Psychiatric Emergencies & Nursing Action

Online Course #9225 / #1225 - 12 Contact Hours
©2008 National Center of Continuing Education, Inc.

For your convenience, this course has been divided into 5 sections:
Below is Part 4 of 5.
Table of Contents …Review Part 1 …Review Part 2 …Review Part 3 … Part 5 … Independent Analysis … Evaluation

You may print this course or save it to your hard drive if desired. You can return later to take your Independent Analysis and submit it for fast processing. Once you have submitted your Independent Analysis, you will see your results immediately. Your certificate will be mailed First Class after we receive your completed Independent Analysis Evaluation.
The "No Electronic Theft Act" makes it a felony to download copyrighted material over the Internet without permission. National Center of Continuing Education, Inc. grants permission for a single download of our on-line course(s) to your computer solely for the use of obtaining continuing education credits. Details on the copyright usage of our courses are specified at the end of this page.

Psychiatric Emergencies : Conditions that are Life-Disrupting - Anxiety

Anxiety is inherent in most nursing situations. People who are physically or emotionally ill are concerned about their biological and psychological safety. Anxiety stems from threats to security on both a conscious and subconscious level. Patients and families are faced with difficult adaptive tasks related to significant disruptions in living, illness, injury and death including:

1. Dealing with the discomfort, incapacitation and other symptoms of illness or injury.
2. Managing the stress of the emergency room, special treatments and the hospital or treatment environment.
3. Developing and maintaining adequate relationships with the physicians, nurses and other helpers. Needing to "trust them with lives."
4. Preserving a satisfactory self-image and maintaining a sense of competency and mastery - difficult when feeling weak and helpless.
5. Preserving a reasonable emotional balance of many disturbing feelings: anxiety, grief, uncertainty, guilt, shame, resentment, anger.
6. Preserving relationships with family and friends despite a changed role.
7. Preparing for an uncertain future where further loss or death, as well as recovery, is possible.

The problems just listed can all be highly anxiety provoking. Anxiety is the feeling of apprehension, tension and uneasiness that stems from the anticipation of danger from some unknown source. It is similar to fear in the physiological reactions it elicits. In fear, the threat is known and external. Anxiety is considered to be primarily of intrapsychic origin. Anxiety is ubiquitous, common to everyone. It becomes pathological when it is present to the extent that it interferes with reasonable emotional comfort, effectiveness in living and the achievement of goals.
Anxiety becomes a psychiatric emergency when a person is experiencing extreme anxiety or panic. In this condition, the person feels overwhelmed with acute, intense feelings and physiological reactions. Panic often is accompanied by other feelings and behaviors, such as depression, agitation, anger, somatic complaints, and confusion. With panic, there is personality disorganization, perceptual distortion and impaired cognitive function. The person seems "scared to death."
The extreme of panic is called psychotic terror. People suffering in this state are frightened, easily startled and highly disorganized in thinking. They may be hallucinating and delusional, especially with paranoid content. The psychotic state may stem from psychological factors or from organic etiology, especially in reaction to drugs such as hallucinogens.
Panic attacks may occur while a person is already being treated for physical or emotional reasons. They may be part of the extremely stressful present and uncertain future. Medications may interact to produce states of high anxiety and confusion. Individuals may seek treatment through an emergency room, crisis center or outpatient department because of extreme anxiety and fear of recurrent panic attacks.
Panic behavior may be life-threatening if the individual attacks others or runs "amok," crashing into walls, running into traffic or jumping out of a window. Immediate action must be taken to control, contain and protect the patient and others. More often, however, the patient's behavior affords time to do a physical examination and initial history assessment.
There are many medical conditions that present with prominent features of anxiety. Some of these are angina pectoris; aspirin intolerance; alcohol, barbiturate and other drug withdrawal; caffeinism; cerebral arteriosclerosis; epilepsy, especially psychomotor and temporal lobe types; hypoglycemia; hyperinsulinism; internal hemorrhage; post-concussion syndrome; obstructive pulmonary disease; asthma; paroxysmal tachyarrhythmias; thyrotoxicosis; hyperthyroidism; and drug-induced psychosis resulting from ingestion of cocaine, amphetamine, or PCP. The appropriate treatment will depend on the specific cause and course. It is important to maintain a calm attitude in talking with and treating a highly anxious person.

