CRISIS THEORY AND

INTERVENTIONS
 PYRAMID POINTS

• Assessment of the phases of a crisis

• Crisis intervention
• Assessment of the levels of depression
• Implementation for the client with depression
• Assessment of the client with suicidal behavior
• Interventions for the suicidal client
 PYRAMID POINTS

• Interventions for the client with abusive

behaviors
• Interventions related to the use of restraints and
seclusion
• Assessment findings when abuse is suspected
• Interventions when abuse is suspected
• Assessment and interventions for a rape victim
 CRISIS

• DESCRIPTION
– Crisis is a temporary state of severe emotional
disorganization due to failure of coping
mechanisms and/or lack of support
– Decision-making and problem-solving are
inadequate
– Treatment is immediate, supportive, and
directly responsive to the immediate crisis to
assist the client and/or the family through the
stressful situation
 PHASES OF A CRISIS

• PHASE 1
– External precipitating event
• PHASE 2
– Perception of threat
– Increase in anxiety
– Client may cope or resolve crisis
 PHASES OF A CRISIS

• PHASE 3
– Failure of coping
– Increasing disorganization
– Physical symptoms emerge
– Relationship problems
• PHASE 4
– Mobilization of internal and external resources
– Resolutions related to pre-crisis functioning
include functioning at a higher level, at the
same level, or at a lower level
 CRISIS INTERVENTION

• Treatment is immediate, supportive, and directly

responsive to the immediate crisis
• Goal-directed intervention
• Feelings of the client are acknowledged
• Provides opportunities for expression and
validation of feelings
• Connections are made between the meaning of
the event and the crisis
• Explores alternative coping mechanisms and
tries out new behaviors
 GRIEVING

• DESCRIPTION
– A normal human process that occurs in
response to a loss
– Progresses through various stages, and the
entire process may take up to 3 years
 GRIEVING

• ASSESSMENT
– Crying
– Guilt and anger
– Fatigue and lethargy
– Insomnia
– Depression
– Agitation
 GRIEVING

• ASSESSMENT
– Anorexia
– Ambivalence
– Somatic complaints
– Sense of detachment and unreality
– Denial
 GRIEVING

• IMPLEMENTATION
– Assess the client’s progress through the grieving
process
– Encourage the client to express feelings about the
loss and its significance on life
– Encourage expression of angry feelings
– Explain the normal stages of the grieving process to
the client
– Assist the client to make appropriate future plans
related to changes caused by the loss
– Encourage the client to work through the feelings
associated with the loss
 DEPRESSION

• DESCRIPTION
– Affects feelings, thoughts, and behaviors
– Can occur after a loss, including loss of self-
esteem, the end of a significant relationship, the
death of a loved one, or a traumatic event
– The loss is followed by grief and mourning and if
this process does not resolve, depression results
– Depression may be mild, moderate, or severe
– Treatment includes counseling, antidepressant
medication, and electroconvulsive therapy (ECT)
therapy
 MILD DEPRESSION

• Triggered by an external event, and the

experience follows the normal grief reaction
• Lasts less than 2 weeks
• Feeling sad
• Feeling let down or disappointed
• Mild alterations in sleep patterns
• Feeling less alert
• Irritability
• Uninterested in spending time with others
• Increased use of alcohol or drugs
 MODERATE DEPRESSION

• Persists over time

• The person experiences a sense of change and
often seeks help
• Despondent and gloomy
• Feels dejected
• Low self-esteem
• Helplessness and powerlessness
 MODERATE DEPRESSION

• May experience intense anxiety and anger

• Diurnal variation—may feel better at a certain
time of the day, such as in the morning
• Slow thought processes and difficulty
concentrating
• Rumination—persistent thinking about and
discussion of a particular subject
• Negative thinking and suicidal thoughts
 MODERATE DEPRESSION

• Sleep disturbances
• Social withdrawal
• Anorexia, weight loss, and fatigue
• Somatic complaints
• Menstrual changes
• Increased use of alcohol or drugs
 SEVERE DEPRESSION

• Intense and pervasive

• Despair and hopelessness
• Guilt and worthlessness
• Flat affect
• May show agitation and pace about
• Poor posture and unkempt appearance
• Decreased speech
• Self-destructive thoughts; however, client may
lack energy to act on thought
 SEVERE DEPRESSION

• Social withdrawal
• Poor concentration and overwhelmed by simple
tasks
• Severe psychomotor retardation
• Anorexia and marked weight loss
• Constipation and urinary retention
• Lack of sexual interest
• Terminal insomnia
• Diurnal variation—the person feels worse in the
morning and better as the day goes on
• Delusions and hallucinations
 IMPLEMENTATION: DEPRESSION

