NLE Foundations of Psychiatric & Mental Health Nursing — Stress, Anxiety, Coping & Crisis InterventionRevision Notes

Exam Tips

• If a question describes a patient with chronic stress-related illness (e.g., hypertension, peptic ulcer, recurrent infections), think EXHAUSTION stage of GAS.
• If a question describes acute fight-or-flight signs (tachycardia, elevated BP, diaphoresis, pupil dilation), think ALARM stage.
• GAS mnemonics: ARE = Alarm, Resistance, Exhaustion; 'Fight-or-Flight' = Alarm stage.
• Connect GAS to pathophysiology: cortisol in the Exhaustion stage suppresses the immune system → increased susceptibility to infection, poor wound healing.

Key Points

• Stress is the body's NONSPECIFIC response to any demand (stressor) placed upon it — the same physiologic response occurs regardless of whether the stressor is pleasant or unpleasant.
• Stressors may be physical, psychological, or social; developmental (expected transitions) or situational (unanticipated events).
• Hans Selye identified three sequential stages of the body's response to prolonged stress — Alarm, Resistance, and Exhaustion.
• ALARM STAGE: the 'fight-or-flight' response — the sympathetic nervous system (SNS) and the hypothalamic–pituitary–adrenal (HPA) axis are activated; catecholamines (epinephrine, norepinephrine) and cortisol are released; heart rate, blood pressure, respirations, blood glucose ALL increase.
• RESISTANCE STAGE: the body attempts to adapt and return to homeostasis while the stressor persists; if coping is successful, recovery occurs.
• EXHAUSTION STAGE: adaptive resources are depleted; physiologic reserves fail; stress-related illness (hypertension, peptic ulcer, immune suppression) or death may result.
• Local Adaptation Syndrome (LAS) is the local, physical counterpart to GAS — example: the inflammatory response at a wound site.
• Key NLE mnemonic for GAS stages: A-R-E = Alarm → Resistance → Exhaustion.

Definitions

Section Title

Stress and Selye's General Adaptation Syndrome (GAS)

Common Mistakes

• Confusing GAS with LAS — GAS is the SYSTEMIC (whole-body) response; LAS is LOCAL (e.g., inflammation at a wound).
• Listing the GAS stages in wrong order — always Alarm FIRST, then Resistance, then Exhaustion (A-R-E).
• Forgetting that during the ALARM stage the person is actually physiologically MORE aroused and briefly less adapted — adaptation happens in the RESISTANCE stage.
• Assuming the Exhaustion stage always leads to death — the stage indicates depletion of adaptive reserves and can produce illness; death occurs only if the stressor persists and no recovery occurs.

Exam Tips

• MASTER the table: Mild = Increased perceptual field → teach; Moderate = Narrowed (selective inattention) → assist with problem-solving; Severe = Greatly reduced → calm, short directions, NO teaching; Panic = Distorted → SAFETY FIRST, never leave alone.
• If an NLE question asks 'what should the nurse do FIRST' with a panicking client, the answer almost always involves: stay with the client AND ensure safety.
• The interpersonal nature of anxiety: if a nurse appears calm and uses a low, steady voice, the client's anxiety decreases — this is both a nursing intervention and an exam point.
• Remember: anxiety is a NANDA-recognized nursing diagnosis. NANDA label: 'Anxiety' (related to unmet needs, perceived threat, etc.) and 'Fear' (related to specific identified threat).
• Buspirone takes 2-4 weeks — it is NEVER the answer for acute panic. Benzodiazepines (lorazepam) act rapidly and are used for acute, severe anxiety and panic.

