Transcript PSYCHOSOCIAL CARE AFTER A BIOTERROR ATTACK

PSYCHOSOCIAL CARE
AFTER A BIOTERROR
ATTACK
Marlene Rankin, Ph D, RN
Clinical Associate Professor, College of Nursing
Rutgers The State University of New Jersey
College of Nursing
Nursing Center for Bioterrorism and Infectious
Disease Preparedness
The format and information in this module
focuses on psychosocial care after a bioterror
attack. This module is designed to highlight
important information about psychological
responses and care after a bioterror attack.
This module was supported in part by
USDHHS, HRSA Grant No. T01HP01407.
Purpose
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Observations following conventional terrorist
incidents and other trauma, including biological and
nuclear accidents, suggest that a biochemical
terrorist incident would have widespread public
effects.
Unlike in natural disasters or other situations
resulting in mass casualties, nurses, health care
workers and physicians would be most likely to
identify the unfolding disaster associated with a
biological attack.
A bioterrorist attack would necessitate treatment of
individuals and communities who experience
psychological symptoms and syndromes.
Recognizing the influence that psychological distress
has on recovery and physical symptoms allows
nurses and health care workers to more effectively
treat patients.
Purpose-2
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Initial psychosocial interventions include effective
and accurate risk assessment, communication,
management of acute abnormal psychological
and somatic symptoms, and an environment that
supports recovery and realistic client response
outcomes.
Factors that influence psychological outcome
include interpersonal and environmental aspects.
The long-term effects following a traumatic event
are influenced by an individual’s unique
combination of health, developmental level,
resources and experiences.
The nurse must be cognizant of personal needs
and self care during this crisis time.
Individual Effects
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Individual effects of disaster trauma include the physical and
psychological consequences of those injured or infected as well
as psychological consequences of the injured person’s loved
ones.
Individuals with no direct connection to the trauma, other than
awareness, can experience psychological symptoms as well.
In bioterrorism, where events often occur with no warning,
individuals may experience random patterns of unpredictable
and continuous fear (Braden, 2002).
No one is safe and people can not within reason change their
behavior to decrease risk.
The victims who are killed, injured or even directly affected are
rarely the primary target (Susser, 2002).
Victims may include adults and children, both genders, and
include multiple racial groups as occurred with the anthrax
attacks.
The risk of panic is heightened when individuals believe there is
a small chance of escape or they are likely to become infected
(Holloway (1997).
Community Effects
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Community physical resources are affected by
bioterrorism as well as the behavior and cohesive
nature of the community.
A range of negative outcomes are possible
including a vulnerable population’s refusal to
accept preventative measures or treatment
regimes such as isolation and quarantine, social
disruption, and civil violence.
Beyond the human health toll, there is the
damage inflicted by ethnic stereotyping,
stigmatization, and finally staggering business
and economic losses (Hall, 2003).
There could be a disruption in the social
infrastructure adversely affecting community,
leadership and safety.
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Most people pull
together and
function after a
disaster, but their
effectiveness is
diminished.
Biological weapons
are especially
effective at causing
fear and horror
Disaster Stress and Grief
Reactions are Normal
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Stress and grief reactions
are normal responses to an
abnormal situation.
Many emotional reactions
of disaster survivors stem
from problems of living
brought about by the
disaster.
In a terror situation most
people will experience
some level of psychological
distress including an
altered sense of safety,
sadness, anger, fear and
decreased concentration.
Disaster Stress and Grief
Reactions are Normal-2
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Yet most individuals do not see
themselves as needing mental health
services following disaster and will
not seek such services.
Most individuals will function
adequately, but a few will need
psychological intervention.
Disaster Stress and Grief
Reactions are Normal-3
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Assessment considerations should include
ethnocultural concerns that reflect ethnic
heritage or cultural identity.
Individuals may value their ethnic
background but wish to avoid being
stereotyped.
