PSYCHIATRY EMERGENCIES

I. INTRODUCTION

An emergency is defined as an unforeseen combination of circumstances which

calls for an immediate action.

A medical emergency is defined as a medical condition which endangers

life and/or causes great suffering to the individual, A psychiatric emergency is a
disturbance in thought, mood and/or action which causes sudden distress to the
individual (or to significant others) and/or sudden disability, thus requiring immediate
management. A similar term crisis means a situation that presents a challenge to the
patient, the family and/or the community.

II. DEFINITION OF PSYCHIATRY EMERGENCIES

“A condition in which the client will have disturbances in thoughts, affect and
psychomotor activity that leads to threat either to himself or his existence. Ex: I)
suicide; threat to people in the environment; 2) homicide; which needs immediate
attention and care”.

“A sudden onset of an unusual, disordered inappropriate behaviour caused by an

emotional and physiological situation”

-Nimla Kapoor, 2002

“It is a stress induced pathologic response, which physically endangers the affected
individual, disrupts the functional equilibrium of the individual and his environment”.

III. CONCEPT OF PSYCHIATRY EMERGENCIES

Acute form of alteration in behaviour, emotion or thought which requires

immediate intervention to safeguard the life of patient by bringing down the
behavioural manifestation and promoting emotional Security to the client and others
in his surroundings. It may be resulting from either psychiatric disorders or due to
medical conditions related to environment. For example, natural disaster or manmade

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disaster (flood, famine) or manmade disaster; conditions like rape, violence etc. It is a
combination of circumstances which needs immediate attention.

IV. OBJECTIVES OF PSYCHIATRY EMERGENCY INTERVENTION

 To safeguard the life of patient

 To reduce the anxiety

 To promote emotional security of client and the family members.

 To educate the client and his family members the ways of dealing emergency
situation by utilizing adaptive coping strategies and appropriate problem
solving techniques.

V. CHARACTERISTICS OF PSYCHIATRY EMERGENCIES

 Certain conditions or stressors predisposes the client and his family members to
seek immediate intervention, as they feel more discomfort.

 Disharmony between client and his environment

 Sudden, unexpected, disorganization in person

 Unable to cope up with the stressful situation or failure in handling the

stressors.

VI. GENERAL GUIDELINES TO MANAGE PSYCHIATRIC

EMERGENCIES

1. Handle with the utmost of tact and speech so that well being of other patients is not
affected.

2. Act in a calm and coordinate manner to prevent other clients from getting anxious.

3. Shift the client as early as possible to a room where they can be safe guarded
against injury.

4. Ensure that all other clients are reassured and the routine activities proceed
normally.

5. Psych. emergencies overlap medical emergencies and staff should be familiar with
the management of both.

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 VII. TYPES OF PSYCHIATRY EMERGENCIES

1. Deliberate harm to self (suicide) or others (Aggression and Violence)

2. Acute Psychiatric disorder

3. Chronic psychiatric disorder with a relapse

4. Organic Psychiatric Disorder

5. Abnormal response to stressful situation

6. Iatrogenic Emergencies

a. Side-effects or toxicity of the psychotropic medication( s)

b. Psychiatric Symptomatology as a side-effect or toxicity of other medication(s)

7. Alcohol or Drug dependence

8. Other Psychiatric Emergencies

a. Severe Depression

b. Hyperventilation syndrome

c. Insomnia

d. Pseudo-seizures

e. Status Epilepticus

f. Anorexia Nervosa

g. Battered Child Syndrome or Child abuse

h. Grief and bereavement

i. Psychosocial Crisis

j. Panic Disorder

k. Acute psychosis

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 VIII. MANAGEMENT OF PSYCHIATRY EMERGENCIES

1. SUICIDE

Suicide (deliberate.self-harm) is defined as a human act of killing oneself.

Epidemiology of Suicide

Suicide occurs throughout the lifespan and it is the 17th leading cause of death in
2015 globally. There are 30,000 suicides each year in the United States vs. 20,000
homicides. It is the ninth leading cause of death in adults. Suicide attempts are ten
times more frequent than completed suicides. There are approximately 20 suicidal
deaths per 1 00, 000. Except for the Great Depression (when rates rose) and WWI and
WWII (when rates fell), this rate has been constant in the US

PREDICTING SUICIDE

Clinicians are not very good at predicting suicide. Some patients may carry many
risk factors and not commit suicide, while others may seem to carry few risk factors
and unexpectedly do so. Assessment involves combining an analysis of a patient’s risk
factors with information about the patient’s suicidal ideation and planning. Half the
people who commit suicide have been seen by a primary care physician within the
month prior to their death. While humbling, this fact offers hope that better screening
can reduce suicide rates.

Suicide prediction

Two simple mnemonics that summarize above risk factors are SAD PERSONS and
NO HOPE.

SAD PERSONS • Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational
thought loss, Social supports lacking, Organized plan, No spouse, Sickness.

NO HOPE• No framework for meaning, Overt change in clinical condition, Hostile

interpersonal environment, Out of hospital recently, Predisposing personality factors,
Excuses for dying to help others.

Scales: Beck’s Hopelessness Scale

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Demographic Factors

Gender

In the US, men have completion rates that are three times higher than those for
women. Women attempt suicide three times more often than men. Theories seeking to
explain the different suicide completion rates: men use highly lethal methods (e.g.,
guns), whereas women useless violent methods (e.g., pills); women are more likely to
seek medical help than men; they tend to have better-social supports (friends, family)
than men. Female rates increase as women get older

Racial, Ethnic, and Cultural Differences in the US

White male and female rates are approximately two to three times higher than African
American (AA) male and female rates. Controlling for socioeconomic differences
narrows the difference in suicide rates. Native Americans have highest suicide rate in
the US. Homosexual men and women appear to have higher rates of suicide than
matched heterosexuals. Urban areas tend to have higher rates than rural areas

Age

 Suicide is rare before the age of 15

 Suicide rates among young white men increase dramatically between ages 15
and 25, whereupon they remain relatively steady until another dramatic
increase after the age of 65

 African American men have a similar peak in adolescence, but the incidence
declines with age

 Between the ages of 15 to 25, suicide is third leading cause of death (after
accidents and homicides). Adolescence features the lowest ratio of attempts to
completions (an attempt is more likely to be fatal)

 While suicide rates among women increase modestly with age, they remain
quite stable after the age of 35

 Female rates are low throughout the life cycle

 Between 1950 and 1980, completion rates for 15-24 Year old men and women

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 (white and black) increased two to three times

 Overall rate of suicide has been constant from 1950 to 1980 (about20 out of
100,000). During this time, elderly rates fell as adolescent rates increased.
Postulated reasons for decreased rates in elderly are improved quality of life
and improved treatment for geriatric depression

Method

In the US, firearms are the most common method of suicide, accounting for 60%,
of all suicides

ETIOLOGIES

Psychological

 Edwin Schneidman: psychache, and tunnel vision associated with bleak world
view of depression, leading to suicide

 Freud: in Mourning and Melancholia, argued that after the internalization of a

loved one, the loss of that loved object leads to an aggression that is turned
inward. It can be postulated that this aggression turned inward leads to the
commonly-seen recriminations, depression, and guilt that tend to accompany
suicidality. The role of aggression is supported clinically by the phenomenon of
murder-suicide

 Karl Menninger: suicidal triad: wish to die, a wish to kill, and a wish to be
killed

Biological

 Genetic: An Amish study described families with mood disorders and suicide
vs. Families with mood disorders without suicide. Adoption studies have also
supported that having biological relatives who committed suicide is an
independent risk factor for suicide. Concordance rate for suicide in
monozygotic twins is 13.2% vs.0.7% for dizygotic twins (i.e., if one member of
a twin pair commits suicide, then 13.2 of the monozygotic twins also commits
suicide while only 0. 7 of the dizygotic twins follow their twin into suicide)

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  Depressed patients who attempted suicide have been shown to have lower
levels of 5-HT than depressed patients who were not suicidal. Violent attempts
are associated with lower 5—HT levels than nonviolent attempts. Low 5-HT
levels have also been shown in non-suicidal impulsive individuals, suggesting
low 5- HT levels may be a marker for poor impulse control

 Cortical hypothalamic pituitary adrenal axis (HPA). Elevated corticotrophin

releasing factor (CRF) in CSF and decreased CRF binding sites in frontal
cortex of suicide completers

Biopsychosocial

 Separating infant rats from mothers predisposes them to react more

profoundly to later stresses ( as measured by elevated cortisol levels) than
controls

 Stress diathesis models of suicide: Individuals with innate tendencies towards

impulsivity, possibly exacerbated by early fife stressors such as physical or
sexual abuse, have increased risk for suicide when depressed

DIAGNOSIS

70-90% of those who complete suicide are found to have a DSM-IV TR diagnosis.
These are primarily Axis I disorders, but people with personality disorders are also at
increased risk.

Axis I Disorders

 While major depression carries with it a 10% lifetime risk of suicide, the risk is
15-20% for bipolar disorder. Elevated risk in bipolar disorder may be
attributable to the difficulty in the treatment of depression in bipolar illness as
well as frequent lack of insight and non adherence to medications in the bipolar
population

 Schizophrenia: Ten percent lifetime prevalence of death By suicide

 Risk factors:

First psychotic break or during the recovery from psychosis and/or a

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 severe depression

Command hallucinations

Substance abuse and panic disorders

Axis II Disorders

 Borderline personality disorder is associated with suicidal and parasuicidal

behaviour. Parasuicidal behaviour, such as self-cutting, is more commonly
aimed at self-soothing than suicide. Borderline patients do commit suicide,
however, and may also inadvertently kill themselves through parasuicidal or
risky behaviour

 Antisocial personality has recently been demonstrated to be associated with an

increased suicide rate. This contrasts with the longstanding notion that people
with antisocial personality would lack the guilt and remorse that are frequently
part of suicidality

Axis Ill Disorders

Medical illness (especially chronic illness with pain), neurological disease, and cancer
are associated with increased suicide rates.

RISK FACTORS AND ISSUES TO BE ADDRESSED IN A POTENTIALLY

Acute

Specific plan, means (especially firearms), prior suicide attempts, substance abuse or
panic disorder with depression, recent losses (relationship, job), and high intention to
die.

Sub Acute

For women more than men, an attempt indicates high risk for death by suicide within
six months. For both sexes, attempts associated with increased risk for succeeding two
to ten years

Chronic (Longer Term)

Past history of suicide attempts ( an acute and chronic risk), history of impulsive
behaviour, family history of depression and/or suicide attempts/completions, living

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alone, widowed or divorced status, white race, male, elderly, access to lethal agents
(acute and chronic risk factor)

 Typical profiles of suicide completers: Single white man with depression,

alcohol abuse, and access to firearms; young women with a personality
disorder, such as borderline, narcissistic, or histrionic personality disorder,
following rejection or loss

 Three Facts: Of those who ever attempt suicide, eight to ten percent ultimately
succeed. Of completed 2/3 never attempted suicide previously. The
overwhelming majority of those who have suicidal ideation never attempt
suicide

PHYSICIAN-ASSISTED SUICIDE

Oregon’s 1997 Death with Dignity Act (AKA, the Physician Assisted Suicide law)
allows physicians to prescribe a dose of lethal medication to selected terminally m
adults. It is controversial, and both the APA and AMA oppose it. While the Act seems
to be serving its purpose among a relatively small group of patients, it has been
demonstrated that suicidality is not typical in the terminally ill and that treatment of
depression and/or pain often alleviates the suicidality.

TREATMENT AND PREVENTION

Work with the suicidal patient includes assessment of risk, maximization of safety,
and both the identification and treatment of the underlying psychiatric disorder. In
addition, it is important to develop an alliance so that current and future suicidality
can be openly addressed. Finally, ongoing work with a high-risk population will likely
lead to experience with people who do commit suicide regardless of the best efforts of
everyone involved. In such situations, self reflection and supervision from peers and
mentors are vital aspects of the ability to maintain this work.

NURSING MANAGEMENT

1. NURSING DIAGNOSIS:

RISK FOR SUICIDE RELATED TO: Feelings of hopelessness and desperation

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OUTCOME CRITERIA

• Client will not harm self.

Nursing Interventions Rationale

1. Ask Client directly: “Have you 1. Risk of suicide is greatly

thought about harming yourself increased if the client has
in any way? If so, what do you developed a plan and particularly
plan to do? Do You have the if means exist for the client to
means to carry out this plan?” execute the plan.

2. Create a safe environment for the

client. Remove all I potentially 2. Client safety is a nursing
harmful objects from client’s priority ..
access (sharp objects, straps,
3. A degree of the ·responsibility
belts, ties, glass items, alcohol).
for his or her safety is given to
Supervise closely during meals
the client. Increased feelings of
and medication I administration.
self-worth may be experienced
Perform room searches as
when client feels accepted
deemed necessary.
unconditionally regardless of
3. Formulate a short-term verbal or thoughts or behaviour.
written contract that the client
4. Close observation is necessary to
will not harm self. When time is
ensure that client not harm self in
up, make another, I and so forth.
any way. Being alert for suicidal
Secure a promise that the client
and escape attempts facilitates
will seek out staff when feeling
being able to prevent or interrupt
suicidal.
harmful behaviour.
4. Maintain close observation of
5. Prevents saving up to overdose or
client. Depending on level I of
discarding and not taking.
suicide precaution, provide one-
6. Prevents staff surveillance from

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 to-one contact, constant I visual becoming predictable. Be aware
observation, or every-15- minute of client’s location is important,
checks. Place in room close to especially when staff is busy and
nurse’s station; do not assign to least available and observable.
private room. Accompany to 7. Depression and suicidal
offunit activities if attendance is behaviours may be viewed as
indicated. May need to anger turned inward on the self.
accompany to bathroom. If this anger can be verbalized in
5. Maintain special care in a nonthreatening environment,
administration of medications. the client may be able to

6. Make rounds at frequent, eventually resolve these feelings.

irregular intervals (especially

night, toward early morning, at
change of shift, or other
predictably busy times for staff).

