Crisis and Disaster

1. Crisis and Disaster Chapter 17 I. Introduction A. Any stressful situation can precipitate a crisis. B. Assistance with problem solving during the crisis period preserves selfesteem and promotes growth with resolution. II. Crisis, Defined A. Crisis is defined as a sudden event in one�s life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. B. Assumptions upon which the concept of crisis is based. 1. Crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology. 2. Crises are precipitated by specific identifiable events. 3. Crises are personal by nature. 4. Crises are acute, not chronic, and will be resolved in one way or another within a brief period. 5. A crisis situation contains the potential for psychological growth or deterioration. III. Phases in the Development of a Crisis A. The individual is exposed to a precipitating stressor. B. When previous problem-solving techniques do not relieve the stressor, anxiety increases further. C. All possible resources, both internal and external, are called upon to resolve the problem and relieve the discomfort. D. If resolution does not occur in previous phases, the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the individual with drastic results often occurs. IV. Whether or not individuals experience a crisis in response to a stressful situation depends upon: A. The individual�s perception of the event. B. The availability of situational supports. C. The availability of adequate coping mechanisms. V. Types of Crises A. Dispositional crisis�an acute response to an external situational stressor B. Crisis of anticipated life transition�normal life-cycle transitions that may be anticipated, but over which the individual may feel a lack of control C. Crisis resulting from traumatic stress�a crisis that is precipitated by an unexpected, external stressor over which the individual has little or no control, and from which he or she feels emotionally overwhelmed and defeated D. Maturational/developmental crisis�crisis that occurs in response to situations that trigger emotions related to unresolved conflicts in one�s life E. Crisis reflecting psychopathology�emotional crisis in which preexisting psychopathology has been instrumental in precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution F. Psychiatric emergencies�crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility VI. Crisis Intervention A. The minimum therapeutic goal of crisis intervention is psychological resolution of the individual�s immediate crisis and restoration to at least the level of functioning that existed before the crisis period. B. A maximum goal is improvement in functioning above the precrisis level. C. Usually lasts from 4 to 6 weeks. VII. Phases of Crisis Intervention: The Role of the Nurse A. Nurses may be called upon to function as crisis helpers in virtually any setting committed to the practice of nursing. 1. Phase 1. Assessment. Information is gathered regarding the precipitating stressor and the resulting crisis that prompted the individual to seek professional help. Relevant nursing diagnoses are selected. 2. Phase 2. Planning of Therapeutic Intervention. From the assessment data, the nurse selects appropriate nursing diagnoses that reflect the immediacy of the crisis situation. Desired outcome criteria are established. Appropriate nursing actions are selected, taking into consideration the type of crisis, as well as the individual�s strengths and available resources for support. 3. Phase 3. Intervention. The actions identified in the planning phase are implemented. A reality-oriented approach is used. A rapid working relationship is established by showing unconditional acceptance, by active listening, and by attending to immediate needs. A problemsolving model becomes the basis for change. 4. Phase 4. Evaluation of Crisis Resolution and Anticipatory Planning. A reassessment is conducted to determine if the stated objectives were achieved. A plan of action is developed for the individual to deal with the stressor should it recur. VIII. Disaster Nursing A. A common feature of disasters is that they overwhelm local resources and threaten the function and safety of the community. B. Disasters leave victims with a damaged sense of safety and well-being, and varying degrees of emotional trauma. C. Application of the Nursing Process 1. Assessment a. Grieving is a natural response. b. Common behavioral responses include anger, disbelief, sadness, anxiety, fear, sleep disturbances, and increases in alcohol, caffeine, and tobacco use. c. Children may experience separation anxiety, nightmares, and problems with concentrating. 