Key Points

• ANXIETY is a vague, diffuse feeling of apprehension or dread in response to a threat whose source is often NONSPECIFIC or UNKNOWN.
• FEAR is a response to a SPECIFIC, IDENTIFIABLE, EXTERNAL threat — this distinction is high-yield on NLE.
• Anxiety is communicated INTERPERSONALLY — a nurse who is anxious can raise the anxiety level of the client (and vice versa). The nurse must manage their own anxiety first.
• Mild anxiety is NORMAL and beneficial — it heightens perception, motivates learning, and promotes growth.
• The PERCEPTUAL FIELD (what the person can take in and process) is the key differentiator across the four anxiety levels.
• MILD: perceptual field is HEIGHTENED/INCREASED — best time for teaching; person is alert and motivated.
• MODERATE: perceptual field NARROWS — selective inattention; some learning still possible with guidance; use short, clear sentences.
• SEVERE: perceptual field GREATLY REDUCED — focus on one small detail; NO teaching or problem-solving; provide calm, quiet environment; stay with the client; use short, firm directions.
• PANIC: perceptual field DISTORTED — loss of rational thought, possible hallucinations, terror, possible harm; NEVER leave the client alone; this is a psychiatric emergency.
• Nursing priority hierarchy: at severe and panic levels, SAFETY and MAINTAINING CALM override all other interventions.

Definitions

Section Title

Anxiety: Definition, Levels, and the Nursing Approach

Common Mistakes

• Attempting to TEACH or give health education to a client in SEVERE or PANIC anxiety — this is a classic NLE trap. Teaching is only effective at mild (best) and moderate levels.
• Confusing perceptual field descriptors: mild = HEIGHTENED (not narrowed); moderate = NARROWED; severe = GREATLY REDUCED; panic = DISTORTED.
• Leaving a client in PANIC to 'get help' — you must NEVER leave a panicking client alone. Call for help while staying with the patient.
• Touching a panic-level client without permission — touch can feel threatening and escalate the panic. Always ask before touching.
• Using long, complex sentences with a severely anxious client — short, simple, firm directions are required at severe and panic levels.

Exam Tips

• NLE vignette approach for defense mechanisms: identify WHAT the client is doing (attributing? avoiding? redirecting?), WHAT emotion or impulse is being managed, and WHETHER it is conscious or unconscious.
• Sublimation = most adaptive. Denial and repression = most primitive. Regression = reverting to childlike behavior (common in hospitalized adults).
• When a question asks 'which defense mechanism is the patient using?', look for the key behavior: claiming amnesia (repression), insisting illness is not real (denial), blaming others for own feelings (projection), acting the opposite of true feelings (reaction formation).
• Nursing intervention for maladaptive defenses: address in the WORKING phase, gently and collaboratively — do NOT aggressively confront denial in acute grief; it may be protective.

Key Points

• COPING MECHANISMS are conscious and unconscious efforts to manage stress and anxiety.
• ADAPTIVE (constructive) coping resolves the source of anxiety and promotes growth: problem-solving, seeking social support, exercise, relaxation techniques, talking through feelings.
• MALADAPTIVE (destructive) coping provides temporary relief without resolving the problem and may cause harm: substance use, withdrawal, aggression, denial, self-harm.
• DEFENSE MECHANISMS are UNCONSCIOUS ego strategies used to reduce anxiety — the single CONSCIOUS mechanism is SUPPRESSION.
• Commonly tested defense mechanisms: repression (forced forgetting), denial (refusal to acknowledge), projection (attributing own feelings to others), displacement (redirecting emotion to a safer target), rationalization (logical-sounding justification), reaction formation (behaving opposite to true feelings), regression (reverting to earlier behavior), sublimation (channeling impulses into socially acceptable activities).
• Defense mechanisms are NORMAL and HEALTHY in moderation — they become MALADAPTIVE when overused or when they replace realistic problem-solving.
• Nursing role: in the WORKING PHASE of the therapeutic relationship, the nurse helps the client identify maladaptive defenses and develop adaptive coping strategies.
• In the Philippine context, strong family and community (bayanihan) support systems are significant adaptive coping resources.

Definitions

Section Title

Coping Mechanisms and Defense Mechanisms

Common Mistakes

• Confusing REPRESSION (unconscious) with SUPPRESSION (conscious) — remember: 'Suppression = you know you are doing it; Repression = you don't know.'
• Identifying all defense mechanisms as maladaptive — they are NORMAL and healthy at moderate, appropriate use. The nurse does NOT always challenge them.
• Confusing DISPLACEMENT with PROJECTION — Displacement redirects an EMOTION to a safer TARGET (e.g., yelling at a family member after a bad day at work); Projection ATTRIBUTES one's own feelings TO ANOTHER PERSON.
• Forgetting that sublimation is the MOST mature/adaptive defense mechanism — it channels unacceptable impulses productively.