• ALTERED THOUGHT PROCESSES

– Encourage client to discuss losses or changes
in life situation
– Encourage client to express sadness or anger
and allow adequate time for verbal responses
– Assist in developing short-term goals
– Encourage the use of problem-solving and
positive thinking
 IMPLEMENTATION: DEPRESSION

• ALTERED THOUGHT PROCESSES

– Limit decision-making
– Spend short periods of time throughout the day
with the client
– Be on time when a schedule is planned with the
client
– Sit in silence with clients who are not
verbalizing
– Use simple, concrete words when
communicating
– Avoid a cheerful attitude
 IMPLEMENTATION: DEPRESSION

• RISK FOR SELF-HARM

– Assess for suicide clues, and intervene to
provide safety precautions as necessary
– Ask client directly, “Have you thought of
hurting yourself?”
– Assess lethality of plans
– Do not leave alone for extended periods
– If the client has a suicide plan, place on one-to-
one supervision
– Develop a contract with the client
 IMPLEMENTATION: DEPRESSION

• ACTIVITY INTOLERANCE
– Encourage daily exercise
– Assist with activities of daily living (ADLs) if
the client is unable to perform
– Begin with one-to-one activities
– Provide activities for easy mastery to increase
self-esteem and assist to alleviate guilt
feelings
 IMPLEMENTATION: DEPRESSION

• ACTIVITY INTOLERANCE
– Provide activities that require little orientation
(card games, drawing)
– Engage in gross motor activities (walking)
– Eventually bring the client into small group
activities, then large groups
 IMPLEMENTATION: DEPRESSION

• ALTERED NUTRITION
– Ensure adequate nutrition
– Offer small, high-calorie, high-protein snacks
and fluids throughout the day
– Stay with the client during meals
– Weigh client weekly
– Assess bowel patterns for constipation
 IMPLEMENTATION: DEPRESSION

• SLEEP PATTERN DISTURBANCE

– Ensure adequate sleep
– Provide rest periods after activities
– Encourage the client to dress and stay out of
bed during the day
– Provide relaxation measures at bedtime
– Decrease environmental stimuli at bedtime
– Spend time with the client before bedtime
 SUICIDAL BEHAVIOR

• DESCRIPTION
– Suicidal clients characteristically have feelings
of worthlessness, guilt, and hopelessness that
are so overwhelming that they feel unable to
go on with life and unfit to live
– The nurse caring for a depressed client always
considers the possibility of the client
attempting suicide
 SUICIDAL BEHAVIOR

• HIGH-RISK GROUPS
– Those with a history of previous suicide attempts
or a family history of suicide attempts
– Adolescents
– Elderly clients
– Disabled or terminally ill adults
– Clients with personality disorders
– Clients with organic brain syndrome or dementia
– Depressed or psychotic clients
– Substance abusers
 SUICIDAL BEHAVIOR

• CLUES
– Giving away personal, special, and prized
possessions
– Canceling social engagements
– Making out or changing a will
– Taking out or changing insurance policies
– Positive or negative changes in behavior
– Poor appetite
– Sleeping difficulties
– Feelings of hopelessness
 SUICIDAL BEHAVIOR

• CLUES
– Difficulty concentrating
– Loss of interest in activities
– Client statements that indicate an intent to
attempt suicide
– Sudden calmness or improvement in a
depressed client
– Client questions about poisons, guns, or other
lethal objects
 SUICIDAL BEHAVIOR

• ASSESSMENT: THE PLAN

– Does the client have a plan?
– What is the plan, how lethal is the plan, and
how likely is death to occur?
– Does the client have the means to carry out the
plan?
 SUICIDAL BEHAVIOR

• ASSESSMENT: CLIENT HISTORY OF ATTEMPTS

– Suicide attempts in the past and the outcomes
– Was the client accidentally rescued?
– Have the past attempts and methods been the
same, or have methods increased in lethality?
 SUICIDAL BEHAVIOR

• ASSESSMENT: PSYCHOSOCIAL
– Is the client alone or alienated from others?
– Is hostility or depression present?
– Do hallucinations exist?
– Is substance abuse present?
– Any recent losses or physical illness?
– Any environmental or lifestyle changes?
 IMPLEMENTATION: SUICIDAL BEHAVIOR

• Initiate suicide precautions

• Remove harmful objects
• Do not leave the client alone
• Provide one-to-one supervision at all times
• Provide a nonjudgmental, caring attitude
• Develop a contract that is written, dated, and
signed and indicates alternative behavior at times
of suicidal thoughts
 IMPLEMENTATION: SUICIDAL BEHAVIOR

