NLE Foundations of Psychiatric & Mental Health Nursing — Stress, Anxiety, Coping & Crisis InterventionCheat Sheet

Section Title

Selye's General Adaptation Syndrome (GAS)

Important Facts

• **Stage 1: Alarm Reaction** — 'fight-or-flight' activates; sympathetic NS + HPA axis increase; catecholamines and cortisol rise; ↑ HR, BP, RR, blood glucose.
• **Stage 2: Resistance (Adaptation)** — Body adapts and attempts to return to homeostasis while managing the stressor; if coping succeeds, recovery occurs.
• **Stage 3: Exhaustion** — Prolonged stressor depletes adaptive reserves; physiologic reserves fail; stress-related illness or death may result.
• **Local Adaptation Syndrome (LAS)** — Local counterpart to GAS; example: inflammatory response at an injury site.
• Selye's model is foundational to understanding why prolonged stress exhausts the body and why early intervention is critical.

Key Definitions

Diagrams To Know

• Three-stage progression of GAS with physiologic changes at each stage
• Alarm reaction cascade: stressor → HPA axis/sympathetic NS → hormonal release → physical symptoms

Section Title

Anxiety: Definition & Distinction from Fear

Important Facts

• Anxiety is **interpersonally communicated** — it spreads from one person to another (contagious effect).
• **Mild anxiety is normal and adaptive** — it motivates learning, problem-solving, and growth.
• Anxiety becomes pathologic when it is **excessive, irrational, persistent**, interferes with functioning, or occurs without a clear trigger.
• The source of anxiety is often **vague, nonspecific, or internal** (worry about the future, generalized dread), whereas fear is directed toward a known external object or event.
• Both anxiety and fear activate the same physiologic systems (sympathetic NS, HPA axis) but anxiety is psychological in origin and fear is more situational.

Key Definitions

Diagrams To Know

• Spectrum showing anxiety (vague threat) vs. fear (specific threat)
• Triggers and characteristics of each

Section Title

The Four Levels of Anxiety — MOST CRITICAL FOR NLE

Important Facts

• **Mild = ↑ Perceptual Field** — Alert, aware, optimal for learning; use this window for teaching and problem-solving.
• **Moderate = Narrowed Perceptual Field (Selective Inattention)** — Can still learn and problem-solve WITH GUIDANCE; use clear, short sentences; may need redirection.
• **Severe = Greatly Reduced Perceptual Field** — DO NOT TEACH or problem-solve; provide calm, quiet, low-stimulus environment; stay with client; short, simple, firm directions; consider PRN medication.
• **Panic = Distorted Perceptual Field** — NEVER LEAVE ALONE; ensure safety above all; firm, low, reassuring voice; minimize stimuli; one simple direction at a time; do NOT touch without permission; administer prescribed medication immediately; **psychiatric emergency — prolonged panic incompatible with life.**
• **The perceptual field determines the nursing approach.** Attempting to teach or reason with a severe/panic client is a trap and can worsen anxiety.
• As anxiety ↑, the ability to perceive, learn, problem-solve, and process information ↓ exponentially.
• **Physical manifestations escalate with level:** mild (slight restlessness) → moderate (↑ HR, RR, tremor, sweating, shakiness) → severe (tachycardia, hyperventilation, headache, nausea, trembling) → panic (terror, possible hallucinations, loss of rational thought).

Key Definitions

Diagrams To Know

• Four-level anxiety spectrum with perceptual field changes
• Comparison of physical symptoms at each level
• Nursing approach decision tree by anxiety level

Section Title

Nursing Approach by Anxiety Level — DIRECT CLINICAL APPLICATION

Important Facts

• **MILD:** Teach, problem-solve, encourage use of anxiety productively, support learning and growth.
• **MODERATE:** Assist refocus; use clear, short sentences; guide problem-solving; allow limited learning.
• **SEVERE:** Reduce stimuli, stay with client, short simple firm directions, ensure safety/comfort, consider PRN medication — **DO NOT TEACH.**
• **PANIC:** Stay with client (never leave), ensure safety, firm low reassuring voice, minimize stimuli, one direction at a time, no touch without permission, administer medication, assess suicidality/homicidality.
• **The rule: Match approach to perceptual field.** High anxiety = simple, directive, protective response. Low anxiety = collaborative, educational, growth-focused response.
• A calm, unhurried nurse who stays present reduces client anxiety through modeling and reassurance.
• Avoid escalating anxiety by attempting complex communication, multiple stimuli, or reasoning at high anxiety levels.