7. Encourage client to express

honest ·feelings, including anger.
Provide hostility release if
needed.

NURSING DIAGNOSIS:

HOPELESSNESS RELATED TO: Absence of support systems and perception of

worthlessness

EVIDENCED BY: Verbal cues (despondent content, “I can’t"); decreased affect; lack
of initiative; suicidal ideas or attempts

OUTCOME CRITERIA

 Client will verbalize a measure of hope and acceptance of life and situations
over which he or she has no control.

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Nursing Interventions Rationale
1. Identify stressors in client’s life that 1. Important to identify causative or contributing
precipitated current crisis. factors in order to plan appropriate assistance.
2. Determine coping behaviors
2. It is important to identify client’s strengths and
previously used and client’s
encourage their use in current crisis situation.
perception of effectiveness then and
3. Identification of feelings underlying behaviors
now.
helps client to begin process of taking control of
3. Encourage client to explore and
own life.
verbalize feelings and perceptions.
4. Provide expressions of hope to 4. Even though the client feels hopeless, it is helpful
client in positive, low- key manner to hear positive expressions from others. The
(e.g., ul know you feel you cannot client’s current state of mind may prevent him or
go on, but I believe that things can her from identifying anything positive in life. It is
get better for you. What you are important to accept the client’s feelings non
feeling is temporary. It is okay if judgmentally and to affirm the individual’s
you don’t see it just now.” “You are personal worth and value.
very important to the people who 5. The client’s emotional condition may interfere
care about you.’’) with ability to problem solve. Assistance may be
4. Help client identify areas of life required to perceive the benefits and consequences
situation that are under own control. of available alternatives accurately.

5. Identify sources that client may use 6. Client should be made aware of local suicide
after discharge when crises occur or hotlines or other local support services from whom
feelings of hopelessness and he or she may seek assistance following discharge
possible suicidal ideation prevail. from the hospital. A concrete plan provides hope
in the face of a crisis situation.
2. DANGEROUSNESS BACKGROUND

Dangerousness refers to an individual’s risk for violent behavior. Clinicians are called
upon to assess dangerousness in several settings:

 To assess a patient’s need for hospital admission.

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  To assess threats made by a patient against someone in the community.

 When evaluating a patient for discharge.

 For the courts

Epidemiology

Violence is universal in human societies. Most perpetrators and victims

are men. Most violence in the population is not associated with mental disorder. 1.6
million People, per year, worldwide die from violence. In 2000, half were suicides,
one-third homicides, and one-fifth casualties of war.

Homicide: suicide ratio varies from culture to culture. Homicides are more common
than suicides in the Americas and Africa, whereas suicide is more common than
homicide in Europe and Southeast Asia.

Etiologies

Violence has been related to certain hormones and neurotransmitters, to brain injuries,
to various environmental stressors, and to some forms of mental illness.

Biological Gender, Hormones

Testosterone is positively associated with violence. Males are more

violent than females {eight times more likely to commit murder, nine times more
likely to commit armed robbery). Anabolic steroids increase aggression, disinhibition,
psychosis, and violent behavior.

Neurotransmitters

Research is still in early stages and inconclusive, but points to possible

serotonin dysregulation. There are reports of low CSF 5-HIAAin aggressive humans.
In one study, men depleted of tryptophan (precursor of serotonin) became more
aggressive in the laboratory setting than non-depleted men. Levels of monoamine
oxidase (MAO), which breaks down serotonin, have been reported to be lower than
normal in aggressive individuals. A point mutation in MAO A, an X-linked gene,
resulting in enzyme deficiency, was associated with violent behavior in members of a

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Dutch family.

Genetics

Adopted children of criminal biological parents have violence risk nearer

that of biological parents. Greatest risk of violence is for children whose biological
and adoptive fathers are criminal (suggesting that an environmental component is
significant).

Environmental

While specific findings are tentative, the research suggests that exposure
to a variety of stressors, from intrauterine through adult life, increases the risk of
violence.

Intrauterine and peri-natal

Noxious prenatal influences, ranging from cocaine addiction to

psychological stressors to anxiety, have been associated with childhood m a
(adaptation and later risk for violence.

Nurturing

Mothers with poor attachment behaviors have been reported to produce

children with increased childhood aggressiveness.

Child Abuse

Physical, sexual, and emotional abuse in childhood is very strongly

correlated to aggressive behavior. Abuse provides behavior model, causes paranoid
worldview, impairs cognition, and impairs normal development of empathy. These
persons often dissociate when they commit violence.

Social Factors

Extreme poverty is associated with aggression, particularly in young men.

Brain Injury

Aggressive behavioral changes have been seen in individuals with damage

to medial temporal lobe and with brain tumors in limbic system. Frontal lobe damage
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(e.g., head trauma) is associated with impulsive, aggressive behavior. PET scans show
hypoactivation of prefrontal cortex areas in individuals prone to impulsive, aggressive
acts.

3. MENTAL ILLNESS AND AGGRESSION

Though most mental patients are not violent, violence is more common
among mental patients than among the general population. Below are seminal studies
that help map out the relationship of mental illness to violence.

Mental Illness

A study by Swanson et al. (1990) of representative households comprising

10,000 people from three US cities found that:

 Violence is more than five times higher among people who meet DSM III
criteria for an Axis 1 disorder (11- 13%) than among people who do not (2%)
 Prevalence of violence among those who meet criteria for schizophrenia, major
depression, or bipolar disorder are similar (11-13%).
 Prevalence of violence is higher among substance abusers.
 Prevalence of violence is highest among mentally ill with comorbtd substance
abuse (approx. 25%)

Active Psychosis

Link et al., (1992) found that when controlling for “current psychotic
symptoms” in a population sample, rates of violence were the same for mental patients
and community controls.

Comorbid Substance Abuse

Steadmanetal (1998) assessed risk of violence in the year following

discharge from a psychiatric hospital. Of those who committed a violent act, 17.9%
had an Axis I major mental disorder without substance abuse; 31.1% had an Axis I
major mental disorder (i.e., major depression, bipolar disorder, and schizophrenia) and
a substance abuse diagnosis; and 43.0% had some other form of mental disorder
(primarily personality disorder or adjustment disorder) and a substance abuse

15
diagnosis. In other words, substance abuse appeared to play a significant role in most
acts of violence among recently discharged psychiatric patients.

Axis It Disorders

Cluster B disorders (antisocial, borderline, histrionic, and narcissistic

personality disorders) are associated with dangerousness. One cluster A disorder,
paranoid personality disorder, is (less commonly) associated with violence. As
mentioned above, cognitive impairment (e.g., mental retardation) is linked to violence,
especially when the patient is frustrated.

ASSESSMENT

Assessment of individuals for violent potential is an inexact science.

Assessments are subjective and qualitative. Dangerousness is a state, not a trait: risk
varies with time, mental state, and setting.

 Clinicians are not very good at predicting dangerousness. Lidz et al., (1993)
asked clinicians to rate potential violence over the coming six months in
patients seen in a psychiatric ER. The patients rated high risk by clinicians had
somewhat higher rates of violence (53%) than those who were not (36%).
Clinicians' accuracy of violence assessment among women was no different
than chance.

FACTORS IN THE ASSESSMENT OF RISK

The cumulative number of risk factors is proportional to future violence risk.

Age - Youth is associated with violence in both men and women. A subset of elderly
patients become violent because of dementia, paranoia, and delirium.

Sex - Men commit the majority of violent crimes in every culture. However, among
mentally ill persons, the sex ratio for violent behavior is approximately equal. Women
are more likely to act violently toward their children than toward men.

Race - When controlling for diagnosis, there is no link between race and aggression.,

Socioeconomic Status (SES) - Violent offenders, as well as violent offenders who are
mentally ill, are more likely to have a low SES.
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Substance Abuse - Increases risk for violence in both intoxication and withdrawal.
Alcohol intoxication is implicated in the majority of violent crimes, including
murders, physical and sexual assaults, and domestic violence.

Mental Status - Active psychosis; paranoia, command hallucinations to commit

violence; mania; narcissistic injuries and feelings of humiliation. Of note, 10 to 17%
of psychiatry emergency visits involve homicidal ideation. Rates of violence peak
around the time of hospital admission or contact with the police.

Situational Factors - Family members and close friends are the most common victims
of violence by mentally ill and nonmentally ill individuals. It is important to discover’
if the patient lives with potential victims, and if weapons are accessible.

The Degree of Planning - This is an important variable in assessing risk of violence.

This must be addressed in interview. What is the plan? What are proposed means?
Timing? Setting?

Historical Factors - Childhood abuse or neglect; childhood triad of fire setting,

enuresis, and cruelty to animals; history of violent, antisocial, or threatening behavior.

Biological Factors - Cognitive impairment from brain damage is associated with

violent behavior in inmates, previously normal individuals following a brain insult,
a/id geriatric patients experiencing organic brain disease.

Medical Conditions - Associated with violence tend to be either metabolic

abnormalities or neuropsychiatric disorders. These include systemic infections,
hypoxia, electrolyte imbalances, hepatic disease, renal disease, syphilis, thyroid
disease, encephalitis, tuberculosis, fungal meningitis, Wilson’s disease, and
intoxication from heavy metals or psychoactive substances.

METHODS FOR ASSESSMENT OF RISK

 Clinical impression is the traditional approach taught in residencies, and uses

historical and current biopsychosocial risk factors (previously listed) to
generate a clinical impression of risk.

 The actuarial approach assesses risk-using methods similar to how insurance

17
 companies calculate a person’s risk for illness or death given age and
characteristics, e.g., PCL-R (Hare Psychopathy Checklist Revised) uses clinical
data to generate a score estimating likelihood of future violence. The
instrument requires clinical judgments (e.g., degree of narcissism, charm, etc.)
so that it actually represents a fusion of the clinical and actuarial methods.
HCR-20 (Historical, Clinical, Risk-20) uses historical, clinical, and risk
variables to generate a score It is generally believed that the clinical method is
better for the short term (e.g., emergency room), whereas actuarial method is
better for the long term (e.g., probability of violence in one year or more).

ACUTE MANAGEMENT

Safety is paramount; If clinician feels unsafe, the interview should be conducted with
the door open or in an open area. If patient does not respond to verbal de- escalation,
medication may be used. The combination of an antipsychotic medication with a
benzodiazepine is frequently used when the underlying diagnosis is uncertain and the
goal is relatively rapid sedation. For example, haloperidol may be given in
conjunction with lorazepam at an approximately 2:1 ratio (e.g., haloperidol 2 mg with
lorazepam 1 mg or haloperidol 5 mg with lorazepam 2 mg)

Seclusion and restraint are indicated: To prevent imminent harm to patient or others,
to prevent serious damage or disruption to physical environment or treatment
program, to provide behavioral therapy. Seclusion without restraint may be indicated
to decrease stimulation or if patient requests seclusion.

Transference and countertransference

Clinicians may feel a variety of intense feelings in response to dangerous

or potentially dangerous patients. These feelings should prompt clinicians to ensure
their own safety, but to also consider whether the intensity of their reactions may stem
from previous experiences or previous relationships. Such counter transference can
lead to a variety of suboptimal clinical reactions that range from excess fear and
avoidance to over involvement and a disregard for personal safety. Acute or chronic
exposure to dangerous situations can also lead clinicians to having acute stress

18
reactions and even PTSD. It is often helpful to discuss intense feelings with
supervisors and colleagues, and within team meetings in order to reduce the likelihood
of acting out or being professionally deskilled.

Legal implications

Most laws regarding clinical practice are state laws. Tarasoff case law
from California has been generally accepted across the US. The Tarasoff decision
ruled that clinicians have a duty to protect identifiable third parties when they deem a
patient a serious danger of violence. In this case, clinicians are obligated to take
reasonable steps to protect the third party, such as warning them and/or notifying the
police.

4. STRESS AND ADOPTION

Psychologists and others have struggled for many years to establish an

effective definition of the term stress. This term is used loosely today and still lacks a
definitive explanation. Stress may be viewed as an individual’s reaction to any change
that requires an adjustment or response, which can be physical, mental, or emotional.
Responses directed at stabilizing internal biological processes and preserving self-
esteem can be viewed as healthy adaptations to stress.

Roy (1976) defined adaptive response as behavior that maintains the integrity of the
individual. Adaptation is viewed as positive and is correlated with a healthy response.
When behavior disrupts the integrity of the individual, it is perceived as maladaptive.
Maladaptive responses by the individual are considered to be negative or unhealthy.

Various twentieth-century researchers contributed to several different of stress. Three

of these concepts include stress as a biological response, stress as an environmental
event, and stress as a transaction between the individual and the environment. This
chapter includes an explanation of each of these concepts.

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Stressor

A biological, psychological, social, or chemical factor that causes physical

or emotional tension and may be a factor in the etiology of certain illnesses.

Adaptation

Adaptation is said to occur when an individual’s physical or behavioral

response to any change in his or her internal or external environment results in
preservation of individual integrity or timely return to equilibrium.

Maladaptation

Maladaptation occurs when an individual’s physical or behavioral

response to any change in his or her internal or external environment results in
disruption of individual integrity or in persistent disequilibrium.

Stress as a biological response

In 1956, Hans Selye published the results of his research concerning the
physiological response of a biological system to a change imposed on it. Since his
initial publication, he has revised his definition of stress, calling it "the state
manifested by a specific syndrome which consists of all the nonspecifically-induced
changes within a biologic system" (Selye, 1976). This syndrome of symptoms has
come to be known as the “fight or flight syndrome.” Selye called this general
reaction of the body to stress the general adaptation syndrome. He described the
reaction in three distinct stages:

1. Alarm Reaction Stage. During this stage, the physiological responses of the “fight
or flight syndrome” are initiated.

2. Stage of Resistance. The individual uses the physiological responses of the first
stage as a defense in the attempt to adapt to the stressor. If adaptation occurs, the
third stage is prevented or delayed. Physiological symptoms may disappear.

