Crisis Intervention and Suicide - · PDF fileCrisis Intervention and Suicide . ... NOC and NIC labels for a suicidal patient ... –Health education Nursing Planning and Implementation

DR. ARNEL BANAGA SALGADO, D.Sc., Ed.D., RN, MA, B.Sc, Cert .Ed, MAT (Psychology)

H/P No.: 050-799-3803 URL: www.ifeet.co; www.ifeet.org; www.ifeet.com.ph

Personal URL: www.abs.com.ph; www.arnelsalgado.com

Doctor of Science (D.Sc.)

Doctor of Education (Ed.D.)

Master of Arts in Nursing (RP)

Master of Arts in Teaching - Psychology (PNU)

Registered Nurse (RP, Mal, UAE)

Licensed Teacher (RP)

Certificate in Teaching,

Bachelor of Science in Nursing (BSN)

Author of

McGraw-Hill

Crisis Intervention and Suicide

http://www.ifeet.co/

http://www.ifeet.org/

http://www.ifeet.com.ph/

http://www.abs.com.ph/

http://www.arnelsalgado.com/

Chapters 13 & 17 of

the

required textbook

Learning Objectives

1. Define crisis

2. Name the types of crisis

3. Describe the various phases of crisis

4. Describe various steps in the nursing process in relation to crisis

5. Name the various psychiatric and medical disorders coexisting with suicidal acts

6. Describe the various risks and protective factors for suicide

7. Discuss the principles of suicide precautions and hazard-free environment in the hospital

8. Describe basic level interventions implemented in the management of a suicidal patient

16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 3

Definitions

Crisis is an acute, short-lived and

overwhelming emotional reaction to a

situation or an event.

A sudden event in one's life that

disturbs homeostasis, during which usual

coping mechanisms cannot resolve the

problem.


Types of Crisis

Maturational

Situational

Adventitious


Maturational Crisis

This relates to the process of maturation and passing through various stages of the life cycle.

Coping skills used earlier may no longer be helpful and appropriate. This leads to anxiety or crisis.

Adolescence, marriage, becoming a parent and retirement are some of the examples of maturational crises.


Situational Crisis

Is precipitated by various life events and is

not anticipated

Change of job, loss of job, divorce, financial

loss, death of a loved one and major

physical illnesses are some of the life

events that can lead to situational crisis.


Adventitious Crisis

Also known as crisis of disaster,

adventitious crisis is a situation that is

not a part of everyday life

It is unplanned and accidental.

Various examples of adventitious crisis

include earthquake, flood, airplane

crashes, rape, murder, war, riots and

terrorism.


Phases of Crisis

Caplan (1964) described four phases of

crisis:

i. When faced with a problem that

seems to be unsolvable, ‘tension’

starts and anxiety mounts. The person

attempts more and more to solve the

situation.


Phases of Crisis (cont.)

ii. Anxiety increases further with impairment of function and results in disorganization and distress. If anxiety and arousal are in excess, it hinders coping behaviour.

iii. Emergency measures are taken and new coping skills are tried.

iv. Failure to resolve the crisis leads to further deterioration, disorganization and decompensation.


Application of the

Nursing Process 1. Nursing Assessment

◦ Determine the severity of the crisis

◦ Assess the risk for suicide/homicide

◦ Assess patient’s perception of the

precipitating events

◦ Assess the patient’s coping skills

◦ Assess the available support system


Application of the

Nursing Process (cont.) 2. Nursing Diagnosis

Various nursing diagnosis in a patient with crisis include:

– Anxiety

– Ineffective coping

– Inability to meet role expectations

– Inability to carry out routine activities


Application of the

Nursing Process (cont.) – Decreased socialization

– Low self-esteem

– Risk to self


Application of the

Nursing Process (cont.) 3. Nursing Outcome

◦ Set short-term and long-term goals with patient and the family

◦ Goals should be realistic, culturally relevant and meet the patient’s level of functioning

◦ Nursing Outcome Classification (NOC) can be used to help set the outcome goals.