Exam Tips

• Memorize the 4-to-6-week timeline — NLE may ask how long a crisis typically lasts or why crisis intervention is time-limited.
• For vignette classification: Typhoon Yolanda survivor experiencing acute distress = ADVENTITIOUS; A new mother struggling to cope = MATURATIONAL; A father who just lost his job = SITUATIONAL.
• Aguilera's balancing factors = Perception + Supports + Coping — if any one is absent or inadequate, the person is at risk for crisis.
• The 'opportunity for growth' concept: NLE questions may frame crisis as negative; remember it is also an OPPORTUNITY — the client is more open to help and change during a crisis.

Key Points

• A CRISIS is an acute state of disequilibrium occurring when a person's usual coping mechanisms FAIL to resolve a stressful event, producing a temporary inability to function.
• A crisis is SELF-LIMITING — it resolves within approximately 4 to 6 weeks, regardless of intervention (though the direction of resolution differs).
• Crisis is NOT an illness — it can happen to ANY person when stressors exceed available coping resources.
• During a crisis, people are often MORE OPEN TO HELP than at other times — this makes crisis an OPPORTUNITY FOR GROWTH as well as a risk.
• Aguilera's BALANCING FACTORS determine whether a crisis occurs and how it resolves: (1) Realistic PERCEPTION of the event, (2) Adequate SITUATIONAL SUPPORTS, (3) Adequate COPING MECHANISMS. Deficits in any of these tip the balance toward crisis.
• THREE TYPES OF CRISIS: Maturational (developmental), Situational, and Adventitious (social).
• MATURATIONAL crisis: arises from expected life transitions (adolescence, marriage, parenthood, retirement) — also called developmental crisis.
• SITUATIONAL crisis: arises from an unanticipated external event (job loss, sudden illness, death of a loved one, divorce).
• ADVENTITIOUS crisis: arises from an unplanned, accidental, unexpected event affecting MANY PEOPLE — natural disasters (highly relevant in the Philippines: typhoons/bagyo, earthquakes, volcanic eruptions), fires, violent crimes, war. This links directly to DISASTER NURSING.
• Without intervention, crisis can resolve toward HIGHER functioning (growth), SAME level, or LOWER functioning (deterioration, psychiatric illness).

Definitions

Section Title

Crisis Theory and Types of Crisis

Common Mistakes

• Confusing SITUATIONAL and ADVENTITIOUS crises — situational affects an INDIVIDUAL; adventitious affects a COMMUNITY or large GROUP.
• Stating that a crisis lasts indefinitely — a crisis is SELF-LIMITING and resolves within 4 to 6 weeks. This is a high-yield NLE fact.
• Treating crisis as equivalent to mental illness — crisis can happen to mentally healthy people and is defined by a MISMATCH between stressor and coping resources.
• Forgetting that unresolved crisis can lead to LOWER functioning and chronic psychiatric illness — the direction of resolution is not automatically positive.

Exam Tips

• NLE priority question on crisis intervention: the first action is ALWAYS assessing for suicide/homicide risk. Safety = first.
• Distinguish crisis intervention from crisis counseling and long-term therapy: crisis intervention = short-term, directive, here-and-now, restores pre-crisis functioning.
• Remember Aguilera: the nurse's interventions target whichever balancing factor(s) are deficient — if the client has distorted perception, reality-orient; if no supports, mobilize family; if poor coping, teach adaptive strategies.
• Philippine context: include NCMH hotline, barangay health centers, Malasakit Centers, and community mental health resources in any crisis discharge planning scenario.

