Psychiatric Emergency Flashcards
Crisis and Mass Disaster/IPV/Child Abuse/Elder Abuse/Anger/Aggression/Violence/Care for Dying and Those Who Grieve
Crisis and Mass Disasters consist of
time-limited (stabilize and back home with resources)
overwhelming emotional reactions
- state of disequilibrium (overwhelmed)
- orientate to reality
- Goal: precrisis level of functioning
developmental, situational, existential
What should nurses do during Crisis intervention occurs?
assist coping and assimilating with broad, creative, and flexible interventions
Factors limiting a person’s ability to cope or problem-solve
Other stressful life events
Mental illness
Substance abuse
History of poor coping skills
Diminished cognitive abilities
Preexisting health problems
Limited social support
Developmental or physical challenges
Who is the crisis theorist?
Erich Lindemann
Erick Lindemann believed in
- The same interventions utilized in bereavement would be helpful with other stressful events
- crisis intervention model as a major element of preventive psychiatry in the community
Joint commission and mental illness and health addresses the need for community health centers throughout the country by providing
crisis services
What is Robert’s 7-stage model of crisis intervention from bottom to top (1st to last)?
- Plan and conduct crisis assessment (lethality measures)
- establish rapport and rapid relationships
- identify major problems (“last straw” and crisis precipitants)
- deal with feelings and emotions (active listening and validation)
- generate and explore alternatives
- develop and formulate an action plan
CRISIS RESOLUTION - follow-up plan and agreement
Developmental Crisis
Erik Erikson identified 8 stages
Situational Crisis
arises from external source such as loss of job, death of a loved one, unwanted pregnancy, a move, change of job, change in financial status, divorce and severe physical or mental illness. Threat ends self-concept and self esteem
Adventitious Crisis
situational but on larger scale, a community.
- Rape
- Natural disasters, national crisis such as terrorists attack, airplane crashes, or crimes of violence such as shootings in public places
Existential Crisis
questioning life’s purpose such as
- marriage,
- the death of a loved one,
- children becoming adults and leaving the home
Erickson’s Psychosocial Stages
Infant - Trust vs Mistrust (hope)
Toddler - Autonomy vs Shame/Doubt (will)
Preschooler - Initiative vs Guilt (purpose)
School Age - Industry vs Inferiority (competence)
Adolescents - identity vs Confusion (fidelity)
Early Adult - Intimacy vs Isolation (love)
Middle-Generativity vs Stagnation (care)
Crisis Phase 1
Crisis starts
- the person becomes anxious, starts to problem-solve
- start to use defense mechanisms
Crisis Phase 2
defense mechanism fails anxiety escalates
- trial and error problem-solving
Crisis Phase 3
trial and error not working
- anxiety is severe and at panic levels
- fight or flight stage
Crisis Phase 4
anxiety is overwhelming
- violence, depression, and suicide ideation may occur
- unable to cope, disorganized
- dissociative s/s: derealization and depersonalization
At any phase of a crisis, defense mechanisms
effective and problem-solving may be successful
What does the nurse assess for in a person in crisis?
determine the need for suicidal or homicidal ideation interventions
perception(dealing, can’t function, affect them)
situational supports - who can you trust and helped you in the past
coping skills - eat, drink, exercise, drugs, cry, yell, sleep, withdrawal, pray (positive or negative)
Disaster Responses
Rescue and evacuation, food and shelter, medical attention (triage), and physical safety
Assistance with housing, jobs, and trauma counseling
Cognitive impairment
Behavioral changes
Emotional issues
PTSD
Assessment Guidelines for a Crisis
Warrant psychiatric treatment or hospitalization (harm to themselves or others)
What was the precipitating event
Religious or cultural beliefs
Does the patient need education, new coping skills, environmental manipulation (new place to live), crisis intervention, or rehabilitation
What can happen (diagnosis) during a crisis?
