Critical Care / Emergency / Trauma

Psychiatric emergencies in med-surg patients: Are you prepared?

Rodney, age 47, was admitted to the hospital 2 days ago with rib and femur fractures and facial contusions. He appears well nourished and well groomed. The previous shift’s report indicates he had a restless night, requested pain medications, and seemed anxious. His chart reveals a routine course with restlessness and anxiety throughout multiple shifts.

Halfway through your shift, you observe that Rodney is restless, is moving about in bed, and has hand tremors. When you walk into his room, he is frantically brushing the bedsheets with his hands and arms in sweeping motions. Despite a reasonably cool room temperature, he’s sweating profusely.

Toward the end of your shift, you find Rodney in a panic, trying to get out of bed. He complains of nausea and has vomited a small amount into an emesis basin. He is sobbing, and yells, “There are bugs all over the sheet!” He can’t stop shaking. You suspect he is in acute alcohol withdrawal and needs immediate intervention to manage his delirium tremens.

Psychiatric disorders and related problems are common in med-surg patients, and scenarios like this one occur every day in acute-care hospitals. One source estimates that in 2007, 46% of the U.S. population experienced such mental-health disorders as anxiety, impulse control, and substance abuse. In 2006, psychosis was the third-highest-volume diagnostic-related group (DRG). This DRG (430) includes major personality disorders, such as schizophrenia, catatonia, bipolar affective disorders, and paranoia.

People with psychosis or substance use disorders are at risk for the same health problems as any other population subset. What’s more, even patients without preexisting mental disorders may become anxious and apprehensive when hospitalized, which may alter their behavior. Consequently, aberrant social behaviors may increase in the hospital setting.

Bottom line: You don’t have to be a psych nurse to encounter patients experiencing psychiatric emergencies. That’s why all nurses should have a basic knowledge of psychiatric nursing, regardless of the setting they work in.


Identifying psychiatric emergencies

On med-surg units, common psychiatric problems include psycho­sis, substance abuse and withdrawal, delirium, anxiety, aggression, bipolar disorder, personality disorders, and suicidal behavior or ideation. To ensure appropriate intervention, these problems need to be identified early and their cause must be determined. (See Hallmarks of psychosis by clicking on the pdf icon above.)

Signs and symptoms of psychiatric problems cross over into many diagnostic categories. Nurses skilled in early assessment of these disorders are best prepared to intervene. During your assessment, seek corroboration from family members, look for a history of such problems in the patient’s medical record, or document the patient’s report that he or she has a known psychiatric disorder. Generally, psychiatric disorders are long-term problems with exacerbations and remissions. Knowing if your patient’s current psychotic symptoms are secondary to an ongoing psychiatric disorder can guide interventions.

Medication reconciliation can yield valuable clues. Has the patient been taking psychiatric medications routinely? If so, which ones? Did she recently stop taking such drugs? If so, when? Is she taking the prescribed dosage at the prescribed frequency? Some psychiatric medications can be dangerous if they build up to a toxic blood level; for example, toxic levels of lithium exceed 1.5 mEq/L. Finding out if the patient’s taking too much or too little of a prescribed medication can help the healthcare team stabilize the drug regimen as soon as possible.

If the patient has no known psychiatric disorder, continue to assess all aspects of the current situation to determine what might be causing the signs and symptoms. Alleviating the cause may resolve the problem. In other cases, short-term use of antipsychotic drugs can calm the patient and reduce agitation.

General goals of care

While each type of psychiatric emergency requires specific nursing interventions, these general care goals apply to all:

  • Assess the problem or potential problem early.
  • Maintain a safe environment.
  • Intervene appropriately using all available resources.
  • Ensure an appropriate follow-up plan, if needed.

Know that good communication and interpersonal skills are crucial when dealing with patients experiencing psychiatric emergencies. (See Key communication tips by clicking on the pdf icon above.)

Substance intoxication and withdrawal

As with Rodney in the opening scenario, substance intoxication or withdrawal can pose a psychiatric emergency. Intoxication with various substances can cause aggressive behavior. Especially during physical assessment, patients may believe you are going to harm them and may become combative or assaultive.

Acute alcohol withdrawal is common in med-surg patients and must be treated. But be aware that some patients aren’t truthful about their alcohol intake. Alcohol withdrawal may not occur for 24 to 72 hours after the last drink, so withdrawal symptoms may come as a surprise to caregivers a few days after a patient’s admission.

Alcohol withdrawal signs and symptoms include high blood pressure, tachycardia, fever, hand tremors, insomnia, nausea and vomiting, anxiety, generalized tonic-clonic seizures, and transient visual, tactile, or auditory hallucinations. Progression to delirium tremens includes disorientation, delusions, severe agitation, profuse perspiration, and fever. The most serious phase of alcohol withdrawal, delirium tremens has a mortality of 5% to 30%.

