses to stress

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The freeze hide response
The tendency to produce a passive response to stress. Natural selection supports the development of different traits of pipe preserving genes for high aggression in hawks and low aggression in doves within a population and between and across genders within the species

Tend and befriend
Males and females respond differently to stress. Females exhibit tend and befriend. It has advantages and reflects the inclination of females towards affiliation, cooperation and caretaking. Tending involves nurturant activities designed to protect the south and offspring that promotes safety and reduce his distress. Befriending is the creation and maintenance of social networks that may aid in this process. Involves oxytocin which has a role in a range of social behaviours such as social memory, attachment, bonding, trust and aggression

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7
Q

Physiologic stress responses

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Dangerous situation triggers an automatic total body response where the brain receives inputs and coordinates physiologic and behavioural responses that enhance survival. Begins in the central nervous system but involves all body systems. Hypothalamus is responsible for maintaining internal environment and initiating the body stress response. Hypothalamus activates the sympathic branch of the ANS which stimulates the adrenal medulla to secrete catecholamines and mediates vigilance arousal activation and mobilization. Also secretes corticotropin releasing hormone to signal the interior Pituitary gland To release adrenocorticotropic hormone into the systemic circulation which stimulates the adrenal cortex to secrete cortisol. Hypothalamus excites locus coeruleus in the brain stem to increase norepinephrine in the CNS. Hypothalamus also synthesizes a VP/ADH which increases blood pressure by causing Vasco construction. If the stressor It’s prolonged the body must make long term metabolic adjustments that ensure a sufficient supply of energy. Cortisol is essential to sustain the stress response since it mobilizes lipid stores and skeletal protein for energy. Short term stressors use glucose and skeletal muscle stores

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8
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Social support and stress

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Social support
Social support is resources provided to us by others. It moderates the adverse effects of stress. Two categories. Functional support is the quality of the relationship and the degree to which an individual believes that help is available. Structural support is the quantitative characteristics of a social support network such as size and number of interconnections. Not all interpersonal interactions are supportive and someone can have a large complex social network but little social support. Dissupport derives from the observation that some relationships can be harmful stressful and damaging to an individual‘s self-esteem.

social network
A social network can be a resource which in Hanses the ability to cope with change and influence the course of illness. Contacts are Categorized into three levels. Level 16 to 12 people with whom the person has intimate contact. Level 230 to 40 people whom the person sees regularly. Level III the several hundred people with whom an individual has direct contact but incidental contact in the course of his or her day-to-day life. And ideal network is dense and interconnected. Intensity is the degree or closeness of a relationship. Intense relationships can restrict a persons opportunity to act interact with other network members but without Intense relationships people lack intimacy. Reciprocity is the extent to which there is a balanced give-and-take in a relationship. Members must provide and receive support aid services and information from each other

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9
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Emotional response to stress

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There’s still a debate between emotion and cognition and which one is primary that gives rise to the other. Emotion is defined as a complex organized psychological reaction consisting of cognitive appraisals, action impulses and patterned somatic reactions. 15 basic emotions, each of which is elicited in response to a particular perception of what a situation or an event means to an individual. Example anxiety is typically associated with the perception of a non-specific threat or some uncertainty.

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10
Q

Coping

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Is an individuals constantly changing cognitive and behavioural efforts to manage specific external or internal demands that are appraised as taxing or exceeding the individuals resources. It has three principles. 1 it continuously changes over the course of an encounter, 2 it must be assessed independently of its outcomes, 3 it consists of what an individual thinks and does in response to the perceived demands of a situation. It reflects an individual’s continued reappraisal of the person environment relationship in light of changing conditions. If people see their efforts as ineffective they can feel helpless and overwhelmed. Positive coping leads to adoption. The inability to cope leads to maladaption and contributes to Ill health.
Two general approaches to coping. Problem focussed coping maybe inner or outer directed. Outer directed strategies attempt to illuminate or alter a situation or another’s behaviour well inner directed strategies in at altering one’s own beliefs attitudes skills and resources. Emotion focussed coping six to manage a persons emotional distress through exercise prayer meditation expressing emotion and talking to friends.

Coping involves continuous reevaluation or reappraisal. Reappraisal incorporates feedback about the effects of coping and allows for continual processing of new information.