Depressed mood
Risk for self-destructive behavior
Anxiety
Caregiver Stress
Dysfunctional grief
Impaired sleep
Acute confusion
After a crisis, what are some expected outcome identifications?
Take short walks every day
Attend counseling sessions every 2 weeks
Will return to school next semester
Learn about her disorder
Will call one person daily for support
Suggest situational supports such as teachers, neighbors, friends, hotline)
decrease anxiety, safety, stabilize and discharge with resources
What communications should a nurse use during an intervention?
provide quiet environment
coping skills
regular follow-up
using eye contact (not paranoid) and supportive body language
patient safety
Crisis Primary Nursing Interventions
Recognize potential problems
Teach coping skills
Crisis Secondary Nursing Interventions
Interventions during acute crisis
Safety of patient
Crisis Tertiary Nursing Interventions
Rehabilitation
Community Support
Continued education
Critical Incident Stress Debriefing
self-care for nurses and other healthcare
- Intro phase - why are we meeting
- fact phase - exactly what happened
- thought phase - what were you thinking when it happened
- reaction phase - what did you do
- symptom phase - physical, cognitive, emotional
- teaching phase - so changes can be made
- reentry phase - encouragement and resources provided
Stress Debriefing: Intro Phase
why are we meeting
Stress Debriefing: Fact Phase
exactly what happened
Stress Debriefing: Thought Phase
what were you thinking when happened
Stress Debriefing: Reaction Phase
what did you actually do
Stress Debriefing: Symptom Phase
physical, cognitive, emotional
Stress Debriefing: Teaching Phase
so changes can be made
Stress Debriefing: Reentry Phase
encouragement and resources provided
What should the nurse check for after a crisis?
Is the patient safe and secure
Is the patient able to use healthy coping skills
Where is the patient’s level of functioning/anxiety
Is the patient relying on their support system
Goal - Precrisis baseline
In a Mass Crisis, what is the goal after it occurs?
get back to the precrisis baseline
decrease anxiety, safety, stabilize and discharge with resources
ACEs
significant associations between childhood maltreatment and health and well-being later in life
ACEs types with Domestic Violence
fetal death
drug/alcohol use
depression and suicide attempts
heart disease
IPV
early sexual activity
adolescent pregnancy
STIs
poor quality of life
When the abused tries to leave 40% are
murdered in the process
77% killed their partner at home
Domestic Violence can include
emotional - verbal abuse, criticism, name-calling, mocking, threats and intimidation (locking in a room, blaming victim, denying)
physical - anything touching them
sexual - non-consensual, watching in inappropriate situations pornography, trafficking,
neglect - not providing or withholding, not letting them go to doctor or school, expose to violent environments
Social Learning Theory
Children who witnesses abuse or is abused in a family of origin learns that violence is acceptable
Societal and Cultural Risk Factors for DV
Poverty or unemployment - stress
Communities with inadequate resources and overcrowding
Social isolation of families - no support
Early parenthood - unplanned and not ready
Inadequate coping skills
Family members with chronic health conditions
What theory talks about domestic violence?
