Crisis Prevention (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:02 That brings us to crisis prevention.

    00:06 What do we mean by crisis prevention? Very often, there are people who say a crisis is a crisis, you never see a crisis coming.

    00:15 And I'm going to beg to differ.

    00:18 As people become really good psychiatric nurses, we realize that most crises have little red flags that come up.

    00:29 And if we are listening, if we are in tune to our patients, if we're into into our environment, we are able to identify those situations and behaviors that can escalate to a crisis situation.

    00:46 One of the important tenets to remember is that aggression is not violence.

    00:53 A person can demonstrate some aggressive behavior.

    00:58 For example, they could yell at you.

    01:01 That's aggressive, but it's not violent.

    01:07 If that aggression takes steps and you see that the aggression becomes more threatening, then you're saying, "Oh, we're going into a violent situation." But when you first hear that aggressive tone, when you first see that stance, when you first hear that stamping of the feet or that fist, "You better not come anywhere closer to me." That is not violent, that's aggressive.

    01:42 And we're able to say to the person, "Wow, I would really appreciate if you just bring your hand down." I'm not coming any closer.

    01:54 But I need you to relax your hand.

    01:58 I'm going to suggest you take a deep breath.

    02:03 Even let it out with a sigh.

    02:08 Relax your shoulders.

    02:12 If you're going to put your hands up, put them up gently.

    02:17 Slow your voice down, drop your voice down.

    02:23 And when you have someone who says to you, "Take another step closer and I'm gonna hit you." I'm going to ask you to say, "I see how angry you are getting.

    02:37 I'm not coming any closer.

    02:41 I would really appreciate if you just lower your hand.

    02:45 I promise I won't come another step closer.

    02:50 This doesn't have to be like that." And if you notice, even now while I'm talking and I won't keep talking like that, because I don't want anyone to go to sleep.

    02:59 My slowing down, my dropping my voice is going to calm the situation down.

    03:07 It's going to reduce the stress level in the room.

    03:13 Situations that go up into crisis, or when you start seeing that stress mounting and mounting and mounting.

    03:20 When you have one person who says, "What macaroni and cheese again? I can't eat macaroni and cheese again, this is ridiculous." And you have a second person at the table saying, "I agree with you.

    03:31 I'm not eating macaroni and cheese either." You want to be able to reduce that stress.

    03:39 Now when we are in the unit, we normally don't have to think about a person using substances, alcohol or other drugs.

    03:53 However, there are times that someone might get a hold of some gummies or other substances in the unit.

    04:05 More likely, when you see situations that are escalating into violence, because of use of substance, it might be in a day program, it might be in a group home, it might be actually out on the street.

    04:23 When a person is using substances, their behavior becomes unpredictable.

    04:28 And when you have unpredictable behavior and you have mental illness which also carries with it a modicum of unpredictability, then you have the perfect storm for crisis.

    04:43 There is nonsuicidal self-injury.

    04:47 We normally see it with adolescents and that comes cutting.

    04:53 Sometimes it is in the form of burning yourself.

    04:58 Sometimes it is in the form of hanging or suffocation.

    05:03 This is nonsuicidal, meaning the person who is engaging in this behavior does not want to die.

    05:11 So, nonsuicidal self-injury is definitely a crisis risk.

    05:20 Because a person who is cutting themselves might cut an artery.

    05:25 A person who is trying to suffocate themselves by hanging but not die might lose their footing and actually hang themselves.

    05:36 So always consider nonsuicidal self-injury as a potential crisis.

    05:56 And then, medical emergencies.

    05:59 If there's been a car accident, if there's internal bleeding, if there's external bleeding, if a person is having crushing chest pain.

    06:08 When you see a person who is having a medical emergency, the only thing to do is call 911.

    06:16 Or if you're in the hospital, you're going to either call a code or a rapid response.

    06:23 Those are crises situation.

    06:27 Now, if we are able to be there before it escalates into that crisis, you want to engage in certain de escalating techniques like the one I just demonstrated.