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11
Q

Stress and illness

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Stressors such as isolation, crowding, exposure to predators, electrical shock can increase morbidity and mortality from tumours and infections. Acute exam stress is linked to reduction in natural killer cells and increased activation of latent viruses. Long-term caregivers can have a reduced immune function.
The stress diathesis model proposes that pre-existing genetic, biologic and psychological vulnerabilities interact with negative or stressful life events to cause illness. Predicts an inverse relationship between vulnerability and stress. The more vulnerable the individual the smaller the stressor required to cause illness. There is a high genetic component to nervousness, emotionality, neuroticism and being high strong.

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12
Q

Trauma and stress related disorders

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Modern psychiatry did not officially recognize extreme stress until 1980 when PTSD appeared in the DSM. 14 years later acute stress disorder was added. In the latest version these were removed from the list of anxietyDisorders and placed in a new category called trauma and stress are related disorders. A traumatic stress or is considered to be any event or events that may cause or threatened death, serious injury, or sexual violence to an individual, a close family member, or a close friend.

Acute Stress Disorder
ASD diagnosis is when an individual has experienced, personally or through witnessing others experiences, a severe threat in which life or injury is or appears to be at stake. This must’ve been continue to affect the individuals mental health status.

Post traumatic stress disorder
PTSD is diagnosed if an individual experiences or witnesses unauthentic, severe threat of death or injury to self or others and this experience then affects the individuals mental health in specific ways. Reliving the Traumatic Experience through intrusive thoughts, avoidance of memories of trauma and inability to concentrate, altered arousal levels, negative effects on sleep. The most common types of threats related to PTSD include witnessing the killing or injury of others and being in a life-threatening accident. Factors that predict the development of PTSD include being female, type and severity of the trauma, past trauma, availability of support at the time of the stressful event. Females have less exposure than males to war like trauma but greater experience of sexual assault. Children especially those under 10 or less likely to experience PTSD after trauma than our adults. Treatments for PTSD include cognitive behavioural therapy, psychotherapy, Eye movement desensitization and repossessing EMDR, and medication

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13
Q

Intergenerational transmission of stress, trauma and resilience

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The process by which the effects of trauma and stress experienced in one generation can be transmitted to the subsequent generations. Adverse experiences in childhood may influence the risk for various health and social outcomes in offspring. Experiences of parents are linked with the way children appraise certain situations, how the appraise stressful experiences and their ability to contend with these stressors. These individuals may be at increased risk of further stressor encounters, increased psychological and neural chemical reactivity to stressors and the promotion of poor mental and physical health outcomes.
These events do not occur in isolation since there are indirect factors that might contribute such as sociocultural environment, physical environment, historical influences and government policies. These factors may result in an impaired ability to provide an adequate early childhood environment which might result in the Recapitulation of the events that occurred in the preceding generation.

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14
Q

Collective trauma and historical trauma

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Significant collective experiences and outcomes can arise when a whole group of people encounter a traumatizing or adverse experience. Collective trauma refers to instances in which a significant portion of any given social group, based on political racial religious cultural or other factors, are collectively exposed to our Trumatic event. Can be random such as a single natural disaster or purposely conducted by one group to another. Community level changes in the aftermath of trauma include erosion of basic trust, collective silence, deterioration in social norms, morals and values and poor leader ship.
Historical trauma highlights the process by which the consequences of multiple collectively experienced adversities experienced by group overtime maybe calmative and be carried forward to subsequent generations if they outweigh contextual and group level resilience factors. Historical trauma has been suggested and shown to be a contributing factor in relation to the high prevalence of certain psychosocial issues faced by first nations. Those with a parent or grandparent who attended residential schools were at greater risk for psychological distress and suicide attempts.

Responses to collective and historical trauma
Collective approaches will often have the most benefit from a public health perspective when resources are limited. Community level mental health and psychosocial support interventions have been shown to help communities affected by disasters. Community-based approaches let interventions reach a larger target population and take preventative and promotional activities. Individuals and families can recover and cope when communities become functional, activating healing mechanisms. Approaches that were useful include creating public awareness, training of grassroot workers, encouraging traditional practises and rituals, promoting positive family and community relationships, rehabilitating and networking with other organizations.

Definitions
Collective trauma occurs when a traumatic event is experienced by significant portion of a given social group, it can have long-term consequences for the social group beyond its additive effect on individuals such as social norms, dynamics, functioning and structure of the group may be modified
Historical trauma is the process by which a social group is affected by the consequences of multiple collectively experienced adversities across time that way group resiliency factors, become cumulative, and are carried forward to subsequent generations that the trauma may be considered as part of a single trajectory.