Intrapersonal aspects must consider the
patient’s developmental level and inner
resilience.
At-Risk Populations for Psychological
Sequelae Following a Bioterror Attack
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Those exposed to the dead and injured including
eye witnesses, emergency first responders, those
endangered by the event, and medical personnel
caring for victims.
The elderly and very young.
Individuals, who because of the event are hungry,
cannot drink clean water, are exposed to weather,
or become extremely fatigued.
Individuals who continue to be exposed to a toxic
contamination.
Individuals with a history of exposure to other
traumas or with recent or major life stressors or
emotional strain such as poverty, homelessness,
unemployment, or discrimination.
Patients with chronic medical or psychiatric
diagnoses.
Assess Normal Coping Behaviors
of Patients
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The active process of
using personal,
psychological, social,
and environmental
resources to manage
stress or anxiety.
Enables the patient to
discern problems to
recognize possible
solutions or strategies
such as defense
mechanisms.
Assess Normal Coping Behaviors
of Patients-2
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Factors Influencing Coping
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Fear of pain and discomfort.
Fear of the unknown, based on experience
and uncertainty about final outcome
Fear of complications or loss of control
Fear of disruption of life pattern
The patient’s previous health care
experiences, hospitalizations, and pre- and
post-event treatment affect psychosocial
functioning
Coping Strategies Include:
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Worrying
Changes in physical
activity, sleeping
patterns, eating
habits
Seeking information
Denial
Repression
Using drugs or
alcohol
Increased smoking
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Physical exercise
Journal writing
Relaxation tapes
Reading books or
magazines
Talking the
problem out
Trusting in religious
faith
Relying on support
from others
Assess and Reinforce the
Individual’s Strengths
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The patient’s
strengths represent an
untapped energy
source.
Identifying the
patient’s strengths will
give perspective.
Determine how the
patient can use these
strengths in this
situation.
Personal values and
goals differ
Mini Mental Status Examination
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Determine the significance and importance
of the event to the patient, nature and
degree of exposure.
Assess the patient’s mood, orientation,
affect, general appearance, and thought
processes.
Use open-ended questions, “Tell me what
is going on”, “It is often difficult to know
where to begin.”
Discuss temporary loss of life’s routines
and possible sexual restrictions.
Mini Mental Status Examination-2
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Assess sleep
patterns for possible
sleep disorder or
trauma.
Examine patient’s
perception of
possible risks or
permanent
limitations from
bioterror agent.
Evaluate according
to individual’s
developmental level.
Additional Assessment
Considerations
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The nurse must be cautious about conversations in
the hospital because the patient may be able to hear
what is going on but unable to clarify or interpret
coherently.
The hospital environment may alter the patient’s
perception.
A patient who has been medicated, receives IV
sedation, or who is undergoing or emerging from a
biological agent may be influenced by:
• physical restraint
• sensory overload
• sensory deprivation due to edema, shock or medical
emergency
• overheard conversation
• generalized and specific effects of drugs
Additional Assessment
Considerations-2
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The patient may have
a transient
psychological
disturbance during the
early assessment
period due to:
• personality structure
• change in appearance
• uncertainty about
outcome of attack or
prognosis
• attitudes and reactions
of significant others
Common Psychological Responses
to a Biological Attack
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Anxiety – a universal unpleasant
feeling of tension and apprehension,
a normal response to stress
accompanied by a variety of
physical, affective, cognitive, and
behavioral symptoms that have both
positive and negative effects and
range from mild to panic (see Table 1
next frame).
Table 1.
