Outline of the Patient’s Crisis Management Plan. You have been working as an outpatient psychiatric nurse practitioner in a busy office for about 6 months. You have a few patients that you know quite well by this point and a few that you are getting to know. Record a video discussing how you would address a crisis with each of the two following patients.
Crisis Management in Psychiatric Care
Instructions
You have been working as an outpatient psychiatric nurse practitioner in a busy office for about 6 months. You have a few patients that you know quite well by this point and a few that you are getting to know. Record a video discussing how you would address a crisis with each of the two following patients.
Each video should be 5-10 minutes each. Submit an unlisted YouTube link. Instructions on creating an unlisted YouTube video.
Include a word document of references utilized in your video, in 7th edition APA formatting. Utilize resources for help with proper formatting.
Patient 1: 45-year-old male who has been married for 15 years with 2 children. He has a history of MDD and pornography addiction which has been dealt with through therapy. This addiction had caused some trouble in the marriage but for the past 5 years, things have been going well in the marriage and the patient denied looking at porn. MDD symptoms started in his 20s and have been well managed with citalopram (Celexa) 20mg daily. He comes in today visibly upset. He reports his wife has been cheating on him for 2 years and he found out when he came home from work to find his wife and kids gone, a note that detailed her infidelity and she took the children to live with the man she has been cheating with. Divorce proceedings are in effect. He states “I had no idea, I know I had my own problems but 2 years? I feel so stupid, I don’t know why I bothered improving myself, I don’t know how I can even go on. My work made me take some time off but I have continued to call in, I’m at risk of losing my job but I just can’t bring myself to go. The kids are my world and I haven’t even talked to them for a month”. You question him about suicidal or homicidal ideations and he replies that he has been suicidal since she left and has been drinking “at least a 6 pack” a night. He has had plans to shoot himself. When asked what is keeping him from acting on plans he said “My kids but I’m losing hope I’ll ever see or talk to them again”. What are your next steps?
Patient 2: 19-year-old married female with a 2-month-old baby for her 4th visit. Her husband is present today. She presents today dressed more provocatively than you have seen her before. Her makeup is heavier than usual as well. The baby is in a carrier and is sleeping. She immediately starts discussing a video series on aliens she has been watching, her speech is rapid, loud, and tangential. She makes several loosenesses of associations between the video series and her baby. From her rambling, it sounds as if she believes the baby is an alien and she needs to take it to the desert and leave it on the mountain for the aliens to come and retrieve it. She reports making plans to go camping with the baby and her husband this weekend. You question her about suicidal and homicidal ideations and she denies both. The husband states she has been acting “different” for a couple of weeks, has never behaved like this before, and he is scared to leave her alone with the baby. She interjects that she knows the secret to world peace and giving their baby back to the aliens will accomplish it. What are your next steps?
Each Case study should be addressed in 7 slides PowerPoint, with speaker notes to be used in the creation of the video.
Include a word file with all references, doi/url should be included.
Crisis Management in Psychiatric Care
Across the lifespan, everyone experiences personal crises in which the individual’s coping capacity is overwhelmed temporarily. While different people have different definitions of what constitutes a crisis, I subscribed to the meaning of acute, time-limited events and situations with an uncertain outcome, leading to the individual in context feeling as if they cannot cope with the event. External events, intrinsic processes, or both may trigger mental health crises that would necessitate a psychiatric nurse practitioner to develop a crisis management plan. As an outpatient psychiatric nurse practitioner in a busy clinic for the last six months, it is natural to be acquainted with a few clients. Consequently, this video presentation outlines how I would address the psychiatric crisis in the context of the patient presented in my office.
The Selected Patient Case Overview
Patient 1 happens to be a 45-year-old male who has been married for 15 years and has two children. He has a history of manic depressive psychosis (MDD) that has been well managed for more than 20 years with Celexa 20mg daily. He also has an addiction to pornography managed through therapy. He further reports having had a stable marriage for the last five years but recently discovered his wife had been cheating on him for two years. He discovered the cheating only a month ago when he came home from work to find the wife gone with the kids, but she left a note detailing her infidelity. Divorce proceedings are in place. The separation and taking away of the children make him feel stupid doesn’t see why he took trouble improving himself and thinks he cannot go on. He risks losing his job and has not talked to his kids (who are his world) for a month). On questioning him about suicide and homicidal ideations, he admits to toying with the idea of shooting himself dead ever since the wife left and has been drinking heavily of late. He feels the kids still need him, but he feels he cannot take it more today. He also has lost all hope of seeing or talking to his children as the outpatient psychiatric nurse practitioner attending to this case; what follows is an outline of the steps that I would take to manage this presenting crisis and therefore prevent a possible suicide. The crisis management plan would also incorporate therapeutic intervention measures to ensure the patient recovers from this acute depression – a psychiatric illness reported to be a leading cause of suicide (Bradvik, 2018).