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15
Q

Trauma informed care

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Is an approach to all clients that is based on knowledge of trauma and its affects with policies and practises incorporating principles of safety, choice and control as well as compassion, collaboration and trustworthiness. Implicit discrimination such as bias, attitudes and beliefs can influence provider behaviour in healthcare settings. There is a growing attention to the need for cultural competence in trauma informed healthcare. We also need cultural safety and cultural humility. Cultural humility is an active and continual engagement in a process of self critique, reflection, acknowledgment, rectification of in balance of power and respectful community partnership in the provision of care. Cultural safety is an examination of colonial, interpersonal and professional power relationships reflected through racism and discrimination.

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16
Q

Nursing care of individuals affected by stress

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The goal is to illuminate or moderate distress or, to reduce an towered affects of the stress response and to facilitate the maintenance or development of positive coping skills. The goals of care for individuals who are at high risk for stress or are experiencing significant life changes are to recognize the potential for stress and to strengthen or develop positive coping skills. It’s important to educate clients about human stress responses in order to normalize body, emotional and social response.

17
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Biological domain

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Biologic assessment
This information comes from health history, physical examination and diagnosis testing. Nurses should pay attention to sympathic and person pathic arousal, alterations in vegetative functions such as appetite sleep arousal and sexual activity, chronic illnesses or conditions with a strong stress component, evidence of immune system suppression, physical appearance such as grooming hygiene muscle tension anxiety or depression, and alterations in activity or exercise patterns. Biologic assessment of stress considers pharmacologic agents including alcohol tobacco illicit drugs prescription and nonprescription medications. Reliance on these can become a secondary stressor and contribute to maladaption.

Interventions for the biologic domain
Reestablishing regular routines for activities of daily living such as eating and sleeping. Ensuring adequate nutrition and sleep. Exercise can reduce the emotional and behavioural responses to stress. Activities such as yoga, meditation, deep breathing and progressive muscle relaxant can help. Health teaching in areas such as nutrition sleep hygiene and medication management can also help

18
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Psychological domain

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Psychological assessment
Nurses should observe behavioural and affective in Decatur‘s of stress such as energy level and general presentation. Explore reports of recent changes in mood or current emotional distress. Note alterations or impairment in mental status such as self-deprecatory thoughts and suicide. Explored the individuals appraisal of significant life events such as loss sexual abuse or vehicleAccidents. Ask about alterations in day-to-day function or inability to fulfil responsibilities. Explored the individuals current resources and effectiveness of usual coping strategies

Interventions for the psychological domain
Interventions include cognitive behavioural interventions, psycho educational interventions, relaxation therapy and assertiveness training

19
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Social domain

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Social assessment
The ability to make healthy life changes Is strongly influenced by one social support system. Nurses should look for the following information. Size and extent of the network both relative a non-relatives and the length and quality of the relationship. Function the network services such as intimacy and social integration. degree of reciprocity between the individual and others in the network. degree of interconnectedness among network members.

Interventions for the social domain
Interventions that facilitate social functioning and promote the health and welfare of the social network members. Educating the family regarding the clients disorders and their support of involvement can help. The family and individual members may also require support including respite. Family therapy might help.

20
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Spiritual domain

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Crisis can lead to acute questioning about one’s life choices and situations, one’s relationships and the meaning of one’s existence. Nurses must refrain from providing their own answers to questions of meaning rather through listening they need to provide support. Thoughtful questions may be helpful in understanding the clients perspective. Rituals sacraments group prayers and actions on beliefs regarding Services and helping others can restore a sense of stability and comfort for those who feel I need to return to their faith after a natural disaster. Spirituality can positively influence the response to disaster. Altruistic behaviours on the part of community leaders religious faith and spirituality or factors that positively affected the early coping of survivors.

21
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Evaluation and treatment outcomes

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Evaluation is guided by treatment goals established in the plan of care. Girls can relate to improved health well-being and social function. They may be goals for the family and other members of the social network. Family outcomes may relate to improve communication or social support. Social network outcomes focus on strengthening the social network and improving its function

22
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Crisis

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A crisis response occurs when an individual encounters an obstacle or problems that may affect his or her life goals and that cannot be solved by customarily problem-solving methods. It is acute, is time-limited and maybe developmental, situational or interpersonal in nature.
Linderman described grief as processing through three stages. Shock and disbelief, acute morning and resolution. You expanded this view to crisis we are changes associated with these events cause emotional strain and require individuals to adapt to a new reality. These adaptive efforts either lead to mastery or impaired functioning. Most individuals achieve resolution to the crisis without professional help within 4 to 6 weeks.