DSM-IV (1994) Criteria For Panic Attack, Posttraumatic Stress
Disorder and Acute Stress Disorder
Panic Attack
(4 or more symptoms
present, sudden onset
peak in 10 minutes)
PTSD
Acute Stress
(Symptoms can be
(Symptoms occur
immediate or delayed
immediately, end within
for years, stressors
4 weeks; 3 or more symptrigger at least 3
toms present for 2 days)
symptoms)
_____________________________________________________________________________________
Palpitations
Experienced an
Exposure to a traumatic
Sweating
event that caused
event involving threat
Trembling/Shaking
severe threat to self
to self
Shortness of breath
Feeling of choking
Response of intense
Response of intense
Chest discomfort
fear, helplessness, or
fear, helplessness, or
Nausea
horror
horror
Feelings of unreality
Hypervigilance
Clinical distress
Fear of losing control
Recurrent thoughts
Detachment/Daze
Fear of dying
or nightmares
Depersonalization
Numbness
Flashbacks
Recurrent dreams
Chills
Intense distress
Flashbacks
Hot flushes
Physiological reactivity
Irritability
GI upset
to symbolic cue
Poor concentration
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Avoidance of cues
Avoidance of
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associated to trauma
recollections of trauma
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Symptoms of arousal
Amnesia
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Sleep disorder
Anxiety
Common Psychological Responses
to a Biological Attack-2
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Mild anxiety is reflected as verbal
expression of concerns, restlessness,
irritability, agitation, or crying. Often times
there are repeated questions and an
inability to focus
Moderate levels of anxiety may include
periods of shortness of breath, gastric
symptoms such as “butterflies” in the
stomach”, selective inattention, facial
twitches and trembling lips, and
irritability.
Common Psychological Responses
to a Biological Attack-3
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Interventions include distraction techniques such
as listening to music, reading a book, talking to
a friend, playing a game, or counting backward
by threes.
Rationale: Distraction techniques allow people to
remain in control when experiencing moderate
levels of anxiety, the brain
cannot hold two thoughts at
the same time (Fontaine,
Kneisl, &Trigoboff, 2004).
Panic
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Panic level of anxiety is associated with
awe, dread, and terror.
The person experiences a loss of control
and is unable to do things even with
direction and results in increased motor
activity, decreased ability to relate to
others, distorted perceptions, and loss of
rational thought.
This level of anxiety is incompatible with
life; death and exhaustion will occur if it
continues for a long period (Stuart and
Laraia, 2005).
Panic-2
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Specific clinical cues include:
• shortness of breath, choking smothering
sensation
• hypotension, dizziness, chest pain or pressure,
palpitations
• nausea
• hot flashes
• agitation, poor motor coordination, body
trembling
• facial expression of terror
• fear of losing control, fear of dying
• completely disrupted perceptual field
Interventions for Panic Attacks
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Use a calm approach, stay with the patient and
give directions using simple, short sentences.
Keep the patient focused on the present.
Suggest deep breathing and tensing and relaxing
muscles of hands and feet. Rationale: Staying
with a patient promotes safety and reduces fear,
deep breathing helps patients feel connected to
the environment and reduces the physical
excitement phase (Fontaine, Kneisl, & Trigoboff,
2004).
Often panic attacks mimic myocardial infarctions.
Depressive Episode
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The patient reports a depressed mood or the loss of
interest or pleasure in nearly all activities.
In children and adolescents the mood may be
irritable rather than sad.
Appetite is usually reduced but in some cases
individuals crave sweets or carbohydrates.
Decreased energy, tiredness, and fatigue are
common with even the smallest tasks requiring a
substantial effort.
There is a sense of worthlessness or guilt that may
include negativity or unworthiness.
Many patients report impaired ability to think,
concentrate, and make decisions.
Children may reflect poor academic performance
and have recurrent thoughts of dying young (DSMIV, 1994).
Patients do not have hallucinations or delusions!
Depressive Episode-2
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Symptoms include:
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Sadness
Demoralization
Isolation/withdrawal
Impaired concentration
Sleep and appetite
disturbances
Somatization Disorder
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The patient has reported physical
symptoms with no clinical findings to
support subjective complaints.