Key Points

• Crisis intervention is SHORT-TERM, focused, ACTIVE, and DIRECTIVE help aimed at restoring the person to AT LEAST the pre-crisis level of functioning.
• The nurse takes a MORE DIRECTIVE ROLE in crisis intervention than in ordinary psychotherapy — the client's impaired functioning requires the nurse to be active, structured, and goal-oriented.
• STEP 1 — SAFETY FIRST: Assess for suicidal and homicidal ideation BEFORE anything else. This is the absolute priority in crisis intervention.
• 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 HERE-AND-NOW: Crisis intervention addresses the IMMEDIATE problem, not long-standing personality issues or chronic psychiatric problems.
• STEP 4 — SET REALISTIC, SHORT-TERM GOALS collaboratively with the client.
• STEP 5 — TAKE AN ACTIVE, DIRECTIVE ROLE: Help the client develop a concrete, achievable action plan.
• STEP 6 — MOBILISE RESOURCES AND SUPPORT SYSTEMS: Family, community support groups, barangay health centers, NCMH crisis hotline, and other referrals.
• STEP 7 — ANTICIPATORY PLANNING: Help the client identify future stressors and rehearse coping strategies to prevent future crises.
• The GOAL is resolution of the IMMEDIATE CRISIS and RESTORATION OF FUNCTIONING — NOT personality reconstruction or long-term therapy.
• Philippine resource: National Center for Mental Health (NCMH) crisis hotline — a relevant community resource to include in discharge planning and family teaching.

Definitions

Section Title

Crisis Intervention: Principles, Steps, and Nursing Role

Common Mistakes

• Beginning crisis intervention by exploring childhood experiences or long-standing personality issues — crisis intervention is HERE-AND-NOW, focused on the IMMEDIATE precipitating event only.
• Being passive or non-directive during crisis intervention — the nurse must be ACTIVE and DIRECTIVE because the client's coping is temporarily overwhelmed.
• Forgetting that SAFETY (suicide/homicide assessment) is ALWAYS the first step in crisis intervention — this is the universal NLE priority.
• Setting long-term goals during crisis intervention — goals must be SHORT-TERM and REALISTIC, achievable within the crisis resolution period.
• Neglecting to involve the family and community support system — in the Philippine context, family is a central pillar of support and must be mobilised.

Exam Tips

• For ACUTE panic: benzodiazepines (lorazepam IV/IM is fastest). For CHRONIC anxiety: SSRIs (first-line) or buspirone.
• Benzodiazepine safety triad: (1) NO alcohol, (2) NO abrupt discontinuation, (3) CAUTION driving/operating machinery.
• NLE drug question approach: match the TIMELINE (acute = benzodiazepine; weeks-long = SSRI or buspirone) and the SETTING (inpatient panic = lorazepam; outpatient chronic = sertraline).
• Beta-blockers for performance anxiety (e.g., a surgeon with tremors before operating) = propranolol; it targets the PHYSICAL not psychological symptoms.

Key Points

• BENZODIAZEPINES (lorazepam, diazepam, alprazolam, clonazepam) act on GABA receptors to rapidly reduce anxiety — onset within minutes to hours, making them appropriate for ACUTE, SEVERE anxiety and panic.
• Benzodiazepines are for SHORT-TERM USE ONLY due to: risk of physical and psychological dependence, tolerance, CNS depression, sedation, and respiratory depression.
• Critical benzodiazepine drug interaction: COMBINING WITH ALCOHOL (or other CNS depressants) can cause FATAL respiratory depression — this is a top safety teaching point.
• Elderly clients on benzodiazepines: FALLS and CONFUSION risk — use with extreme caution; falls are a priority safety concern.
• Do NOT stop benzodiazepines ABRUPTLY — taper gradually to avoid withdrawal (seizures, rebound anxiety, tremors, diaphoresis).
• BUSPIRONE (Buspar): non-benzodiazepine anxiolytic; non-sedating, NO dependence potential, NO interaction with alcohol — BUT takes 2 to 4 WEEKS to achieve full therapeutic effect. NOT useful for ACUTE panic.
• SSRIs (sertraline, fluoxetine, escitalopram, paroxetine): FIRST-LINE for long-term management of anxiety disorders; also require several weeks for full therapeutic effect; NOT for acute panic.
• BETA-BLOCKERS (propranolol): blunt the peripheral (physical) symptoms of situational/performance anxiety (tachycardia, tremor, palpitations) — do NOT treat the psychological component.
• Nursing monitoring priorities for benzodiazepines: respiratory rate, level of consciousness, fall risk, signs of dependence, and signs of withdrawal on discontinuation.

