CRISIS AND NURSING INTERVENTION

DEFINITIONS

Crisis is an acute time limited phenomenon experienced as an over whelming emotional reaction
to a stressful event or the perception of that event.

It is the struggle for equilibrium and adjustment when problems are perceived as insolvable.

Crisis intervention is a short term focuses on the solving of the immediate problem, aims to
establish the former coping pattern and problem solving ability. It is usually limited to 4 – 6
week period after which resolution will be attained.

TYPES OF CRISIS

1. Maturational -each development stage can be referred to as the same.

2. Situational -arises from an external rather than an internal source.
3. Adventitious –it is not a part of every day life, is accidental and unplanned

CRISIS THEORY

Gerald Caplan -1960s defined crisis theory and outlined crisis intervention.

Caplan identified four distinct phases of crisis.

Erich Lindermann - 1940s conducted study of the grief reactions of close relatives of victims in
a club fire. This study formed the foundation of crisis theory and clinical intervention. She
showed that preventive intervention in crisis situations could eliminate or decrease serious
personality disorganisation and other psychological consequences from the sustained effects of
severe anxiety.

FOUR PHASES OF CRISIS PROCESS

1st phase –

A person confronted by a conflict or problem that threatens the self concept responds with
increased feelings of anxiety. The increase in anxiety stimulates the use of problem solving
techniques in an effort to solve the problem and lower anxiety.

2nd phase –

If the usual defence response fails, and if the threat persists, anxiety continues to rise and
produce feelings of extreme discomfort. Individual functioning becomes disorganised.

3rd phase –
 If the recovering attempts fail, anxiety can escalate to severe and panic levels, and the person
mobilises automatic relief behaviour, such as withdrawal and flight. (compromising needs or
solutions should be made)

4th phase –

If the problem is not solved, anxiety can over whelm the person and leads to serious personality
disorganisations. This maladaptive response can take the form of confusion, suicidal behaviour,
yelling and running aimlessly.

Systemic evaluation facilitates the child’s progress towards his or her maximal level of function,
especially as it changes during the various stages of development.

CRISIS AND NURSING INTERVENTION

The plans to care are then implemented through direct intervention.

The nurse establishes goals in collaboration with the child,family and the interdisciplinary team
members.

Systematic process deals with recurrent actual or potential crisises and the impact of these
events.

Appraising Crisis Systematically:

HOSPITALISED CHILD

Functions Of Hospitalisation

Promotion of health

Prevention of health

Care for sick and injured development

Accomplish therapeutic goals child’s

Develop positive attitude to others the

Lesser the stress separation to

Feel more secure threat

Provides diversion and relaxation minimise

PRINCIPLES OF HOSPITALISATION

1.Nurse should begin to build a working relationship with the patients and the child from the first
contact with them.

2.Nurse should be aware that all behaviour is meaningful.

3.Nurse should accept the parents and the child exactly as they are.

4.Nurse should have empathy for parents and children.

5.Nurse should let them know that their problems are of importance, the nurse is there to aid
their solutions.

6.Nurse must be willing to acknowledge the parents rights to their own decisions concerning
their children.

7.Nurse permits the parents and the child to express even negative emotions.

8.Nurse should ask questions limited to a single idea or reference.

9.Nurse should speak the language understandable to parents and the child

10.Health team members should help the parents to feel that there is unity among them.

MODERN CONCEPTS OF HOSPITALISATION

Parent Support

Self Care groups

Visiting Care By Parent Unit

CONCEPTS OF HOSPITALISATION

Tape recording could be made and played.

Siblings should be accompanied by parent and who have been exposed to infections is not
permitted.

Siblings of 2 – 12 years are permitted in some hospitals for certain hours and older siblings fro
any time.

If parents are unable to visit frequently, grandparents, uncles or aunts may visit instead.
Visiting is determined by child’s need to see parents.
Flexible unlimited visiting any time

2 – 8 pm visiting- early morning to bedtime

VISITING

Parents of seriously ill children could stay whole night if they desire.

If there is no dietary restriction, food should be brought from home.

Sometimes they can have food with children.

Some hospitals provide a waiting rooms for parents.

Should not prohibit parents to stay at child’s bedside if they desire.

ROOMING- IN

Nurse can observe parent’s skills, attitudes, techniques and any problem in parent child relation.

Nurses’ responsibility is to meet needs of child, prepare parent for this, interpret medical
procedures, diagnostic tests, health teachings etc.

When parents are nearby, children can continue to learn and grow throughout hospital
experience.

Main fear about separation is eliminated.

Child gets attention from familiar person.

Parents live with child, to involve whole family in care of sick.

CARE BY PARENT UNIT

Parents may feel comfortable enough to move away from hospital routine and ventilate their
feelings and concerns to relieve anxiety and stress.

This may be conducted by nurses, play therapists or by child life program staff, who act as
facilitators or develop a support system among parents.

Parents with common concern should emotionally support and comfort.

PARENT SUPPORT GROUPS

Time and method depends on child’s cognitive abilities, emotional state and readiness to
learn.Help to learn self-care skills.
Assess abilities of child

SELF CARE

Dietitian, physiotherapist work together focusing different facet of growth, toward full
development

Psychologists and psychiatrists help with serious emotional problems.