The DSM-IV (1994) includes the following
criteria:
• A history of many physical complaints that
begins to interfere with social, occupational
and other important areas of functioning.
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This disorder may occur in patients
undergoing serious life stressors, and
whose coping patterns and defense
mechanisms are failing.
Somatization Disorder-2
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Symptoms may include:
• Fatigue
• Weakness
• Malaise
• GI complaints
• Headache
• Impaired balance
• Skin rashes
Post Traumatic Stress Disorder
(PTSD)
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The patient has experienced a traumatic
event (bioterrorism) that threatens
serious injury, death or is a threat to one’s
own physical integrity.
The patient reacts with horror, extreme
fright, or helplessness and repeatedly reexperiences the event or avoids anything
that evokes memories of it.
These patients tend to be easily startled,
anxious, and tense and the full symptom
picture must be present for more than one
month.
PTSD-2
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Most patients complain of insomnia
and they struggle with concentration.
Major depression is common in
delayed reactions.
Many patients will use alcohol or
sleeping medications.
Children will have scary nightmare
and think they will die young.
PTSD-3
The DSM-IV (1994) lists the following cluster of
symptoms:
• Re-experiencing
• Efforts to avoid
thoughts, feelings
associated with the
trauma
• Shock
• Fear
• Panic
• Numbing
• Inability to recall an
important aspect of the
trauma
• Hyperarousal or
hypervigilance
• Anger
• Difficulty concentrating
• Irritability
• Detachment
• Estrangement from
others
• Nightmares
• Distressing dreams
• Flashbacks
• Reawakening
Treatment for PTSD
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Most patients suffer some form of PTSD
initially and in the majority of cases it will
diminish over two months.
However, referral to a mental health clinic
is appropriate for patients who have
symptoms of PTSD after three months for
treatment and usually includes cognitive
and behavioral therapies.
Medication such as fluoxetine (Prozac) has
been effective in controlled clinical trials.
Treatment for PTSD-2
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After the World Trade Center 9/11 attack,
the estimated prevalence of PTSD in
Manhattan was 20% (Hall et al. 2003).
Unfortunately, PTSD is rarely a patient’s
only psychiatric diagnosis and it is
sometimes difficult to distinguish
overlapping independent symptoms from
effects of the trauma.
Nearly half of all people with PTSD also
suffer from major depression and more
than a third from phobias and alcoholism.
PTSD is a highly prevalent and impairing
condition (Moore & Jefferson, 2004).
Psychological Responses to Bioterror
Trauma in Children and Adolescents
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Pre-school age
• depressed or irritable
mood,
• temper tantrums,
• clinginess,
• increased dependency,
• changes in appetite,
• sleep disturbances and
somatic complaints.
• After any disaster,
children are most afraid
that the event will
happen again or they
will be separated from
their family and left
alone.
Psychological Responses to Bioterror
Trauma in Children and Adolescents-2
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School Age Children
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separation anxiety,
avoidance,
regressive symptoms,
fear of the dark,
decrease in school
performance,
re-enactment through
traumatic play,
withdrawal from friends,
depression,
aggressive behavior at
home or school, and
hyperactivity that was not
present earlier.
Psychological Responses to Bioterror
Trauma in Children and Adolescents-3
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Adolescents
• increased risk taking behavior,
• drug or alcohol abuse,
• decline in previous
responsible behavior,
• social withdrawal,
• apathy,
• depression,
• rebellion at home or at school, and
• increased sexual acting out.
Helping Children Cope After A
Traumatic Event
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Younger children under the age of 5 will
understand the disaster in more general
terms.
Eight to eleven year olds will be more
concrete in their understanding and ask
for more details.
Teenagers will understand all the
implications and feel increasingly unsafe.
The child may feel responsible in some
way- do not allow them to feel
accountable for events that they have no
control over.
Helping Children Cope After A
Traumatic Event-2
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Talk with them openly at their developmental
level, focus on the future and what they can do
going forward.
