In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of crisis intervention in order to:

  • Assess the potential for violence and use safety precautions (e.g., suicide, homicide, self-destructive behavior)
  • Identify the client in crisis
  • Use crisis intervention techniques to assist the client in coping
  • Apply knowledge of client psychopathology to crisis intervention
  • Guide the client to resources for recovery from crisis (e.g., social supports)

A crisis is an acute phenomenon that most often lasts for only a couple of weeks and one that pushes the client well beyond their ability to effectively cope with it using their current coping mechanisms. Some of the defining characteristics of a crisis include its unexpected and unanticipated emergence without any time to prepare for it, an awareness on the part of the client that the crisis is highly threatening to the client, a radical change in one's communication with others, a major change in terms of the client's abilities to perform activities including the activities of daily living, feelings of grief, including anticipatory grief, and feelings of loss relating to the crisis. The severity of the crisis is typically described in terms of its ability to incapacitate the client and even lead to the client's demise.

Generally, crises can be categorized as situational, maturational and adventitious. Examples of these crises classifications are the loss of a limb secondary to a traumatic amputation, the loss of bodily functioning as the result of the normal changes associated with the aging process, and the loss of personal possessions as the result of a violent armed robbery in the home, respectively.

The severity of a crisis can be categorized with levels of severity from 1 to 4. A level 1 of severity is the least disruptive of crises and a level 4 of severity of the crisis is the worst of crises in terms of severity.

Assessing the Potential for Violence and Using Safety Precautions

The typical signs and symptoms experienced by the patient that can, and should, be identified by the nurse, according to the level of severity for the crisis are as follows.

  • Level 1 Crisis Signs and Symptoms: Patients experiencing a level one crisis typically experience anxiety and they also typically begin to use one or more psychological ego defense mechanisms that were discussed above under the section entitled "Evaluating the Constructive Use of Defense Mechanisms by a Client".
  • Level 2 Crisis Signs and Symptoms: Patients experiencing a level two crisis most likely exhibit some loss of their ability to function. They may also try to experiment with alternative methods of coping in order to deal with the crisis that is not being effectively coped with using one's currently used coping mechanisms.
  • Level 3 Crisis Signs and Symptoms: Patients experiencing a level three crisis show the signs and symptoms of the General Adaptation Syndrome which is characterized with fight, flight and panic as discussed above under the section entitled "Coping Mechanisms: Introduction".
  • Level 4 Crisis Signs and Symptoms: Clients experiencing a level four crisis exhibit severe signs and symptoms such as being totally detached and removed from others, feeling overwhelmed, becoming disoriented, and even with thoughts of violence toward self and others.

Suicide, homicide, suicide - homicide and other episodes of violence are severe psychological crises that must be prevented. Prevention is based on the nurses' knowledge about the client, their knowledge about the risk factors and warning signs related to these acts of violence and applying this knowledge to the care and monitoring of clients at risk for these acts of violence. For example, a client with severe depression must be identified and treated so that this person, at risk for suicide and other acts of violence, does not place self and others at risk for serious harm, including acts like homicide and suicide.

Acts of violence can be broadly described and categorized as violence directed at others and violence directed towards self. According to the National North American Nursing Diagnosis Association International (NANDA), the risk of violence directed towards others is the potential the client to be "at risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally and/or sexually harmful to others"; and the National North American Nursing Diagnosis Association International (NANDA), defines the risk of self directed violence is defined as the "risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally and/or sexually harmful to self".

Some of the risk factors associated with acts of violence towards others include:

  • A history of substance related abuse and addiction
  • A personal history of a psychiatric illness and/or a past history of violence towards others
  • A personal or family history of abuse, neglect and acts of violence
  • A history of violence towards animals
  • A traumatic head injury
  • Paranoid delusions
  • Hallucinations, particularly command hallucinations that entail a "voice" in the client's head instructing them to commit an act of violence
  • Hyperactivity
  • Changes in terms of the client's body language and posturing with such signs and symptoms as a clenched jaw and/or fist

Some of the risk factors associated with acts of violence towards self include:

  • An age of over 45 years of age
  • An age of 15 to 19 years of age
  • A history of depression
  • A history of substance related abuse and addiction
  • A personal history of a psychiatric illness and/or a past history of violence towards others
  • A personal or family history of abuse, neglect and acts of violence
  • Behavioral and verbal cues such as giving away one's personal treasured possessions and taking out a recent life insurance policy to insure that the family left behind will have some financial resources
  • Employment problems
  • Problems with interpersonal relationships
  • A history of previous suicide attempts
  • Severe physical illness such as a disfiguring one and/or a terminal disease
  • Sexual orientation other than heterosexual

Homicide and suicide homicide risk are also a grave threat among clients who are adversely affected with unresolved crises and depression, when compared to other clients without this depression and unresolved crises. For example, some patients may decide on homicide or suicide homicide because they are lashing out at those who they perceive caused their problems, others may try to "save others" by killing them in order to keep them from the pain and suffering that the crisis brought to them, and still more kill others and then promptly kill themselves to avoid further pain and suffering.

Identifying the Client in Crisis

The first step of the nursing process, assessment, is done by collecting primary and secondary data, objective and subjective data about the client and their possible potential for violence.