23
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Types of crises

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Situational crisis
A situational crisis is an event that overwhelms and individuals coping resources and upsets their equilibrium. Example includes illness, death of a loved one, divorce, job loss.

Developmental crisis
Demands from the social environment exert pressure on an individual to move onto the next developmental stage and that a failure to meet these new expectations precipitates a developmental crisis. Successful resolution of this crisis is necessary for movement into the next stage. These crises are unexpected part of maturation and or at times during which individuals acquire new skills and resources. This concept is useful for describing unfavourable person environment relationships that relate to maturational events such as leaving home for the first time, completing school or the birth of a child

24
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Crisis or not? The effects of balancing factors

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Three balancing factors. Perception of the event, available situational supports, coping mechanisms. Successful resolution of a crisis is more likely if an individual has a realistic view of the situation, adequate supports and effective coping mechanisms.

25
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Nursing care of individuals experiencing crisis

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Crisis intervention
Crisis intervention is the provision of emergency psychological care to assist victims in returning to an adaptive level of functioning and to prevent or moderate the potentially negative affects of psychological trauma.
1) Early intervention. Inability to resolve a crisis in a timely manner renders those affected at higher risk for long-term health problems. Crisis teams provide telephone triage and counselling but my travel to the scene of the crisis.
2) Stabilization. The goal of the crisis intervention is to prevent the situation from worsening. Stabilization involves mobilizing resources and support networks with the aim of minimizing harm and restoring order or routine
3) Facilitating understanding. Helping individuals develop an accurate understanding of the situation and it’s possible consequences. Involves listening to the individuals accounts and helping them identify and articulate their feelings.
4) Focussing on problem-solving. Identification and prioritization of immediate problems is the primary task. Interventions focussed on assisting those involved to find short term solutions
5) Encourage self-reliance. Supporting individuals to participate in identifying and solving problems facilitates the return to independent functioning and the development of a sense of mastery

Telephone help lines
Staffed by mental health professionals or train volunteers which offer support for problems such as child abuse, suicide and family stress.

Short stay hospitalization and community based emergency housing
Medications assessed or stabilized, or require other health services. Community-based emergency housing such as shelters for children and youth, shelters for victims of domestic violence and short and long-term accommodations for individuals with serious mental illnesses are often available. These provide users with food, a place to stay, emotional support and referrals to other community services

26
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Response to disaster

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A disaster is a social phenomenon that occurs when a hazard, originating in the Geo physical or biological environment or as a result of an intentional or malicious human action, exceeds the communities ability to cope.
Disasters are sudden severe social phenomena. They have far-reaching effects and can cause extensive and sustain social and mental health problems. The Canadian disaster database contains Information on disasters that have occurred since 1900 that directly affected Canadians. They are categorized as natural, conflict or technology. Disaster management needs to be intersectional, be community-based and involved planning, mitigation, response and recovery.

27
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Emergency preparedness and response

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Role of the United Nations
Rule is to work with nations to reduce natural hazards and their impact. Involves analyzing and decreasing causal factors of disaster by decreasing exposure, reducing variability and increasing resiliency to hazards, improving preparation and early warning abilities and identifying wise approaches to sustaining the environment and usage of land and water. Nurses around the globe have a role in enhancing health infrastructure resilience and preparedness as well as in the promotion of gender equitable and universally accessible disaster preparedness

Role of the government
Federal provincial governments can help communities to mitigate and prepare for disaster and to assist them during such a event. Federal government mobilize resources through public safety and preparedness Canada when assistance is needed for more than one province is affected. Public safety Canada is responsible for national policy. Public Health agency has information concerning responses to chemical, biological, radiologic and nuclear threats. Health Canada is responsible for providing emergency healthcare to first nations, for working to decrease the adverse effects of disaster and the coordinated response to a nuclear or radiologic emergency. Provincial governments are responsible for policies and disaster plans and can be found on their website. Canada is a member of the international initiative for mental health leader ship and assists other nations in times of disaster

Role of nurses
Nurses play a key role across all phases such as planning mitigation response and recovery. Nurses have a duty to provide care during a disaster or pandemic. There are circumstances when it is acceptable for the nurse to withdraw care such as unreasonable burdens. Example the SARS outbreak 43% of the cases were healthcare workers. Nurses should have the basic knowledge and skills required in disaster response and public health emergencies, promote preparedness among their community and within the organization in which they practice, and be proactive and enhancing their professional competence in this area such as preparation drills, disaster exercises.