The Continuum of Anxiety
Anxiety ranges on a continuum from mild, moderate, severe, to panic. A person may move up or down the continuum. A goal in most care is to help the patient to reduce anxiety to manageable proportions.
With mild anxiety the senses are sharpened so that learning is enhanced and the person is more vigilant. With moderate anxiety, the person has a narrowed perceptual field - seeing, hearing and grasping less. Considerable discomfort is experienced, and there is a blurring of reality as the person distorts cues. The person experiences interference with learning.
Severe anxiety describes the state of the person about to panic. Such individuals seem oblivious to the world around them and temporarily become primitive, tortured and incapacitated human beings. Extreme hyperactivity or complete immobility can be signs of overwhelming anxiety. Some of the behaviors observed in severe anxiety are disorientation to time, place or person; memory loss; decreased ability to attend and respond to surroundings; emotional lability, with episodes of crying, screaming, or laughing; agitation and hyperactivity; incoherence and confusion; hallucinations; delusional thoughts and verbalizations; verbal and physical aggression; reaching out for help by crying, begging, or touching; and rapid, pressured speech or uncharacteristic silence. All these can indicate that the person is in great mental anguish. Specific signs and symptoms of anxiety are listed in Figure 5.

Signs & Symptoms of Anxiety

Physiological Changes

• Increased heart rate, blood pressure and respiration; tremor; increased perspiration; cold, clammy hands and feet; need to urinate or defecate; loss of appetite; sleeplessness or disturbed sleep pattern; muscle tenseness; disturbances of the endocrine, autonomic nervous and circulatory systems.

Behavioral Characteristics

• Facial expressions: raised forehead and eyebrows, wide open eyes with fixed stare, pupils dilated, blanched complexion, sweat, trembling lips and chin, licking of lips
• Body stance: ready for fight or flight, trembling, rigid, guarded posture and gestures, holding on to self, restless hands and feet
• Speech: trembling, halting, rapid, high or low pitched, repetitive rambling, disjointed, muteness, screaming, crying, swearing, excessively controlled, pressured laughter
• Action: random, purposeless activity; excessive smoking, eating or drinking; use of drugs; mechanical quality to routine activity

Subjective Reactions

• "I am . . . afraid, anxious, nervous, timid, apprehensive, terrified, panicked."
• "I feel like . . . running, going to pieces, hiding, crying, exploding, cracking up, screaming, falling apart."
• "I feel like I did when . . . I had terrible nightmares, had my appendix out, my parents were killed in an accident, I flunked my final."
• "I've got . . . butterflies in my stomach, jelly legs, ice water in my veins, cold feet, hair standing on end, goose pimples."

Mental Changes

• Difficulty thinking, concentrating, learning new things; distortion of perceptions; preoccupation with self, body processes and dreaded thoughts

Nursing Action in Helping Highly Anxious Patients
Nurses intervene with patients experiencing significant amounts of anxiety. They are cognizant of the common factors in medical settings which may precipitate anxiety: admission to a unit, strangeness of the routine, difficulty maintaining a sense of identity, confronting relatives, laboratory studies and treatments, fear of the diagnosis, prognosis and treatment, and death of a loved one.
Anxiety can be lessened by sharing. However, it is also contagious. When an acutely anxious patient comes onto a unit, nursing staff must be aware of the increase in anxiety in themselves as well as the other patients. Nursing intervention in anxiety has four aspects:

1. Recognition that the patient is anxious through physiologic, emotional and behavioral cues
2. Encouragement verbally to recognize and express feelings
3. Exploration of the thoughts and circumstances that led to the anxiety
4. Coping with what is now an identified specific threat

These steps are all part of crisis intervention and enable the person to cope adequately with the precipitating causes of the anxiety.
Nurses help patients with anxiety before the anxiety reaches panic proportions. They are alert to the subjective and objective indications of anxiety. They do the following things to help diminish the terror:

1. Stay with the person and maintain a sense of calmness in voice tone, actions and words. Establish and maintain eye contact. Speak slowly and clearly, and use short, uncomplicated sentences.
2. If necessary, remove the person from the stressful situation to a quiet, undisturbed place.
3. Use touch if it seems appropriate and helpful - holding the person's hand or putting an arm around the shoulder. This is particularly indicated if the patient is a child. Give something to drink - water or something warm.
4. If the patient is disoriented, tell him/her repeatedly that he/she is in a hospital and that he/she will be getting help. Use direct reassurance.
5. If the patient is hyperventilating, help regulate breathing.
   a. Verbally instruct the person to change breathing patterns; to slow down and take deeper breaths
   b. Standing close to the person, breathe along with him and instruct him to follow your pace as you gradually decrease it.
   c. Instruct the person, "That's enough. You're getting yourself more upset. Open your eyes and look at me."
6. If patients show by behavior that they are anxious but deny it verbally, give feedback to help integrate the physical and emotional self. Some examples are:
    "You say you don't feel upset. You look frightened to me."
    "You're very restless. I wonder if something isn't bothering you after all."
    "Most people are apprehensive the night before surgery. Maybe you're more worried than you think."