Diagrams To Know

• Anxiety level → Perceptual field → Nursing approach decision matrix

Section Title

Coping & Defense Mechanisms

Important Facts

• **Adaptive coping resolves the stressor and promotes growth.** Examples: problem-solving, seeking support, exercise, relaxation, verbalization, humor, spirituality.
• **Maladaptive coping provides temporary relief but does NOT resolve the problem and may cause harm.** Examples: substance abuse, aggression, avoidance, denial, rumination.
• Defense mechanisms are **unconscious** (person is unaware they are using them), whereas coping is often conscious.
• **Suppression is unique** — it is the only conscious defense mechanism; all others are unconscious.
• In the **working phase of therapeutic relationship**, the nurse helps the client identify maladaptive coping and replace it with adaptive strategies.
• Assessment of coping is part of **NANDA nursing diagnosis** and informs interventions (e.g., 'Ineffective coping,' 'Denial').
• Healthy coping is a **sign of psychological resilience and adaptation;** identifying and strengthening adaptive coping is therapeutic.

Key Definitions

Diagrams To Know

• Spectrum of coping: adaptive ↔ maladaptive with examples
• Defense mechanisms classified by intensity (mild, moderate, psychotic) and examples of each

Common Values

Section Title

Crisis Theory & Types

Important Facts

• **A crisis is self-limiting** — resolves within **4 to 6 weeks** one way or another (toward higher, same, or lower functioning).
• **A crisis is NOT an illness.** It can happen to any person; it is a normal response to an abnormal situation.
• **A crisis is an opportunity for growth.** The person is often more open to help during crisis than at other times; intervention during crisis can produce lasting positive change.
• **Crisis outcome depends on three balancing factors:** (1) perception, (2) supports, (3) coping. Strengthening any of these can tilt outcome toward resolution.
• **Maturational crises are predictable** but can still overwhelm coping if the person is unprepared or has poor supports.
• **Situational and adventitious crises are unexpected** — the person has no chance to prepare psychologically.
• **In the Philippines, adventitious crises** (typhoons, earthquakes, flooding) are common and nurses must be trained in disaster mental health and crisis response.
• The outcome of a crisis is not determined by the event itself but by the person's **perception, supports, and coping resources.**

Key Definitions

Diagrams To Know

• Three types of crisis with examples and time course
• Aguilera's balancing factors diagram showing how each influences crisis resolution

Section Title

Crisis Intervention — Steps & Principles

Important Facts

• **Step 1: ENSURE SAFETY FIRST** — Always assess for **suicide and homicide risk** before any other intervention. This is the absolute priority.
• **Step 2: Assess the crisis** — Identify the precipitating event, the client's **perception** of it, and the **three balancing factors** (perception, supports, coping).
• **Step 3: Focus on the immediate problem** — Work in the **here-and-now,** not on long-standing personality issues or past trauma. Crisis is acute and time-limited.
• **Step 4: Set realistic, short-term goals collaboratively** — Goals should be achievable within days or weeks, not months. Involve the client in planning.
• **Step 5: Take an active, directive role** — The nurse is **more directive than in ordinary therapy.** Help the client develop concrete plans, make decisions, and use supports.
• **Step 6: Mobilise resources and support systems** — Connect client with family, friends, community resources, employers, religious leaders, referrals (mental health, financial, legal).
• **Step 7: Anticipatory planning** — Help the client prepare for future stressors; teach coping skills; identify warning signs; plan responses to prevent future crises.
• **Goal is restoration to pre-crisis functioning, NOT personality reconstruction.** Crisis intervention is short-term and focused, not psychotherapy.
• **The therapeutic relationship in crisis is more directive** — the nurse makes suggestions, provides guidance, and is actively involved in decision-making.