    06:42 You, yourself need to remain calm.

    06:45 And sometimes, it's really hard.

    06:48 If you're stepping into a situation that is a potential crisis, your heartbeat might be going up, you might be feeling that surge of adrenaline.

    07:00 You're assessing the situation, you realize that the crisis is beginning, you take a deep breath.

    07:08 You want to make sure that you're not stepping into someone's personal space.

    07:13 If you feel that someone needs to be restrained usually in the hospital, there is a code that you can call like a doctor strong.

    07:23 And there is a group of individuals who are specifically trained in being able to calm down and restrain a psychiatric patient who is becoming violent.

    07:39 Listen to what is being said.

    07:42 Do not argue with the person.

    07:44 If the person says everyone here is listening to me, they're listening in, they've put something in my head.

    07:51 And now I can't listen, I can't breathe, I can't eat.

    07:55 Don't judge the person.

    07:57 Say, "Wow, it must be very hard to have to deal with that kind of feeling.

    08:04 I just want to talk to you about it." Listen without judging.

    08:09 It's one of the hardest things that you may have to do.

    08:13 So we have to be really careful that we are not becoming that person who actually just by the tone of our voice, the loudness and the speed of our delivery, that we are actually getting that person to react to us.

    08:29 We also want to be really careful about our body language.

    08:33 Remember I said before, walking in, hands open.

    08:37 Iif you want someone to stop, I usually have one hand up, one hand down, so that they know that I'm not just pushing them away, but I'm somewhat open.

    08:48 I really focus on my shoulders to try and get my shoulders to relax.

    08:54 I always make sure that I have one foot back and one foot forward just in case I have to move quickly.

    09:01 If I have two feet standing, and someone's coming towards me, it's going to be a little bit harder for me to move.

    09:07 So I just sort of give myself a stance that gives me an ability to turn if I need to.

    09:13 I very rarely will ever walk into a room like this because this body language says I'm totally closed off.

    09:21 We want to de-escalate.

    09:23 So we need to be calm.

    09:26 We need to know that there is a personal space that should not be broached.

    09:32 If you feel that you need to get closer to that person, to stop that person, you need to be calling people who are specially trained.

    09:41 Because otherwise that person might reach out and hurt you.

    09:45 You want to be able to hear the person what they're saying.

    09:48 Listen to them without passing judgment on what they're saying.

    09:53 Be in control of your own voice and watch the body language.

    10:01 Most of the time, what my patients and what other people, the way they are reacting to me is not about me.

    10:09 It's their life, it's their difficulties, it's their stress level.

    10:13 And I don't need to react to them.

    10:16 I need to act both in my best interest as well as in my patient's best interest.

    10:24 So not personalizing what is being said to you, even if they insult you.

    10:29 If your patient is calling you an ugly so and so.

    About the Lecture

    The lecture Crisis Prevention (Nursing) by Brenda Marshall, EdD, MSN, RN is from the course Accessing Acute Psychiatric Care (Nursing).

    Included Quiz Questions

    1. Reduce the speed of the voice
    2. Match the client’s volume
    3. Adopt a challenging stance with arms folded over the chest
    4. Reduce the space between the nurse and the client
    1. NSSIs are often used as a way to use pain to relieve stress.
    2. NNSIs are always a precursor to suicide attempts.
    3. NNSIs are most prevalent in males age 40-65 and least prevalent in youth.
    4. NNSIs are thoughts of wanting to hurt oneself and are considered a suicide attempt.
    1. “It sounds like you are experiencing a lot of fear and frustration, and I’m sorry you’re going through that.”
    2. “I am sorry you are upset, but you need to stop yelling and take a seat or you will be placed in restraints.”
    3. “The government is not after you. You are in an inpatient psychiatric unit and what you’re experiencing is a symptom of schizophrenia.”
    4. “That’s a very scary situation. Let’s get you back to your room while I call the government to get to the bottom of this.”

    Author of lecture Crisis Prevention (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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