Hospitals may have school teacher or a recreational specialist to create pleasant situation.

All members needed to foster in every area of growth and development.

Professional team work is important

GROWTH AND DEVELOPMENT OF HOSPITALISED CHILD

PLAY IN ILLNESS

3 year old Christie was due to receive a course of radio therapy. A play program was designed to
prepare her for the experience, which involved Christie lying on a large sheet of paper on which
her outline was drawn. The purpose of this was to explain the importance of lying still during the
radio therapy session. To emphasis this, a water spray was used to show that when she moved it
was difficult to spray the correct part of her body.

FUNCTIONS OF PLAY IN ILLNESS

Diversional activities ,Social development ,Emotional expression, Development of moral value,

Creative expression

TYPES OF PLAY

Dramatic play

Energy release

Creative play

Drawings

TECHNIQUES OF THERAPEUTIC PLAY INCLUDE:

Stories, Music, Puppets, Pets

SUITABLE PLAY FOR VARIOUS AGE GROUPS

INFANT
• -Baby likes to pat and hug.

• -Toys should be soft to hug and provide comfort.

• -Brightly coloured, washable toys.

• -Large enough that cannot be aspirated.

• -Have smooth edges.

• -Soft stuffed animals, soft balls, bath toys,

• -Rattles, pots and pans.

TODDLER

Rocking horse or chair

Telephone

Push-pull toys

Nest of blocks.

Engages in parallel play.

Dolls Likes to place things in containers and dump them out.

Enjoys exploring drawers

They may have favourite toys

SCHOOLER

Video tapes.

Drums, horns

Dolls, dishes

Paint with brush, finger paints

Crayons, simple puzzles

Creative play, and dramatic play.

 Engages in imitative play

They exchange ideas with others.

It is the beginning stage of cooperative play.

PRESCHOOLER

Skipping rope, dress up materials, table games, bicycle.

Doll house, dolls, puppets and music.

Collection of things will be his hobby.

Attention span increases, play is more organised, more competitive.

ADOLESCENT

Telephone, easy puzzles, radio, hand puppets, and cut outs.Ball on string They pay attention
to special interest. Play will not acquire great energy expenditure.

A research study conducted by Uttara Chari, Uma Hirisave, and L. Appaji in 2012 reported the
benefits of play therapy in paediatric oncology. The study was conducted with a 4 year old girl
diagnosed with acute lymphoblastic leukaemia and outcome was examined using a combination
of qualitative and quantative assessments. The play therapy manifested in better illness
adjustment and general mental well being, enhanced coping and normalisation.

In this study the child initially inhibited, avoided medical toys and engaged in rudimentary play.
Her affect was considered and the interaction with the researcher was limited. As sessions
progressed, she became active and engaged in various types of play. Her initial avoidance of
medical toys followed by repeated enactment of medical procedures carried out on her reflects
the mechanism of play therapy in facilitating catharsis and mastery through re- enactment of
stressful experiences. Thus as sessions progressed, child’s play become similar to those of
healthy children indexing normalisation. This reflects enhanced coping and use of adaptive
defences in play sessions.

This help child to return to school after cure.Child will keep busy, feels useful and important.
If child is too ill to return to school, continuing class is important as a link with outside world.
Use of television, radio or computerised self instruction program enhances contact with school
system. Public school teacher is employed by local board of education in paediatric ward.

SCHOOL

Unfamiliar procedures.  Witnessing frightening sights and sounds  Exposed to unfamiliar

equipment  Unknown environment  Varied emotional changes 
PREPARATION FOR HOSPITALISATION

• For well children who do not need immediate hospitalisation

• For children who are scheduled for hospitalisation

• For all children of all age group

• booklets, films and puppet shows.

• pre admission parties should be conducted.

• Familiarising the hospital before admission and pre hospital counselling

BASIC BELIEFS REGARDING CHILDREN

• The family is the basic unit of society

• Each child needs love and security to develop feelings of trust and self esteem.

• Each child is an unique individual with different needs based on his or her family background,
level of growth and development and degree of illness

• Nurse seeks to promote, maintain and restore health in both children and their parents.

• Each ill child should be under the accountable care of one professional nurse.

• The family and child should be included in planning for therapeutic and nursing interventions
and for implementing and evaluating the plan of care.

• Within a safe environment, the ill child needs expert physical care, emotional support, play
that allows for expression of feelings to promote continued growth.

• Parents who have trusted relation with nurses feel welcome whenever they visit and participate
in child care.

• Family members and terminally ill child who are at great stress should be emotionally
supported so that child can die with dignity and with feeling of being loved.

GUIDELINES HOSPITAL ADMISSION

• Assign a room based on child’s developmental age, seriousness of diagnosis, communicability

of illness and length of stay.

• Preparing the roommates for the new patient.

• Prepare room for the child and family

• Introduce primary nurse

• Orient to the inpatient facility.

• Facilities in the room

• Unit ( play room, dining room, lab)

• identification band.