Social Learning Theory
Risk Factors of Domestic Violence Perpetrators
Low self esteem
Poor problem-solving skills
History of impulsive behavior
Hypersensitivity (sees self as victim)
Narcissism (self-centered and lacks compassion)
Immaturity
Genetics
Substance abuse
Intimate Partner Violence
Occurs within the context of an emotionally intimate relationship
- Includes lesbian, gay, & transgender relationships
- Includes physical abuse and/or psychological abuse
everyone and all patients
Intimate Partner Violence includes what s/s
Physical Injury
Psychological Abuse
Sexual Assault
Progressive Social Isolation (no support or help to leave and don’t want others to say how bad they are)
Stalking
Deprivation - no money (can’t leave)
Intimidation and threats
- Threats to harm a pet, child or loved one
Instilling fear and anger to manipulate
- 30-61% children are also abused (even if only exposure)
Intimate Partner Abuse is the leading cause of
women ER visits
homelessness
men as victims are underreported
female homicides and birth defects in pregnancy
attempting to leave 45% will be murdered
Teen Dating Violence s/s
Extreme possessiveness and jealousy
Physical or cyber stalking
Manipulation and control
Demeaning one’s partner in front of others
Threatening to commit suicide
Forced intimacy or sex
- 25-31% verbal, physical, emotional, sexual abuse
Battered Partner emotions
Lives in terror
May retaliate in self-defense
Victim of irrational jealousy, isolation, verbal and physical abuse
Feelings of low self-esteem and powerlessness are common
“Brainwashing” occurs and self-hatred develops
Characteristics of Violent Partner
Denial and Blame
Emotional Abuse
Isolate for control
Intimidation control
economic control
power control
Characteristics of Battered Partner
- Believes she does the right thing abuse will stop
- recreating childhood abuse
- devasted psychologically, believing words, low self-esteem, unhealthy bond with the abuser
- no boundaries: inaccurately assess the situation without a supportive network
- constant fear and terror become oppressed: think suicide, homicide, attempts, or completes
= PTSD develops - economic and emotional dependence = depression, secret drug and alcohol abuse
- if works, frequently loses jobs due to stalking and harassing (Can’t save enough money to leave)
-lose sense of self and no power (only related to partner and children)
Denial and Blame:
Denies that abuse occurs, shifts responsibility of abuse to partner; makes statements that the victim caused the abuse or caused the abuser to react that way
Emotional Abuse:
Belittles, criticizes, insults, uses name-calling, undermines
Control Through Isolation:
Limits family or friends, controls activities and social events, tracks time or mileage on car and activities, stalks at work, takes to and from work or school, may demand permission to leave house
Control Through Intimidation:
Uses behaviors to instill fear, such as vile threats, breaking things, destroying property, abusing pets, displaying weapons, threatening children, threatening homicide or suicide, and increasing physical, sexual, or psychological abuse
Control Through Economic Abuse:
Controls money, makes partner account for all money spent; if partner works, calls excessively, forces partner to miss work; refuses to share money
Control Through Power:
Makes all decisions, defines role in the relationship, treats spouse like a servant, takes charge of the home and social life
- victim has no independence
The person who is the abuser is commonly
- abusing someone less powerful/more vulnerable helps a violent partner feel more in control and powerful
- adjusted from the outside
- possessive and jealous
- male supremacy
- drug or alcohol problem
- w/o tx = excel behaviors
The cycle of violence**
Tension-building phase
serious battering phase
honeymoon phase
- repeats
The tension-building phase of Cycle of Violence**
Abuser = edgy, verbally abusive, minor hitting, slapping
Victim = tense, afraid, “walking on eggs”, helpless, compliant, accepts blame
The Serious Battering Phase of the Cycle of Violence**
Tension = unbearable, victim might be provoked “to get it over with”
Victim = try to cover up the injury or look for help
The honeymoon phase of the Cycle of Violence**
Abuser = loving, gifts/flowers/special things for the victim
Victim = trusting, hopes for change, wants to believe promises
Why do abused partners stay?
lack of financial support
fear of being murdered
lack of support system
depression/low self-esteem
religious beliefs against divorce
believe they deserve abuse
stay for the children
IPV Assessment
maybe seen in ED, clinics, outpt, primary care
- Screening at each pediatric visit for women within reproductive age
- assess pt alone
IPV S/S
Discrepancy between injury and explanation
Minimization of the injury
Fearfulness
Complete physical assessment - wounds in various stages of healing
Psychological signs (HA)
- drugs and alcohol use, contact police and children = CPS,
Dx of Abusive relationship
IPV victim
risk for spiritual distress
post-trauma response
lack of support
physical injury from abuse
Expected Outcome for a victim of abuse
safe environment
create safety plan
What are the nursing steps when assessing an abused patient?