Intervention

Alcohol withdrawal symptoms can be managed fairly easily with immediate and consistent care. Early, continuous treatment promotes rapid stabilization. Benzodiaze­pines, such as chlordiazepoxide or lorazepam, routinely are given every 4 to 6 hours; patients receiving these drugs should be monitored closely.

A common, easy-to-administer tool for assessing alcohol withdrawal and guiding management is the Clinical Institute Withdrawal Assessment—Alcohol, Revised (CIWA-AR). It takes about 5 minutes to administer and yields a score indicating the severity of the patient’s withdrawal symptoms. To use it, the examiner asks specific questions or makes specific observations.
The primary care goal for patients in acute alcohol withdrawal is to promote safe withdrawal without injuries or medical complications. Nursing care includes:

  • monitoring vital signs
  • maintaining a quiet, calm environment
  • offering support and reassuring the patient he or she is safe
  • instituting fall precautions
  • addressing pain caused by medical-surgical conditions (and not withholding analgesia)
  • promoting good hygiene
  • monitoring food and fluid intake
  • encouraging supportive family members and others to stay at the bedside
  • promoting use of relaxation techniques, such as soft music, controlled breathing, and visualization.

Delirium

Many med-surg patients experience delirium secondary to stroke, intracranial tumors, trauma, surgical complications, fever, infection, heart failure, substance toxicity or withdrawal, sedative drugs, or excessive or deficient stimuli. Among the elderly, delirium is common with or without mental illness.

Whatever its cause, delirium may result in:

  • perceptual disturbances
  • disorientation
  • restlessness
  • reduced level of consciousness
  • disorganized thinking
  • decreased attention span
  • memory impairment
  • sleep disturbances.

Delirium resembles dementia to some extent. However, signs and symptoms of delirium tend to be labile (in some cases, unpredictably so) while those of dementia are less likely to fluctuate. (See Differentiating dementia and delirium by clicking on the pdf icon above.)

Intervention

The behavioral problems that can accompany delirium may interfere with routine nursing care, causing frustration for care providers. Also, patients with delirium may be unable to participate in their care.

Nursing actions should include providing structure, as routines are helpful to patients with disorganized thinking. Maintain an orderly environment, keeping items in the same place and within the patient’s view. Because of fluctuating signs and symptoms, finding the right time for certain interventions can promote a better outcome.

Be aware that you may have to repeat yourself when speaking to the patient. And sometimes you may need to back off and wait until the patient is calmer and more receptive. Also, finding distractions from the task at hand can be helpful if the patient is particularly disturbed or distraught by your interventions. Remember—if you don’t insist emphatically, the patient isn’t likely to resist. In light of the disorganized thinking caused by delirium, giving patients some space and options can help you gain their cooperation.

Violent behavior

Violent behavior may result from such problems as substance intoxication, disordered or paranoid thinking and beliefs, and anger. Violent patients are a threat to their own safety as well as that of staff members, other patients, and visitors.

Generally, violent outbursts don’t occur suddenly without warning. For example, agitated patients experience an inner tension that may manifest as hyperactivity and behavioral disorganization. So stay alert for violent tendencies. Trust your own judgment and tell others of your concerns.

Intervention

If a patient becomes violent, maintaining the safety of everyone involved—the patient, yourself, other staff members and patients, and anyone else in the immediate area—takes priority. Don’t approach the patient alone. Ask colleagues to remain nearby; no one should be isolated or left in a vulnerable space with a potentially violent patient.

Make sure you can’t be trapped away from an exit. Check the environment for dangerous objects. Stay out of the patient’s physical space while keeping the patient within view at all times.

Many hospitals have an emergency procedure for managing violent persons. Nursing staff must receive training on how and when to initiate this procedure. Enacting periodic mock scenarios helps prepare staff for a true emergency.

Staff members should use de-escalation techniques and crisis communication to avert aggressive behavior. (See Managing a psychiatric crisis.) All healthcare facilities should implement and provide staff education in violence de-escalation. Well-known programs include those from the Crisis Prevention Institute, Mandt System, and Pro-ACT. Some facilities have designed their own de-escalation programs.

Early identification of and interventions for violent behavior promote appropriate care planning and improve communication among team members, who can share their perception of what works and what doesn’t. For instance, staff members can alert each other to potential violence triggers.