• Encourage the client to talk about feelings and to

identify positive aspects about self
• Encourage active participation in own care
• Keep client active by assigning simple tasks
• Check that visitors do not leave harmful objects
in the client’s room
• Identify support systems
• Do not allow the client to leave the unit unless
accompanied by a staff member
• Continue to assess the client’s suicide potential
 ABUSIVE BEHAVIORS

• ANGER
– A feeling of annoyance that may be displaced onto an
object or person
– Is used to avoid anxiety and gives a feeling of power
in situations in which the person feels out of control
• VIOLENCE
– The physical force that is threatening the safety of
self and others
• AGGRESSION
– Can be harmful and destructive when not controlled
 ABUSIVE BEHAVIORS

• ASSESSMENT
– History of violence or self-harm
– Poor impulse control and low tolerance of
frustration
– Defiant and argumentative
– Verbal threats
– Increased pacing and agitation
– Muscle rigidity
– Flushed face
– Glaring
– Loud voice
 ABUSIVE BEHAVIORS

• IMPLEMENTATION
– Acknowledge anger
– Set limits on behavior
– Listen actively and assist client to deal with
consequences of anger
– Provide safety for expressing anger and safety
to others
 RESTRAINTS AND SECLUSION

• PHYSICAL RESTRAINTS
– Any manual method or mechanical device,
material, or equipment that inhibits free
movement
• CHEMICAL RESTRAINTS
– Medications given for a very specific purpose of
inhibiting a specific behavior or movement; have
an impact on the client’s ability to relate to the
environment
 RESTRAINTS AND SECLUSION

• SECLUSION
– The last step in a process to maximize safety
to a client and others, in which a client is
placed alone in a specially designed room for
protection and close supervision
 USE OF RESTRAINTS AND SECLUSION

• Should never be used as punishment or for the

convenience of the health care staff
• The least restrictive means of restraint for the
shortest duration should be used
• Used when behavior is physically harmful to the
client or others
• Used when the disruptive behavior presents a
danger to the facility
• Used when alternative or less restrictive measures
are insufficient in protecting the client or others
from harm
 USE OF RESTRAINTS AND SECLUSION

• Used when the client anticipates that a controlled

environment would be helpful and requests
seclusion
• Requires a written order of a physician, which
must be reviewed and renewed every 24 hours
and which also must specify the type of restraint
to be used
• In an emergency, the charge nurse may place a
client in restraint or seclusion and obtain a
written or verbal order as soon as possible
thereafter
 USE OF RESTRAINTS AND SECLUSION

• Laws require the consent of the client unless an

emergency situation exists and can be
documented
• The client must be removed from restraint or
seclusion when safer and quieter behavior is
observed
• While in restraint or seclusion, the client must be
protected from all sources of harm
 USE OF RESTRAINTS AND SECLUSION

• The nurse must document the behavior leading to

restraint or seclusion and the time the client is
placed in and released from restraint or seclusion
• The client in restraint or seclusion must be
assessed every 15 to 30 minutes for physical
needs, safety, and comfort and these
observations are also documented
 FAMILY VIOLENCE

• The violence begins with threats or verbal or

physical minor assaults, and the victim attempts to
comply with the requests of the abuser
• The abuser loses control and becomes destructive
and harmful while the victim attempts to protect
him- or herself; the abuser then becomes loving and
attempts to make peace
• The behavior of the abuser may be an attempt
toward closeness and companionship
• The abuser believes that violence is normal and that
the victim is responsible for the abuse
 FAMILY VIOLENCE

• Outsiders are not aware of what is happening in

the family, and when outsiders try to enter the
family, the family feels assaulted
• Family members are socially isolated and lack
autonomy and trust among each other
• Caring and intimacy in the family are absent
• Family members expect other members in the
family to meet their needs but none are able to do
so
• The abuser threatens to abandon the family
 FAMILY VIOLENCE

• CHARACTERISTICS OF ABUSERS
– Impaired self-esteem
– Strong dependency needs
– Narcissistic and suspicious
– History of sexual abuse during childhood
– Perceive victims as their property and believe
that they are entitled to abuse the victim
 FAMILY VIOLENCE

• CHARACTERISTICS OF VICTIMS
– Feel trapped, dependent, helpless, and
powerless
– Depressed
– Low self-esteem and blame themselves for the
problems
 IMPLEMENTATION: FAMILY VIOLENCE

• Report cases of suspected abuse

• Assess situations associated with family violence
• Assess for evidence of physical injuries
• Ensure privacy and confidentiality during
assessment and provide a nonjudgmental and
empathetic approach to foster trust
• Assist in resolving family dysfunction with
prescribed therapies
 IMPLEMENTATION: FAMILY VIOLENCE