- medical attention and document injuries body map (ask permission for photos)
- private interview and confidentiality
- assess through a non-threatening manner information about
- sexual, physical, emotional, children, drug abuse, or thoughts of suicide or homicide - encourage them to speak w/o interruption
- Ask how are they doing with children
- Assess safe places when violence escalates (list of shelters)
- cards can fit in a shoe to not endanger the victim
- report to cops and assist the victim
- emphasize to the victim it is not their fault
- reach out to family and friends
- psychotherapies with experience in abuse - If not ready to act, provide a list of community resources
- hotlines, shelters, groups and advocates, therapists, law enforcement, Medical assistance or Aid with Dependent Children, CPS
Nurses are mandated to report
child abuse even if only a suspicion
What is considered a form of child abuse?
overindulgence
- over eat
Assessment of a Child abuse victim
timid or fearful of parent/caregiver
disheveled
Hx of absenteeism
after the initial interview of a parent, interview the child alone
open-ended questions
reassure the child it was not their fault
provide a complete physical assessment of the child
The use of dolls/drawings helps the child to tell how the injury or accident happened
Child Abuse Assessment Findings
physical - injuries do not aline with the stories, different types of healing
neglect - malnutrition, withholding physical or emotional love, no positive reinforcement
sexual
emotional - hate themselves and not the parent
- risk for impairing development (delayed)
What is the expected outcome for the abused child?
child safety and well-being
What does the nurse do after the assessment of the child abuse victim?
understand the child does not want to betray parents
- notify CPS
- collect physical evidence
- document carefully
- tx injuries
What does the nurse tell the parent/caregiver of the suspected abused child?
Adopt a nonthreatening, nonjudgmental relationship with parents
Be direct, understanding and professional
Be honest about having to report to CPS
Open ended questions
Characteristics of Abusive Parents
A history of violence, neglect, or emotional deprivation as a child
Low self-esteem, feelings of worthlessness, depression
Poor coping skills
Social isolation may be suspicious of others
Few or no friends, little or no involvement in social or community activities
Involved in a crisis such as unemployment, divorce, financial difficulties, abusive relationship
Rigid, unrealistic expectations of a child’s behavior
Frequently uses harsh punishment
History of severe mental illness, such as schizophrenia
Violent temper outbursts
Look to child for satisfaction of needs for love, support, and reassurance
Projects blame the child for his or her problems
Lack parenting skills
Inability to seek help from others
Perceives the child as bad or evil
History of drug or alcohol abuse
Feels little or no control over life
Low tolerance for frustration
Poor impulse control
Elder Abuse by
Individuals, Institutions, or Self Neglect
For Adult Protective Services to intervene, the elder has to be
deemed unable to care for self
What are the 5 types of elder abuse?
physical
psychological
financial/exploitation
neglect
sexual abuse
Physical abuse of elders is
The infliction of physical pain or injury through slapping, hitting, kicking, pushing, restraining, overmedicating, or sexually abusing
Psychological abuse of elders is
The infliction of mental anguish through yelling, name-calling, humiliating, or threatening
Financial abuse/exploitation of elders is
misuse of someone’s property and resources by another person or refusal by a caregiver to provide needed resources
Neglect of elders is the
Failure to fulfill a caretaking obligation to provide nutrition, hydration, shelter, clothing, utilities, medical services, or other basic needs. This category may also include self-neglect
Sexual abuse of elders is
Nonconsensual sexual molesting, touching, inappropriate comments or exposure to videos or acts, or actual rape
The elder abuser’s characteristics
Caretaker stress and burden
Middle-aged adult child or family member
Caregiver dependent on the elder
Maybe using substances
May have been abused as children
In institutions, abuse may be from other residents
Nurses notice what signs of elder abuse (assessments)
Fear of being alone with a caregiver
Malnutrition or dehydration (impaired nutrition)
Bedsores, skin tears, bruises, swelling or fractures
Passive, withdrawn, or emotionless behavior
Appears overmedicated
Vaginal or rectal pain, tears, bleeding, or STI
Concern over finances
Transfer of property who lacks the mental capacity to do so
Valuables missing
Expected Nurse’s Outcomes of Elder Abuse
Abuse has ceased
Plans in place to maintain safety
Less anxiety and tension between patient and caregiver
Respite, sharing of responsibilities for caregiver
The nurse can implement what for victims of elder abuse?