Outline of the Patient’s Crisis Management Plan
Every nurse practitioner specializing in psychiatric care needs to suspect depression, whether acute or chronic, as a possible cause of suicide ideation or attempts, as in this 45 y/o male. Considering the patient is undergoing life stressors like discovering a cheating spouse, separation from his family, divorce proceedings, and the threat of losing a job, I would focus on how to alleviate the symptoms of depression before they overwhelm the patient and make him act out the attempt on his life (Thomas & Seedat, 2018).
Assessing the Patient specific Risk Factors and Protective Factors for Suicide
The first step that I would take a step in this patient is to identify the risk factors like his history of MDD, history of alcohol and substance abuse, feelings of hopelessness, the current feeling of being cut off from his children and wife, and the potential loss of his marriage relationship after 15 years and the impending loss of work and make the patient accept the current reality and let go what cannot be regained. After risk factors, I would identify suicide protective factors like having the children at home, talking to them, and amicably solving the divorce proceedings. Having a sense of responsibility to the family is another factor in crafting a suicide prevention plan. Successful management of the patient’s mental health crisis would help prevent suicide and arrest the situation before it becomes a healthcare emergency or lead to actual loss of life.
After diagnosing the patient as having acute depression and a possible suicide case if his life crises are not definitively resolved, I would then embark on crafting an effective suicide prevention plan by taking a suicide risk assessment (Sequira et al., 2019). The SRA is a structured evaluation that involves identifying the current psychiatric signs and symptoms, past suicidal behavior, past treatment history, family history and the psychosocial stressors that precipitated the current crisis. I would concentrate on the current suicidal ideation so that all the steps of the SAFE-T package can be appropriately utilized. These are identifying the risk factors, identifying the protective factors, conducting the suicide inquiry, determining the risk level and matching intervention before, lastly, documenting the intervention plan.
Sequira et al. (2019) further note that once the mental healthcare provider has collected appropriate information during the inquiry about suicidality, then effective management would follow. I would then identify the patient as vulnerable and take purposive measures to prevent the looming suicide attempt by specifically addressing his mental ideation, planning and suicide action deactivation so that the suicide switch is not activated. On a scale of levels 1 to 5(where level 1implies the patient has minimal active suicidal thinking and Level 5 extreme case with a clear intention to die by suicide), I would put the patient’s level of suicide risk as severe and since the patient has specific suicidal thoughts with intent, increased frequency of mental ill-health symptoms and reduced protective factors.
Despite advances in mental health and psychiatry, it is important to note that it is not possible to definitively predict suicide for an individual but providers can formulate mitigation measures to prevent the risk of suicide (Hegerl et al., 2021). However, the mnemonic IS PATH WARM is an important risk factors indicator. I stand for ideation, S- substance abuse, P- purposelessness, A- anxiety, T-trapped, H- hopelessness, W –withdrawal from friends, A- anger- recklessness, and M mood changes.
The Suicide Prevention Plan
It is a psychosocial fact that multiple factors cause depression, and therefore I would have to adopt a multimodal approach to successfully implement a suicide prevention plan in the outpatient care setting. The patient has not yet made suicide–specific presentations to necessitate referral to psychiatric in-patient care. Be that as it may, I would optimize the options for organizing his care as an incidentally detected patient with a positive suicide screening in this acute care setting from the time of positive screen to post-discharge. In a nutshell, I would encourage the patient to communicate with family and friends who are supportive, be respectful and acknowledge the patient’s feelings while stressing that his death is not the ultimate solution, avoid being patronizing or judgmental, and with the patient’s permission inform his close confidant so that the latter will keep him safe by for example reducing his access to lethal means like guns or pesticides. Lastly, I would advise the patient to stay connected and call my number or suicide hotline if and when he feels overwhelmed. Additionally, I would prescribe incorporating anti-suicide psychotherapeutic techniques.