Psychiatric Emergencies: Conditions that Impair Functioning - Organic Brain Syndromes

The conditions that make up this group of psychiatric emergencies have mixed psychological and physical components. They are the result of organic brain dysfunction which may present as confusion, memory disturbance, disorientation, altered levels of consciousness, motor difficulties such as poor balance or incoordination, decreased impulse control, impaired judgment, and disturbances of physiological functioning which could lead to death. These states may stem from alcohol or drug overdose, withdrawal, or toxic or idiosyncratic reactions; or they may be due to brain dysfunction from trauma, vascular infections, disturbances in metabolic functioning, or neoplasms of the central nervous system.
These and a wide variety of other medical conditions may present with similar symptom profiles. It is essential to have a thorough physical examination to rule out pneumonia, thyroid imbalance, diabetes and other general medical conditions that can affect brain function.

Alcohol Related Problems
Alcohol is the most abused drug in the United States. Two of the most common medical problems are found among persons who abuse alcohol - acute intoxication and withdrawal from continued use. These conditions are considered both psychiatric and medical emergencies because if left untreated, they could lead to the death or injury of the person or others due to the impaired behavior resulting from the alcohol. A high percentage of fatal accidents occur with a driver of a motor vehicle under the influence of alcohol. The risk of suicide and homicide increases significantly when alcohol is used.
Acute alcohol intoxication: An uncomplicated picture of an acutely intoxicated person includes alcohol odor, unsteady gait, slurred speech, and sometimes nausea, dizziness and vomiting. Giddiness and uninhibited speech and behavior are common. This person usually needs only to be protected, prevented from drinking more, escorted home or to an overnight facility to "sleep it off," and observed in case of other complications.
More serious degrees of alcohol intoxication are suggested by central nervous system disturbances such as incoordination, dysequilibrium and impaired level of consciousness. Behavioral warning symptoms include excessive crying, laughing, hostility, aggressive behavior, depression and seizures. Medical evaluation and treatment are indicated.
In addition to the physical examination and monitoring of vital signs, the following questions help in the evaluation of an acutely intoxicated person. The individual or other informants may be able to give the answers, which must always be regarded with some degree of skepticism.

1. How long has the person been drinking? What? How much? When was the last drink?
2. What is the drinking history over a period of time? Treatment?
3. Previous seizures?
4. Delirium tremens? Hallucinations?
5. Has the person taken Antabuse within the past five days?
6. Any other drugs recently or concomitantly with the alcohol?
7. What other physical conditions are known - ulcer, diabetes, heart condition, etc.?
8. Have any other injuries or accidents occurred during the drinking bout - falling down, struck by another person or object?
9. Is there a history suggesting significant psychiatric disorder?

The very young, the elderly, and people with organic brain damage are unusually susceptible to alcohol. Alcohol taken with other drugs may produce disorientation to time, place and person. This may produce panic, which should be treated by a calm attitude and protection until time helps to wear off the effects. A person who is combative or assaultive while drunk may be suffering from other underlying conditions. He/she may have ingested drugs, especially the hallucinogens or stimulants. Gross disturbance, belligerence and confusion can result.
Many people use alcohol as self-medication. If it is being used to ward off a psychotic state, this becomes more apparent as the acute intoxication subsides. Alcohol lowers defenses and inhibitions and can result in rage reactions, suicidal behavior and agitation. Many interpersonal confrontations take place during drinking with assault and violence the outcome. Spouse and child abuse are often linked with alcohol intoxication.
Those who become significantly depressed while drinking need to be evaluated for the degree of intoxication and for suicide potential. Driving a motor vehicle while intoxicated may result in planned or unintentional accidents and death.
A seizure in an intoxicated person may indicate the beginning of delirium tremens or an underlying seizure disorder. Some people with temporal lobe epilepsy are unusually sensitive to alcohol. The seizure often takes the form of an unprovoked rage reaction that results in fights or assaults on property.

Emergency management of the patient with acute alcohol intoxication: The health team works together to help the patient during the acute medical situation. His/her situation may be compounded by behavior that is uncooperative, aggressive, abusive or demanding. It is important during this period not to take this behavior personally or to react with retaliation. As with any person with an acute brain syndrome, the person is "not in his right mind." Action includes:

• Approach with a non­judgmental attitude of helpfulness, firmness and consistency
• Don't be intimidated or antagonized by belligerence, hostility or uncooperativeness
• Speak calmly, firmly with reassurance
• Don't laugh, ridicule or challenge
• Use safety precautions and enough staff with a potentially assaultive person
• Maintain observation and check vital signs frequently
• Keep a patent airway - remove foreign objects from mouth and throat, such as mucous, blood, vomit, dentures
• Draw blood for alcohol and drug level determination if indicated
• Examine for injuries and other physical conditions
• Sedate the restless, noisy, belligerent
• Allow the person to "sleep it off" while under observation
• Hospitalize if indicated
• When the patient is conscious, offer fluids by mouth, especially fruit juices
• After acute treatment, refer to longer-term treatment resources.

