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  1. Trauma Interventions Suicide, self-injury, crisis, anger & violence, abuse (child, older adult, & intimate partner), sexual assault Chia-Ling Mao

  2. Objectives • Suicide • Profile, precipitating events, risk factors & coexisting psychiatric disorders, nurses’ common reactions, nursing interventions • Crisis • Definition, categories, • Anger, violence, • Predictors, determinants, assessment, interventions, • Abuse & Assault • Types, assessment, intervention, documentation and reporting

  3. Suicide • Definition: the intentional act of killing oneself by any means • Significance • Involves pains, guilty, self-loathing, and hopelessness & helplessness. • The 10th leading cause of death. Every 14 minutes, a human life ends as the result of suicide; 105 American lives end daily. • May underreported i.e. accident cases • It is preventable • Cry for help – primary care provider, mental health provider, ER… • Ambivalent about death

  4. Pictures of Suicide case • Suicidal ideation with intent • History – esp within the 24 months; individual and family, abusive childhood • Psychiatric disorders (account for 90% of completed suicides) – major depression (2/3 cases), bipolar, schizophrenia, substance abuse, personality disorders… • Others – recent stressful life event ie. loss of relationships, financial difficulty, and impulsivity… • Common profile (risk factors) • Gender, age, race, religion, marriage, profession, physical health • Support system

  5. Assessment • Biological factors • Psychological factors • Cultural factors • Societal factors

  6. Biological Factors • Suicidal behavior tends to run in families • Low serotonin levels are related to depressed mood

  7. Psychosocial Factors • Freud—aggression turned inward • Menninger • Wish to kill • Wish to be killed • Wish to die • Aaron Beck—central emotional factor is hopelessness • Recent theories—combination of suicidal fantasies and significant loss

  8. CulturalFactors • Protective factors • African Americans • Religion, role of the extended family • Hispanic Americans • Roman Catholic religion and importance of extended family • Asian Americans • Adherence to religions that tend to emphasize interdependence between the individual and society

  9. Societal Factors • Oregon’s Death with Dignity Act of 1994—terminally ill patients allowed physician-assisted suicide • Washington state—physicians can prescribe lethal medication • Netherlands—non-terminal cases of “lasting and unbearable” suffering • Belgium—non-terminal cases when suffering is “constant and cannot be alleviated” • Switzerland—assisted suicide legal since 1918

  10. Application of the Nursing Process • Assessment • Verbal and nonverbal clues • Overt statements • Covert statements • Lethality of suicide plan • Assessment tools • SAD PERSONS scale • Self assessment

  11. Suicide ideation assessment • Have you ever felt that life was not worth living? • Have you been thinking about death recently? • Did you ever think about suicide? • Have you ever attempted suicide? • Do you have a plan for completing suicide? • If so, what is your plan for suicide?

  12. Levels of Intervention • Primary—activities that provide support, information, and education to prevent suicide • Secondary—treatment of the actual suicidal crisis • Tertiary—interventions with a circle of survivors left by individuals who completed suicide to reduce the traumatic aftereffects

  13. Interventions • Teamwork and safety • Counseling • Health teaching and health promotion • Case management • Pharmacological interventions • Post-vention for survivors of completed suicide

  14. Advanced Practice Interventions • Psychotherapy • Psychobiological interventions • Clinical supervision • Consultation

  15. Question – Dangerous moment for suicide A patient is hospitalized with major depression and suicidal ideation. He has a history of several suicide attempts. For the first 2 days of hospitalization, the patient eats 20% of meals and stays in his room between groups. By the fourth day, the nurse observes that the patient is more sociable, is eating meals, and has a bright affect. Which factor should the nurse consider?

  16. Nonsuicidal Self-Injury • Def - deliberate & direct attempts to cause bodily harm that does not result in death • Prevalence – 13-23 % globally, begins between 10-15 y/o and peaks in the late teens • Comorbidity - depression (parents or individual), borderline personality disorder, anxiety, substance use disorders

  17. Non-suicidal Self-Injury Etiology • Biological factors • Inconclusive, maybe r/t neurobiological mechanisms; lower levels of cerebrospinal fluid endogenous opiods and serotonin, dopamine, norepinephrine … • Cultural factors • German adolescent (10.4%) vs. Romanian youth (1.9%) • Societal factors – mass media

  18. Crisis - Characteristics • Profound disruption of normal psychological homeostasis • Normal coping mechanisms fail • Results in inability to function as usual • Acute and time-limited- 4-6 weeks

  19. Balancing factors • Outcomes depend on • Realistic perception of the event • Adequate situational supports • Crisis intervention • Adequate coping mechanisms

  20. Types of Crisis • Maturational • New developmental stage is reached • Old coping skills no longer effective • Leads to increased tension and anxiety • Situational • Arise from events that are • Extraordinary • External • Often unanticipated • Adventitious • Unplanned and accidental • Natural disaster • National disaster • Crime of violence

  21. Phases of Crisis - Phase 1 • Conflict or problem • Self-concept threatened • Increased anxiety • Use of problem-solving techniques and defense mechanisms • Resolve conflict or problem • Reduce anxiety

  22. Phases of Crisis - Phase 2 • Defense mechanisms fail • Threat persists • Anxiety increases • Feelings of extreme discomfort • Functioning disorganized • Trial-and-error attempt to solve problem and restore normal balance