Follow-up
Follow-up commences with the patient’s entry into the clinic and will continue until the patient is safely back on the road to recovery (Ghabari et al., 2016). A positive suicide screen entails determining whether to discharge, make a referral, or admit for patient care. I would include making follow-up phone –calls. These include phone calls twice a day, sending short message texts and home visits after seven days. If the patient’s symptoms persist, an antipsychotic like clozapine 50 mg PO once daily would be considered if the suicide risk assessment indicates increasing levels of risk (Nugent et al., 2019). The outpatient discharge plan includes a safety net between contacts to ensure continuity of care and continued assessment and management of emerging suicide risks. The follow-up care also details mood check and risk assessment, revision and revision of safety plan, review of upcoming appointments and barriers to problem-solving.
Patient 2 Case Overview
Patient 2 Case review underpins the fact that multiple factors contribute to the complexity of mental health crisis, thereby calling for multifaceted interventions in psychiatric care crisis management. The patient in context is a 19 y/o married female with a 2- month old baby and is accompanied by her husband today-on, her fourth visit. She discusses video series on aliens and links it to her baby. She has delusions that her child holds ‘the secret to world peace if the baby is given back to aliens. The patient further reports making plans to go camping with both baby and husband. On being questioned about suicidal and homicidal ideations, she denies both. The husband states she has been acting differently for some weeks now and adds that it is her first strange behavior. As the outpatient psychiatric nurse practitioner attending to this patient, Part 2 of this video presentation outlines how I would manage this crisis by using a five-step approach of making a correct diagnosis of the problem postpartum psychosis disorder instead of early onset of schizophrenia.
Determining Whether the Patient Presents with a Psychiatric Crisis or Psychiatric Emergency
Whether in outpatient or in-patient care settings, the health care team must also act promptly the moment a psychiatric crisis presents to prevent it from morphing into a dangerous or life-threatening situation. My first step in the case of Patient 2 would be to determine whether her symptoms merit an emergency or emotional crisis coding. According to Osborne (2017), a psychiatric emergency emotional medically describes a sudden specific behavioral state that could lead to life-threatening or psychologically damaging consequences if not promptly resolved. On the other hand, a psychiatric crisis refers to a less immediate event or situation that has developed over time in a psychologically stressful situation. In order to establish the adolescent mother’s case as either one of the two, the mnemonic I’VE HAD IT was used. In my considered opinion, Patient 2 presents a psychiatric crisis when measured against the level of I- impasse, V- victim or violence, E- emergency, H helplessness or hopelessness, A agitation or Apathy, D despair and disorganization, I incapacitation and T terror that would require a psychiatric emergency coding.
Assessment of the Precipitating Factors and Psychiatric Illness Diagnosis
Childbirth in a woman’s life marks a major milestone but is also a leading physical, emotional and social stressor (Raza, 2021). I would make both the patient and her husband appreciate these obstetrics and maternal care facts. Within the first six weeks, some women experience mental disturbances like mood swings, depression, and even post-traumatic disorder. Others develop major depression and even full-blown psychoses like postpartum psychosis disorder (PPPD), which is the case in this 19-year-old mother of a two-month-old infant. These changes in maternal behavior are triggered by several factors like lack of sleep, exhaustion, physical and hormonal changes. In this patient’s careful assessment for risk factors of PPPD would turn a positive screen bearing in mind that the patient presents with extreme confusion, loss of touch with reality, and disorganized thought, as evidenced through loose associations on videos about aliens and her two-month baby.
Further inquiries that I would need to take are her Family history of psychosis or bipolar disorder and other factors. Recent history of psychosis after giving birth necessitates a thorough history, and neuropsychiatric evaluation is mandatory to expedite correct diagnosis, effective treatment and eventual recovery. I would also analyze her prenatal and perinatal health records analysis to help me rule out a complicated obstetrical history, medical comorbidities, organic causes, or negative birth outcomes
I should then determine the patient’s psychiatric disorder that precipitated the current crisis through differential diagnosis. PPPD was confirmed because most of the symptoms occurred within two months of giving birth. Along with the same vein, early-onset schizophrenia and bipolar disorder were ruled out because a confirmatory diagnosis of either one of them or both requires the symptoms to have lasted more than six months which is not the case here.