Alcohol withdrawal states: Those who are physically dependent on alcohol develop characteristic withdrawal symptoms within 12-24 hours after the blood alcohol begins to drop. The person may have stopped drinking or have lessened the usual amount of intake. Withdrawal symptoms range from relatively mild, though miserable, to reactions that are severe and life threatening. Delirium tremens (D.T.'s) is the most extreme withdrawal reaction, with a death rate that has been estimated from 5-30%.
Planned withdrawal from alcohol occurs when individuals gradually or abruptly decrease alcohol intake. They may or may not seek medical attention with the subsequent reactions. Planned withdrawal is also called detoxification. Many communities offer both medical and non-medical options to help with safe withdrawal.
Unplanned withdrawal occurs when an addicted person is suddenly cut off from alcohol through lack of funds, lack of supply or through the decision to quit abruptly. Patients who are hospitalized for medical conditions or accidents may develop withdrawal symptoms while being treated. This may drastically affect their recovery.
Signs and symptoms of acute withdrawal may include "the shakes:" coarse tremor of hands, tongue and eyelids that is more apparent with movement; anorexia, nausea and vomiting; malaise and weakness; anxiety, sense of dread and shakiness, uneasiness, jumpiness; autonomic hyperactivity - tachycardia, sweating, increased blood pressure; depressed mood; irritability; insomnia or disturbed sleep with bad dreams; orthostatic hypotension and dizziness; and distortions in visual perceptions. These symptoms generally begin about 24 hours after the onset of abstinence and reach their peak in another 24 hours, although they may occur at any time within the next fifteen days.
Moderate to severe withdrawal syndromes in otherwise healthy individuals can be handled on an outpatient basis through supportive measures that include bed rest, adequate fluids, adequate vitamins and nutrition, continued abstinence from alcohol and planned short-term use of minor tranquilizers (Librium, Valium, Vistaril).

The medical and psychiatric crisis aspects of withdrawal indicate hospitalization when:

1. The person wants to quit drinking but has a poor social support system. There is no one to help or there are active drinkers who would discourage the effort to quit.
2. There is a history of previous severe reaction to withdrawal and the person fears return of the D.T.'s or other frightening symptoms.
3. The person has already started to withdraw with symptoms of anxiety, seizures, extreme agitation, hallucinations or delusions.
4. The person is physically debilitated or has an alcohol related condition, such as cirrhosis, peripheral neuropathy or pneumonia. Wernicke's syndrome from thiamine deficiency requires immediate treatment to prevent permanent brain damage. (In many settings, it is routine to administer at least one dose of thiamine IV or IM to all alcoholic patients admitted to the hospital with altered mental status.)

Alcohol withdrawal delirium: This condition is generally known as delirium tremens or the D.T.'s, an acute brain syndrome that is usually due to the cessation or reduction of alcohol consumption in an addicted person. It occurs most often in those with a history of heavy drinking over a 3 to 5 year period or longer. Delirium tremens is a medical emergency. It is a serious and dangerous reaction characterized by autonomic hyperactivity, seizures, agitated behavior with restlessness and overtalkativeness, coarse tremor, confusion and disorientation, delusions, and hallucinations - most often visual and tactile and often terrifying.
Symptoms often get worse at night. D.T.'s result from a disturbed metabolic state. They require adequate medical treatment and skilled nursing care. Successful recovery occurs within 3 to 10 days. After a period of prolonged sleep, the patient wakes refreshed, oriented and free of hallucinations. Alcohol-withdrawal delirium is often precipitated by abrupt alcohol withdrawal due to trauma or infection. The patient may be in the hospital for these reasons when the withdrawal syndrome begins. Chronic alcohol abusers are poor surgical risks because of lowered resistance and organ damage. They have a poor response to anesthesia. If excessive use of alcohol is known, the metabolic balance of the patient can be evaluated before surgery. Often, the impending D.T.'s are not recognized until postoperatively, which gravely affects recovery.

Nursing action in treatment of delirium tremens: The problem of this disorder is the acute medical syndrome with subsequent behavioral manifestations, including agitation, combativeness, terror and disorientation.
The goals of treatment are to control the delirium, lessen agitation, restore fluid and electrolyte balance, and control seizures. A combined medical and nursing approach is necessary to control the terror of the delirium and to restore health.