Medical services
Contact APS
Family or caregiver support - TEACHING ABOUT COPING SKILLS, FAMILY THERAPY,
Alternate housing
Notify community agencies
What is crucial in the evaluation process for elder abuse victims?
follow-up (safety or modify plan)
Anger
normal emotion
- unplanned reaction to stressors
- range (irritation to fury and rage)
- cultural perception and social backgrounds
Anger is a response to
vulnerability
- hurt, fear, threat to one’s physical or emotional needs (challenge)
Anger can be constructive if
assertive communication and critical reasoning id applied
Catharsis
expression of anger and aggression with safe activities
- not in a harmful way
Unhealthy anger alters
person’s functioning or relationship
- escalates to aggression and violence
-OKAY WITH SELF-DEFENSE and protect others
Aggression and Violence are defined as
hurting others physically or psychologically
- appropriate if self-protective
- overt (obvious) or covert (not)
Violence
expression of hostility and rage with intent to injure or damage
T/F: Anger is always the origin of harm.
False
Violence leads to
significant physical and psychological harm to others
What is the most common form of violence?
bullying
Bullying defined as
offensive, intimidating, malicious, condescending behavior designed to humiliate and terrorize (intentional)
- Persistent systemic violence toward an individual/group
- different levels of authority
Bullying in general is between
people with different levels of authority
Lateral Bullying
bullying among equals
Nursing Bullying
??% at risk for violence
??% bullying in their workplace
??% experienced verbal or nonverbal aggression from a peer
??% from a person with a higher level of authority
21% said they were at risk for violence
25-50% reported various instances of bullying in their workplace
50% said they experienced verbal or nonverbal aggression from a peer
42% from a person with a higher level of authority
??/?? Nurses quit their jobs because of bullying
1/3
- 80% have had bullying in their career
- and wages is the reason for global nursing shortage
Bullying Behaviors
- unwanted and invalid criticism with excessive monitoring of others
- gossiping, spreading lies, rumors, derogatory nicknames
- taking credit for other’s work and blocking career pathways and other work opportunities
- publicly derogatory comments about staff (eye rolling, dismissive behavior in front of others)
- sarcasm or ridicule
- blaming w/o factual justifications
- condescending or patronizing
- break confidence
- use physical/verbal innuendo or abuse, foul language, raising voice, humiliate in front of colleagues
Theory of Bullying
- adult violence linked to childhood aggression (setting fires, animal cruelty, aggressive to peers) = McDonald’s Triangle
- targets of violence in childhood
- neurocognitive results in agitated, aggressive, or violent behavior
- substance and alcohol abuse
- Low socioeconomic
- social reaction learned and reinforced through family and societal norms
Limbic system controls
emotions. Regulates the behavior of aggression in humans and animals, and it judges events as either aversive or rewarding
Amygdala supports
aggression and violence and responds to perceived threats
Hypothalamus stimulated by
anger and causes the body to respond to anticipated harm
Prefrontal cortex does
receives messages from the limbic system and modulates the aggressive impulses in a social context, making judgments of these impulses
MRIs and PET scans of the prefrontal cortex show changes in what individuals
violent
-A reduction in the gray matter and decreased blood flow and metabolism are seen
Low serotonin function =
increased impulsive aggression
Increased norepinephrine =
enhances vigilance, and impulsivity, and violence
Higher dopamine storage =
higher degrees of aggressive responses
Genetic factors alone don’t contribute to violence although
there is a genetic component to violence
Cultural Considerations for Violence
males are more violent than females
- higher in low economic status males, substance abuse, and psychotic or organic medical disorders
- use intimidation and aggression as acceptable reinforce use of violence
The nurse should do what when faced with violent patient behavior?
limit setting - nonthreatening
possible triggers and responses escalate
incompetence in conflict resolution with patients
personal anxiety escalates pt’s anxiety
follow policies
Assessment for Violent Patients
- ask about previous violence, substance abuse, or psychotic behavior
- Thought, injured, most violent thing, plan, means to carry out the plan?