3. Stage of Exhaustion. This stage occurs when there is a prolonged exposure to the
stressor to which the body has become adjusted. The adaptive energy is depleted,
and the individual can no longer draw from the resources for adaptation described

20
 in the first two stages. Diseases of adaptation (e.g,, headaches, mental disorders,
coronary artery disease, ulcers, colitis) may occur. Without intervention for
reversal, exhaustion ensues, and in some cases even death (Selye, 1956,1974).

This "fight or flight” response undoubtedly served our ancestors well. Those Homo
sapiens who had to face the giant grizzly bear or the saber-toothed tiger as part of their
struggle for survival must have used these adaptive resources to their advantage. The
response was elicited in emergency situations, used in the preservation of life, and
followed by restoration of the compensatory mechanisms to the preemergent condition
(homeostasis). Selye performed his extensive research in a controlled setting with
laboratory animals as subjects. He elicited the physiological responses with physical
stimuli, such as exposure to heat or extreme cold, electric shock, injection of toxic
agents, restraint, and surgical injury. Since the publication of his original research, it
has become apparent that the "fight or flight" syndrome of symptoms occurs in
response to psychological or emotional stimuli, just as it does to physical stimuli. The
psychological or emotional stressors are often not resolved as rapidly as some physical
stressors, and therefore the body may be depleted of its adaptive energy more readily
than it is from physical stressors. The "fight or flight" response may be inappropriate,
even dangerous, to the lifestyle of today, in which stress has been described as a
psychosocial state that is pervasive, chronic, and relentless. It is this chronic response
that maintains the body in the aroused condition for extended periods of time that
promotes susceptibility to diseases of adaptation.

Stress as an environmental event

A second concept defines stress as the “thing”or “event” that triggers the
adaptive physiological and psychological responses in an individual. The event creates
change in the life pattern of the individual, requires significant adjustment in lifestyle,
and taxes available personal resources. The change can be either positive, such as
outstanding personal achievement, or negative, such as being fired from a job. The
emphasis here is on change from the existing steady state of the individual’s life
pattern. Miller and Rahe (1997) have updated the original Social

Readjustment Rating Scale devised by Holmes and Rahe in 1967. Just as in the earlier

21
version, numerical value are assigned to various events, or changes, that are common
in people’s lives. The updated version reflects an increased number of stressors not
identified in the original version. In the new study, Miller and Rahe found that women
react to life stress events at higher levels than men, and unmarried people gave higher
scores than married people for most of the events. Younger subjects rated more events
at a higher stress level than did older subjects. A high score on the Recent Life
Changes Questionnaire (RLCQ) places the individual at greater susceptibility to
physical or psychological illness. The questionnaire may be completed considering
life stressors within a 6-month or 1-year period. Six-month totals equal to or greater
than 300 life change units (LCUs) or 1-year totals equal to or greater than 500 LCU
are considered indicative of a high level of recent life stress, thereby increasing the
risk of illness for the individual. It is unknown whether stress overload merely
predisposes a person to illness or actually precipitates it, but there does appear to be a
causal link (Pelletier, 1992).

Life changes questionnaires have been criticized because they do not

consider the individual’s perception of the event. Individuals differ in their reactions
to life events, and these variations are related to the degree to which the change is
perceived as stressful. These types of instruments also fail to consider the individual’s
coping strategies and available support systems at the time when the life change
occurs. Positive coping mechanisms and strong social or familial support can reduce
the intensity of the stressful life change and promote a more adaptive response.

Stress as a transaction between the individual and the environment

This definition of stress emphasizes the relationship between the

individual and the environment. Personal characteristics and the nature of the
environmental event are considered. This illustration parallels the modern concept of
the etiology of disease. No longer is causation viewed solely as an external entity;
whether or not illness occurs depends also on the receiving organism’s susceptibility.
Similarly, to predict psychological stress as a reaction, the properties of the person in
relation to the environment must be considered.

Precipitating Event

22
 Lazarus and Folkman (1984) define stress as a relationship between the
person and the environment that is appraised by the person as taxing or exceeding his
or her resources and endangering his or her well being. A precipitating event is a
stimulus arising from the internal or external environment and is perceived by the
individual in a specific manner. Determination that a particular person/ environment
relationship is stressful depends on the individual's cognitive appraisal of the situation.
Cognitive appraisal is an individual's evaluation of the personal significance of the
event or occurrence. The event "precipitates" a response on the part of the individual,
and the response is influenced by the individual’s perception of the event. The
cognitive response consists of a primary appraisal and a secondary appraisal.

The Individual’s Perception of the Event Primary Appraisal

Lazarus and Folkman (1984) identify three types of primary appraisal:

irrelevant, benign-positive, and stressful. An event is judged irrelevant when the
outcome holds no significance for the individual. A benign-positive outcome is one
that is perceived as producing pleasure for the individual. Stress appraisals include
harmlIoss, threat, and challenge. HarmlIoss appraisals refer to damage or loss already
experienced by the individual.

Appraisals of a threatening nature are perceived as anticipated harms or

losses. When an event is appraised as challenging, the individual focuses on potential
for gain or growth, rather than on risks associated with the event. Challenge produces
stress even though the emotions associated with it (eagerness and excitement) are
viewed as positive, and coping mechanisms must be calfed upon to face the new
encounter. Challenge and threat may occur together when an individual experiences
these positive emotions along with fear or anxiety over possible risks associated with
the challenging event. When stress is produced in response to harm/Ioss, threat, or
challenge, a secondary appraisal is made by the individual.

Secondary Appraisal

This secondary appraisal is an assessment of skills, resources, and

knowledge that the person possesses to deal with the situation. The individual

23
evaluates by considering the following:

 Which coping strategies are available to me? Will the option l choose be
effective in this situation?

 Do I have the ability to use that strategy in an effective manner?

The interaction between the primary appraisal of the event that has
occurred and the secondary appraisal of available coping strategies determines the
quality of the individual’s adaptation response to stress.

Predisposing Factors

A variety of elements influence how an individual perceives and responds

to a stressful event. These predisposing factors strongly influence whether the
response is adaptive or maladaptive. Types of predisposing factors include genetic
influences, past experiences, and existing conditions. Genetic influences are those
circumstances of an individual’s life that are acquired through heredity. Examples
include family history of physical and psychological conditions (strengths and
weaknesses) and temperament (behavioral characteristics present at birth that evolve
with development). Past experiences are occurrences that result in learned patterns
that can influence an individual’s adaptation response. They include previous
exposure to the stressor or other stressors, learned coping responses, and degree of
adaptation to previous stressors. Existing conditions incorporate vulnerabilities that
influence the adequacy of the individual’s physical, psychological, and social
resources for dealing with adaptive demands. Examples include current health status,
motivation, developmental maturity, severity and duration of the stressor, financial
and educational resources, age, existing coping strategies, and a support system of
caring others.

STRESS MANAGEMENT

The growth of stress management into a multimilliondollar- a-year

business attests to its importance in our society. Stress management involves the use
of coping strategies in response to stressful situations. Coping strategies are adaptive
when they protect the individual from harm (or additional harm) or strengthen the

24
individual’s ability to meet challenging situations. Adaptive responses help restore
homeostasis to the body and impede the development of diseases of adaptation.
Coping strategies are considered maladaptive when the conflict being experienced
goes unresolved or intensifies. Energy resources become depleted as the body
struggles to compensate for the chronic physiological and psychological arousal being
experienced. The effect is a significant vulnerability to physical or psychological
illness.

Adaptive Coping Strategies Awareness

The initial step in managing stress is awareness to become aware of the

factors that create stress and the feelings associated with a stressful response. Stress
can be controlled only when one recognizes that it is being experienced. As one
becomes aware of stressors, he or she can omit, avoid, or accept them.

Relaxation

Individuals experience relaxation in different ways. Some individuals

relax by engaging in large motor activities, such as sports, jogging, and physical
exercise. Still others use techniques such as breathing exercises and progressive
relaxation to relieve stress.

Meditation

Practiced 20 minutes once or twice daily, meditation has been shown to

produce a lasting reduction in blood pressure and other stress-related symptoms
(Davis, Eshelman, & McKay, 2008). Meditation involves assuming a comfortable
position, closing the eyes, casting off all other thoughts, and concentrating on a single
word, sound, or phrase that has positive meaning to the individual.

Interpersonal Communication with Caring Other

As previously mentioned, the strength of one’s available support systems

is an existing condition that significantly influences the adaptiveness of coping with
stress. Sometimes just “talking the problem out" with an individual who is empathetic
is sufficient to interrupt escalation of the stress response. Writing about one’s feelings

25
in a journal or diary can also be therapeutic.

Problem Solving

An extremely adaptive coping strategy is to view the situation objectively

(or to seek assistance from another individual to accomplish this if the anxiety level is
too high to concentrate). After an objective assessment of the situation* the problem-
solving/decision-making model can be instituted as follows:

 Assess the facts of the situation.

 Formulate goals for resolution of the stressful situation.

 Study the alternatives for dealing with the situation.

 Determine the risks and benefits of each alternative

 Select an alternative.

 Implement the alternative selected.

 Evaluate the outcome of the alternative implemented.

 If the first choice is ineffective, select and implement a second option.

Pets

Studies show that those who care for pets, especially dogs and cats, are
better able to cope with the stressors of life (Allen, Blascovich, &Mendes, 2002;
Barker et al., 2005). The physical act of stroking or petting a dog or cat can be
therapeutic. It gives the animal an intuitive sense of being cared for and at the same
time gives the individual the calming feeling of warmth, affection, and
interdependence with a reliable, trusting being. One study showed that among people
who had had heart attacks, pet owners had one-fifth the death rate of those who did
not have pets (Friedmann & Thomas, 1995). Another study revealed evidence that
individuals experienced a statistically significant drop in blood pressure in response to
petting a dog or cat (Whitaker, 2000).

26
Music

It is true that music can “soothe the savage beast.” Creating and listening
to music stimulate motivation, enjoyment, and relaxation. Music can reduce
depression and bring about measurable changes in mood and general activity.

5. CRISIS

CHARACTERISTICS OFACRISIS

A number of characteristics have been identified that can be viewed as

assumptions upon which the concept of crisis is based (Aguilera, 1998; Caplan, 1964;
Winston, 2008). They include the following:

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. What may be considered a crisis situation by one
individual may not be so for another.

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.

Individuals who are in crisis feel helpless to change. They do not believe
they have the resources to deal with the precipitating stressor. Levels of anxiety rise to
the point that the individual becomes nonfunctional, thoughts become obsessional, and
all behavior is aimed at relief of the anxiety being experienced. The feeling is
overwhelming and may affect the individual physically as well as psychologically.

Bateman and Peternelj-Tayior (1998) state: Outside Western culture, a

crisis is often viewed as a time for movement and growth. The Chinese symbol for
crisis consists of the characters for danger and opportunity: When a crisis is viewed as
an opportunity for growth, those involved are much more capable of resolving related
issues and more able to move toward positive changes. When the crisis experience is
overwhelming because of its scope and nature or when there has not been adequate
27
preparation for the necessary changes, the dangers seem paramount and overshadow
any potential growth. The results are maladaptive coping and dysfunctional behavior.

PHASES IN THE DEVELOPMENT OF A CRISIS

The development of a crisis situation follows a relatively predictable

course. Caplan (1964) outlined four specific phases through which individuals
progress in response to a precipitating stressor and that culminate in the state of acute
crisis.

Phase 1. The individual is exposed to a precipitating stressor. Anxiety increases;

previous problem-solving techniques are employed.

Phase 2. When previous problem-solving techniques do not relieve the stressor,

anxiety increases further. The individual begins to feel a great deal of discomfort at
this point. Coping techniques that have worked in the past are attempted, only to
create feelings of helplessness when they are not successful. Feelings of confusion
arid disorganization prevail.

Phase 3. AH possible resources, both internal and external, are called on to resolve the
problem and relieve the discomfort. The individual may try to view the problem from
a different perspective, or even to overlook certain aspects of it. New problem-solving
techniques may be used, and, if effectual, resolution may occur at this phase, with the
individual returning to a higher, a lower, or the previous level of premorbid
functioning.

Phase 4. If resolution does not occur in previous phases, Caplan states that “the
tension mounts beyond a farther threshold or its burden increases over time to a
breaking point. Major disorganization of the individual with drastic results often
occurs." Anxiety may reach panic levels. Cognitive functions are disordered,
emotions are labile, and behavior may reflect the presence of psychotic thinking.

These phases are congruent with the transactional model of

stress/adaptation outlined in Chapter 1. Similarly, Aguilera (1998) spoke of
“balancing factors” that affect the way in which an individual perceives and responds
to a precipitating stressor.

28
Stages of Crisis:

Crisis intervention

First Stage rise in Use of habitual problem

tension solving
Uuuuseresponse (If
ineffective)

Habitual problem-solving
response (If still ineffective in
resolving crisis)
Second stage
increased tension Emergency problem solving
mechanism activated (If still
ineffective)

Redefinng and resolution of

problem o Discontinuance of
Third stage level efforts to achieve goal or
of tension Avoidance of problem by
continues to distorting reality (If all are
increase ineffective)

Redefinng and resolution of

Fourth stage: problem or
Tension continues
Discontinuance of efforts to
to increase
achieve goal or

Avoidance of problem by
distorting reality (If all are
ineffective)

The paradigm set forth by Aguilera suggests that whether or not an individual
experiences a crisis in response to a stressful situation depends upon the following
three factors:

 The individual’s perception of the event: If the event is perceived realistically,

the individual is more likely to draw upon adequate resources to restore
29
 equilibrium. If the perception of the event is distorted, attempts at problem
solving are likely to be ineffective, and restoration of equilibrium goes
unresolved.