Looking toward the future will empower the child
and give a sense of control.
Focusing on the past will increase feelings of
helplessness and anxiety.
Ask what they think has happened and about
their fears
Emphasize the normal routine, going to school,
sports, and activities.
Limit media re-exposure.
Allow expression in private ways; storytelling,
art, pictures, play, journal writing.
General Crisis Intervention Principles
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Establish a trusting nurse/patient
relationship during the outreach stage.
Focus on communication between the
nurse and the patient/victim.
Demonstrate a positive, nonjudgmental
attitude.
Focus on the patient’s verbal messages,
gestures, facial expressions, along with
listening to the patient.
General Crisis Intervention Principles-2
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Discuss tests and procedures with the patient and
significant others.
Provide an opportunity for questions and answers
if possible and if patient is coherent.
Never assume they cannot hear or understand!
Allow the patient to verbalize any concerns or
fears.
Providing consistent emotional support and
information in a nonthreatening manner
increases emotional safety.
Place importance on understanding the personal
meaning of the patient’s words, behaviors, and
feelings.
Priority Nursing Interventions
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The first priority is to assess the lethality of the
bioterror event and to provide for the safety
needs of the victim.
Normal patterns of response and coping
mechanisms are inadequate, and extra resources
from within the patient, family, and health care
team are necessary (Aguilera, 1998).
• Knowing and understanding the nature of the
threat/attack.
• Assessing the patient’s perception of the threat.
• Identifying and reinforcing positive coping behaviors.
• Providing assistance for significant others.
• Coordinating care.
• Serving as a patient advocate.
• Mobilizing community resources as appropriate.
• Psychopharmacology (anti-anxiety agents) as ordered.
Priority Nursing Interventions-2
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Provide the patient with specific
instructions, such as:
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written literature and educational materials
teaching activities
verbal reassurance, expression of concern
emergency phone number and pager
instructions
Provide your full attention when you are
with the patient.
Priority Nursing Interventions-3
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Reassure patient that
the nurse is present
and available:
• do what you say you
will do
• answer patient’s
questions clearly and
precisely
• help patient verbalize
feelings
• touch patient when
he/she needs comfort
Clinical Application: Depression
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Many losses may be associated with
a bioterror attack such as
bereavement following the death of
loved ones, finances, occupational
changes and social withdrawal.
Patients may be depressed, with
suicidal thoughts present.
Many experience “survivor guilt” (
Stuart& Laraia, 2005).
Nursing Interventions for
Depression
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Assess for suicidal thoughts and plans. A high
percentage of patients who are depressed commit
suicide, the first priority of care is prevention and
patient safety.
• Has the patient made any verbal suicide threats?
• Has the patient communicated nonverbally by giving away
prized possessions or revised a will?
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Referral for psychopharmacological evaluation.
Evidence supports that selective serotonin reuptake
inhibitors (SSRIs) are effective for the treatment of
depression.
Patient’s thoughts are slowed down, give extra time
to process questions and respond to messages.
Use reality testing to help patients identify irrational
beliefs and thoughts.
Nursing Interventions for
Depression-2
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Set limits on amount of time patient spends
discussing bioterror event and trauma.
Rumination may intensify guilt and feelings
of helplessness.
Encourage some form of physical exercise
such as walking.
The literature gives evidence that even
walking for 20 minutes three times per
week improves depressive symptoms.
Facilitate patients use of coping strategies
that improve functioning; prayer, journal
writing, meditation, yoga, and relaxation
techniques.
Clinical Application:
Altered Body Image
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When the bioterror attack involves an
agent such as smallpox or disfiguring
germs, many patients may have a
diagnosis of disfigured or altered body
image.
There will be a severe psychological
disconnect between the individual’s
perception of how his or her body was and
the modified “new” body or disfigurement
(Stuart& Laraia, 2005).