Role of individuals and families
Public safety Canada has a get prepared initiative to prepare for the first three days following a disaster. Three components. No the risks and get prepared, make an emergency plan, and get an emergency kit. Resources are available for free

28
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Phases of disaster

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Preparedness, response, recovery, mitigation. Critical factors of disaster that can potentially shape aftermath reactions include causation natural or human, degree of personal impact, size and scope, visible impact/low point, probability of reoccurrence. When human impact causes a disaster such as bombing the stress reaction is greater. High exposure to a disaster or intimate personal loss will cause a more intense impact. An entire community destroyed will have more negative and lasting impact. Toxic spills and nuclear accidents have no clear it’s over point and chronic stress fear and anxiety can continue for years.
Effects of a disaster our greatest when two of the following are present. Extreme and widespread property damage. Serious and ongoing finance problems for the community. Human intent was the cause. High prevalence of trauma: injuries, loss of life.

29
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Response to mental health and illness in a disaster

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Social cohesion in community increases resilience to disaster. Every day cooperation of community members is crucial to recovery. It’s important to keep people in their normal groups if relocation is necessary. Key response is to provide accurate, timely into information that allows informed action. There is mandatory broadcaster participation regarding disaster in Canada. Information after disaster should be brief, basic and focussed on promoting coping among survivors

Psychological first aids
Psychological first aid involves intervention with the purpose of immediate relief of distress in the prevention of pathologic sequelae and can be performed by prepared non-professionals. Competency domains are establishing rapport, stabilization at initial contact, performing screening and assessment, interviewing in acute distress and fostering coping, triage for immediate or delayed care, referring/advocating for those requiring more intensive care and being self-aware and self caring. PFA involves promoting a sense of safety, calming, sense of self and community efficacy, connectedness and hope.

30
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Vulnerable populations in disaster

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People who are particularly at risk in a disaster me include those with communication difficulties such as people who don’t speak the language, those who are physically impaired either visually hearing mobility, those who are cognitive glee or psychologically impaired, those were geographically or culturally isolated and those who lack a means of transportation when evacuation becomes necessary

Aboriginal peoples and disaster
Communities are often geographically remote. Can be dealing with poverty. Lack of funding on reserve for mitigation efforts. Key is getting the necessary resources in a timely and culturally sensitive way. Notions of healing and tradition are central to efforts to confront the legacy of injustice and suffering brought on by colonialization. Must consider the ongoing use of tradition in the community and assert cultural identity. Aboriginal people are involved in healing their traditions, repairing the ruptures and discontinue ease in the transmission of traditional knowledge and values and asserting their collective identity and power

Children and adolescents
Children will be influenced by the adults around them. Assessment of mental health for children involves two components. Screening and then clinical evaluation for those who are densified as at risk during screening. PFA and psychosocial interventions such as the use of play and art activities can be effective.

People with an existing mental disorder
People with pre-existing conditions are at risk for exacerbation of their symptoms, poor coping responses and difficulty achieving good recovery. During emergencies the WHO predicts that severe mental disorders increase from the pre-emergency rates of 2 to 5% And mild mental disorders increased from 10 to 20%.

Disabled persons
People with disabilities are more likely to be left behind in evacuations and a disability can be a discriminating factor in allocation of scarce resources. The public safety is Canada‘s emergency preparedness guide for people with disabilities provides information about emergency packs, resources and tips for helping people with disabilities

Ethnic minorities
Stress and distress can be reduced if information is available to ethnic minorities in their mother tongue and if recovery efforts are culturally appropriate and involve Ki community figures. Things to consider include gender issues, touching, need for certain clothing items and religious beliefs that will influence the meaning given to the disaster event

Disaster relief workers
Volunteers have the higher complaint levels with factors contributing to this being determined as identification with victims as a friend, severity of exposure to gruesome events during disaster work, anxiety sensitivity and lack of post disaster social support