Definitions

Section Title

Pharmacology: Anxiolytics and Related Medications

Common Mistakes

• Choosing buspirone for a patient in acute panic — buspirone takes 2-4 weeks to work and cannot address acute anxiety.
• Failing to counsel patients to AVOID ALCOHOL when taking benzodiazepines — the combined CNS depression can be fatal.
• Teaching a patient to stop benzodiazepines abruptly — ALWAYS taper; abrupt cessation can cause life-threatening withdrawal seizures.
• Forgetting fall risk for elderly patients on benzodiazepines — always include fall prevention in the care plan.
• Treating beta-blockers as a general anxiolytic — they only address PHYSICAL symptoms (heart racing, tremor) and do not treat the psychological experience of anxiety.

Exam Tips

• NLE priority-setting with anxiety: always assess LEVEL first, then match intervention to level. Any question asking 'what should the nurse do first' usually requires identifying the anxiety level as the foundation.
• NANDA diagnoses to know: Anxiety (vague threat), Fear (specific threat), Ineffective Coping, Compromised Family Coping, Risk for Self-Directed Violence (in crisis with suicidal ideation).
• Maslow-based prioritization: in severe/panic anxiety, physiologic safety (airway, preventing exhaustion/harm) and psychological safety (panic = psychiatric emergency) are the hierarchy priorities.
• RA 9173 link: health teaching is an independent nursing function. The nurse can independently assess anxiety, provide environmental interventions, teach coping, and refer — no physician order needed for these actions.
• Community resource in Philippine context: National Center for Mental Health (NCMH) Mandaluyong — both a tertiary psychiatric facility and a source of crisis hotline support.

Key Points

• STEP 1 — ASSESS ANXIETY LEVEL FIRST: Every subsequent nursing action depends on accurately identifying the anxiety level. Assessment drives intervention.
• STEP 2 — ENSURE SAFETY: Priority at severe and panic levels and in any crisis situation. Never leave a panicking client alone.
• STEP 3 — REDUCE ENVIRONMENTAL STIMULI: Calm, quiet, structured, low-stimulation environment for high anxiety levels.
• STEP 4 — STAY WITH THE CLIENT: Therapeutic presence reduces anxiety. The nurse's calm demeanor is itself an intervention.
• STEP 5 — USE APPROPRIATE COMMUNICATION: Short, simple, clear, firm directions at severe/panic levels. Teaching is reserved for mild-to-moderate levels.
• STEP 6 — ADMINISTER PRESCRIBED ANXIOLYTICS: Monitor respiratory rate, level of consciousness, and response to medication.
• STEP 7 — IN CRISIS: Work here-and-now, mobilise supports, set short-term goals, and involve family.
• PATIENT TEACHING CONTENT: Teach recognition of personal anxiety triggers and EARLY WARNING SIGNS so the client can intervene when anxiety is still at the MILD level.
• Teach RELAXATION TECHNIQUES when the client is calm (mild anxiety): deep breathing, progressive muscle relaxation, guided imagery, grounding techniques, physical exercise.
• ADDRESS STIGMA: In the Filipino context, there is significant stigma around seeking mental health help. Emphasize that a crisis is time-limited, seeking help is a sign of strength, and mental health is integral to overall health.
• Provide emergency contacts: NCMH crisis hotline, community mental health resources, and barangay health services.
• Reinforce MEDICATION TEACHING: adherence, side effects, avoiding alcohol with benzodiazepines, not stopping medications abruptly.
• Under RA 9173 (Philippine Nursing Act of 2002), the professional nurse has independent and collaborative functions that include assessment of mental status, health teaching, and referral to appropriate resources.

Definitions

Section Title

Nursing Management Priorities and Patient Teaching

Common Mistakes

• Teaching relaxation techniques to a client who is currently in severe or panic anxiety — you cannot teach at those levels; wait until anxiety subsides to mild-to-moderate.
• Neglecting to address mental health stigma in Filipino patients — Filipino cultural values (hiya, pakikisama) may prevent help-seeking; proactive, non-judgmental education is essential.
• Overlooking the interpersonal transmission of anxiety — if the nurse is visibly rushed, worried, or disorganized, the client's anxiety will increase.
• Failing to include the family in discharge and follow-up planning — Filipino family systems are a major protective factor and must be engaged.