 The availability of situational supports. Aguilera states, "Situational supports

are those persons who are available in the environment and who can be
depended on to help solve the problem”. Without adequate situational supports
during a stressful situation, an individual is most likely to feel overwhelmed
and alone.

 The availability of adequate coping mechanisms. When a stressful situation

occurs, individuals draw upon behavioral strategies that have been successful
for them in the past. If these coping strategies work, a crisis may be diverted. If
not, disequilibrium may continue and tension and anxiety increase.

As previously set forth, it is assumed that crises are acute, not chronic,
situations that will be resolved in one way or another within a brief period.
Winston (2008) states, “Crises tend to be time limited, generally lasting no
more than a few months; the duration depends on the stressor and on the
individual's perception of and response to the stressor”. Crises can become
growth opportunities when individuals learn new methods of coping that can be
preserved and used when similar stressors recur.

TYPES OF CRISIS

Baldwin (1978) identified six classes of emotional crises, which progress

by degree of severity. As the measure of psychopathology increases, the source of the
stressor changes from external to internal The type of crisis determines the method of
intervention selected.

Class 1: Dispositional Crises: An acute response to an external situational stressor.

Class 2: Crises of Anticipated Life Transitions: Normal life-cycle transitions that

may be anticipated but over which the individual may feel a lack of control.

Class 3: Crises Resulting from Traumatic Stress: Crises precipitated by unexpected

30
external stresses over which the individual has little or no control and from which he
or she feels emotionally overwhelmed and defeated.

Class 4: Maturational/Developmental Crises : Crises that occur in response to

situations that trigger emotions related to unresolved conflicts in one’s life. These
crises are of internal origin and reflect underlying developmental issues that involve
dependency, value conflicts, sexual identity, control, and capacity for emotional
intimacy.

Class 5: Crises Reflecting Psychopathology: Emotional crises in which preexisting

psychopathology has been instrumental in precipitating the crisis or in which
psychopathology significantly impairs or complicates adaptive resolution. Examples
of psychopathology that may precipitate crises include borderline personality, severe
neuroses, characterological disorders, or schizophrenia.

Class 6: Psychiatric Emergencies: Crisis situations in which general functioning has

been severely impaired and the individual rendered incompetent or unable to assume
persona! responsibility. Examples include acutely suicidal individuals, drug
overdoses, and reactions to hailucinogenic drugs, acute psychoses, uncontrollable
anger, and alcohol intoxication.

Phases of crisis intervention: the role of the nurse

Nurses respond to crisis situations on a daily basis. Crises can occur in

every unit in the general hospital, in the home setting, the community healthcare
setting, schools, offices, and in private practice. Indeed, nurses may be called on to
function as crisis helpers in virtually any setting committed to the practice of nursing.
Roberts and Ottens (2005) provide a seven-stage model of crisis intervention.
11
Aguilera (1998) describes four specific phases in the technique of crisis intervention
that are clearly comparable to the steps of the nursing process. These phases are
discussed in the following paragraphs.

31
Phase 1. Assessment

In this phase, the crisis helper gathers information regarding the

precipitating stressor and the resulting crisis that prompted the individual to seek
professional help. A nurse in crisis intervention might perform some of the following
assessments:

 Ask the individual to describe the event that precipitated this crisis.

 Determine when it occurred.

 Assess the individual’s physical and mental status.

 Determine if the individual has experienced this stressor before. If so, what
method of coping was used? Have these methods been tried this time?

 If previous coping methods were tried, what was the result?

 If new coping methods were tried, what was the result?

• Assess suicide,or homicide potential, plan, and means.

• Assess the adequacy of support systems.

• Determine level of precrisis functioning. Assess the usual coping methods,

available support systems, and ability to problem solve.

• Assess the individual’s perception of personal strengths and limitations.

• Assess the individual’s use of substances.

Information from the comprehensive assessment is then analyzed.and appropriate

nursing diagnoses reflecting the immediacy of the crisis situation are identified. Some
nursing diagnoses that may be relevant include

1. Ineffective coping

2. Anxiety (severe to panic)

3. Disturbed thought processes

4. Risk for self- or other-directed violence

32
5. Rape-trauma syndrome

6. Post-trauma syndrome

7. Fear

Phase 2. Planning of Therapeutic Intervention

in the planning phase of the nursing process, the nurse selects the appropriate nursing
actions for the identified nursing diagnoses. In planning the interventions, the type of
crisis, as well as the individual's strengths and available resources for support, are
taken into consideration. Goals are established for crisis resolution and a return to, or
increase in, the precrisis level of functioning.

Phase 3. Intervention

During phase 3, the actions that were identified in phase 2 are implemented. The
following interventions are the focus of nursing in crisis intervention:

 Use a reality-oriented approach. The focus of the problem is on the here and
now.

 Remain with the individual who is experiencing panic anxiety.

 Establish a rapid working relationship by showing unconditional acceptance,

by active listening, and by attending to immediate needs.

 Discourage lengthy explanations or rationalizations of the situation: promote an

atmosphere for verbalization of true feelings.

 Set firm limits on aggressive, destructive behaviors. At high levels of anxiety,

behavior is likely to be impulsive and regressive. Establish at the outset what is
acceptable and what is not, and maintain consistency.

 Clarify the problem that the individual is facing. The nurse does this by
describing his or her perception of the problem and comparing it with the
individual’s perception of the problem.

 Help the individual determine what he or she believes precipitated the crisis.

33
  Acknowledge feelings of anger, guilt, helplessness, and powerlessness, while
taking care not to provide positive feedback for these feelings.

 Guide the individual through a problem-solving process by which he or she

may move in the direction of positive life change:

a) Help the individual confront the source of the problem that is creating the crisis
response.

b) Encourage the individual to discuss changes he or she would like to make.

Jointly determine whether or not desired changes are realistic.

c) Encourage exploration of feelings about aspects that cannot be changed, and

explore alternative ways of coping more adaptively in these situations.

d) Discuss alternative strategies for creating changes that are realistically possible.

e) Weigh benefits and consequences of each alternative.

f) Assist the individual to select alternative coping strategies that will help
alleviate future crisis situations.

 Identify external support systems and new social networks from whom the
individual may seek assistance in times of stress.

Phase 4. Evaluation of Crisis Resolution and Anticipatory Planning

To evaluate the outcome of crisis intervention, a reassessment is made to

determine if the stated objective was achieved:

 Have positive behavioral changes occurred?

 Has the individual developed more adaptive coping strategies? Have they
been effective?

 Has the individual grown from the experience by gaining insight into his or
her responses to crisis situations?

 Does the individual believe that he or she could respond with healthy
adaptation in future stressful situations to prevent crisis development?

34
  Can the individual describe a plan of action for dealing with stressors
similar to the one that precipitated this crisis?

During the evaluation period, the nurse and client summarize what has occurred
during the intervention. They review what the individual has learned and “anticipate”
how he or she will respond in the future. A determination is made regarding follow-up
therapy; if needed, the nurse provides referral information

6. DISASTER NURSING

Although there are many definitions of disaster, a common feature is that the
event overwhelms local resources and threatens the function and safety of the
community (Norwood, Ursano, & Fullerton, 2006). A violent disaster, whether natural
or man-made, may leave devastation of property or life. Such tragedies also leave
victims with a damaged sense of safety and well-being, and varying degrees of
emotional trauma (Oklahoma State Department of Health [OSDH], 2001), Children,
who lack life experiences and coping skills, are particularly vulnerable.* Their sense
of order and security has been seriously disrupted, and they are unable to understand
that the disruption is time limited and that their world will eventually return to normal.

NURSING PROCESS TO DISASTER NURSING

Background Assessment Data

Individuals respond to traumatic events in many ways. Grieving is a natural

response following any loss, and it may be more extreme if the disaster is directly
experienced or witnessed (OSDH, 2001). The emotional effects of loss and disruption
may show up immediately or may appear weeks or months later. Psychological and
behavioral responses common in adults following trauma and disaster include: anger;
disbelief; sadness; anxiety; fear; irritability; arousal; numbing; sleep disturbance; and
increases in alcohol, caffeine, and tobacco use (Norwood, Ursano, & Fullerton, 2006).

Preschool children commonly experience separation anxiety, regressive

behaviors, nightmares, and hyperactive or withdrawn behaviors. Older children may
have difficulty concentrating, somatic complaints, sleep disturbances, and concerns
about safety. Adolescents’ responses are often similar to those of adults. Norwood,

35
Ursano, and Fullerton (2006) state: Traumatic bereavement is recognized as posing
special challenges to survivors. While the death of loved ones is always painful, and
unexpected and violent death can be more difficult to assimilate. Family members
may develop intrusive images of the death based on information gleaned from
authorities or the media. Witnessing or learning of violence to a loved one also
increases vulnerability to psychiatric disorders.

The knowledge that one has been exposed to toxins is a potent traumatic
stressor . . . and the focus of much concern in the medical community preparing for
responses to terrorist attacks using biological, chemical, or nuclear agents.

Nursing Diagnoses/Outcome Identification

Information from the assessment is analyzed, and appropriate nursing

diagnoses reflecting the immediacy of the situation are identified. Some nursing
diagnoses that may be relevant include: e Risk for injury (trauma, suffocation,
poisoning)

 Risk for infection ® Anxiety (panic)

 Fear

 Spiritual distress

 Risk for posttrauma syndrome

 ineffective community coping

The following criteria may be used for measurement of outcomes in the care of the
client having experienced a traumatic event. Timelines are individually determined.

The client:

1. Experiences minimal/no injury to self.

2. Demonstrates behaviors necessary to protect self from further injury.

3. Identifies interventions to prevent/reduce risk of infection.

4. Is free of infection

36
 5. Maintains anxiety at manageable level.

6. Expresses beliefs and values about spiritual issues.

7. Demonstrates ability to deal with emotional reactions in an individually

appropriate manner.

8. Demonstrates an increase in activities to improve community

functioning.

Planning/lmplementation

Table provides a plan of care for the client who has experienced a
traumatic event. Selected nursing diagnoses are presented, along with outcome
criteria, appropriate nursing interventions, and rationales for each.

Evaluation

In the final step of the nursing process, a reassessment is conducted to

determine if the nursing actions have been successful in achieving the
objectives of care. Evaluation of the nursing actions for the client who has
experienced a traumatic event may be facilitated by gathering information
utilizing the following types of questions:

 Has the client escaped serious injury, or have injuries been resolved?

 Have infections been prevented or resolved?

 Is the client able to maintain anxiety at a manageable level?

 Does he or she demonstrate appropriate problem solving skills?

 Is the client able to discuss his or her beliefs about spiritual issues?

 Does the client demonstrate the ability to deal with emotional reactions in an
individually appropriate manner?

 Does he or she verbalize a subsiding of the physical manifestations (e.g., pain,

nightmares, flashbacks, fatigue) associated with the traumatic event?

 Has there been recognition of factors affecting the community’s ability to meet,

37
 its own demands or needs?

 Has there been a demonstration of increased activities to improve community

functioning?

 Has a plan been established and put in place to deal with future contingencies?

Care Plan for the Client Who Has Experienced a Traumatic Event

Nursing diagnosis: anxiety (panic)/fear Related to: Real or perceived threat to

physical wellbeing: threat of death; situational crisis; exposure to toxins; unmet
needs

EVIDENCED BY: Persistent feelings of apprehension and uneasiness; sense of

impending doom; impaired functioning; verbal expressions of having no control or
influence over situation, outcome, or selfcare; sympathetic stimulation; extraneous
physical movements

Outcome Criteria

Client will maintain anxiety at manageable level

Nursing Interventions Rationale

1. Determine degree of anxiety/fear 1. Clearly understanding client’s perception
present, associated behaviors (e.g., is pivotal to providing appropriate
laughter, crying, calm or agitation, assistance in overcoming the fear.
excited/hysterical behavior, Individual may be agitated or totally
expressions of disbelief and/or overwhelmed. Panic state increases risk
selfblame), and reality of perceived for client’s own safety as well as the safety
threat. of others in the environment.
2. Note degree of disorganization. 2. Client may be unable to handle ADLs or
3. Create as quiet an area as possible. work requirements and need more
Maintain a calm confident manner. intensive intervention.
Speak in even tone using short
3. Decreases sense of confusion or
simple sentences.
overstimulation; enhances sense of safety.
4. Develop trusting relationship with
Helps client focus on what is said and

38
 the client. reduces transmission of anxiety.
5. Identify whether incident has 4. Trust is the basis of a therapeutic nurse-
reactivated preexisting or coexisting client relationship and enables them to
situations (physical or work effectively together.
psychological).
5. Concerns and psychological issues will be
6. Determine presence of physical
recycled every time trauma is re
symptoms (e.g., numbness, headache,
experienced and affect how the client
tightness in chest, nausea, and
views the current situation.
pounding heart)
6. Physical problems need to be
7. Identify psychological responses
differentiated from anxiety symptoms so
(e.g., anger, shock, acute anxiety,
appropriate treatment can be given.
panic, confusion, denial). Record
emotional changes. 7. Although these are normal responses at the
8. Discuss with client the perception of time of the trauma, they will recycle again
what is causing the anxiety. and again until they are dealt with
adequately.