Actions:

• Provide a well-lit room with few external stimuli.
• Reassure and reorient repeatedly.
• Limit the number of staff and visitors.
• Protect the patient from self-injury or acting on the delusions or hallucinations by getting out of bed, running through windows, etc.
• Speak in a calm, soothing voice.
• Use mechanical restraints only when absolutely necessary as the patient may fight against them.
• Administer prescribed medication to decrease agitation - Vistaril, Thorazine, Librium, Valium, paraldehyde and chloral hydrate may be prescribed, depending on the medical regimen. The goal is to provide rest and sleep, without inducing coma or stupor.
• Administer and record appropriate intravenous fluids with necessary vitamins and minerals added.
• Prevent or treat seizures by administering appropriate anticonvulsant medication.

When the patient has recovered from this acute emergency situation, many treatment teams make concerted efforts to arrange for longer-term treatment of the alcoholism and other problems. Some patients are motivated and able to follow through. Others return to treatment units in desperate condition again and again. This can lead to discouragement and cynicism among the staff if their feelings and the dynamics of this difficult condition are not reviewed and discussed.

Drug Abuse Related Problems
Drugs, other than alcohol, are also often the cause of psychiatric and medical emergencies. The most frequent drugs of abuse include:

1. The opiates - opium, morphine, heroin, codeine, Dilaudid, paregoric, methadone, Demerol and Darvon.
2. Central nervous system depressants - the barbiturates and similarly acting drugs (other than alcohol), bromides, anesthetic gases and vapors, chloral hydrate, paraldehyde, methaqualone, Placidyl, Miltown, Equanil, Valium and Librium.
3. Central nervous system stimulants - cocaine, amphetamines and similarly acting substances, dextroamphetamines, methamphetamine (speed), Ritalin, Adderal, and many combinations of "diet pills."

The main problems arising from use of these substances are 1) acute intoxication, which is also referred to as overdosing or poisoning, planned or unintentional; and 2) withdrawal symptoms on cessation of the drug-taking.

Acute intoxication or overdose: This is the result of sufficient intake of the drug to produce signs and symptoms of distress. An organic brain syndrome occurs, which ranges from moderate to severe. The acute organic brain syndrome may be characterized by disorientation; impairment of memory, judgment, and intellectual function; emotional lability; decreased coordination; dysarthria (slurred speech); fine tremor; and unsteadiness of balance and gait.
The first step when an overdose is suspected is to assess the seriousness of the potential emergency. A person may overdose on drugs as a suicide attempt, through mistakes in self-medication, through confusion because drug potency is increased or by a combination of drugs and alcohol. The range of seriousness is:

1. Life-threatening - immediate medical care is needed to prevent death
2. Serious - requires hospitalization for treatment and further evaluation
3. Potentially serious but not requiring hospitalization
4. Not immediately dangerous but requiring evaluation and possible referral

The serious complications of acute drug intoxication are coma, respiratory failure and circulatory collapse. Every case of drug overdose is regarded as potentially serious until medical attention is given. The patient's physical condition can shift rapidly to a more life-threatening level.
People found unconscious from drug overdose must be taken immediately to an emergency room. Mouth-to-mouth resuscitation, oxygen and other life support systems may be necessary en route. Specific treatment for the drug overdose will vary with the substance and the physiological response. At this point, the emergency is a medical one.
Part of the evaluation is a drug history, either from the person, if possible, or those who know him/her. This includes specific drug taken, how much, whether and when physician prescribed; use of street drugs; medical history, especially of diabetes and seizure disorders; concomitant use of alcohol; known drug use; and previous overdoses and outcomes. During the medical history and evaluation it is important for the nurse to establish if the patient has ever used intravenous drugs. In consideration of community health problems and the rapid spread of disease, many psychiatric emergency facilities are screening patients for AIDS virus and hepatitis C. It is important for the patient's safety and proper treatment as well as for the safety of the health care workers and other patients.
After the person has been adequately treated medically, he/she should be evaluated in terms of emotional state. If the overdose was suicidal in intent, the person should be evaluated further for suicide risk. Referral to special drug facilities or mental health facilities is indicated but may or may not be acted upon.