Key Definitions

Diagrams To Know

• Seven-step crisis intervention process flow
• Crisis assessment framework: event → perception → balancing factors → intervention → outcome

Common Values

Section Title

Pharmacology of Anxiety & Panic

Important Facts

• **Benzodiazepines = RAPID relief (minutes to hours); SHORT-TERM use.** Do not prescribe for chronic anxiety.
• **Buspiron & SSRIs = SLOW onset (2-4 weeks); LONG-TERM use.** Useless for acute panic; must be used preventively.
• **Medication complements but does NOT replace therapeutic and environmental interventions.**
• **Benzodiazepine cautions:** Avoid alcohol (severe CNS depression, respiratory failure), do NOT stop abruptly (withdrawal seizures), avoid driving until effects known, caution in elderly (falls, confusion, delirium).
• **Teach clients on benzodiazepines:** Do not drink alcohol, do not stop suddenly, do not drive, take as directed, report side effects.
• **SSRI onset:** 2-4 weeks for partial effect; 4-8 weeks for full therapeutic effect; counsel client to continue even if no immediate benefit.
• **Beta-blockers are NOT first-line anxiolytics** — used only for physical symptoms of situational anxiety, not for the anxiety itself or panic disorder.

Key Definitions

Diagrams To Know

• Medication choice by anxiety type: acute panic, chronic anxiety, situational anxiety, performance anxiety
• Timeline of onset: benzodiazepines (rapid) vs. SSRIs & buspirone (slow)

Section Title

Priority Nursing Interventions

Important Facts

• **Priority 1: Assess anxiety level accurately.** It determines every subsequent action and approach.
• **Priority 2: Ensure safety.** ALWAYS check for suicide/homicide risk, especially in crisis and at panic level.
• **Priority 3 (Severe/Panic): Reduce environmental stimuli.** Quiet room, dim lights, minimal noise, remove unnecessary people, eliminate clocks/reminders.
• **Priority 3 (Severe/Panic): Stay with the client.** NEVER leave a panicking client alone; your presence is reassuring and ensures safety.
• **Priority 4: Use calm communication.** Speak in a low, even tone; short, simple, clear sentences; avoid complex explanations; give one direction at a time.
• **Priority 5: Do NOT teach or problem-solve at severe/panic levels.** Reserve teaching for mild-to-moderate anxiety when the perceptual field allows learning.
• **Priority 6: Administer prescribed anxiolytic medication** and monitor for response and side effects (especially respiratory depression).
• **Priority 7: In crisis, work in the here-and-now.** Focus on the immediate problem, mobilize supports, set short-term goals, ensure safety.
• **General principle: A calm, unhurried nurse lowers the client's anxiety through modeling, presence, and reassurance.**

Diagrams To Know

• Nursing intervention hierarchy by anxiety level

Section Title

Patient & Family Teaching

Important Facts

• **Teach recognition of personal anxiety triggers and early warning signs** — enables the client to intervene early (at mild level) before anxiety escalates.
• **Teach relaxation and coping skills:** Deep breathing, progressive muscle relaxation, grounding techniques (5-4-3-2-1 sensory method), physical activity, mindfulness — best taught at mild-to-moderate anxiety.
• **Explain that crisis is time-limited and resolves within 4-6 weeks** — helps client maintain hope and perspective.
• **Emphasize that seeking help is a strength, not a weakness.** Counter Filipino stigma around mental health help-seeking; normalize mental health care as part of overall health.
• **Provide emergency contacts:** NCMH crisis hotline, local mental health services, suicide prevention numbers, trusted healthcare providers.
• **Involve family as a support system.** Teach family to recognize signs of crisis, support the client, access community resources.
• **Reinforce medication teaching:** Purpose, timing, side effects, importance of adherence, what to do if side effects occur, never stop suddenly.
• **Teach anticipatory coping:** Prepare for foreseeable stressors, develop action plans, identify resources, practice coping skills in advance.
• **Normalize anxiety as a human experience** — mild anxiety is normal, adaptive, and part of life; it is only problematic when excessive or persistent.

Diagrams To Know

• Grounding technique (5-4-3-2-1 sensory method) step-by-step
• Deep breathing technique with timing

Rows

Columns

• Characteristic
• Anxiety
• Fear

Table Title

Anxiety vs. Fear

Rows

Columns

• Anxiety Level
• Perceptual Field
• Cognitive/Learning Ability
• Physical Signs
• Nursing Approach

Table Title

Four Levels of Anxiety: Perceptual Field & Nursing Approach

Rows

Columns

• Crisis Type
• Nature
• Characteristics
• Examples

Table Title

Types of Crisis

Rows

Columns

• Medication Class
• Examples
• Onset Time
• Duration of Effect
• Use Case
• Key Cautions

Table Title

Anxiolytic Medications: Onset, Duration, & Use

Rows

Columns

• Type
• Mechanism
• Outcome
• Examples

Table Title

Adaptive vs. Maladaptive Coping