8. Increases the ability to connect symptoms

9. Assist client to correct
distortions being experienced. Share
perceptions with client.
10. Explore with client or significant
other the manner in which client has
previously coped with
producing events.
11. Engage client in learning new coping
behaviors (e.g., progressive muscle
relaxation, thought-stopping)
12. Encourage use of techniques to
any to subjective feeling of anxiety, providing
opportunity to gain insight/control and
make desired changes.
9. Perceptions based on reality will help to
decrease tearfulness. How the nurse views
anxiety-
the situation may help client to see it
differently.
10. May help client regain sense of control and
recognize significance of trauma.
11. Replacing maladaptive behaviors can

manage stress and vent emotions enhance ability to manage and deal with

such as anger and hostility. stress. Interrupting obsessive thinking

13. Give positive feedback when client allows client to use energy to address

39
 demonstrates better ways to manage
anxiety and is able to calmly and
realistically appraise the situation.
14. Administer medications as indicated
Antianxiety; diazepam, alprazolam,
oxazepam; or Antidepressants
fluoxetine, paroxetine, bupropion.
underlying anxiety, whereas continued
rumination about the incident can retard
recovery.
12. Reduces the likelihood of eruptions that
can result in abusive behavior.
13. Provides acknowledgment and
reinforcement, encouraging use of new
coping strategies. Enhances ability to deal
with fearful feelings and gain control over
situation, promoting future successes.

14. Provides temporary relief of anxiety

symptoms, enhancing ability to cope with
situation. To lift mood and help suppress
intrusive thoughts and explosive anger.

NURSING DIAGNOSIS: SPIRITUAL DISTRESS

RELATED TO:

Physical or psychological stress; energy-consuming anxiety; loss(es), intense

suffering; separation from religious or cultural ties; challenged belief and value
system.

EVIDENCED BY: Expressions of concern about disaster and the meaning of life
and death or belief systems; inner conflict about current loss of normality and effects
of the disaster; anger directed at deity; engaging in self-blame; seeking spiritual
assistance.

Outcome Criteria

Client expresses beliefs and values about spiritual issues.

Nursing Interventions Rationale

1. Determine client's religious/spiritual 1. Provides baseline for planning care and

40
 orientation, current involvement, and accessing appropriate resources.
presence of conflicts. 2. Promotes awareness and identification
2. Establish environment that promotes of feelings so they can be dealt with. It
free expression of feelings and is helpful to understand the client’s and
concerns. Provide calm, peaceful significant others’ points of view and
setting when possible. how they are questioning their faith in
3. Listen to client’s and significant the face of tragedy.
others’ expressions of anger, 3. These thoughts and feelings can result
concern, alienation from God, belief in the client feeling paralyzed and
that situation is a punishment for unable to move forward to resolve the
wrongdoing, etc. situation.
4. Note sense of futility, feelings of 4. May indicate need for further
hopelessness and helplessness, lack intervention to prevent suicide attempt.
of motivation to help self. 5. Presence or lack of support systems
5. Listen to expressions of inability to can affect client’s recovery.
find meaning in life and reason for 6. Promotes trust and comfort,
living. Evaluate for suicidal ideation. encouraging client to be open about
6. Determine support systems available sensitive matters.
to client. 7. Helps client to begin to look at basis
7. Ask how you can be most helpful. for spiritual confusion.
Convey acceptance of client's 8. Wofe.-There is a potential for care
spiritual beliefs and concerns.8. provider's belief system to interfere
Make time for nonjudgmental with client finding own way.
discussion of philosophic issues and Therefore, it is most beneficial to
questions about spiritual impact of remain neutral and not espouse own
current situation. beliefs.
9. Discuss difference between grief and 9. Blaming self for what has happened
guilt and help client to identify and impedes dealing with the grief process
deal with each, assuming and needs to be discussed and dealt
responsibility for own actions, with.
expressing awareness of the 10. Helps client find own solutions to

41
 consequences of acting out of false concerns.
guilt. 11. This can help to heal past and present
10. Use therapeutic communication pain.
skills of reflection and active- 12. Enhances commitment to goal,
listening. optimizing outcomes and promoting
11. Encourage client to experience sense of hope.
meditation, prayer, and forgiveness. 13. Specific assistance may be helpful to
Provide information that anger with recovery (e.g., relationship problems,
God is a normal part of the grieving substance abuse, suicidal ideation).
process. 14. Discussing concerns and questions with
12. Assist client to develop goals for others can help client resolve feelings
dealing with life situation.
13.Identify and refer to resources that
can be helpful, e.g., pastoral/parish
nurse or religious counselor, crisis
counselor, psychotherapy,
Alcoholics/ Narcotics Anonymous.
14.Encourage participation in support
groups.

NURSING DIAGNOSIS: RISK FOR POSTTRAUMA SYNDROME

RELATED TO: Events outside the range of usual human experience; serious
threat or injury to self or loved ones; witnessing horrors or tragic events;
exaggerated sense of responsibility; survivor’s guilt or role in the event;
inadequate social support
Outcome Criteria
Client demonstrates ability to deal with emotional reactions in an individually
appropriate manner.
Nursing Interventions Rationale
1. Determine involvement in event 1) All those concerned with a traumatic event are
(e.g., survivor, significant other, at risk for emotional trauma and have needs

42
 rescue/aid worker, healthcare related to their involvement in the event.
provider, family member). Note: Close involvement with victims affects
2. Evaluate current factors associated individual responses and may prolong
with the event, such as displacement emotional suffering.
from home due to illness/ injury, 2) Affects client’s reaction to current event and
natural disaster, or terrorist attack. is basis for planning care and identifying
Identify how client’s past appropriate support systems and resources.
experiences may affect current 3) Statements such as these are indicators of
situation. “survivor’s guilt" and blaming self for actions.
3. Listen for comments of taking on 4) Noting positive or negative coping skills
responsibility (e.g.,“I should have provides direction for care.
been more careful or gone back to 5) Family and others close to the client may also
get her.") be at risk and require assistance to cope with
4. Identify client’s current coping the trauma.
mechanisms. 6) Awareness of these factors helps individual
5. Determine availability and usefulness identify need for assistance when signs and
of client’s support systems, family, symptoms occur,
social contacts, and community 7) Provides information to build on for coping
resources. with traumatic experience.
6. Provide information about signs and 8) Events that trigger feelings of despair and
symptoms of post-trauma response, hopelessness may be more difficult to deal
especially if individual is involved in with, and require long term interventions.
a high-risk occupation.
9) Strengthens coping abilities.
7. Identify and discuss client’s strengths
10)It is important to talk about the incident
as well as vulnerabilities.
repeatedly. In congruencies may indicate
8. Evaluate individual's perceptions of deeper conflict and can impede resolution.
events and personal significance
11)These responses are normal in the early post-
(e.g., rescue worker trained to
incident time frame. If prolonged and
provide lifesaving assistance but
persistent, they may indicate need for more
recovering only dead bodies).

43
9. Provide emotional and physical intensive therapy.
presence by sitting i with client/- 12)Helps client deal with the disruption in their
significant other and offering solace. life.
10. Encourage expression of feelings. 13)Promotes relaxation and helps individual
Note whether feelings expressed exercise control over self and what has
appear congruent with events happened.
experienced. 14)Dealing with the stresses promptly may
11. Note presence of nightmares, reliving facilitate recovery from the event or prevent
the incident, loss of appetite, exacerbation.
irritability, numbness and crying, and 15)Provides opportunity for ongoing support to
family or relationship disruption. deal with recurrent feelings related to the
12. Provide a calm, safe environment. trauma.
13. Encourage and assist clientin 16)Low doses may be used for reduction of
learning stress- management psychotic symptoms when loss of contact with
techniques. reality occurs, usually for clients with
14. Recommend participation in especially disturbing flashbacks. Tegretol may
debriefing sessions that may be be used to alleviate intrusive recollections/
provided following major disaster flashbacks, impulstvity, and violent behavior.
events.
15. Identify employment, community
resource groups.
16. Administer medications as indicated,
such as antipsychotics (e.g.,
chlorpromazine,haloperidol,olanzapi
ne, or quetiapine) or carbamazepine

NURSING DIAGNOSIS: INEFFECTIVE COMMUNITY COPING

RELATED TO: Natural or man-made disasters (earthquakes, tornados, floods,

reemerging infectious agents, terrorist activity); ineffective or nonexistent community
systems (e.g., lack of or inadequate emergency medical system, transportation system,

44
or disaster planning systems)

EVIDENCED BY: Deficits of community participation; community does not meet its
own expectations; expressed vulnerability; community powerlessness; stressors
perceived as excessive; excessive community conflicts; high illness rates.

Outcome Criteria

 Client demonstrates an increase in activities to improve community

functioning.

Nursing Interventions Rationale

1) Evaluate community activities 1. Provides a baseline to determine community
that are related to meeting needs in relation to current concerns or
collective needs within the threats.
community itself and between 2. Provides a view of how the community itself
the community and the larger sees these areas.
society. Note immediate needs, 3. In the face of a current threat, local or
such as health care, food, national, community resources need to be
shelter, funds. evaluated, updated, and given priority to meet
2) Note community reports of the identified need.
functioning including areas of 4. Information necessary to identify what else is
weakness or conflict. needed to meet the current situation.

3) Identify effects of related 5. Promotes understanding of the ways in which

factors on community activities. the community is already meeting the
identified needs.
4) Determine availability and use
6. Promotes a sense of working together to meet
of resources. Identify unmet
the needs.
demands or needs of the
community. 7. Deals with deficits in support of identified
goals.
5) Determine community
8. Meets collective needs when the
strengths.
concerns/threats are shared beyond a local
6) Encourage community
community.

45
 members/ groups to engage in 9. Readily available accurate information can
problem-solving activities. help citizens deal with the situation.

7) Develop a plan jointly with the 10. Using languages other than English and
members of the community to making written materials accessible to all

address immediate needs. members of the community will promote

understanding.
8) Create plans managing
11. Homeless and those residing in lower
interactions within the
income areas may have special requirements
community itself and between
that need to be addressed with additional
the community and the larger
resources.
society.

9) Make information accessible to

the public. Provide channels for
dissemination of information to
the community as a whole (e.g.,
print media, radio/ television
reports and community bulletin
boards, internet sites, speaker’s
bureau, reports to committees/
councils/ advisory boards).

10) Make information available in

different modalities and geared
to differing educational
levels/cultures of the
community.

11) Seek out and evaluate needs of

underserved populations

46
8. GRIEF AND LOSS

LOSS

Experiences of loss are normal and essential in human life. Letting go,
relinquishing, and moving on happen continually as a person travels through the
stages of growth and development. People frequently say "goodbye” to places, people,
dreams, and familiar objects. Examples of necessary losses that accompany growth
include abandoning a favorite blanket or toy, leaving a first-grade teacher, and giving
up the adolescent hope of becoming a famous rock star. Loss allows a person to
change, develop, and fulfill his or her innate human potential. Loss may be planned,
expected, or sudden. Although it can be difficult, loss sometimes is beneficial. Other
times, it is devastating and debilitating.

Grief refers to the subjective emotions and affect that are a normal
response to the experience of loss. Grieving, also known as bereavement, refers to the
process by which a person experiences the grief. It involves not only the content (what
a person thinks, says, and feels) but also the process (how a person thinks, says, and
feels). All people grieve when they experience life's changes and losses. Often,
grieving is one of the most difficult and challenging processes of human existence;
rarely is it comfortable or pleasant. Anticipatory grieving is when people facing an
imminent loss begin to grapple with the very real possibility of the loss or death in the
near future (Zilberfein, 1999).

Mourning is the outward expression of grief. Rituals of mourning include

having a wake, sitting shivah, holding religious ceremonies, and arranging funerals.

TYPES OF LOSSES

A helpful way to examine different types of losses is to use Abraham

Maslow's hierarchy of human needs. According to Masiow (1954), a hierarchy of

47
needs motivates human actions. These needs begin with physiologic needs (food, air,
water, sleep), then safety needs (a safe place to live and work), then security and
belonging needs (satisfying relationships). After those needs comes the need for self-
esteem, which leads to feelings of adequacy and confidence. The last and final need is
self-actualization, the ability to realize one’s full innate potential. When these human
needs are taken away or not met for some reason, the person experiences loss.
Examples of losses related to specific human needs in Maslow’s hierarchy are as
follows:

 Physiologic loss. Examples include amputation and loss of adequate air

exchange or pancreatic functioning

 Safety loss. Loss of a safe environment such as following domestic or public

violence. A person may perceive a breach of confidentiality in the professional
relationship as a loss of psychological safety secondary to broken trust
between client and provider.

 Loss of security and a sense of belonging. The loss of a loved one affects the
need to love and be loved. Loss accompanies changes in relationships such as
birth, marriage, divorce, illness, and deatn; as the meaning of a relationship
changes, a person may lose roles within a family or group.

 Loss of self-esteem. Any change in how a person is valued at work or in

relationships can threaten his or her need for self-esteem. A change in self-
perception can challenge sense of self-worth, which the person may experience
as a loss. A loss of role function and the self-perception and worth tied to that
role may accompany the death of a loved one.

 Loss related to self-actualization. An external or internal crisis that blocks or

inhibits strivings toward fulfillment may threaten personal goals and individual
potential (Parkes, 1998). A change in goals or direction will precipitate an
inevitable period of grief as the person gives up a creative thought to make

48
 room for new ideas and directions. Examples include having to give up plans
to attend graduate school or losing the hope of marriage and family.

The fulfillment of human needs requires dynamic movement throughout

the various levels in the hierarchy.The simultaneous maintenance of needs in the areas
of physiologic integrity, safety, security and sense of belonging, self-esteem, and self-
actualization is challenging and demands flexibility and focus. At times, a focus on
protection may take priority over professional or self-actualization goals. Likewise,
human losses demand a grieving process that simultaneously challenges each level of
need. Specific examples include the loss of a pregnancy or loss of sight or hearing.

GRIEF

Most individuals experience intense emotional anguish in response to a significant

personal loss. A loss is anything that is perceived as such by the individual. Losses
may be real, in which case they can be substantiated by others (e.g., death of a loved
one, loss of personal possessions), or they may be perceived by the individual alone,
unable to be shared or identified by others (e.g., toss of the feeling of femininity
following mastectomy). Any situation that creates change for an individual can be
identified as a loss. Failure (either real or perceived) also can be viewed as a loss.

may be real, in which case they can be substantiated by others (e.g., death of a loved
one, loss of personal possessions), or they may be perceived by the individual alone,
unable to be shared or identified by others (e.g., toss of the feeling of femininity
following mastectomy). Any situation that creates change for an individual can be
identified as a loss. Failure (either real or perceived) also can be viewed as a loss.

