In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of crisis intervention in order to: Show
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 PrecautionsThe 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.
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:
Some of the risk factors associated with acts of violence towards self include:
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 CrisisThe 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:
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:
Using Crisis Intervention Techniques to Assist the Client in CopingAll 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:
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 InterventionsResponses 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 CrisisOngoing 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
Some of the expected patient goals or expected outcomes for clients adversely affected with violent behaviors towards others include:
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Alene Burke, RN, MSN Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.  Latest posts by Alene Burke, RN, MSN (see all) Which is most essential when planning care for a client who is experiencing a crisis quizlet?Which of the following is most essential when planning care for a client who is experiencing a crisis? evaluate the potential for self-harm.
Which of the following is essential for a therapeutic relationship?Edward Bordin, defined a good therapeutic relationship as consisting of three essential qualities: an emotional bond of trust, caring, and respect; agreement on the goals of therapy; and collaboration on the "work" or tasks of the treatment.
Which would be a reason for a student nurse to use the DSM?Although student nurses do not use the DSM to diagnose clients, they will find it a helpful resource to understand the reason for the admission and to begin building knowledge about the nature of psychiatric illnesses.
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Which is most essential when planning care for a client who is experiencing a Crisis?
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