Withdrawal from drugs: An abstinence or withdrawal syndrome occurs after cessation of taking a drug to which one has become addicted. The symptoms vary with the specific drug, as does the treatment. At this point the primary concern and treatment are medical.
Withdrawal treatment for barbiturates should take place within a hospital because of the difficulties in reducing the amount of medication needed, the likelihood of seizures and the period of transient psychosis which is marked by confusion, disorientation, agitation and hallucinations. Nurses provide highly skilled care during this time, using physical skills as well as basic care for disturbed persons with the above behavior.
The term "bad trip" was coined several decades ago to describe a negative outcome of drug intake that still can occur today. Instead of the anticipated pleasant experience, there is a state of unpleasant-to-horrifying perceptions and feelings. Panic and confusion predominate. The person may develop a toxic psychosis with agitation, hallucinations, and delusions. This may be precipitated by one of the central nervous system stimulants or by a hallucinogen.
Amphetamines are in the former category and hallucinogens include mescaline, psilocybin, D-lysergic acid diethylamide (LSD), STP, phencyclidine (PCP), marijuana and hashish. PCP is a particularly powerful agent that can produce extreme agitation or a state resembling a catatonic reaction. Many times treatment within a hospital will be necessary because of the severity of the symptoms and the unpredictability of the person's actions. Anticholinergic drugs include the active agents of atropine and scopolamine. These are easily obtained as nonprescription drugs, often for sleep problems.
These drugs are taken for the experiences they produce and are marked by perceptual changes. Body, time and reality distortions become a problem if the person loses the perspective that these are drug-induced and develops a panic reaction. Psychosis may result, and this is when the experience becomes a psychiatric emergency. Symptoms include increased paranoid ideation which results in terror and potential aggression; fear of going crazy; and impaired judgment, resulting in injuries from such behaviors as running into traffic or believing one can fly out the window.
The need for treatment of these reactions depends on the severity. Many of them are time-related. As the drug wears off, so do the disturbing experiences. If medication is needed, it will probably be Valium by mouth or injection. Use of barbiturates and phenothiazines (Thorazine) is contraindicated. This is true also if the drug reaction is from an anticholinergic agent. Acute reactions may be treated by quiet, supportive talking with the panicked person. Drug-experienced friends and counselors can be very helpful during this time to "talk the person down." Helpful steps include the following.

• Find a quiet place where external stimuli are minimal. If in the E.R. find a place away from the mainstream.
• Do not leave the person in isolation or in a potentially unsafe place.
• Establish eye contact, and use a calm, gentle attitude and voice.
• Remind the patient that the experiences are drug-induced and will wear off. Repeat and reassure over and over and over.
• Reorient to time, place and person.
• Stay in the immediate "now."
• Instruct the person to keep eyes open and focus on external reality - an object or candle.
• Keep friends and other drug-experienced people around.
• Gently hold or touch the person if this doesn't seem threatening.
• Encourage the person to talk about the immediate sensations and experiences to decrease the sense of alienation.
• Explain reasons for medication, if needed, especially by injection.

Problems and Goals
The initial and most pressing problems associated with substance abuse are the physical results of the organic brain syndrome. The physical problems include intoxication, withdrawal and undesired responses to the drugs, and the basic cause(s) of the brain pathophysiology whatever that cause may be. Physical complications may include respiratory depression, cardiovascular collapse, shock, temperature dyscontrol, renal problems, and seizures.

The short-term treatment goals are:

1. Restore physiological equilibrium by careful detoxification and withdrawal; prevent further medical complication, treat current conditions
2. Restore impulse control
3. Prevent suicide or violent behavior
4. Establish communication
5. Increase reality testing
6. Develop plans for long-term treatment
7. Establish working relationships with family and significant others
8. Dehydration to fluid overload
9. Changed electrolyte balances

Emergency medical treatment can save lives, but does not solve the problem of drug and alcohol abuse and addiction. To help prevent future emergencies and possible death by substance abuse, the following long-term goals are identified:

1. Recognition by the person of the significance and dangers of continued substance abuse
2. Improved health - abstinence or decreased use
3. Increased social participation and meaningful relations with others
4. Discontinuance of criminal behavior
5. Improvement of family relationships
6. Increased use of job potential and skills
7. Alternative ways of coping with stress and needs

 
Nurses are active participants in the emergency treatment given in the emergency room, intensive care unit and medical floor. They are also involved in special drug-treatment clinics, methadone programs and community mental health programs that help the person with the very complex problems of substance abuse.

Cerebral Dysfunction from Other Causes
As noted above, the presenting symptoms of brain trauma, bacterial and viral infections, metabolic problems, brain tumors, epilepsy, and a host of other medical conditions can be very similar to those resulting from alcohol and drug use. Consequently, it is imperative that anyone presenting with cognitive or behavioral disturbances be given a thorough examination as soon as possible, which includes a detailed history and lab tests. These patients may exhibit behavior that is disruptive, combative, uncooperative and disoriented. General nursing actions can be used to handle the immediate situation and assist in the differential diagnosis.
Often family members are highly distressed about the changes in their loved one, and they need support and realistic reassurance. They may also be helpful in supplying needed information and in staying with and comforting the patient.