Nursing Interventions for Altered
Body Image
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Recognize the stages of grief and encourage
patients to utilize appropriate coping mechanisms
to work through reintegration of body image
changes.
Discuss with patient perceptions of changed
appearance. The patient will feel depersonalized
and have a feeling of unreality and alienation
from the self.
Provide incremental exposure to social
environments and support the patient in his/her
rehearsal of useful coping strategies.
Focus on the patient as a whole.
Emphasize the acknowledgment and utilization of
what remains, rather than focusing on what was
lost.
Nursing Interventions for Altered
Body Image-2
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Assist patient in coping with temporary
changes such as bruising and edema.
Provide patient opportunities for privacy to
reflect on what has happened and what
the body changes mean, and to
experiment with approaches to deal with
body image alterations.
Although body image contains elements of
reality and the ideal, the nurse should
emphasize reality.
Nursing Interventions for Altered
Body Image-3
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Sensory input is vital to body image
reintegration, especially when body
boundaries need to be reestablished
(e.g., loss of limb).
Provide sensory stimulation to
damaged areas to renew and reinforce
previous responses and mobilize
forgotten sensations and functions.
Facilitate body image reintegration by
encouraging the patient to look at and
touch the site, face, limb while
exploring questions and feelings about
appearance and/or function.
Stress Management and Self Care
of Nurses
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Nurses need to be aware of their own
stress responses, especially if they are
providing direct care to victims.
Psychological preparation can reduce
psychological risk in first responders.
The more exposure to trauma the more
the nurse is at risk.
It is cumulative!
Experience is not necessarily protective,
intense feelings occur while confronting
beliefs about personal safety, trust and
control.
Stress Management and Self Care
of Nurses-2
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Many nurses feel burdened by
responsibility and expectations.
Fears and frustrations may be transferred
to patients, thus compounding their
problems.
The nature of the emergency creates
fracturing across organizations and may
lead to miscommunication,
disengagement, escape or refusal to work.
Loyalties between taking care of one’s own
family and one’s professional patients will
be a challenge that needs to be
addressed.
Common Stress Responses of
Nurses
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High degree of
burnout related to
increased work load
and organizational
stress
Feelings of rage, guilt,
helplessness, fear,
shame, and a fearful
or evil world view.
Emotions such as
anxiety, sadness,
anger or feel
overwhelmed.
Practical Suggestions to Decrease
Stress
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Practice relaxation techniques, deep
breathing, yoga, journal writing,
spirituality breaks, and guided imagery to
clarify feelings and reduce anxiety
Attend exercise sessions, short walks in
the hall
Regular scheduled breaks from tending to
patients.
Establish a break area for nurses and
health care providers to talk and receive
support from colleagues.
Practical Suggestions to Decrease
Stress-2
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Encourage frequent contact with loved
ones through telephone interactions or emails
Progressive relaxation exercises reduce
internal anxiety and promote blood flow to
body organs
Complements serve as powerful
motivators.
Hold department or hospital meetings to
keep people informed of plans and events.
Summary of Psychological
Principles After A Bioterror Attack
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The most useful attitude for the nurse to possess is
to view the patient as a person coping, perhaps in a
most inadequate way, with a situation that is
overwhelming and frightening.
Patients are sensitive to the nurse’s feelings and
attitudes as evidenced by touch, handling of the
patient’s body, willingness to talk and listen, and in
discussion of the changes that have occurred in the
body and through trauma the patient has suffered
through.
Patients who perceive their nurses as concerned and
caring are better prepared to deal with the stress the
recovery phase.
Summary of Psychological
Principles After A Bioterror Attack-2
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They report fewer vague complaints,
feelings of disappointment, expressions of
anger and hostility, and are more satisfied
with their outcomes.
Encourage sufficient rest and sleep,
normalizing eat-sleep-work cycles, limiting
exposure to media reports and
traumatizing images and sounds are all
measures that facilitate coping and
recovery.
