Week 9 - Psychological Impact of Injury

Question 1

What are some patient characteristics of stage 3 of this cycle? (4 main ones)

Answer 1

Regaining control and facing reality and losses - Patients are now challenged by the immense process of healing and recovery

Family as anchor (lonely without) - May still be profoundly lonely when left alone and see their family as their anchor.

Grief, denial, anger begin (wish for miracle to return to old life) - Denial is not uncommon and is used unconsciously as a defense mechanism to buy time to deal with the loss. Anger and blame is also not uncommon, particularly in response to feeling dependent on others.

Fear and regaining hope

Question 2

When asking questions, what should we try to do with them? Why?

Answer 2

Try making your question into a statement instead (e.g. “Are you worried about being a burden to your family” say “I sense that you are worried about being a burden to your family”)

Why: It can feel like an interrogation from the patient’s perspective!

Question 3

What are some interventions we can do for the patient during stage four of this cycle?

Answer 3

vary based on mental health status, but same as stage 3!!

based on the patient’s mental health status—many are the same as previous stages such as celebrating successes

Question 4

What phase of the cycle do patients patients begin to face their losses? What can it be for them?

Answer 4

Stage 3: The intermediate care phase is usually where patients begin to face their losses (which can be many and overwhelming).

Question 5

In stage 3 of this cycle, what are patients challenged by?

Answer 5

Patients are now challenged by the immense process of healing and recovery.

Question 6

What are some family interventions we can do for stage one of this cycle? (5 things)

Answer 6

-update/reassure;

-repeat information (providing written information)

-designate key family member (designating a family point person to limit miscommunication)

-spiritual care/crisis support if necessary;

-non-judgmental listening (Nonjudgmental listening is often the best approach to help families through their grief process and the emotions that come with it)

Question 7

What characterizes stage four of this cycle for the patient?

Answer 7

The rehabilitation phase!

-striving to regain self/merging old and new reality

Patients in this stage are learning to accept their new body image, find meaning from their experiences, and accept the consequences of the trauma events

Question 8

At what stage of this cycle does the family usually begin their grieving process?

Answer 8

the family, who started their grieving in the resuscitation phase, the intermediate care phase is usually where patients begin to face their losses (which can be many and overwhelming).

Question 9

What are some family interventions we can do for stage two of this cycle? (3 main things)

Answer 9

facilitate family presence;

include in care plan (and care itself) - Including what is ok—such as touching the patient/holding their hand/stroking their hair/talking to them)

facilitate self-care and mobilize the families own support system

Question 10

Reactions to this crisis are?

Answer 10

Reactions to this crisis are highly variable

Question 11

What are some family characteristics for stage one of this cycle? (what is the family heavaily focsed on in this stage? (4 main things)

Answer 11

Heavily focused on whether the patient will survive and what happens in the immediate future.

Will usually display signs of anxiety (pacing, restlessness, disconnected thoughts).

Range of other responses depending on what happened as well as their prior relationship with the patient.

Anger/hostility/mistrust - Reactions should be responded to with empathy but limited if dysfunctional (e.g. persistent denial for days/weeks, or threats/aggression towards staff).

Question 12

What are some patient interventions we can do for stage three of this cycle?

Answer 12

Interventions:
-celebrate success;

-boundaries for acceptable behavior (no aggression E.g. not threatening staff)

-offer hope,

• provide choices;

-limit rumination by focusing patient;

-assess for thoughts of suicide (not normal grieving) - these are never part of a normal grief process)

Question 13

At what stage in the cycle are patients learning to accept their new body image, find meaning from their experiences, and accept the consequences of the trauma events

Answer 13

Stage 4 - Rehabilitation stage

Question 14

What are the different stages of the psychological impacts of a traumatic injury? What is important to remember about this cycle?

Answer 14

Important to remember that these stages are generalized, fluid, and non-linear

1.) Resuscitation Phase
2.) Critical Care phase
3.) Intermediate Care Phase
4.) Rehabilitation Phase

Question 15

What is common and still rampant for patients in stage two of the cycle?

Answer 15

Pain is common and uncertainty is still rampant

Question 16

What characterizes stage two of this cycle for the family? Why?

Answer 16

Stress (They are highly stressed, their life processes are disrupted e.g. visiting in hospital instead of working or caring for children)

-The family have a need to see, touch, and help the patient but are often not allowed to in ICU (or are limited in doing so).

Question 17

What is an important principal to remember when it comes to the psychological impacts of injury?

Answer 17

Reminder: trauma is a “crisis” to most patients and families. It is sudden, unpredictable, and often life threatening

Reactions to this crisis are highly variable

Question 18

What are some interventions we can do for the family during stage three of this cycle?