Traumatic Brain Injury
Traumatic brain injury is one of the "organic" group of psychiatric disorders, in that the physiological changes that cause it are clear and relatively well understood. It is frequently seen in medical offices and clinics as well as in the emergency department setting, and it has been frequently misdiagnosed. When dealing with a psychiatric emergency, the nurse must be knowledgeable and skillful in identification and evaluation of this group. Virtually any trauma to the head can potentially result in a traumatic brain injury and affect the function of the brain.
How many times have you taken care of patients who come to an emergency room after having been in an auto accident? The patient is examined and there is no visible sign or symptom of trauma. Although the patient may complain of pain, dizziness or confusion, everything appears normal on physical examination and the patient is sent home. Cognitive or behavioral changes, especially if mild, are commonly attributed to the psychological effects of the accident, and the staff, family and friends may even suspect that the patient is faking it to get attention or for law suit purposes.
Days or even weeks later the patient has experienced disturbed sleep patterns and starts to develop behaviors that could be considered disturbed: confusion, irritability, and poor impulse control. He may even be hostile and aggressive, posing a danger to self and to others. The initial injury may not be recalled or reported, especially if it was dismissed as inconsequential by medical personnel at the time. Is this a bipolar disorder? Is the patient experiencing a schizophrenic episode? What does the psychiatrist say? What does the neurologist say? All too often the patient is diagnosed with a psychiatric illness, and inappropriate treatments, if any, are offered.
Traumatic brain injury and related syndromes are complicated conditions that often are considered a gray area of psychiatry, medicine, neurology, nursing and law practice. It is the unfortunate patient who is incorrectly diagnosed. A vicious cycle develops. If the patient does not respond to the psychiatric medications, the physician or psychiatrist may increase the dosages. As the need for increased medication continues, the patient is looked upon as severely psychiatrically disabled; when, in fact, the true etiology is neurological trauma and requires an entirely different approach to patient care. Just imagine the increasing frustration of the patient. All of a sudden, he has become a mentally disabled individual.
In many cases of head trauma, there are no concrete lab and/or x-ray findings. Even structural and space occupying lesions such as subdural or epidural hematomas and brain contusions may not show up immediately after the injury, but develop relatively slowly over time. The more common injuries, especially those resulting from motor vehicle accidents, involve damage to the axons of individual nerve cells as the brain twists and turns on its axis and bounces against the surface of the skull from the forces of the impact. These may be accompanied by tiny punctate hemorrhages of the surrounding capillaries which are similarly stretched and torn, but otherwise remain invisible to neuroimaging techniques. Swelling may also add to the problem. Recovery of cognitive functions may take months to years, and is based on healing of injured brain tissue as well as compensation through use of alternative neural pathways.
Appropriate rehabilitation and consultation can be of significant benefit to the patient throughout this recovery process. Misdiagnosis may deprive the patient of needed treatment, while prescription of unneeded psychotropic medications may complicate the underlying neurological problem. Head trauma patients who present a psychiatric emergency need to be treated for the immediate behaviors they exhibit. After the psychiatric emergency is dealt with, an in-depth and on-going evaluation must take place. The nurse can help to discover the etiology of the present problem by making an accurate and comprehensive on-going nursing assessment, with careful evaluation of the effectiveness of the interventions made.