Survivors experience profound grief,
anguish, anger, guilt and sadness.
Summary of Psychological
Principles After A Bioterror Attack-3
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Talking through one’s emotions is an
important part of the recovery process for
both patients and providers.
Refer patients with abnormal stress
responses to psychiatric treatment team.
Anxiety responses are most likely
following a BT attack, but depressive
symptoms, PTSD and substance abuse
may also occur.
Encourage re-entry into social roles when
possible and appropriate.
References
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Aguilera, D.M.. (1998). Crisis intervention: Theory and
methodology (8th edition). St. Louis, MO: C.V. Mosby
Company.
Bleiberg,KL, & Markowitz, JC. (2005) A pilot study for
interpersonal psychotherapy for posttraumatic stress
disorder. Am J Psychiatry, 162: 181-183.
Diagnostic and Statistical Manual of Mental Disorders. (4th
ed.). (1994). American Psychiatric Association, Washington,
D.C.
Fagan,F., Freme, K. (2004) Confronting posttraumatic
stress disorder. Nursing 2004,34(2), 52-53.
Fontaine, KL, Kneisl, CR, Trigoboff, E. (2004) Clinical
companion for psychiatric mental health nursing. Upper
Saddle River: Prentice Hall.
Galea, S., Ahern J., Resnick, H, Kilpatrick, D., Bucuvalas,
M., Gold, J., Vlahov, D. (2002) Psychological sequelae of
the September 11 terrorist attacks in New York City. New
Eng J Med. 346:982-987.
References-2





Garrett, L. (2002) Betrayal of trust: The collapse of
global public health. New York: Hyperion.
Hall, MJ, Norwood, AE, Ursano, RJ, Fullerton, CS.
(2003) The psychological impacts of bioterrorism.
Biosecurity and bioterrorism: Biodefense strategy,
practice and science 1(2); 139-144.
Holloway, HC, Norwood, AE, Fullerton, CS. Engel,
CC, Ursano, RJ. (1997) The threat of biological
weapons: Prophylaxis and mitigation of
psychological and social consequences. J Am Med
Assoc, 278 (5) : 425-427.
Moore, DP, & Jefferson, James, W. (2004) Handbook
of Medical Psychiatry (2nd Ed.) Philadelphia:
Elsevier/Mosby
Norwood, AE, Holloway, HC, Ursano, RJ. (2001)
Psychological effects of biological warfare. Military
Med. Dec 166 (12 Suppl) 27-8.
References-3




Ruzek, JI, Young, BH, Cordova, MJ, Flynn,
BW.(2004) Integration of disaster mental health
services with emergency medicine. Prehospital
Disaster Medicine, 19:(1) 46-53.
Schlenger, WE, Caddell, JM, Ebert, L, Jordan, BK,
Rourke, KM, Wilson, D., Thalji, L., Dennis, JM,
Fairbanks, JA, Kulka, RA. (2002) Psychological
reactions to terrorist attacks: Findings from the
national study of Americans’ reactions to September
11. J Am Med Assoc. 288:581-588.
Stuart, GW & Laraia, MT. (2005) Principles and
practice of psychiatric nursing. 8th ed. St Louis,
Mo: Elsevier Mosby.
Susser, ES, Herman, DB, et al. Combating the
terror of terrorism. (2002) Scientific American, 287:
72-77
Web Resources
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American Academy of Experts in Traumatic Stress
www.aaets.org
American Association of Suicidology
www.suicidology.org
Center for Disease Control and Prevention
www.bt.cdc.gov/emcontact/index.asp
Disaster Relief
www.diasterrelief.org
FBI Terror
www.fbi.gov.terrorism/terrorism/htm
Mail security
www.usps.com
National Institutes of Mental Health
www.nimh.nih.gov
Substance Abuse and Mental Health Administration
www.samhsa.gov
Federal Emergency Management Agency
www.fema.gov