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CrisisandDisaster

CHAPTER26

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Crisis“TheChinesewordforcrisisiswrittenbyjoiningtwo

ideogramstogether.ThesetwoideogramsmakeuptheChinesewordforcrisis.Whentheseideogramsare

presentedseparatelytheystandfortwodifferentideasorconcepts.Thefirstideogramsstandsfordangerandthe

secondideagrandstandsforopportunity.”(Russell,1979)

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Crisis

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Crisis intervention is what nurses and other health professionals do to assist those in crisis to cope. Interventions need to be broad, creative, and flexible.

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Crisis•  Profound disruption of normal psychological homeostasis

•  Astruggleforequilibriumandadaptation

•  Results in inability to function as usual

•  Presentsopportunityforpersonalgrowth

•  Acuteandtime-limited

•  Responsetoacrisisisanormalnotpathologiclifeexperience

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OutcomesofCrisis• Dependsupon

•  Perceptionoftheeventbyindividual,family,community

•  Adequatesituationalsupports

•  Crisisintervention

•  Adequatecopingmechanisms

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CrisisInterventionFoundations

�  Crisisisself-limiting(4-6weeks)

�  Goalofcrisisintervention:returntopre-crisisleveloffunctioning

�  Duringacrisis,peoplearemoreopentonewproblemsolvingandcopingtechniques

�  Focusontheimmediatecrisisonly

� Nursewillbeactive,evendirective

�  Earlyinterventionincreaseschanceforgoodoutcomes

�  Goalsshouldberealisticandmutual

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Theory

•  ErichLindemann(1940s):ReportedCoconutGrovenightclubfireinBoston.

•  GeraldCaplan(1964):Outlinedcrisisinterventionstrategies.

•  JeffersonCenterforMentalHealth(JCMH)(1961):Reportresultedincrisiscenters.

•  Aguilera/Messnick(1970):Providedframeworkfornursingcrisisassessmentandintervention.

•  Roberts(2005):Seven-stagemodelofcrisisinterventionhelpsinacutesituationalcrisisandacutestressdisorder.

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(Continued)

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Roberts’s Seven-Stage Model of Crisis Intervention

Follow-up plan and

agreement

Develop and formulate an action plan

Generate and explore alternative

Deal with feelings and emotions (including active listening and validation)

Identify major problems (including the “last straw” or crisis precipitants)

Establish rapport and rapidly establish relationship

Plan and conduct crisis assessment (including lethality measures)

Crisis resolution

ClinicalPicture:TypesofCrisis

Threebasictypesofcrises:

(1)Maturational(2)Situational(3)Adventitious(disasters)

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Divorce

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TypesofCrisis• Maturational

• Newdevelopmentalstageisreached

• Oldcopingskillsnolongereffective

• Leadstoincreasedtensionandanxiety

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TypesofCrisis(Cont.)

• Situational

• Arisefromeventsthatare

• Extraordinary

• External

• Oftenunanticipated

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TypesofCrisis(Cont.)

• Adventitious

• Unplannedandaccidental

• Naturaldisaster

• Nationaldisaster

• Crimeofviolence

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TextQuestion

Ms.T.,asinglemotheroffour,comestothecrisiscenter24hoursafteranapartmentfireinwhichallthefamily’shouseholdgoodsandclothingwerelost.Ms.T.hasnofamilyinthearea.Hereffortstomobilizeassistancehavebeendisorganized,andsheisstillwithoutshelter.Sheisdistraughtandconfused.Thenurseassessesthesituationaswhichofthefollowingtypesofcrisis?A. MaturationalcrisisB. SituationalcrisisC. AdventitiouscrisisD. Evidenceofaninadequatepersonality

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Caplan’sFourPhasesofCrisis:Phase1Conflictorproblem

$�Self-conceptthreatened

$Increasedanxiety

$Useofproblem-solvingtechniquesanddefense

mechanisms$

Resolveconflictorproblem$

Reduceanxiety

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Caplan’sFourPhasesofCrisis:Phase2Problem-solvingtechniquesanddefensemechanismsfail