- Male 15-24 y/o with low socioeconomic and weak support
What s/s sometimes (not always) precede violence?
angry, irritable affect
hyperactivity = pacing, restless, slamming doors
increase anxiety and tension = clenching, rigid, mumbling
SOB, sweating, rapid pulse
verbal abuse, profanity, argumentative
loud voice, pitch change, very soft forcing others to strain
intense eye contact or avoid eye contact
Predictive Factors of Violence
recent acts of violence (property violence)
stone silence
suspicious or paranoid thinking
alcohol or drug intoxication(withdrawal)
possession of weapons
Milieu characteristics conducive to violence
loud
overcrowded
staff inexperience
provocative or controlling staff
poor limit setting
staff inconsistency
Nurses should be aware of what when assessing a violent pt?
Hx of violence
paranoid ideation and frank psychosis (command hallucinations)
hyperactive, impulsive, predisposed to irritability
recognize cues and know triggers
assess place in aggression cycle
What is the best predictor of future violence?
hx of violence
What are paranoid hallucinations?
paranoid ideation and frank psychosis
Nursing Dx for Violent Patients
risk for self-destructive behaviors
risk for self-mutilation
impaired impulse control
risk for violence
difficulty coping
What are the expected outcomes for a patient with violent behaviors?
display nonviolent behaviors
recognize when anger and aggressive tendencies begin to escalate and will employ at least one new tension-reducing behavior
make plans to continue with long-term therapy
safe
Hostility toward self and others will cease
What can a nurse plan for a violent patient need during treatment?
education
counseling interventions
immediate = de-escalation, restraints, seclusion, medications?
milieu
new way of handling anger
How should a nurse portray herself when taking in a violent patient?
dignity
respect
privacy
Nursing Priority for Violent Patients
safety
- move to a calm and quiet place
- search for contraband
- at least one arm’s length away (10 ft and 45 degree)
- set limits
- “You seem ?????????” = Feedback
- have 5 people (possible restraint) but one spokesperson
If anger continues to escalate then
leave
- do not touch
- do not wear ponytails, dangling earrings, necklace
- clear staff roles
In the Preassaultive Phase, what is used?
de-escalation techniques
De-escalation Techniques
respond as early as possible
emphasize on the patient’s side ( we want to help and this is a safe place
- stand at 45 angle
personal safety and self-care
appear calm and in control
do not try to speak while they are yelling
no judgment or provocative
genuine and concern
- “What will help now? - no humiliation
set clear consistent and enforceable limits on behavior - no threatening
if willing - both sit at a 45-degree angle
listen and use clarification
acknowledge needs
can offer medication
Preassaultive Stage: De-escalation Approaches
pt becomes increasingly agitation
- verbal intervention
- maintain self-esteem and dignity (doing the best, improve, and behavior makes sense)
“It sounds like …”
“You’re here for help and we’re trying to figure out what’s going on”
“Let us help you, don’t be afraid.”
Assaultive Stage: Medication Seclusion, and Restraints
manage environment
- 10-foot rule
- prepare for a show of force
- at least five staff to restrain
Restraint and seclusion can be used under what circumstances
REQUIRES AN ORDER
- clear and present danger to self or others
- requests seclusion or restraints
- legally detained for involuntary tx and escape risk
- Alternative Tx attempted prior - deescalate, meds
- require training and proof of competency
- use least restrictive restraint to most
- know unit and hospital policy
Alternative Tx used before restraints or seclusions
Trauma-informed approach
Verbal interventions
Medications
Decrease in stimulation
Removal of a particular stimulus
Presence of significant other
Sitter with 24-hour observation
After all other attempts, if the patient is a danger to others, then use
restraints
After all other attempts, if the patient is only disruptive and uncooperative, then use
seclusion
After all other attempts, if the patient will sit willingly in a quiet room, then use
unlocked seclusion room
After all other attempts, if the patient is a danger to self in seclusion, then use
restrain as well
What medications are used for acute aggressive episodes?