Answer 18

Giving the family “permission” to care for themselves

Question 19

What are some family characteristics for stage two of this cycle? (5 characteristics)

Answer 19

Stress

Role change (how injury will impact them)

Uninvolved but want to see and help the patient (touch too)

Need to share and be supported (life is now changed – at hospital instead of work)

Highly variable reactions - Families are in a state of grief for losses that the patient and they have/will experience and remain fearful that the patient will die—responses to these stressors are highly varied and sometimes dramatic compared to their normal personalities.

Question 20

What is unique about trauma patients?

Answer 20

Remember, what is unique about trauma patients is that it is a crisis, that these patients experience an unexpected ability to decline suddenly and in unexpected ways.

Question 21

What are some family characteristics for stage three of this cycle? (5 things)

Answer 21

-Emotionally depleted

-Role shifts to adapt to changes - Roles shift as families take on new care tasks and adapt to expected life changes

-Families are calmer but more distant

-Possibly more involved in care

-Helping the patient to grieve

Question 22

What are some patient interventions we can do for stage two of this cycle?

Answer 22

Interventions include:
-giving choice where possible,
-asking simple questions,
-giving clear simple instructions,
-reorienting,
-staying calm and reassuring,
-allowing for uninterrupted sleep if possible,
-and celebrating even small achievements.

Question 23

What are some patient characteristics for stage four of this cycle?

Answer 23

-Accept new body, find meaning in experience, accept consequences

-Physical adaptations

-Withdrawal, rumination (wide range of responses) - Wide variety of responses somewhat based on the previous stages—might be thankful that their injuries were not more severe, or could still ruminate over the experience.

-Development of PTSD (dysphoria and hopelessness risk factors) depression, or other mental illnesses

Question 24

What are some interventions we can do with patients to respond to distress? Why? (7 different ones)

Answer 24

Rapport: If your patients don’t trust you, you won’t get far. You need rapport before they will be willing to open up. Every person will take a different amount of time to get there

Curious and authentic: Your patients will know when you don’t genuinely want to listen… At the same time, don’t force an emotion that isn’t there (e.g. crying when you aren’t sad)

Trust them: Patients are experts on themselves, and can have surprising inner strength and resources for healing

Stay neutral and patient-focused: Remember this is a therapeutic relationship—keep the focus on their story and stay non-judgmental

Don-t interrupt: Spend ¾ of your time listening, and don’t worry about what you’re going to say next

Allow for Silence: …sometimes nothing said is actually best! This silence can leave the door open to elaborate further on how they are feeling/what they are thinking

Being with” rather than “doing to”: Sometimes walking alongside the patient (figuratively) is all we can do, and all that they need. In other words, sometimes we can’t fix things, and thinking that we can may do more harm than simply being with them.

Question 25

What characterizes stage three of this cycle for the family?

Answer 25

Shift in anxiety from “will the patient live?” to “what is our life going to be like now?”.

Question 26

In stage two of the cycle, what are patients usually comforted and anchored by?

Answer 26

Patients are usually comforted and anchored by the presence of family and be profoundly lonely when they are not there

Question 27

What are some interventions we can do for the family during stage four of this cycle? (7 things)

Answer 27

-Assess family structure/dynamics (CFAM anyone?) -Prep for discharge -Emotional support -Guidance -Listening -Facilitate support systems -Promote positive coping strategies

Question 28

At what stage in this cycle might families tend to be calmer but also more emotionally distant?

Answer 28

Families tend to be calmer but also more emotionally distant in stage 3 (the intermediate care phase)

Question 29

If we want to ask questions, what 3 things should we consider making restatements or open questions about?

Answer 29

Use questions sparingly! But if you do want to be curious (without just using silence), consider restatements or open questions about: 1.) The emotion underlying the statements you hear 2.) An idea that seems half-formed or hinted at 3.) The main theme of what they have just said

Question 30

In stage four of this cycle for patients, what are some risk factors for developing PTSD later?

Answer 30

Dysphoria (unease and dissatisfaction in life) and hopelessness in this stage are risk factors for developing PTSD later.

Question 31

What characterizes stage four of this cycle for the family?

Answer 31

Families are faced with accepting the new limitations of the patient, which are usually much clearer by this stage. -Assuming the caregiver role – faced with new limitations of the patient (much clearer now)

Question 32

When asking a patient questions, what should we do? How many should we ask?