Proposed Therapeutic Intervention
Aguilera and Mesick’s theory and methodology were then utilized where individuals experienced biological and psychosocial stressful events that triggered a state of disequilibrium. I would consider that the husband and the patient felt the need to restore equilibrium distorted by the mother’s mistaken perception of the baby as holding the secret to world peace and must therefore be handed over to Aliens to do as they wish with the baby comes to mind. The mother has inadequate coping mechanisms means the problem remains unresolved, and disequilibrium continues precipitating the current crisis.
Most importantly, after assessment and diagnosis and crisis intervention theory, it is my considered opinion that the mother poses no immediate threat to the baby, herself or others. Although she wants to hand over the baby to aliens, she still plans to go camping with her husband. Subsequently, the patient is not referred for in-patient care. I would recommend outpatient care as the best approach at the moment, with antipsychotics being prescribed. Lithium 900 mg Twice daily PO in the morning and nighttime. Psychotherapy will also reinforce medication. Both mother and husband will receive patient and family education on living with PPPD and alleviate the symptoms (Poel et al., 2018). The husband should be goal-directed, keep track of all details, accompany his wife for all physician appointments, join support groups, and learn how to manage stress. The husband should also keep track of his wife’s recent symptoms and a new source of stressors
Follow-up
The follow-up plan is designed to incorporate key components of mental health promotion. These include but are not limited to preventive measures, early intention approaches, effective and appropriate treatment, enhanced continuing care to ensure the patient’s road to recovery is not obstructed. The next follow-up visit is slated 14 days from the current visit. During this visit, I would have the opportunity to evaluate the efficacy of the medications and non-pharmacological interventions. If necessary, the patient’s medication dosage will be adjusted, and follow-up visits to continue up to six months to rule out early schizophrenia.
References
Brådvik, L. (2018). Suicide risk and mental disorders. International journal of environmental research and public health, 15(9), 2028.
Forde, R., Peters, S., & Wittkowski, A. (2019). Psychological interventions for managing postpartum psychosis: a qualitative analysis of women’s and family members’ experiences and preferences. BMC psychiatry, 19(1), 1-17. URL:https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-019-2378-y
Ghanbari, B., Malakouti, S. K., Nojomi, M., Alavi, K., & Khaleghparast, S. (2016). Suicide prevention and follow-up services: a narrative review. Global journal of health /science, 8(5), 145. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877223/
Hergerl, U, Heinz, I, Oconnor,A, & Reich,H.(2021) The 4- level approach prevention of suicidal behavior through community-based intervention URL:file:///C:/Users/Administrator/Downloads/fpsyt-12-760491.pdf
National Center of Continuing Education Inc(2020) Managing the psychiatric Crisis URL: https://nursece.com/courses/121-managing-the-psychiatric-crisis
Nugent, A. C., Ballard, E. D., Park, L. T., & Zarate, C. A. (2019). Research on the pathophysiology, treatment, and prevention of suicide: practical and ethical issues. BMC psychiatry, 19(1), 1-12. URL: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-019-2301-6
Osborne, L. M. (2018). Recognizing and managing postpartum psychosis: a clinical guide for obstetric providers. Obstetrics and Gynecology Clinics, 45(3), 455-468. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174883/
Poels, E. M., Bijma, H. H., Galbally, M., & Bergink, V. (2018). Lithium during pregnancy and after delivery: a review. International Journal of Bipolar Disorders, 6(1), 1-12. URL:https://journalbipolardisorders.springeropen.com/articles/10.1186/s40345-018-0135-7
Raza, S. K., & Raza, S. (2019). Postpartum Psychosis. URL: https://www.ncbi.nlm.nih.gov/books/NBK544304/
Sequeira, L., Strudwick, G., Bailey, S. M., De Luca, V., Wiljer, D., & Strauss, J. (2019). Factors influencing suicide risk assessment clinical practice: protocol for a scoping review. BMJ Open, 9(2), e026566. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398626/
Thomas, E., & Seedat, S. (2018). The diagnosis and management of depression in the era of the DSM-5. South African Family Practice, 60(1), 22-28. URL: file:///C:/Users/Administrator/Downloads/168568-Article%20Text-433667-1-10-20180322%20(2).pdf