2. Nursing Diagnoses/Outcome Identification a. Risk for injury b. Risk for infection c. Anxiety (panic) d. Fear e. Spiritual distress f. Risk for post-trauma syndrome g. Ineffective community coping 3. Planning/Implementation 4. EvaluationI. Introduction A. Any stressful situation can precipitate a crisis. B. Assistance with problem solving during the crisis period preserves selfesteem and promotes growth with resolution. II. Crisis, Defined A. Crisis is defined as a sudden event in one�s life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. B. Assumptions upon which the concept of crisis is based. 1. Crisis occurs in all individuals at one time or another and is not necessarily equated with psychopathology. 2. Crises are precipitated by specific identifiable events. 3. Crises are personal by nature. 4. Crises are acute, not chronic, and will be resolved in one way or another within a brief period. 5. A crisis situation contains the potential for psychological growth or deterioration. III. Phases in the Development of a Crisis A. The individual is exposed to a precipitating stressor. B. When previous problem-solving techniques do not relieve the stressor, anxiety increases further. C. All possible resources, both internal and external, are called upon to resolve the problem and relieve the discomfort. D. If resolution does not occur in previous phases, the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the individual with drastic results often occurs. IV. Whether or not individuals experience a crisis in response to a stressful situation depends upon: A. The individual�s perception of the event. B. The availability of situational supports. C. The availability of adequate coping mechanisms. V. Types of Crises A. Dispositional crisis�an acute response to an external situational stressor B. Crisis of anticipated life transition�normal life-cycle transitions that may be anticipated, but over which the individual may feel a lack of control C. Crisis resulting from traumatic stress�a crisis that is precipitated by an unexpected, external stressor over which the individual has little or no control, and from which he or she feels emotionally overwhelmed and defeated D. Maturational/developmental crisis�crisis that occurs in response to situations that trigger emotions related to unresolved conflicts in one�s life E. Crisis reflecting psychopathology�emotional crisis in which preexisting psychopathology has been instrumental in precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution F. Psychiatric emergencies�crisis situations in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility VI. Crisis Intervention A. The minimum therapeutic goal of crisis intervention is psychological resolution of the individual�s immediate crisis and restoration to at least the level of functioning that existed before the crisis period. B. A maximum goal is improvement in functioning above the precrisis level. C. Usually lasts from 4 to 6 weeks. VII. Phases of Crisis Intervention: The Role of the Nurse A. Nurses may be called upon to function as crisis helpers in virtually any setting committed to the practice of nursing. 1. Phase 1. Assessment. Information is gathered regarding the precipitating stressor and the resulting crisis that prompted the individual to seek professional help. Relevant nursing diagnoses are selected. 2. Phase 2. Planning of Therapeutic Intervention. From the assessment data, the nurse selects appropriate nursing diagnoses that reflect the immediacy of the crisis situation. Desired outcome criteria are established. Appropriate nursing actions are selected, taking into consideration the type of crisis, as well as the individual�s strengths and available resources for support. 3. Phase 3. Intervention. The actions identified in the planning phase are implemented. A reality-oriented approach is used. A rapid working relationship is established by showing unconditional acceptance, by active listening, and by attending to immediate needs. A problemsolving model becomes the basis for change. 4. Phase 4. Evaluation of Crisis Resolution and Anticipatory Planning. A reassessment is conducted to determine if the stated objectives were achieved. A plan of action is developed for the individual to deal with the stressor should it recur. VIII. Disaster Nursing A. A common feature of disasters is that they overwhelm local resources and threaten the function and safety of the community. B. Disasters leave victims with a damaged sense of safety and well-being, and varying degrees of emotional trauma. C. Application of the Nursing Process 1. Assessment a. Grieving is a natural response. b. Common behavioral responses include anger, disbelief, sadness, anxiety, fear, sleep disturbances, and increases in alcohol, caffeine, and tobacco use. c. Children may experience separation anxiety, nightmares, and problems with concentrating. 2. Nursing Diagnoses/Outcome Identification a. Risk for injury b. Risk for infection c. Anxiety (panic) d. Fear e. Spiritual distress f. Risk for post-trauma syndrome g. Ineffective community coping 3. Planning/Implementation 4. Evaluation