$Threatpersists

$Anxietyincreases

$Feelingsofextremediscomfortproduced

$Functioningdisorganized

$Trial-and-errorattempttosolveproblem

andrestorenormalbalance

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Caplan’sFourPhasesofCrisis:Phase3Trial-and-errorattemptsfail

$ Anxietycanescalatetosevere

andpaniclevels$

Automaticreliefbehaviorsmobilized(i.e.,withdrawalandflight)

$ Someformofresolutionmaybemade

(i.e.,compromisingneedsorredefiningsituation)

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Caplan’sFourPhasesofCrisis:Phase4Problemnotsolved

andcopingskillsineffective$

Overwhelminganxiety$

Possibleseriouspersonalitydisorganization,depression,confusion,violenceagainstothers,orsuicidalbehavior

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ApplicationoftheNursingProcess• Assessment

•  Firstassessforsuicidalorhomicidalideationsorgestures•  Generalassessment•  Assessmentofperceptionofprecipitatingevent•  Assessmentofsituationalsupports•  Assessmentofpersonalcopingskills•  Selfassessment

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NursingProcess(Cont.)

• Diagnosis(Table25-2)•  Riskforsuicide•  Ineffectivecoping

• Outcomesidentification(Table25-3)•  Implementation

•  Basiclevel•  Patientsafety•  Anxietyreduction

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CrisisIntervention:ThreeLevelsofNursingCare

•  PrimaryCare

•  Promotesmentalhealthandreducesmentalillnesstodecreasetheincidenceofcrisis

•  SecondaryCare•  Establishesinterventiontopreventprolongedanxietyfromdiminishingpersonaleffectivenessandpersonalityorganization

•  TertiaryCare•  Providessupportforthosewhohaveexperiencedaseverecrisisandarenowrecoveringfromadisablingmentalstate

•  Rehabilitationcenters,shelteredworkshops,dayhospitals,outpatientclinics

•  Socialandcommunityfacilitiesthatprovidestructuredenvironmentsthatcanhelppreventproblemsituations

Evaluation:Crisis

• Anevaluationforapersonincrisisisusuallyperformed4to8weeksaftertheinitialinterview.

• Appropriatequestionstoaskareasfollows:•  Isthepatientsafe?•  Hasthepatientdevelopedmoreadaptivewaystocopewithstress

andanxiety?•  Doesthepatienthaveastrongerexistingsupportsystem?•  Hasthepatientmaintainedanoptimalleveloffunctioning?•  Hasthepatientreturnedtothepre-crisisleveloffunctioning?

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ClassActivity

Defineanddiscussthefollowing:• Terrorism• Masscasualtyincidents(MCIs)• Disasterresponse• TheNationalIncidentManagementSystem(NIMS)

• Triage

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Disasters• Disastermanagementcontinuum

• Preparedness

• Mitigation

• Response

• Recovery

• Evaluation

CriticalIncidentStressDebriefing

Criticalincidentstressdebriefing(CISD)isatertiaryinterventiondirectedtowardagroupthathasexperiencedacrisis.

CISDisusedtodebrief:•  Staffmembersonaninpatientunitafterthesuicideofapatient

•  Staffmembersafterincidentsofpatientviolence•  Crisishotlinevolunteers•  Schoolchildrenandschoolpersonnelaftershootingshaveoccurredinaschool

•  Rescueandhealthcareworkerswhohaverespondedtoanaturaldisasterorterroristattack

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CriticalIncidentStressDebriefing(CISD)

• Sevenphases• Introductoryphase• Factphase

• Thoughtphase• Reactionphase

• Symptomphase

• Teachingphase

• Re-entryphase

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AudienceResponseQuestions1.  Whichtermismostapplicabletocrisis?

A.  Self-limitingB.  BoundariesC.  AmnesiaD.  Chronic

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AudienceResponseQuestions2.  Acategory5hurricanedestroyshomesandbusinessesina

community.Howwouldthiscrisisbeclassified?

A. DisequilibriumB. AdventitiousC. MaturationalD. Situational