Benzodiazepines (Pam and Lam)
Antipsychotics
Antipsychotics for acute aggressive episodes
Ziprasidone IM
Olanzapine IM or orally disintegrating (might bite - no thank you)
Haloperidol IM
Post Assaultive Stage includes
when no longer requires seclusion and restraints
- review the incident with pt
- discuss precipitating factors
- plan alternative responses
Critical Incident Debriefing
Critical Incident Debriefing
Was quality care provided
Could we have done anything to prevent the violence
If yes, what could have been done instead
Did the team respond as a team?
Is there a need for more education?
Fear and anger must be discussed to prevent long-term psychological effects - humiliation
What documentation should be done for a violent episode?
Reason for seclusion and restraints
Assessment of behaviors occurred during the preassaultive and assaultive stage
All nursing interventions for each stage and the patient’s response
Evaluation of interventions
Detailed description of the behavior of the patient for each stage
Name of provider who came and assessed patient within an hour
Time the patient placed in restraints or seclusion
Interventions were performed while the patient was in restraints or seclusion
Any injuries to patient or staff
How was the patient was reintegrated into the unit
The Recovery Model
Seclusion and restraints have no therapeutic value, cause human suffering, and frequently result in severe emotional and physical harm, and even death
- comfort, trauma-informed, safety, trustworthiness, transparency, peer support, collaboration and mutuality, empowerment, voice, and choice
- consider cultural, historical, and gender issues
Hospitals can intimidate some people as they do not feel
heard
out of control of the situation and tired
- resort to violence because of poor coping skills
- want no surprises
Patients with chemical or alcohol dependency may be
anxious because they do not have access to their substance
What can be provided before request is sent to decrease anxiety?
provision of comfort items
- certain foods, decaf drinks
clear communication decrease ambiguity to decrease anxiety
What should the nurse do when the patient becomes angry?
leave the room and return when the situation is calmer
- no chastising, threatening, or being punitive
Withdrawal attention form the abuse and replace with
compassion and emotional support
Patients with neurocognitive defects can result in
acting aggressive
- delirium, dementia, or brain injury
What should be used in a neurocognitive deficit patient with aggression?
reality orientation and medication
Catastrophic reaction
scream, stroke out, or cry
What should the nurse do when a patient has a catastrophic reaction?
Remain calm, smile, use gentle touch, keep your voice soft
Say the patient’s name. Ask the patient what they need. Bathroom?
Use short simple sentences
Decrease stimulus
What psychotherapy does a violent aggressive patient need?
Behavioral Management
Cognitive-behavioral techniques
Limit setting, distraction, redirecting, relaxation and biofeedback
Family behavioral management
Trauma Informed Approach and Trauma Approach Therapy
Loss is
part of human experiences (loved one, job , or health)
Grief is
response to the loss
Uncomplicated loss
normal progression through grief
- insomnia, dream of deceased, isolate, + others in 3rd memo
- up to 2 years
Anticipatory grief
start grieving prior to the loss and know they are going to pass away
Disenfranchised grief
not socially sanctioned due to the nature, type of death, or relationship with the loss or not publicly mourn the loss
- affair
- suicide
Complicated grief
persistent complex bereavement disorder
- unresolved
- individuals are not able to function and continue to and never resolves the grief after a long time of grieving
Mourning is
the outward expression of grief
- wakes, funerals, decorating gravesite
- influenced by culture, religious, or spiritual practices or family traditions
Ambiguous loss
no resolution and no predictable ending or closure
- physical body is absent but psychologically present
- plane crash, MIA
2nd kind = body is present but the person is psychologically changed (dementia)
Bereavement
time of sadness after significant loss
- symbols and context (wearing black or black armband
bereaved is the person grieving
Meaning Reconstruction Theory (After a loss) means to experience
Shock and disbelief
Denial
Anger
Denial
The sensation of somatic distress (anything with the body)
Change in behavior (panic, restlessness)
Reorganization of behavior directed towards new object or activity
Acceptance
Four Tasks of Mourning made by
J William Worden
Four Tasks of Mourning is the
Accept the reality of the loss
Process the pain of grief while caring for the self
Adjust to a world without the deceased
Find a meaningful connection with the deceased while starting a new life
”Resilient people show no grief”
Resilient people show what type of grief?