The loss, or anticipated loss, of anything of value to an individual can trigger the grief
response. This period of characteristic emotions and behaviors is called mourning.
The “normal” mourning process is adaptive and is characterized by feelings of
sadness, guilt, anger, helplessness, hopelessness, and despair. Indeed, an absence of
mourning after a loss may be considered maladaptive.

49
THE GRIEVING PROCESS

Nurses interact with clients responding to a myriad of losses along the

continuum of health and illness. Regardless of the type of loss, nurses must have a
basic understanding of what is involved to meet the challenge that grief brings to
clients. By understanding the phenomena that clients experience as they deal with the
discomfort of loss, nurses may promote the expression and release of emotional as
well as physical pain, thus supporting the grieving process. Supporting this process
means ministering to psychological as well as physical needs.

The therapeutic relationship and therapeutic communication skills such as

active listening are paramount when assisting grieving clients. Recognizing the verbal
and nonverbal communication content of the various stages of grieving can help
nurses to select interventions that will meet the client’s psychological and physical
needs.

STAGES OF GRIEF

Kubler-Ross (1969), in extensive research with terminally ill patients, identified five
stages of feelings and behaviors that individuals experience in response to a real,
perceived, or anticipated loss:

Stage 1—Denial: This is a stage of shock and disbelief. The response may be one of
"No, it can't be true!” The reality of the loss is not acknowledged. Denial is a
protective mechanism that allows the individual to cope in an immediate time frame
while organizing more effective defense strategies.

Stage 2—Anger: “Why me?” and “It’s not fair!” are comments often expressed during
the anger stage. Envy and resentment toward individuals not affected by the loss are
common. Anger may be directed at the self or displaced on loved ones, caregivers,
and even God. There may be a preoccupation with an idealized image of the lost
entity.

Stage 3—Bargaining: During this stage, which is usually not visible or evident to
others, a "bargain” is made with God in an attempt to reverse or postpone the loss, "if

50
God will help me through this, I promise I will go to church every Sunday and
volunteer my time to help others.” Sometimes the promise is associated with feelings
of guilt for not having performed {or having the perception of not having performed)
satisfactorily, appropriately, or sufficiently.

Stage 4—Depression: During this stage, the full impact of the loss is experienced. The
sense of loss is intense, and feelings of sadness and depression prevail. This is a time
of quiet desperation and disengagement from all association with the lost entity. It
differs from pathological depression, which occurs when an individual becomes fixed
in an earlier stage of the grief process. Rather, stage four of the grief response
represents advancement toward resolution.

Stage 5—Acceptance: The final stage brings a feeling of peace regarding the loss that
has occurred. It is a time of quiet expectation and resignation. The focus is on the
reality of the loss and its meaning for the individuals affected by it.

All individuals do not experience each of these stages in response to a loss, nor do
they necessarily experience them in this order. Some individuals’ grieving behaviors
may fluctuate, and even overlap, between stages.

THEORIES OF THE GRIEVING PROCESS

KUBLER-ROSS’S STAGES OF GRIEVING

Elisabeth Kubler-Ross (1969) established a basis for understanding how loss affects
human life. As she attended to clients with terminal illnesses, a process of dying
became apparent to her. Through observations of and work with dying clients and
their families, Kubler-Ross developed a model of five stages to explain what people
experience as they grieve and mourn:

1. Denial is shock and disbelief regarding the loss.

2. Anger may be expressed toward God, relatives, friends, or health care providers.

3. Bargaining occurs when the person asks God or fate for more time to delay the
inevitable loss.

51
4. Depression results when awareness of the loss becomes acute.

5. Acceptance occurs when the person shows evidence of coming to terms with death.

This model became a prototype for care providers as they looked for ways to
understand and assist their clients in the grieving process.

BOWLBY’S THEORY OF ATTACHMENT BEHAVIORS

John Bowlby, a British psychoanalyst, proposed a theory that humans

instinctively attain and retain affectional bonds with significant others through
attachment behaviors, which are crucial to the development of a sense of security and
survival. Examples of attachment behaviors include following, clinging, calling out,
and crying. Bowlby saw that human beings modified these attachment behaviors as
they matured from childhood into adulthood, but that patterns of attachment behavior
formed early endure throughout the life cycle. People experience the most intense
emotions when forming a bond such as falling in love; maintaining a bond such as
loving someone; disrupting a bond such as in a divorce; and renewing an attachment
such as resolving a conflict or renewing a relationship (Bowlby, 1980). An attachment
that is maintained is a source of security; an attachment that is renewed is a source of
joy. When a bond is threatened or broken, however, the person responds with anxiety,
protest, and anger.

Actual loss leads to sorrow. According to Bowlby, these emotions reflect

affectional bonds. Loss strongly activates - or arouses attachment behaviors. Thus the
clinical picture of increased anxiety, sorrow, anger, looking for the lost person or
object, calling out, crying, and protesting is an attempt to restore the lost affectional
bond through* attachment behaviors.

Phases of the Grieving Process Bowlby’s understanding of grieving will serve

as the predominant framework for this chapter. Bowlby described the grieving process
as having four phases:

1. Experiencing numbness and denying the lossEmotionally

52
2. yearning for the lost loved one and protesting the permanence of the
loss

3. Experiencing cognitive disorganization and emotional despair with difficulty

functioning in the everyday world

4. Reorganizing and reintegrating the sense of self to pull life back together

Another theorist, John Harvey (1998), described similar phases of grieving:

1. Shock, outcry, and denial

2. Intrusion of thoughts, distractions, and obsessive review of the loss

3. Confiding in others as a way to emote and to cognitively restructure an account of

the loss

Rodebaugh, Schwindt & Valentine (1999) viewed the process of grief as a journey
through four stages:

1. Reeling. The person feels shock, disbelief, or denial.

2. Feelings. The person experiences anguish, guilt, profound sadness, anger, lack
of concentration, sleep disturbances, appetite changes, fatigue, and general
physical discomfort.

3. Dealing. The person begins to adapt to the loss by engaging in support groups,
grief therapy, reading, and spiritual guidance.

4. Healing. The person integrates the loss as part of life. Acute anguish lessens.
Healing does not imply, however, that the person has forgotten or accepted the
loss.

Theorist/Clini Phase I Phase III

cian Phase II Phase IV
Rubler-Ross StageI:denial Stage II: anger Stage IV: Stage V:
(1969) Stage III: bargaining acceptance
Depression

53
 Bowlby(1980) Numbness: Emotional Cognitive Cognitive
denial yearning for the disorganizati reorganizati
loved one: on despair; on
protesting difficulty reintegrating
permanence of the functioning sense of self
loss
Harvey(1998) Shock: outcry: Intrusion of Confiding in
denial thoughts,distractio other to
ns; obsessive emote and to
reviewing of the cognitively
loss restructure
account of
loss
Rodebaugh et Reeling: Feeling: anguish, Dealing: Healing:
al.(1999) shock,disbelief, guilt, sadness, adapting to integration
or denial anger, lack of the loss of loss:
concentration, acute
sleep disturbances, anguish
appetite changes, dissipated:
fatigue, general loss may or
discomfort may not be
forgotten or
accepted

Nurses should not expect all clients to follow predictable steps in the grieving process.
Indeed, such an expectation may put added pressure or stress on a client when he or
she most needs acceptance, reflection, and support from care providers to ease the
grieving.

TASKS OF THE GRIEVING PROCESS

54
Rando (1984) describes tasks inherent to grieving:

• Undoing psychosocial bonds to the loved one and eventually creating new ties

• Adding new roles, skills, and behaviors and revising old ones into a "new identity
and sense of self

• Pursuing a healthy lifestyle that includes people and activities

• Integrating the loss into life, which does not mean ending the grieving but
accommodating the reality of the loss

DIMENSIONS OF GRIEVING

People have many and varied responses to loss. They express their
bereavement in their thoughts, words, feelings, and actions as well as their physiologic
responses. Therefore, nurses must use a holistic model of grieving that encompasses
cognitive, emotional, spiritual, behavioral, and physiologic dimensions (Davis &
Nolen-Hoeksema, 2001; Bonano & Kaltman, 1999).

Cognitive Responses to Grief

In some respects, the pain that accompanies grieving results from a disturbance
in the person’s beliefs (Parkes, 1998). The loss disrupts, if not shatters, basic
assumptions about life’s meaning and purpose. Grieving often causes a person to
change beliefs about self and the world such as perceptions of the world’s
benevolence, the meaning of life as related to justice, and a sense of destiny or life
path. Other changes in thinking and attitude include reviewing and ranking value,
becoming wiser, shedding illusions about immortality, viewing the world more
realistically, and re-evaluating religious or spiritual beliefs (Zisook & Downs, 2000).

Emotional Responses to Grief

Anger, sadness, and anxiety are the predominant emotional responses to loss. The
grieving person may direct anger and resentment toward the dead person and his or
her health practices, family members, or health care providers or institutions.
Common reactions the nurse might hear are as follows:
55
 "He should have stopped smoking years ago.”

 “If you had taken her to the doctor earlier this might not have happened."

 “It took you too long to diagnose his illness.”

Guilt over things not done or said in the lost relationship is another painful
emotion. Feelings of hatred and revenge are common when death has resulted from
extreme circumstances such as suicide, murder, or war (Zisook & Downs, 2000). In a
study to assess short-term grief responses after elective abortion, Williams (2001)
noted that some women experience feelings of loss of control, death anxiety, and
dependency as well as feelings of despair and anger. Emotional responses are evident
in all phases of Bowlby’s grief process.

During the phase of numbing, the common first response to the news of a loss
is to be stunned, as though not perceiving reality. Emotions vacillate in frequency and
intensity. Contrasting emotions are common such as experiencing an impulsive
outburst of anger toward the deceased, oneself, or others at one moment then feeling
unexpected elation at a sense of union with the deceased (Bowlby, 1980). The person
may function automatically in a state of calm then suddenly become overwhelmed
with panic.

In the second phase of yearning and searching, reality begins to set in. The
grieving person exhibits anger, profound sorrow, and crying. He or she often reverts to
the attachment behaviors of childhood by acting similar to a child who loses his or her
mother in a store or park. The grieving person may express irritability, bitterness, and
hostility toward clergy, medical providers, relatives, comforters, and even the dead
person. The hopeless yet intense desire to restore the bond with the lost person
compels the bereaved to search for and recover him or her. The grieving person
interprets sounds, sights, and smells associated with the lost one as signs of the
deceased’s presence, which may intermittently provide comfort and ignite hope for a
reunion. For example, the ring of the telephone at a time in the day when the deceased
regularly called will trigger the excitement of hearing his or her voice. Or the scent of
the deceased's perfume will spur her late husband to scan the room for her smiling
56
face. As hopes for the lost one’s return diminish, sadness and loneliness become
constant.

During the phase of disorganization and despair, the bereaved person begins to
understand the loss's permanence. He or she recognizes that patterns of thinking,
feeling, and acting attached to life with the deceased must change. As the person
relinquishes all hope of recovering the lost one, he or she inevitably experiences
moments of depression, apathy, or despair. Night is a time of acute loneliness during
this phase.

In the final phase of reorganization, the bereaved person begins to re-establish

a sense of personal identity, direction, and purpose for living. He or she gains
independence and confidence (Bowlby, 1980). By experimenting with and
accomplishing newly defined roles and functions, the bereaved becomes personally
empowered. This emotional and affective experience is associated closely with the
inherent cognitive recognition that life without the loved one is a reality and,
therefore, must be different. In this phase, the person still misses the deceased but
thinking of him or her no longer evokes painful feelings

Spiritual Responses to Grief

Closely associated with the cognitive and emotional dimensions of grief are the
deeply embedded personal values that give meaning and purpose to life. These values
and the belief systems that sustain them are central components of spirituality and the
spiritual response to grief. During loss, it is within the spiritual dimension of human
experience that a person may be most comforted, challenged, or devastated.

The grieving person may become disillusioned and angry with God or other
religious figures such as the priest who in Margaret’s situation seemed more
concerned about getting a paper than being aware of her loneliness in the waiting
room. The anguish of abandonment, loss of hope, or loss of meaning can cause deep
spiritual suffering. Ministering to the spiritual needs of those grieving is an essential
aspect of nursing care. The client’s emotional and spiritual responses become
intertwined as he or she grapples with pain. With an astute awareness of such

57
suffering, nurses can promote a sense of well-being. Providing opportunities for
clients to share their suffering assists in the psychological and spiritual transformation
that can evolve through grieving. Finding explanations and meaning through religious
or spiritual beliefs, the client may begin to identify positive aspects of grieving. The
grieving person also can experience loss as significant to his or her own growth and
development.

Behavioral Responses to Grief

Behavioral responses to grief are often the easiest to observe. By recognizing

behaviors common to grieving, the nurse can provide supportive guidance for the
client’s exploration of emotionally and cognitively rough terrain. To promote the
process, the nurse must provide a context of acceptance in which the client can
explore his or her behavior. For example, observing the grieving person as functioning
“automatically” or routinely without much thought can indicate that the person is in
the phase of numbness—the reality of the loss has not set in. Tearfully sobbing, crying
uncontrollably, showing great restlessness, and searching are evidence of yearning and
seeking. The person actually may call out for the deceased or visually scan the room
for him or her.