Possible Outcome Criteria in Crisis

Intervention

Short Term

Refrains from harming self or attempting suicide

Level of anxiety goes down

Sleeps better

Becomes more coherent and organized

Interacts better with others

Able to see some hope in life

Long Term Feels safe even when alone

Sleep and appetite patterns are back to pre-crisis level

Learns new coping skills

Able to carry out roles at home and at the workplace

Has confidence in self to handle life and problems effectively


Application of the Nursing Process (cont.) 4. Nursing Intervention

◦ Crisis intervention is a brief psychiatric treatment to forestall the process of mental decompensation in severe emotional stress.

◦ Two basic aims of crisis intervention are safety and anxiety reduction.

◦ Nursing interventions in a crisis can be carried out at three levels.


Levels of Crisis Intervention

Primary level: promotes mental well-being and reduces the incidence of crisis

Secondary level: works towards preventing prolonged anxiety, diminished efficacy and personality disorganization.

Tertiary level: aims at providing support to patients recovering from a crisis


Application of the Nursing Process

(cont.) 5. Evaluation

◦ To judge the effectiveness of the crisis

intervention strategies used

◦ Usually carried out 4–8 weeks after the initial

assessment

◦ Nurse may decide to follow up with patient

or refer to other agencies


Crisis Stabilization

People with mental illness are more prone to crisis.

The nurse can adapt the crisis model by taking the following steps: ◦ Clarify the reality of the situation

◦ Make the patients aware of own capabilities and social support available


Crisis Stabilization (cont.)

◦ Set realistic goals according to level of

functioning

◦ Take up responsibility and help the patient for

the initial period


Suicide is the third leading cause of death among 14–25 years olds, after accidents and homicides.

The majority of people with suicidal ideations have a treatable psychiatric disorder.

Only 1% of the people with suicidal ideations commit suicide.

Suicide does not always mean presence of a psychiatric disorder.


Comorbidity

Psychiatric Conditions

◦ Major depressive disorder

◦ Bipolar disorder

◦ Schizophrenia

◦ Substance use disorder

◦ Panic disorder

◦ Borderline and antisocial personality disorder

Medical Conditions

◦ AIDS

◦ Myocardial infarction

◦ Cardiac failure

◦ Cirrhosis

◦ Stroke

◦ Epilepsy

◦ Huntington’s disease

◦ Multiple sclerosis

◦ Peptic ulcer

Clinical Conditions Associated with High Suicide Risk


i. Psychosocial factors

Freud described suicide as aggression turned inward, towards an internalized love object.

Menninger expanded on Freudian theory and described suicidal hostility as the wish to kill, the wish to be killed and the wish to die.

Aaron Beck identified hopelessness as a central factor underlying the act of suicide.

Aetiology


Durkheim divided suicides into 3 categories:

– Egoistic suicide, which occurred in persons who have lost their sense of integration within their social group.

– Anomic suicides are seen in times of major social changes or political crisis when the society lacks order.

– Altruistic suicide means sacrificing one’s life for the welfare of the social group.

Aetiology (cont.)


ii. Biological factors

Evidence of the role of genetic factors in suicide comes from the findings that suicide runs in families.

Low levels of serotonin or its metabolites in the cerebrospinal fluid have been associated with the suicidal act.

Aetiology (cont.)


iii. Cultural factor

◦ Cultural factors including family values,

religious beliefs and attitudes towards life

and death have a bearing on the suicide

rates.

Aetiology (cont.)


Clear suicidal intent

Lethal suicidal plan

Previous suicidal attempt

Comorbid psychiatric/ medical conditions

Unemployment

Being single (especially in males)

Old age

Family history of suicide

Recent stressful life event

Poor social support

Poor impulse control

Risk factors

Risk and Protective Factors for Suicide

Good coping skills

Good social support

Family cohesiveness

Sense of responsibility to

family

Religious beliefs

Pregnancy

Intact reality testing

Protective factors

Assessment

Assessment of suicide risk involves:

– taking detailed psychological and medical history

– identifying risk and protective factors.