Use of restraints

Violent patients who pose an immediate danger to themselves or others may need to be physically restrained for a brief period until they can gain self-control. How-ever, patient injuries and litigation risks associated with physical restraints are well documented, so restraints should be avoided when­ever possible. Use them only as a last resort for the shortest time needed and in the least restrictive manner possible—and only if you’ve been trained in the proper application technique. The restrained patient should be monitored closely and appropriate interventions followed. Several regulatory agencies, such as the Centers for Medicare & Medicaid Services and the Joint Commission, have established guidelines for restraint use. Most likely, your facility has a policy and procedure that comply with these guidelines. All nurses applying restraints need to be familiar with these.

Medications

Medications may be given to calm a violent patient and promote self-control. Work with the physician to identify the need for medication. Encourage the patient to accept the recommended drug, and administer it before the patient’s behavior escalates. Medications commonly used to reduce agitation include lorazepam (alone or in combination with haloperidol) and atypical antipsychotics, such as risperidone, olanzapine, and ziprasidone. These drugs are available orally; some can be given intramuscularly. Haloperidol (lactate form only) is available for I.V. use.

Suicidal patients

Some med-surg patients have suicidal thoughts or exhibit suicidal behavior. Patients may be hospitalized after a failed suicide attempt, such as an intentional drug overdose, hanging, or a nonfatal gunshot wound. Other med-surg patients may become suicidal when hospitalized for other reasons. A 2007 Patient Safety Goal of the Joint Commission was to identify patients with suicidal ideation. Although that goal applies mainly to patients being treated for mental illness in psychiatric settings, acute-care general hospitals can adopt it to assess for this potential problem.

Intervention

For a patient with known or suspected suicidal tendencies, take appropriate precautions. Med-surg units can pose a danger to such a patient; even psychiatric units aren’t completely safe. As a rule of thumb, assume no place is completely safe. Patients can hang or strangle themselves with sheets, towels, bedclothes, tubing, or cords. They may take large doses of drugs (legal or illegal) that they have brought with them or saved up. Also, sharp objects abound in hospitals, and even plastic cutlery can prove dangerous to those intent on harming themselves.

The best approach is to closely monitor the patient’s environment and behavior. Patients at high risk for suicidal behavior should receive one-on-one care. The staff member should stay within arm’s reach of the patient at all times and never leave, even for a break, until directly relieved by another staff member.

Special skill sets

If you work in a setting where many patients pose behavioral problems, consider obtaining further education in psychiatric problems and crisis management. For instance, emergency departments see more psychiatric emergencies than other hospital areas. Patients in intensive care units have a higher acuity and thus may require different approaches and interventions in psychiatric emergencies. If you work on a pediatric unit, you may require a specialized skill set to care for children and adolescents with psychiatric or emotional problems. A maternity nurse may encounter patients with severe postpartum psychiatric emergencies that call for interventions encompassing the mother, newborn, and family.

Psychiatric emergencies can occur in any healthcare setting—acute-care, hospice, long-term care, and outpatient clinics as well as psychiatric facilities. Nurses caring for patients from all walks of life with any type of healthcare problem can expect to encounter patients who are at risk for or are experiencing a psychiatric crisis. Make sure you have a fundamental understanding of psychiatric problems, including their identification and intervention.

Selected references

Allen M, Currier GW, Hughes DH, Reyes-Harde M, Docherty JP. The Expert Consensus Guidelines™: Treatment of Behavioral Emergencies. A Postgraduate Medicine Special Report. New York, NY: McGraw-Hill; 2001.

Fossett B, Nadler-Moodie M, Thobaben M. Psychiatric Principles and Applications for General Patient Care. 4th ed. Brockton, MA: Western Schools; 2004.

Gilbert SB. Psychiatric crash cart: Treatment strategies for the emergency department. Adv Emerg Nurs J. 2009;31(4):298-308.

Hermanns MS, Russell-Broaddus CA. “But I’m not a psych nurse!” RN. 2006;69(12):28-31.

Kerrison SA, Chapman R. What general emergency nurses want to know about mental health patients presenting to their emergency department. Accid Emerg Nurs. 2007;15:48-55.

Ramadan M. Managing psychiatric emergencies. Internet J Emerg Med. 2007;4(1). http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijem/vol4n1/psycho.xml. Accessed March 10, 2010.

Stokowski L. Alternatives to restraint and seclusion in mental health settings: Questions and answers from psychiatric nurse experts. Medscape Nurses. May 5, 2007. http://www.medscape.com/viewarticle/555686. Accessed March 10, 2010.

Sullivan JT, Sykora K, Sneiderman J, Naranjo CA, Sellars EM. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-AR). Brit J Addict. 1989;84:1353-1357. www3.interscience.wiley.com/journal/119445441/abstract. Accessed March 10, 2010.

Marlene Nadler-Moodie is a clinical nurse specialist in psychiatry and mental health nursing at Sharp Mesa Vista Hospital and Scripps Mercy Hospital in San Diego, California. The planners and author of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.

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