• Encourage psychotherapy, counseling, group

therapy, and support groups to assist family
members to develop coping strategies
• Encourage individual therapy for victims that
promotes coping with the trauma and prevents
further psychological conflict
• Provide individual therapy for abusers that
focuses on preventing violent behavior and
repairing relationships
 IMPLEMENTATION: FAMILY VIOLENCE

• Assure that the victim is not left alone with

abuser
• Assist the victim to develop self-protective
abilities and other problem-solving abilities
• Provide support and assistance in coping with
contacting the legal system
• Assist the family to identify and access
community and personal resources
 CHILD ABUSE

• Refer to Module 42, entitled Neurological,

Cognitive, and Psychosocial Disorders, for
information on child abuse
 ELDER ABUSE

• DESCRIPTION
– Abuse can be physical, sexual, psychological, or
financial
– Neglect can include unintentional failure to care
for the elder person’s needs or an intentional
neglect, such as abandonment
– Victims may attempt to dismiss injuries as
accidental and abusers may prevent victims from
receiving proper medical care to avoid discovery
– Victims are often socially isolated
– Victims may be care providers for the abuser
 ELDER ABUSE

• ASSESSMENT: PHYSICAL ABUSE

– Fractures
– Lacerations
– Punctures
– Bruises
– Burns
 ELDER ABUSE

• ASSESSMENT: SEXUAL ABUSE

– Torn or stained underclothing
– Discomfort or bleeding in the genital area
– Difficulty in walking or sitting
– Unexplained genital infections or disease
 ELDER ABUSE

• ASSESSMENT: PSYCHOLOGICAL ABUSE

– Confusion
– Fearful and agitated
– Changes in appetite and weight
– Withdrawn and loss of interest in self and
social activities
 ELDER ABUSE

• ASSESSMENT: FINANCIAL ABUSE

– Fearful when discussing finances
– Confused, inaccurate, or no knowledge of
finances
– Inability to pay bills
 ELDER ABUSE

• ASSESSMENT: NEGLECT
– Disheveled appearance
– Dehydration and malnutrition
– Dressed inadequately or inappropriately
– Lacking physical needs, such as glasses,
hearing aids, and dentures
– Skin breaks
– Signs of medication overdose
 IMPLEMENTATION: ELDER ABUSE

• Report cases of suspected abuse

• Assess for physical injuries
• Assist with providing care to treat physical
injuries
• Assist with legal procedures such as police
reports, order of protection, and court-ordered
counseling
 IMPLEMENTATION: ELDER ABUSE

• Explore alternative living arrangements which are

least restrictive and disruptive to the victim
• Assist with financial management protection
• Encourage counseling and provide referrals to
emergency community resources
• Refer to protective services for adults
• Arrange counseling and treatment for the abuser
 RAPE AND SEXUAL ASSAULT

• Engaging another person in a sexual act and/or sexual

intercourse through the use of force and without the
consent of the sexual partner
• The victim is not required by law to report the rape or
assault
• The victim is often blamed by others and often receives
no support from significant others
• Acquaintance rape involves someone known to the
victim
• Statutory rape is the act of sexual intercourse with a
minor under the age of legal consent even if there is
consent from the minor
 RAPE AND SEXUAL ASSAULT

• ASSESSMENT: FEMALE CLIENT

– Obtain the date of the last menstrual period
– Determine form of birth control used and last
act of intercourse before rape
– Duration of intercourse, orifices violated, and
penile penetration
– Use of condom by perpetrator
 RAPE AND SEXUAL ASSAULT

• ASSESSMENT
– Shame, embarrassment, and humiliation
– Anger and revenge
– Fear of telling others for fear of not being
believed
 RAPE TRAUMA SYNDROME

• Sleep disturbances, nightmares

• Loss of appetite
• Fears, anxiety, phobias, suspicion
• Decrease in activities and motivation
• Disruptions in relationships with partner, family,
friends
• Self-blame, guilt, shame
• Lowered self-esteem, feelings of worthlessness
• Somatic complaints
 RAPE AND SEXUAL ASSAULT

• IMPLEMENTATION
– Encourage the client not to shower, bathe,
douche (female), or change clothing
– Assist with the female pelvic examination and
obtaining specimens to detect for semen
– Preserve any evidence
– Treat physical injuries
– Provide client safety
 RAPE AND SEXUAL ASSAULT

• IMPLEMENTATION
– Assist client to refrain from self-blame
– Reinforce to the client that survival of the
assault is most important; if the victim
survived the rape, then he or she did exactly
what was necessary to stay alive
– Refer to crisis intervention and support groups