If there is no clear desire to die, suicidal feelings can be managed at the outpatient level with frequent follow-ups.

The presence of clear intent with a lethal plan or a history of parasuicide would warrant emergency hospitalization.

Nursing Process


Almost all suicidal patients give clues and hints about their suicidal ideas and plans (intent).

These clues can be:

– verbal—overt ones like ‘I wish I were dead’ or covert ones (e.g. ‘Soon I would not be a burden on anyone’).

– non-verbal (behavioural)—sudden improvement in mood and energy levels, giving away personal belongings or organizing finances.

Nursing Process (cont.)


It is important to evaluate the lethality of suicidal plans. Lethality can be judged by the proposed method and the accessibility to the planned method.

High risk (‘hard’) methods include:

– jumping off a high building

– jumping in front a running train

– hanging

Nursing Assessment (cont.)


– using a gun

– staging a car crash.

– poisoning with organophosphorus chemicals (pesticides)

Low-risk (‘soft’) methods include

– overdosing on pills

– slashing wrists

Nursing Assessment (cont.)


Risk for suicide is the diagnosis with the highest priority and should be handled immediately.

Nursing Diagnoses for a Suicidal Patient:

– Risk for suicide

– Ineffective coping

– Hopelessness

– Powerlessness

Nursing Diagnosis

– Social isolation

– Loneliness

– Low self-esteem

– Deficient knowledge


Nursing Outcome Criteria

Nursing Outcome Criteria Nursing Intervention Criteria

Suicide self-restraint Suicide prevention

Hope Hope installation

Self-esteem Self-esteem enhancement

Coping Coping enhancement

Social support Family mobilization

Spiritual health Support system enhancement

NOC and NIC labels for a suicidal patient


During the acute suicidal crisis, the following interventions will help in the recovery process.

– Specialized milieu therapy

– Appropriate psychobiological interventions

– Counselling

– Case management and

– Health education

Nursing Planning and Implementation


Suicide Precautions

1. Continuous nursing observation on one-to-one basis

2. Restrain, if warranted

3. Continuous assessment of risk

4. Ensure hazard-free environment

5. Recording of mood, thoughts and behaviour every 15–30 minutes

Specialized Milieu Therapy


– Supervise medication intake to ensure that patient swallows tablets

–Maintain the physical distance

–Explain all these to the patient and the reason for doing so

Specialized Milieu Therapy (cont.)


Electroconvulsive therapy (ECT)

Antidepressants (SSRIs are preferred to tricyclic antidepressants considering their safety profile even when overdosed)

Antipsychotics (atypical antipsychotics are preferred to the typical ones because these have fewer adverse effects)

Anti-anxiety agents to control anxiety and insomnia.

Psychobiological Interventions


Establishing a working relationship with the patient encourages him to solve the problems in a realistic manner.

A No-Suicide contract is written by the patient where he agrees not to harm himself but to use alternative methods to control suicidal ideas (e.g. use help-line, talking to the staff).

The patient should come for regular follow-up after discharge from the hospital.

Counselling


The patient is helped to recognize the support system available to him.

Re-establishing the contacts with family and friends is the major focus of case management.

The patient should be given information on aftercare referral, crisis hotlines, support groups and recreational groups.

Depending upon the religious beliefs, the patient may be encouraged to join a spiritual support group.

Case Management


The nurse should provide information about

the psychiatric diagnosis, if any, the need for

treatment, maturational crisis, coping and

communication skills and various community

resources available.

Family and friends should also be included in

the health teaching sessions.

Health Education


Evaluation is an ongoing process. The evaluation should include short-term goals and establish long-term ones as the suicidal ideas resolve.

The patient is observed to see whether he is able to talk about his thoughts and feelings freely and readily, is able to use problem-solving methods and is using the social support system.

The patient is constantly monitored for any sudden change in the mood and behaviour as it may indicate a suicidal intent.

Nursing Evaluation


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Crisis Intervention and Suicide - · PDF fileCrisis Intervention and Suicide . ... NOC and NIC labels for a suicidal patient ... –Health education Nursing Planning and Implementation