Irritability and hostility toward others reveal anger and frustration in the
process. Seeking out as well as avoiding places or activities once shared with the
deceased and keeping or wanting to discard valuables and belongings of the deceased
illustrate fluctuating emotions and perceptions of hope for a reconnection. ,

During the phase of disorganization, the cognitive act of redefining self*identity is

essential, although difficult. Although superficial at first, efforts made in social or
work activities are behavioral means to support the person’s cognitive and emotional
shifts. Drug or alcohol? abuse indicates a maladaptive behavioral response to the
emotional and spiritual despair. Suicide and homicide attempts may be extreme
responses if the bereaved person cannot move through the grieving process. In the
phase of reorganization, the bereaved person participates in activities and reflection
that are personally meaningful and satisfying.

58
Physiologic Responses to Grief

Physiologic symptoms and problems associated with grief responses are often a
source of anxiety and concern for the grieving person as well as friends or caregivers.
Those grieving may complain of insomnia, headaches, impaired appetite, weight loss,
lack of energy, palpitations, indigestion, and changes in the immune and endocrine
systems. Sleep disturbances are among the most frequent and persistent
bereavementassociated symptoms (Zisook & Downs, 2000).

DIMENSIONS9RESPONSES) AND SYMPTOMS OF THE GRIEVING CLIENT

1 Cognitive Responses  Disruption of assumptions and

beliefs

 Questioning and trying to make

sense of the loss

 Attempting to keep the lost one

present

 Believing in an afterlife and as

though the lost one is a guide
2 Emotional responses  Anger, sadness, anxiety

 Resentment

 Guilt

 Feeling numb

 Vacilating emotions

 Profound sorrow, loneliness

 Intense desire to restore bond

with lost one or object

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  Depression, apathy, despair
during phase of disorgansization

 Sense of independence and

confidence as phase of
recorganization evolves
3 Spiritual resposes  Disillusioned and angry with
God

 Anguish of abandonment or
perceived abandonment

 Hopelessness; meaninglessness
4 Behavioral responses  Functionning "automatically"

 Tearful sobbing: uncontrollable

crying

 Great restlessness; searching

behaviors

 Irritability and hostility

 Seeking and avoiding places and

activities shared with lost one

 Keeping valuables of lost one

while wanting to discard them

 Possibly abusing drugs or

alcohol

 Possible suicidal or homicidal

gestures or attempts

 Seeking activity and personal

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 reflection during phase of
reorganization
5 Physiologic responses  Headaches, insomnia

 Impaired appetite, weight loss

 Lack of energy

 Palpitations, indigestion

 Changes in immune and

endocrine systems

MALADAPTIVE GRIEF RESPONSES

Maladaptive responses to loss occur when an individual is not able to

satisfactorily progress through the stages of grieving to achieve resolution. These
responses usually occur when an individual becomes fixed in the denial or anger stage
of the grief process. Several types of grief responses have been identified as
pathological. They include responses that are prolonged, delayed or inhibited, or
distorted.

The prolonged response is characterized by an intense preoccupation with

memories of the lost entity for many years after the loss has occurred. Behaviors
associated with the stages of denial or anger are manifested, and disorganization of
functioning and intense emotional pain related to the tost entity are evidenced. In the
delayed or inhibited response, the individual becomes fixed in the denial stage of the
grieving process.

The emotional pain associated with the loss is not experienced, but anxiety
disorders (e.g., phobias, hypochondriasis) or sleeping and eating disorders (e.g.,
insomnia, anorexia) may be evident. The individual may remain in denial for many
years until the grief response is triggered by a reminder of the loss or even by another,
unrelated loss. The individual who experiences a distorted response is fixed in the

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anger stage of grieving. In the distorted response, all the normal behaviors associated
with grieving, such as helplessness, hopelessness, sadness, anger, and guilt, are
exaggerated out of proportion to the situation.

The individual turns the anger inward on the self, is consumed with
overwhelming despair, and is unable to function in normal activities of daily living.
Pathological depression is a distorted grief respons

ANTICIPATORY GRIEF

When a loss is anticipated, individuals often begin the work of grieving before the
actual loss occurs. Most people re-experience the grieving behaviors once the loss
occurs, but having this time to prepare for the loss can facilitate the process of
mourning, actually decreasing the length and intensity of the response. Problems arise,
particularly in anticipating the death of a loved one, when family members experience
anticipatory grieving and the mourning process is completed prematurely. They
disengage emotionally from the dying person, who may then experience feelings of
rejection by loved ones at a T time when this psychological support is so necessary.

Resolution

The grief response can last from weeks to years. It cannot be hurried, and
individuals must be allowed to progress at their own pace. In the loss of a loved one,
grief work usually lasts for at least a year, during which the grieving person
experiences each significant “anniversary” date for the first time without the loved one
present. Length of the grief process may be prolonged by a number of factors. If the
relationship with the lost entity had been marked by ambivalence or if there had been
an enduring “love-hate” association, reaction to the loss may be burdened with guilt.
Guilt lengthens the grief reaction by promoting feelings of anger toward the seif for
having committed a wrongdoing or behaved in an unacceptable manner toward that

62
which is now lost, and perhaps the grieving person may even feel that his or her
behavior has contributed to the loss.

Anticipatory grieving is thought to shorten the grief response in some

individuals who are able to work through some of the feelings before the loss occurs.
If the loss is sudden and unexpected, mourning may take longer than it would if
individuals were able to grieve in anticipation of the loss.

Length of the grieving process is also affected by the number of recent losses
experienced by an individual and whether he or she is able to complete one grieving
process before another loss occurs. This is particularly true for elderly individuals who
may be experiencing numerous losses, such as spouse, friends, other relatives,
independent functioning, home, personal possessions, and pets, in a relatively short
time. Grief accumulates, and this represents a type of bereavement overload, which
for some individuals presents an impossible task of grief work. Resolution of the
process of mourning is thought to have occurred when an individual can look back on
the relationship with the lost entity and accept both the pleasures and the
disappointments (both the positive and the negative aspects) of the association
(Bowlby & Parkes, 1970). Disorganization and emotional pain have been experienced
and tolerated. Preoccupation with th lost entity has been replaced with energy and the
desire to pursue new situations and relationships.

DISENFRANCHISED GRIEF

Disenfranchised grief is grief over a loss that is not or cannot be acknowledged

openly, mourned publicly, 6r supported socially. Three categories of circumstances
can result in disenfranchised grief:

 A relationship has no legitimacy.

 The loss itself is not recognized.

 The griever is not recognized.

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In each situation, there was a attachment followed by a loss that leads to grief. The
grief process is more complex because the usual supports that facilitate grieving and
the healing process are absent(Lenhardt, 1997). In our culture, kin-based relationships
receive the most attention in cases of death. Relationships between lovers, friends,
neighbors, foster parents, colleagues, and caregivers may be long lasting and intense,
but people suffering loss in these relationships may not be able to mourn the loss
publicly with the same social support and recognition as family members. In addition,
some relationships are not always recognized publicly or sanctioned socially. Possible
examples include same-sex relationships, cohabitation without marriage, and
extramarital affairs.

Some losses are not recognized or seen ass socially significant; thus,
accompanying grief is not legitimized, expected, or supported. Examples in this
category include prenatal death, abortion, relinquishing a child for adoption, death of a
pet, or other losses not involving death such as job loss, separation, divorce, and
children leaving home. Though these losses can lead to intense grief, other people
may perceive them as minor (Lenhardt, 1999). People who experience a loss may not
be recognized or fully supported as a griever. For example, older adults and children
experience limited social recognition for their tosses and the need to mourn.

As people grow older, they "should expect” others their age to die. Adults
sometimes view children as “not understanding or comprehending” the loss and can
assume wrongly that their children’s grief is minimal. Children also may experience
the loss of a “nurturing parental figure" from death, divorce, or family dysfunction
such as alcoholism or abuse. These losses are very significant, yet they may not be
recognized. Nurses may experience disenfranchised grief when their need to grieve is
not recognized. For example, nurses who work in areas involving organ donation or
transplantation are involved intimately with the death of clients who may donate
organs to another person(s). The daily intensity of relationship between nurses and
clients/families creates strong bonds among them. The emotional effects of loss are
significant for these nurses; however, there is seldom a socially ordained place or time
to grieve. The solitude in which the grieving occurs usually provides little or no

64
comfort (Albert, 2001).

COMPLICATED GRIEVING

Some believe complicated grieving to be a response outside the norm and

occurring when a person is void emotion, grieves for prolonged period, or had
expressions of grief that seem disproportionate to the event. People may suppress
emotional responses to the loss or become obsessively preoccupied with the deceased
person or lost object. Others actually may suffer from clinical depression when they
cannot make progress in the grief process (Enright & Marwit, 2002). Figure 12-1
depicts an overview of complicated grieving. Previously existing psychiatric disorders
also may complicate the grief process, so nurses must be particularly alert to clients
with psychiatric disorders who also are grieving. Grief can precipitate major
depression in a person with a history of the disorder.

These clients also can experience grief and a sense of loss when they
encounter changes in treatment settings, routine, environment, or even staff. Although
nurses must recognize that complications may arise in the grief process, the process
remains unique and dynamic for each person. Immense variety exists in terms of the
cultural determinants in communicating the experience and the individual differences
in emotional reactions, depth of pain, and time needed to acknowledge and grasp the
personal meaning or assimilate the loss. Box 12-1 discusses styles of grieving.

Characteristics of Susceptibility

For some, the effects of grief are particularly devastating because their
personality, emotional state, or situation makes them susceptible to complications
during the process. People who are vulnerable to complicated grieving include those
with the following characteristics:

 Low self-esteem

 Low trust in others

 A previous psychiatric disorder

 Previous suicide threats or attempts

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  Absent or unhelpful family members

 An ambivalent, dependent, or insecure attachment to the deceased person

 In an ambivalent attachment, at least on partner is unclear about how the couple

loves or does not love each other. For example, when a woman is uncertain
about and feels pressure from others to have an abortion, she is experiencing
ambivalence about her unborn child.

 In a dependent attachment, one partner relies on the other to provide for his or
her needs without necessarily meeting the partner’s needs.

 An insecure attachment usually forms during childhood, especially if a child

has learned fear and helplessness (i.e., through intimidation, abuse, or control
by parents).

A person’s perception is another factor contributing to vulnerability:

perception, or how a person thinks or feels about a situation, is not always reality.
After the death of a loved one, a person may believe that he or she really cannot
continue and is at a great disadvantage. He or she may become increasingly sad and
depressed, not eat or steep, and perhaps entertain suicidal thoughts.

RISK FACTORS LEADING TO VULNERABILITY

Parkes (1998) and Stroebe (2002) identified experiences that increase the
risk for complicated grieving for the vulnerable parties mentioned above. These
experiences are related to trauma or individual perceptions of vulnerability and
include the following:

 Death of a spouse or child

 Death of a parent (particularly in early childhood or adolescence)

 Sudden, unexpected, and untimely death

 Multiple deaths

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  Death by suicide or murder

Based on the experiences identified above, those most intimately affected

by the terrorist attacks on September 11, 2001 could be considered at increased risk
for complicated grieving.

Complicated Grieving as a Unique and Varied Experience

The person with complicated grieving also can experience physiologic

and emotional reactions. Physical reactions can include impaired immune system,
increased adrenocortical activity, increased levels of serum prolactin and growth
hormone, psychosomatic disorders, and increased mortality from heart disease.
Characteristic emotional responses include depression, anxiety or panic disorders,
delayed or inhibited grief, and chronic grief (Parkes, 1998).

Because the grieving process is unique to each person, the nurse must assess the
degree of impairment within the context of the client's life and experiences— for
example, examining current coping responses compared with previous experiences
and assessing whether or not the client is engaging in maladaptive behaviors such as
drug and alcohol abuse as a means to deal with the painful experience (Enright &
Marwit, 2002).

NURSING PROCESS

Nursing diagnoses used for clients experiencing grief include the following:

 Grieving related to actual or perceived loss such as a physiologic loss {e.g.,

loss of a limb). Loss of security and sense of belonging (e.g., loss of a loved
one) is defined as a normal process in the human experience of loss.

 Anticipatory Grieving (NANDA), related to the intellectual and emotional

responses and behaviors by which individuals, families, and communities work
through the process of modifying self-concept based on the perception of
potential loss.

 Dysfunctional Grieving (NANDA diagnosis for complicated grieving) related

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 to the extended, unsuccessful use of intellectual and emotional responses by
which individuals, families,-and communities attempt to work through the
process of modifying self-concept based upon the perception of loss.

Nursing Diagnosis: Risk for Dysfunctional Grieving Related To: Loss of a valued
concept/object; loss of a loved one

Evidenced By: Feelings of sadness, anger, guilt, self- reproach anxiety, loneliness,
fatigue, helplessness, shock, yearning, and numbness.

Outcome criteria: Client will progress through the grief process in a healthful
manner toward resolution.