  23. Phases of Crisis - Phase 3 • Trial-and-error attempts fail • Anxiety can escalate to severe level or panic • Automatic relief behaviors mobilized (i.e., withdrawal and flight) • Some form of resolution may be devised(i.e., compromising needs or redefining situation)

  24. Phases of Crisis - Phase 4 • Problem is unsolved and coping skills are ineffective • Overwhelming anxiety • Possible serious personality disorganization, depression, confusion, violence against others, or suicidal behavior

  25. Application of the Nursing Process • Assessment • General assessment • Assessment of perception of precipitating event • Assessment of situational supports • Assessment of personal coping skills • Self assessment

  26. Nursing Process (Cont.) • Diagnosis • Ineffective coping, anxiety, risk for suicide, low self-esteem, social isolation, … • Outcomes identification • Implementation • Basic level • Patient safety • Anxiety reduction

  27. Anger and Aggression • Anger • An emotional response to frustration of desires, threat to one’s needs (emotional or physical), or a challenge • Aggression • Action or behavior that results in verbal or physical attack

  28. Epidemiology • In the hospital, violence is most frequent in • Psychiatric units • Emergency departments • Geriatric units

  29. Comorbidities • Posttraumatic stress disorder (PTSD) • Substance abuse disorders • Coexists with • Depression • Anxiety • Psychosis • Personality disorders

  30. Etiology • Biological factors • Areas of the brain • Neurotransmitters • Predisposition • Psychological factors • Behavioral theory—learned response • Social learning theory—imitate others

  31. Application of the Nursing Process • General assessment • A history of violence is the single best predictor of future violence. • Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. • Aggression by patients occurs most often in the context of “limit setting” by the nurse. • Patients with a history of limited coping skills, including lack of assertiveness or use of intimidation, are at higher risk of using violence.

  32. Assess the risk for violence • Does the patient have a wish or intent to harm? • Does the patient have a plan? • Does the patient have means available to carry out the plan? • Does the patient have demographic risk factors • i.e., male gender, age 14 to 24 years, low socioeconomic status, inadequate support system, prison time?

  33. Self assessment • Assess self for personal triggers and responses likely to escalate patient violence, including patient characteristics or situations that trigger impatience, irritation, or defensiveness. • Assess personal sense of competence when in any situation of potential conflict; consider asking for the assistance of another staff member.

  34. Nursing Process (Cont.) • Nursing diagnoses • Ineffective coping • Stress overload • Risk for self-directed violence • Risk for other-directed violence

  35. Nursing Process (Cont.) • Outcomes identification • Implementation • Psychosocial interventions • Considerations for staff safety • Pharmacological interventions

  36. Nursing Process (Cont.) • Implementation • Health teaching and health promotion • Case management • Teamwork and safety • Use of restraints or seclusion

  37. Keep safe while working • Attire – avoid dangling stuff • Enough staff for back up. • know the layout of the area. • Do not stand directly in front of the patient or in front of the doorway. It is better to stand off to the side and encourage the patient to have a seat. • If a patient's behavior begins to escalate, provide feedback. “You seem to be very upset.” Such an observation allows exploration of the patient’s feelings and may lead to de-escalation of the situation. • Avoid confrontation with the patient. Verbal confrontation and discussion of the incident must occur when the patient is calm.

  38. Seclusion or Restraints • Seclusion • Involuntary confinement alone in a room that the patient is physically prevented from leaving • Restraints • Any manual method, physical or mechanical device, material, or equipment that restricts freedom of movement

  39. Guidelines for Use of Mechanical Restraints • Indications for use • Legal requirements • Documentation • Clinical assessments • Observation • Release procedure • Restraint tips

  40. Case Study - restraints • A patient becomes violent and must be placed in restraints. • What questions need to be asked after this incident? • Is it preventable? What should have been done? • Team work? Policy & procedure? • Debriefing? Staff’s injury and feeling, fear, anger, peer support? • need for additional staff education? • What could be done differently? • If injury occurred, has it been reported and cared for?

  41. Audience Response Questions • A violent patient is restrained. What is the nurse’s first priority? • Debrief the patient • Ensure the patient’s safety • Administer a sedating medication • Obtain an order from the health care provider

  42. Audience Response Questions • Which patient behavior is a criterion for mechanical restraint? • Screaming profanities • Assaulting a staff person • Refusing a medication dose • Throwing a pillow at another patient

  43. Chapter 28 Child, Older Adult, and Intimate Partner Abuse

  44. Types of Abuse • Physical abuse • Sexual abuse • Emotional abuse • Neglect • Economic abuse

  45. Epidemiology and Comorbidity • Prevalence • Half of all Americans have experienced violence in their families • Comorbidity • Secondary effects of violence • Anxiety • Depression • Suicidal ideation

  46. Occurrence of Violence • Requires • Perpetrator • Vulnerable person • Crisis situation

  47. Characteristics of Perpetrators • Consider their own needs more important than the needs of others • Poor social skills • Extreme pathological jealousy • May control family finances

  48. Cycle of Violence • Tension-building stage • Acute battering stage • Honeymoon stage

  49. Characteristics of Vulnerable Persons: Women • Pregnancy may trigger or increase violence • Violence may escalate when wife makes move toward independence • Greatest risk for violence when the woman attempts to leave the relationship

  50. Characteristics of Vulnerable Persons: Children • Younger than 3 years • Perceived as different • Remind parents of someone they do not like • Product of an unwanted pregnancy • Interference with emotional bonding between parent and child