• hospital regulations and schedules

• Perform nursing admission list

• vital signs, anthropometric measurements

• Obtain specimens

• physical examination.

PRE- ADMISSION

Emergency admission • Appropriate introduction • Use of child’s name • Determination of

child’s age and some judgment made about developmental age • chief complaint from both
parents and child. • general state of health, sensitivity to medication, previous hospitalisation.
ICU admission • Prepare child and parents for elective ICU admission. • Guide the child’s
appearance and behaviour. • Emotional support and answer questions. • Prepare sibling visit. •
Encourage parents to stay with child.

REACTIONS TO HOSPITALISATION

Physiological reactions • Temperature elevations: as response to infections • Convulsions :

resulted from rise in temperature • Immobilisation • Anorexia, vomiting and diarrhoea •
Nutritional deficiencies • Fluid and electrolyte imbalance • Inconsistent weight loss • Lack of
growth Psychological reactions • Separation anxiety • Stranger anxiety • Sleep deprivation • Loss
of self control • Fear of darkness • Fear of death • Sensory overload

REACTIONS OF EACH AGE GROUP

Neonates

• Interruption in the early stages of development • Impairment of bonding and trusting

relationship • Inability of the parents to love and care for the baby and inability of baby to
respond to parents

INFANT
Promote a quite environment Topical aesthetics  Homely routine  Rooming-in  Nursing
implications  Crying  Rejection of feed  Displays excessive irritability  Feeling routines
disrupted  Sleep awake cycle disrupted  Responses  Sensory overload  Sleep deprivation 
Immobilization  Painful invasive procedure  Stranger anxiety  Separation anxiety  Stressors

TODDLERS

Provide night light Explain the procedure in sequence  anaesthetics  Give choices  Allow
the parent to hold the child in her lap to do any procedure  Encourage parental presence 
Wonder why the parents are not rescuing Nursing implications  Think as a punishment 
Frightened to sleep in supine position  Fear of bodily restraint,injury Reactions  Loss of
autonomy and control  Regression  Denial  Despair  Protest  Reactions of toddlers are
expressed as protest, despair, denial and regression.  Separation anxiety Stressors

Provide night light Explain the procedure in sequence  anaesthetics  Give choices 
Encourage parental presence  Regression Nursing implications  Aggression  Fear of pain 
Fear of body part loss  Fear of ghost  Displace difficulty in separating  Fear of dark
Responses  Painful invasive procedure  Bodily injury  Loss of self control  Separation
anxiety  Stressors

PRESCHOOLERS

Encourage peer interaction Explain all the procedure  Utilise topical anaesthetics  Encourage
parental presence  Nursing implications  Demonstrates detailed cause for illness  Displays
increased sensitivity to the environment  Responses  Loss of own control  Loss of privacy 
Fear of death  Painful invasive procedure  Bodily injury  Separation from family and friends
 Loss of self control  Stressors

SCHOOLER

Explain each steps of procedures prior Parental involvement  Encourage peer group
interaction  Include the adolescent in plan of care  Depression Nursing implications 
Bargaining  Withdrawal  Regression  Anger  Loss of privacy Responses  Separation from
peer group  Fear of death / disability  Fear of disfigurement  Fear of lack of body integrity 
Lack of privacy  Lack of control Stressors

ADOLESCENT

Encourage to perform the tasks Counselling  Psychological support  Parent support group
and care by parent unit  Maintain parent child relationship  Encourage to obtain help from
other family members or friends  Recognise the need for support  This anxiety could be
recognised by the trembling,coarse voice, restlessness, irritability and withdrawal. Nursing
implications  The anxiety interferes with the parent’s ability to care the child, support. 
anxiety, anger, fear, disappointment,self blame,guilt  Unbearable financial obligations
Reactions  Spread of infections to other members in family  The suffering of the child 
Unknown events and outcomes  Separation from the child  Strange environment in the
hospital  Stressors

EFFECTS OF HOSPITALISATION ON THE FAMILY OF CHILD PARENTS

Sibling visits Provision for sibling to remain home  Explanation about the condition  Guilt
Nursing implications  Jealousy  Resentment  Anger  Received little information about their
sibling Reactions  Cared for outside by care providers  Experiencing the changes  Younger
child SIBLINGS Stressors

DISCHARGE FROM HOSPITAL

• plan for discharge with the assistance of parents, child and other health team members. • A
discharge preparation involves education for family • The preparation of discharge begins during
the admission assessment. • Short and long term goals are established to meet the child’s
physical and psychosocial needs. • For children with complex care needs, discharge planning
focuses on obtaining appropriate equipment and health care personnel at home. • The teaching
plan involves levels of learning, such as observing, participating with assistance and finally,
acting without help. • All families need to receive detailed written instructions

OBJECTIVES OF PLANNING FOR DISCHARGE

1. To make certain that the care given in the hospital will be continued as necessary at home –
the nurse can assist the parent and child to meet the objective by educating them concerning the
illness and the essential requirements for care.

2. To share information with other appropriate community resources or agencies to enable them
to assist the parents and the child to continue care at home.