Nursing Interventions Rationale

1. Assess client's stage in the grief 1. Accurate baseline data are required
process. to provide appropriate assistance.
2. Develop trust. Show empathy, concern, 2. Developing trust provides the basis
and unconditional positive regard. for a therapeutic relationship.
3. Help the client actualize the loss by 3. Reviewing the events of the loss can
talking about it. “When did it happen? help the client come to full
How did it happen?” and so forth. awareness of the loss.
4. Help the client identify and express 4. Until client can recognize and
feelings. Some of the more problematic accept personal feelings regarding
feelings includes. Anger. The anger the loss, grief work cannot progress.
may be directed at the deceased, at God, a. Many people will not admit to
displaced onto others, or retroflected angry feelings, believing it is
inward on the self. Encourage the client inappropriate and unjustified.
to examine this anger and validate the Expression of this emotion is
appropriateness of this feeling.b. Guilt. necessary to prevent fixation in
The client may feel that he or she did this stage of grief.
not do enough to prevent the loss. Help b. Feelings of guilt prolong
the client by reviewing the resolution of the grief process.
circumstances of the loss and the reality c. The client may have fears that he
that it could not be prevented. Anxiety or she may not be able to carry

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 and helplessness. Help the client to on alone.
recognize the way that life was 5. Understanding of the grief process
managed before the loss. Help the client will help prevent feelings of guilt
to put the feelings of helplessness into generated by these responses.
perspective by pointing out ways that he Individuals need adequate time to
or she managed situations effectively accommodate to the loss and all its
without help from others. Role-play life ramifications. This involves getting
events and assist with decision-making past birthdays and anniversaries of
situations. which the deceased was a part.
5. Interpret normal behaviors associated 6. Understanding of the grief process
with grieving and provide client with will help prevent feelings of guilt
adequate time to grieve. Interpret generated by these responses.
normal behaviors associated with Individuals need adequate time to
grieving and provide client with accommodate to the loss and all its
adequate time to grieve. ramifications. This involves getting
6. Provide continuing support. If this is not past birthdays and anniversaries of
possible by the nurse, then offer which the deceased was a part.
referrals to support groups. Support 7. The availability of emotional
groups of individuals going through the support systems facilitates the grief
same experiences can be very helpful process.
for the grieving individual. 8. The bereavement process is
7. Identify pathological defenses that the impaired by behaviors that mask the
client may be using (e.g., drug/alcohol pain of the loss.
use, somatic complaints, social 9. Only when the client is able to see
isolation). Assist the client in both positive and negative aspects
understanding why these are not healthy related to the loss will the grieving
defenses and how they delay the process be complete.
process of grieving.
8. Encourage the client to make an honest
review of the relationship with that
which has been lost. Journal keeping is

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 a facilitative tool with this intervention.

Nursing Diagnosis: Risk for Spiritual Distress

Related To: Dysfunctional grieving over loss of valued object

Evidenced By: Anger toward God, questioning meaning of own existence, inability to
participate in usual religious practices

Outcome Criteria: Client will express achievement of support and personal

satisfaction from spiritual practices.

Nursing Interventions Rationale

1. Be accepting and non judgmenta!
When client expresses anger and
bitterness toward God. Stay with the
client.
2. Encourage the client to ventilate
feelings related to meaning of own
existence in the face of current loss.
3. Encourage the client as part of grief
work to reach out to previously used
religious practices for support.
Encourage client to discuss these
practices and how they provided
support in the past.
4. Ensure client that he or she is not
alone when feeling inadequate in the
search for life’s answers.
5. Contact spiritual leader of client's
6. The nurse’s presence and
nonjudgmental attitude increase the
client’s feelings of self-worth and
promote trust in the relationship.
7. Client may believe he or she cannot go
on living without lost object. Catharsis
can provide relief and put life back
into realistic perspective.
8. Client may find comfort in religious
rituals with which he or she is familiar
9. Validation of client’s feelings and
assurance that they are shared by
others offer reassurance and an
affirmation of acceptability.
10. These individuals serve to provide
relief from spiritual distress and often
can do so when other support persons

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 choice, if he or she requests. cannot

10. HYPERVENTILATION SYNDROM

Hyperventilation syndrome (HVS) is a name given to a collection of

physical and emotional symptoms, largely brought about by hyperventilation. This
happens when we over-breathe. The main signs of this are when we breathe much
more quickly and more shallowly than our bodies needs. Over time, all sorts of
physical changes can take place in our body. These include a decrease in carbon
dioxide pressure in the alveoli (in our lungs) and arteries, an increase in arterial pH
(respiratory alkalosis), constriction of cerebral arteries and increased production of
lactic and pyruvial acid.

Definition

Hyperventilation occurs in many persons under stresses of daily living. It

is manifest not only in those overtly stressed, anxious and depressed but also in those
who appear outwardly calm as they “bottle up” their feelings, often because of
undeveloped or lack their feelings, often because of undeveloped or lack of acceptable
emotional outlets.

Causes '

One of the main causes of HVS is anxiety which is brought on by stress.

Stress can be bought on by all sorts of different factors. You may be the sort of person
who has generally been a worrier. Or you may have had some particular recent
stressful experience (e.g. bereavement, family conflict, financial problems, work
problems, other major life changes) that has led to increased anxiety. This is more
likely if the incident was experienced as life threatening (e.g. a work /road traffic
accident or a serious illness).

Different people respond to stress in different ways. People with HVS are
particularly inclined to tense the muscles of their upper body in response to stress.
This can particularly affect the ability of the diaphragm to function fully. This puts
extra pressure on the thoracic muscles for breathing. Prolonged overuse of these
71
muscles can eventually lead to the feelings of breathlessness, tightness in the chest and
even suffocation. Hyperventilation may occur as a reaction to these unpleasant
symptoms. We start to breathe more quickly and shallowly. This could perhaps be
interrupted by bursts of sighing.

Unfortunately, one of the problems faced by many people with HVS is that
their symptoms can lead to further anxiety. Sometimes, people with HVS fear that
their symptoms are a sign of serious illness. Other people become very anxious that
they are going to collapse. This can particularly occur when outside the home.

Other people become very stressed and frustrated with their symptoms. All
these reactions can lead, accidently, to making the symptoms of HVS worse than they
originally were.

Symptoms

HVS ca n show itself in different ways. Most people with H VS will have
experienced some, if not many, of the following symptoms.

Respiratory symptoms: breathlessness, tightness around the chest, fast breathing,

frequent sighing

Tetanic symptoms: tingling (e.g. in fingers, arms, mouth) muscle stiffness, trembling
in hands

Cerebral symptoms: dizziness, blurred vision, faintness, headaches

Cardiac symptoms: palpitations, tachycardia (rapid heartbeat)

Temperature symptoms: cold hands or feet, shivering, warm feeling in the head.

Gastrointestinal symptoms: sickness, abdominal pain,

General symptoms: Tension, Anxiety, fatigue and lethargy, insomnia

Obviously, these symptoms can in some cases be due to other physical

causes than HVS. This is why you may often be asked to undergo various physical
tests before you are d iagnosed as having HVS. Underlying physical problems have to
be ruled out before your physician can be sure that you are experiencing HVS.

72
Diagnosis

Tests are not usually needed to diagnose hyperventilation, but may be

done to exclude a more serious cause of your symptoms. T hese tests may include
blood tests, an ECG (tracing of your heart) or a chest x-ray

Management

The first thing that you need to do is to recognise your symptoms for what
they are. If you have been diagnosed as having HVS, it means that your symptoms
have been assessed as not being caused by an underlying physical problem. Certainly
your Symptoms are very real and can be very unpleasant but they are not life
threatening. In fact, dealing with the symptoms of HVS is very much under personal
control. :or some people. That can feel initially disappointing. It can be a relief to feel
that a treatment will take away your physical problems. This is not usually the case
with HVS. Instead, it can help for you to become your own physician and to take
control of the causes and consequences of your symptoms.

There are two important things to be done about HVS. Firstly, it is

necessary to cope with hyperventilation. Secondly, is to learn to cope with potentially
stressful situations. In order to learn to cope with hyperventilation, it can help to do
regular breathing and relaxation exercises. Sometimes you might be referred to a
physiotherapist, clinical psychologist or specialist nurse to help you develop breathing
and relaxation skills. Learning to breathe slowly and deeply is especially important for
people with HVS.

Most of the time we are not aware of our breathing. It is controlled

without us even having to think about it. However, to breathe slowly and deeply to
help the relaxation response you will need to practice. To be able to breathe slowly,
deeply and effectively you will need to use all your lungs (not just the top part) and to
expand the whole of your chest, including the muscle between your lungs and your
stomach (the diaphragm muscle)

How to check your breathing pattern

 To check that you are breathing deeply using your diaphragm muscle, sit or lie

73
 with your hands resting across the lowest part of your chest.

 Your hands should be just slightly above your waistline and have your
fingertips just touching.

 If you are breathing deeply and expanding the whole of your chest and lungs,
then your fingertips will move apart when you breathe in and together again
when you breathe out.

Self help for hyperventilation symptoms

If you have been diagnosed with hyperventilation then you can treat
yourself at home without needing to come to the Emergency Department and learn
how to control your symptoms.

Remember: the symptoms are very unpleasant but are not harmful and you do not
have a serious medical problem.

They can lead to a vicious cycle of feeling very ill, producing more anxiety and
worsening of symptoms. If you feel the symptoms coming on:

 Stop what you are doing and sit down.

 Concentrate on slow regular breathing - in and out - aim for 8-10 breaths a
minute.

 If this doesn't help, use the re-breathing technique: make a mask with your
hands, breathe in through your nose and out through your mouth, or use a paper
bag (never plastic) over your mouth and nose.

 As your breathing slows, your symptoms will settle.

Further important advice

 Practice diaphragmatic breathing during the day. You only need to take three or
four deep breaths each time you practice to get the benefit. Do not continue
deep breathing for long periods of time. Do not try too hard. Remember it takes
time and practice to be able to achieve good breathing.

 When doing any breathing exercise, it is important to try and make the rate at
74
 which you breathe in and out a steady and a constant rate.

In order to cope with stressful situations, you may find it useful to develop a number
of strategies.

 You may be referred to a clinical psychologist to help you with this. Sometimes
it is possible to take direct action to reduce the stress. Sometimes it is possible
to view situations in a different way. This may help to take a different
perspective either on the particular situation that is causing you stress, or on
your life more generally. Sometimes it is possible to get friends, family or work
colleagues involved to support you in tackling the sources of your stress.

 People with HVS find that, if they are able to cope better with the causes of
their symptoms, over time their symptoms begin to reduce or even disappear.
In this way, it is possible to return to a healthier and more comfortable life

VI. ROLE OF NURSE IN PSYCHIATRIC EMERGENCY

 Assess and have processes in place to enhance the environmental safety of the
patient and others.
 Establish a provisional diagnosis (or diagnoses) of the mental disorder most likely
to be responsible for the current emergency, including identification of any general
medical condition(s) or substance use that is causing or contributing to the
patient’s mental condition.
 Review current medications (prescribed and non-prescribed) and known
indications.
 Review relevant laboratory or radiologic study reports.
 Identify family or other involved persons who can provide information that will
help the mental health provider determine the accuracy of reported history,
particularly if the patient is cognitively impaired, agitated, or psychotic and has
difficulty communicating a history of events.

75
 Identify any current treatment providers who can supply information relevant to
the evaluation. Community mental health providers should be encouraged to
contact and provide clinically relevant information when referring their patients to
an emergency care facility.
 Identify social, environmental, and cultural factors relevant to immediate
treatment decisions.
 Determine whether the patient is able and willing to form a therapeutic
partnership alliance that will support further assessment and treatment.
 Identify what precautions are needed if there is a substantial risk of harm to self or
others, and whether involuntary treatment is necessary. Treatment should be
delivered in the least restrictive manner to ensure positive clinical outcomes.
 Determine whether the patient requires treatment in a hospital or other supervised
setting and what follow up will be required if the patient is not placed in a
supervised setting.
 Develop collaborative relationships and policies to facilitate the admission of
patients to the most appropriate mental health facility with the least delay after
evaluation and disposition by the emergency health care professional.
 Develop a specific plan for follow-up, including immediate treatment and
disposition.

VII. SUMMARY

Psychiatric emergency is a condition wherein the patient has disturbances

of thought, affect and psychomotor activity leading to a threat to his existence
(suicide), or threat to the people in the environment (homicide), This condition needs
immediate intervention to safeguard the life of the patient, bring down the anxiety of
the family members and enhance emotional security to others in the environment.
Acute form of alteration in behaviour, emotion or thought which requires immediate

76
intervention to safeguard the life of patient by bringing down the behavioural
manifestation and promoting emotional Security to the client and others in his
surroundings. It may be resulting from either psychiatric disorders or due to medical
conditions related to environment. For example, natural disaster or manmade disaster
(flood, famine) or manmade disaster; conditions like rape, violence etc. It is a
combination of circumstances which needs immediate attention.

VIII. CONCLUSION

An emergency is defined as an unforeseen combination of circumstances

which calls for an immediate action. A medical emergency is defined as a medical
condition which endangers life and/or causes great suffering to the individual, A
psychiatric emergency is a disturbance in thought, mood and/or action which
causes sudden distress to the individual (or to significant others) and/or sudden
disability, thus requiring immediate management. A similar term crisis means a
situation that presents a challenge to the patient, the family and/or the community,

Psychiatric emergency is a condition wherein the patient has disturbances

of thought, affect and psychomotor activity leading to a threat to his existence
(suicide), or threat to the people in the environment (homicide), This condition needs
immediate intervention to safeguard the life of the patient, bring down the anxiety of
the family members and enhance emotional security to others in the environment.
Acute form of alteration in behaviour, emotion or thought which requires immediate
intervention to safeguard the life of patient by bringing down the behavioural
manifestation and promoting emotional Security to the client and others in his

77
surroundings. It may be resulting from either psychiatric disorders or due to medical
conditions related to environment. For example, natural disaster or manmade disaster
(flood, famine) or manmade disaster; conditions like rape, violence etc. It is a
combination of circumstances which needs immediate attention.

IX. BIBLIOGRAPHY

1. Elakkuvana bhaskara raj (2014),text book of mental health nursing, first edition,
emmess publication. page no; 298-301

2. Neeraja K P, Essentials of mental health and psychiatric nursing, volume one, jaypee
publications, page no; 318-339

3. Shija, Text book of foundation of psychiatric mental health nursing, 1st edition, Jaypee
publication, page no; 224-265

4. Sreevani, Text book of mental health & psychiatric nursing, 4th edition, Jaypee
publication, page no; 317-332

5. Subash Indra Kumar C.L, Text book of Psychiatry and mental health nursing, emmess
publivations, pp; 590-622

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 6. Townsend Mary C, Text book of Psychiatric mental health nursing,8 th edition, Jaypee
publication, Page no; 217-224

Internet sourses

http://www.cmha.ca

http://www.mentalhelp.net

http://helpguide.org.

http://www.oprah.com

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