Some of the signs and symptoms that occur quite often among clients at risk for suicide are the saying goodbyes, oral or written statements about suicide, giving possessions away, a lack of interest in the future, guilt, shame, significant changes in the client's personal appearance and/or personality, sleep alterations, self harming behaviors, threats of suicide and the appearance that the client's depression has lifted. This appearance of the client's "feeling better" is a signal that the client may have completed their suicide plan and NOT a sign that the depression has been resolved and that the client is no longer at risk for suicide. The depression has lifted because a plan is now in place.

Some nursing diagnoses that may be appropriate for a client who is at risk for self harm, including suicide are:

  • At risk for suicidal ideation and suicide related to an unresolved situational crisis
  • At risk for suicidal related to depression
  • At risk for self harm or suicide related to the lack of resources and the lack of social support systems
  • At risk for self harm and suicide related to a previous trauma such as abuse or neglect

Some nursing diagnoses that may be appropriate for a client who is at risk for harm to others, including homicide, homicide-suicide and other violent acts are:

  • At risk for violence towards others related to a substance related or psychiatric mental health disorder
  • At risk for violence towards others related to poor impulse control
  • At risk for violence towards others related to an unresolved crisis
  • The risk for violence towards others related to a history of childhood abuse or neglect
  • The risk for violence towards others related to head trauma or another neurological deficit
  • The risk for violence towards others related to command hallucinations
  • The risk for violence towards others related to delusions

Using Crisis Intervention Techniques to Assist the Client in Coping

All threats of suicide and violence directed towards others must be taken seriously and not minimized. The environment of care must be open, supportive, honest, nonjudgmental, caring and filled with trust, compassion, and understanding.

Constant observation, and often one-to-one observation, as well as the use of restraints or seclusion may be necessary when the risk of suicide, homicide and self harm are high in order to protect the safety of the client. The safety of the suicidal person and others in imminent harm must be preserved and maintained.

In addition to maintaining the patient's safety, emotional and physical interventions are used to resolve the crisis and return the client back to their optimal level of functioning.

The first step is establishing trust and then allowing the patient to fully and freely ventilate their feelings in the therapeutic patient nurse relationship. Throughout the course of care, the nurse establishes and maintains the use of therapeutic communication, caring, compassion, respect and, depending on the needs of the particular client, and other interventions include:

  • The active engagement of the client and family members as well as significant others in the plan of care within an environment that is supportive of the client and their choices
  • The development and enhancement of the client's coping mechanisms
  • Engaging the client in individual and group therapy groups
  • Providing positive reinforcements for appropriate behaviors
  • Encouraging the client to employ stress management and relaxation techniques
  • Insuring that the client adheres to their medication and treatment plan
  • Increasing the client's knowledge about and insight into their current psychiatric mental health disorder, the risk factors, the warning signs, and when to communicate any symptoms and warning signs of a relapse, including the use of a suicide hot line, when indicated
  • Educating the client about the need for ongoing follow up care after an acute admission for violent behaviors to self and others and/or the risk thereof including the use of self-help and peer support groups in the client's community

Some of the essential components of the teaching plan relating to violence prevention should include the warning signs and symptoms of crisis, depression, and the risk factors associated with suicide and violent acts towards others.

Applying a Knowledge of Client Psychopathology to Crisis Interventions

Responses to crises can lead to a number of psychopathological effects including those discussed in this section and others that were discussed above under the section entitled "Coping Mechanisms" and below under "Mental Health Concepts". For example, a client with a traumatic head injury will require care and treatments related to their neurological deficits and risks as based on this specific psychopathology; a client who has a history of an underlying psychiatric mental health disorder or substance related abuse disorder will necessitate that the nurse plan crisis interventions based on this specific psychopathology; and a client who has had a history of physical, emotional or sexual abuse will require crisis interventions as indicated for this underlying psychopathology.

Guiding the Client to Resources for Recovery from Crisis

Ongoing follow up care is necessary for clients who are recovering from a crisis not only to prevent a future crisis but also to return the client to their normal level of functioning as it was prior to the crisis without any episodes of violence and harm to self or others. Some of these resources, in addition to those that provide psychiatric mental health services, are peer support groups in the community and the use of other social supports

Some of the expected patient goals or expected outcomes for clients adversely affected with harm to self include: The client will

  • The client will employ effective coping strategies to cope with their crises and stressors
  • The client will maintain self control
  • The client will express that they have gained better control of their impulses and behaviors
  • The client will express decreased levels of anxiety
  • The client will openly ventilate their feelings to others
  • The client will employ relaxation and stress management techniques
  • The client will seek help when urges for self harm and/or self mutilation arise
  • The client will utilize appropriate methods to express their anger and anxiety

Some of the expected patient goals or expected outcomes for clients adversely affected with violent behaviors towards others include:

  • The client will refrain from all acts of violence
  • The client will displace and diffuse anger in an appropriate manner
  • The client will maintain self-control of impulses
  • The client will cease aggression, hostility and antisocial behaviors
  • The client will avoid situations and circumstances that could trigger anger and violence towards others
  • The client will employ relaxation and stress management techniques
  • The client will openly ventilate their feelings to others
  • The client will follow their medication regimen
  • The client will adhere to their treatment plan including their follow up plan of care after an acute episode
  • The client will return to their pre-crisis level of functioning

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