Answer 32

No more than two questions at a time/back to back! After that it can feel more like an interrogation from the patient’s side of things. *Try making your question into a statement instead (e.g. “Are you worried about being a burden to your family” say “I sense that you are worried about being a burden to your family”)*

Question 33

When asking questions, what should the emotion you state should reflect?

Answer 33

The emotion you state should reflect the tone and intensity of what you hear. E.g. if it’s panic, don’t call it nervousness. If it’s joy, don’t call it contentment

Question 34

What are some patient characteristics for stage two of this cycle? (5 characterisitcs) - What character terizes this stage for the patient?

Answer 34

*Great fear and confusion characterize this stage* Disruption/Taking time out” – fear and confusion Alteration in body image – small hope to future now Sleep deprivation - They may have disturbing dreams, feel in a fog of confusion, or be unable to determine sleep from wake. ALSO - Trauma and medical interventions disrupt sleep, worsening coping, cognition, etc. Impaired thinking - Communication can be difficult when intubated, sedated, trached, etc. Physiologic responses to injury can alter cognitive processes Continued/Profound loss of control - Patients have difficulty coping in this stage and have a profound loss of control and power (even the most basic ideas of power and control such as voiding).

Question 35

If you want to ask questions what should you consider using?

Answer 35

Use questions sparingly! But if you do want to be curious (without just using silence), consider restatements or open questions about: 1.) The emotion underlying the statements you hear 2.) An idea that seems half-formed or hinted at 3.) The main theme of what they have just said

Question 36

What characterizes stage three of this cycle for the patient?

Answer 36

The intermediate care phase: Enduring the self/confronting and regrouping.

Question 37

What characterizes stage one of this cycle for the patient?

Answer 37

Becoming engulfed” – heightened senses -Vigilance/becoming engulfed. Heightened senses during a time of threat to life

Question 38

When asking question what should we keep our restatements?

Answer 38

Keep your restatements short and tentative. E.g. “It sounds like you’re very angry about that” or “I wonder if your daughter knows that about you?”

Question 39

In stage four of this cycle, what is essential for the family to have? Why?

Answer 39

Need for a strong support system for the family now - A strong support system for the family is essential, as they themselves are stretched and stressed with their new reality.

Question 40

What are some patient characteristics for stage one of this cycle?

Answer 40

“Becoming engulfed” – heightened senses -Dissociation (time slows) - Time slows (what took minutes feels like hours). Usually very aware of the seriousness of their injuries very quickly -Relinquishing control - They will have an instinct of self-preservation, but usually relinquish control to someone they see as competent (e.g. EMT/firefighter during extrication).

Question 41

In stage 3 of this cycle, what may patients wish/hope for? What can it lead to?

Answer 41

They struggle to regain independence and may still wish for a miracle to return their old life. Unlike the family, who started their grieving in the resuscitation phase, the intermediate care phase is usually where patients begin to face their losses (which can be many and overwhelming). This can lead to frustration or conflict between patient and family.

Question 42

What thoughts are not normal while grieving (patient)?

Answer 42

-assess for thoughts of suicide (not normal grieving) - these are never part of a normal grief process)

Question 43

What are some family characteristics for stage 4 of this cycle?

Answer 43

Stress, burnout (long-term caregiver now based on injury [spinal, TBI]) - Stress and burnout remain a challenge as families assume a long term caregiver role (depending on the patient’s injuries). Need for a strong support system for the family now - A strong support system for the family is essential, as they themselves are stretched and stressed with their new reality.

Question 44

If you view trauma as a crisis, particularly severe trauma what makes sense?

Answer 44

If you view trauma as a crisis, particularly severe trauma, many of the reactions from patient and family make sense

Question 45

What might happen to the patient while they are in the ER during stage 1 of this cycle?

Answer 45

In the ER they detach or outright dissociate from themselves into a calm state of passive observer. There may also be gaps in their awareness. Anxiety can be increased if they can see other injured patients or tubes/machines around their own body. Less severely injured patients may actually react more dramatically because they don’t have detached calmness as often.

Question 46

What characterizes stage one of this cycle for the family?

Answer 46

Shock/fear/anxiety Family also in a state of crisis, ++++fear/uncertainty.

Question 47

What are some patient interventions we can do for stage one of this cycle? ( 4 main things)

Answer 47

Interventions include: -providing information on what happened/is happening/will happen next, -gentle touch, -focusing the patient’s attention, -and remaining calm and empathetic

Question 48

What characterizes stage two of this cycle for the patient? (what shifts the focus?)

Answer 48

Great fear and confusion characterize this stage (“Disruption/Taking time out” – fear and confusion) Focus shifts from threat to life slightly into thinking about the future—may be coping with altered body image and concept of self.