no grief
Mourning Assessment for Nurses
Was the bereaved heavily dependent on the deceased
Was there persistent unresolved conflict between them (can not make peace with them - guilt)
Was the deceased a child
Does the bereaved have a support system
Does the bereaved have sound coping skills
Has the bereaved had trouble resolving past significant losses
Does the bereaved have a history of depression, drug or alcohol abuse or other psychiatric illnesses
Responses of Grieving 5 categories (uncomplicated grief)
Cognitive
Emotional - depression, anger, sadness, anxiety, despair,
Spiritual - blame
Behavioral - abuse of substances
Psychologic - insomnia, or too much sleep, immune problems, indigestion, palpations
The nurse should assess what in the client’s grieving process
Evaluate for psychotic symptoms
Is grieving stalled or complicated
Is there spiritual anguish
Nursing Dx for a Grieving person
Dysfunctional grieving
Risk for depressed mood
Risk for dysfunctional grieving
Grief
Expected Outcomes of Mourning and Grieving
Can tolerate intense motions
Reports decreased preoccupation with the deceased
Demonstrates increased periods of stability
Takes on new roles and responsibilities
What should the nurse do for a grieving person
Give your full presence
Be caring
Explain what may occur during normal grieving process
Encourage support of family and friends
Offer spiritual support referrals
Show understanding and support
Encouragement full expression of emotions and affect
Help them come to peace with a new relationship to the deceased
Offer end of life resources
Address spirituality and consider cultural differences
How should a nurse speak to a person grieving?
Be genuinely interested in what they have to say
Ask open ended questions
Seek for unspoken questions
Be patient in times of silence
Be aware of your nonverbal communication
When you are in this situation, you should say
- when you sense an overwhelming sorrow
“This must hurt terribly.”
When you are in this situation, you should say
- when you hear anger in the bereaved person’s voice
“This must hurt terribly.”
When you are in this situation, you should say
- if you discern guilt
“Are you feeling guilty? This is a common reaction many people have. What are some of your thoughts about this?”
When you are in this situation, you should say
- if you sense a fear of the future
“It must be scary to go through this.”
When you are in this situation, you should say
- when the bereaved seems confused
“This can be a confusing time.”
When you are in this situation, you should say
- in almost any painful situation
“This must be very difficult for you.”
What should the nurse educate the bereaved on?
Take the time needed to grieve
Express your feelings
Establish a structure for each day and stick to it
Do not feel that you have to answer all the questions
Take care of yourself
Expect the unexpected
Make use of rituals (good habits and daily and weekly outings)
Tell your physician if you do not begin to feel better
Seek support outside of family
Helping People Say Goodbye - Dr. Ira Byock
Forgiveness (I forgive you, please forgive me)
Love (I love you; I know you love me)
Gratitude (Thank you, and I receive your thanks)
Farewell (We will have an enduring connection)
Encourage spending time with the patient and reminiscing
What Tx can be given for a bereaved patient?
- Psychotherapy
For those at risk for complicated grief because of a history of mental illness, loss by suicide or homicide, facing multiple simultaneous losses, or loss of a child. - Antidepressants