2. Concept of Crisis Crises are universal experiences Crisis represents struggle for equilibrium and adjustment when problems seem unsolvable Presents both danger to personality organization as well as opportunity for personal growth Definition of crisis: acute, time-limited event experienced as overwhelming emotional reaction Crisis intervention: assistance in coping for those in crisis. Interventions used are broad, creative and flexible

3. Theory Related to Crisis and Crisis Intervention Crisis is self-limiting (4 to 6 weeks) Resolution of crisis: person will emerge at: Higher level of functioning Same level of functioning Lower level of functioning Goal of crisis intervention: return individual to previous level of functioning Deal with person�s present problems: �here and now� Nurse takes active, directive role when intervening Important to set realistic goals

4. Types of Crisis Maturational Related to identified developmental stages occurring throughout life Each new stage requires new coping mechanisms Examples Marriage, birth of a child, retirement Situational Arises from external rather than internal source; usually unanticipated Examples Loss of job, death of loved one, change in financial status, divorce

5. Types of Crisis Adventitious Crisis or disaster not part of everyday life Arise from Natural disaster (floods, fires, earthquakes) National disaster (acts of terrorism, war, riots, airplane crashes) Crime of violence (rape, assault, murder in workplace/school, bombing in crowded areas, abuse) U.S.: 460 major disasters from 1990-2000

6. Phases of Crisis Phase 1: person is confronted by conflict or problem that threatens self-concept and causes anxiety Phase 2: if usual defensive response fails and threat persists, anxiety continues to rise Phase 3: if trial-and-error attempts fail, anxiety can escalate to panic levels Phase 4: if problem is not solved and new coping skills are ineffective, anxiety can overwhelm person Serious personality disorganization, depression, confusion, violence against self/other can occur

7. Nursing Process: Assessment Guidelines Patient�s perception of precipitating event Perception critical: one person�s minor irritation can be another�s major problem Assess patient�s situational supports Does stressful event also affect patient�s family/support systems? Assess patient�s personal coping skills Evaluate patient�s anxiety level and use of defense mechanisms

8. Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnoses Risk for self- or other-directed violence, Spiritual distress, Hopelessness, Anxiety (moderate, severe, panic), Disturbed thought processes, Ineffective coping, Risk for post-trauma syndrome Outcomes identification Outcomes need to realistic Patient and family need to be involved in identifying outcomes Outcomes need to be congruent with patient�s values, cultural expectations

9. Nursing Process: Planning and Implementation Planning Nurse plans interventions via variety of modalities Disaster nursing, mobile crisis units, group work, health education and crisis prevention, victim outreach programs, telephone hotlines Implementation Nurse can intervene for individual, group, or community Questions important How much has crisis affected person�s life? How is state of disequilibrium affecting patient�s significant others? Goals of intervention: patient safety, anxiety reduction

10. Common Nursing Interventions for Patient in Crisis Identify patient support systems and mobilize these Plan with patient interventions acceptable Plan regular follow-up to assess patient�s progress toward established goals

11. Crisis Intervention Primary Promote mental health and decrease incidence of crisis Secondary Interventions to prevent prolonged anxiety and personality disorganization Tertiary Support for those who have experienced severe crisis and are recovering Goal: facilitate optimal level of functioning

12. Critical Incident Stress Debriefing (CISD) Used to assist a group that has experienced a crisis Consists of seven-step procedure offering individuals opportunity to share thoughts and feelings in safe and controlled environment CISD used in following situations Debrief staff following patient suicide Help staff/students following incident of school violence Debrief rescue personnel who responded to disaster

13. Nursing Process: Evaluation Performed 4-8 weeks after initial interview Successful intervention characterized by: Patient�s anxiety and ability to function has returned to pre-crisis level Questions to ask Is patient safe? Has patient developed adaptive coping? Has patient maintained optimum level of function?