Medications in Psychiatric Emergencies

In many psychiatric emergencies, use of psychotropic medication plays an important part in de-escalating the immediate situation. It is prescribed most often for the target symptoms of acute agitation, excitement, moderate-to-severe anxiety, hostility and ideas of persecution.
The severity of the symptoms is evaluated by the degree of ­psychomotor disturbance, whether extreme agitation or extreme retardation; presence of extreme conceptual disorganization or psychosis; marked symptoms of anxiety; or history of protracted sleep disturbances. Often in an acutely disturbed person, these symptoms are all present. The decision to use medication depends on both the severity of the symptoms and the person's response to the interview situation.
Medication may be necessary before the situation can be assessed in depth if the person is too agitated to talk or respond. In that case, in order to rule out organic factors, the person should have a brief medical examination during which vital signs are taken and information about medical history and drug ingestion is ascertained. In the very rare case, this examination is not possible and immediate medication is required. This is generally given by IM, IV or by rapid sedation.
With a less drastic situation, medication is postponed while assessment takes place. If the person is able to respond to the interviewer and generally calms down, only oral medication may be needed if any at all. For some people, the very act of receiving a pill or shot reassures them that something is being done, and impulse control may be strengthened.
Medication may be part of the time-limited period of crisis intervention or part of the long-term treatment. It may be administered on an inpatient or outpatient basis. For outpatient treatment, the patient must be able to cooperate with the regimen as the dosage is adjusted. Depressed people on antidepressants must be in good enough control so that they will not act on suicidal impulses before the medication becomes effective. It typically takes up to two weeks or more for the desired antidepressant effects to occur, although the patient may notice some earlier improvement in depression-related cognitive difficulties such as poor concentration. Furthermore, medication should never be prescribed in amounts that would constitute a lethal dose. It is better for the individual to keep close contact, daily if needed, with the clinic to renew the prescription. In addition to the safety factor, this also provides the necessary human lifeline to move the intervention plan forward.
Acute treatment of agitated patients has traditionally consisted of a combination of typical antipsychotics and benzodiazepines, usually administered IM. An 8 to 10 mg dose of haloperidol (Haldol) is generally effective in reducing acute symptoms, but higher doses only result in increased adverse effects. Benzodiazepines are effective in controlling acute agitation also, and are better tolerated than the typical antipsychotics. IM lorazepam (Ativan) acts as quickly and as effectively as IM haloperidol in most instances, and oral lorazepam acts much more quickly than oral haloperidol. Recent studies have shown that lorazepam with risperidone (Risperdal) is generally equivalent to lorazepam with IM haloperidol in controlling acute agitation; given the greater tolerability of risperidone, this combination may become the treatment of choice.
A number of medications have been shown effective in control and treatment of aggression in a variety of psychiatric conditions. Clozapine (Clozaril) has been demonstrated to decrease substantially the need for restraints and seclusion of aggressive psychotic patients in hospital settings; however, potentially serious side effects include seizures and agranulocytosis. Risperidone has been demonstrated to be more effective in reducing hostility among schizophrenic patients than haloperidol, and it is also effective in reducing aggression in patients with dementia and mental retardation. Olanzapine (Zyprexa) and quetiapine (Seroquel) have alleviated hostility and aggression in psychotic patients as well. Mood stabilizers have also been tried. Lithium has been reported to reduce anger and aggression, but has also been reported to increase aggression. Divalproex (Depakote) has been shown to be a safer alternative to lithium among most patient groups, and has been used to control aggression successfully in patients with neurological illness across a wide age range.
Impulsive behaviors are seen in many psychiatric emergencies. Impulsivity is a tendency to participate in spur of the moment behavior that has a high probability of negative outcome. It is associated with higher rates of aggression, suicide, and substance abuse as well as being a component of many psychiatric disorders. Many classes of medications have been used to treat impulsivity. Among these are the antidepressants, typical and atypical antipsychotics, beta blockers, lithium, and anticonvulsants.
Benzodiazepines are generally contraindicated, as they can have a disinhibitory effect similar to that of alcohol, which may actually increase impulsivity. Also, they present a potential for addiction in a population that may already be at risk for substance abuse. Among the antidepressants, MAO inhibitors are infrequently used due to their problematic safety profile. The tricyclic antidepressants may increase irritability due to their stimulation of the norepinephrine system. Selective serotonin reuptake inhibitors have been used with some success.
Among the beta blockers, propranolol (Inderal) has been used to control impulsivity and agitation, but use must be monitored carefully for potentially dangerous effects on cardiovascular function. Both carbamazepine (Tegretol) and divalproex have been used effectively, with divalproex often chosen due to its relatively benign side effect profile.
Many psychiatric drugs interact with other drugs to increase or decrease their action. The nurse should interview the patient and/or his or her family and establish data regarding the current medications the patient is taking, both prescription and non-prescription. Of particular concern are interactions with anti-diabetic medications, cardiac and respiratory medications, and anti-seizure medications.
Some psychiatric drugs can cause life-threatening side effects. Perhaps the most serious of these is neuroleptic malignant syndrome, a rare but potentially fatal idiosyncratic reaction that occurs in about 0.2% of patients on antipsychotic drugs. The syndrome can develop at any time, but onset is usually within the first thirty days of therapy. It is characterized by very high fever, change in mental status, labile blood pressure, and increased pulse rate. Mortality rates range from 5 to 20%. Treatment includes discontinuation of the antipsychotic medication immediately; and provision of supportive therapy including IV hydration and cooling blankets, and monitoring of ventilation.
More common side effects include extrapyramidal manifestations such as apathy, akathisia, postural hypotension, muscle rigidity, shuffling gait, tremors, gesticulatory movements of the face and mouth, drooling, difficulty swallowing, and swollen tongue. These side effects need to be monitored carefully, not only because they influence many patients to quit taking the medication, but also because a number of them can continue after cessation of the medication.
The nurse should evaluate nutrition and fluid balance of the patient, even in psychiatric emergency situations. Many patients who present themselves in a psychiatric emergency have a long history of psychiatric treatment and may be on psychiatric drugs at the time of their admission. Effectiveness of the psychiatric emergency drug administered may depend on these factors, as well as the patient's overall physical condition.
It is important for the nurse to know if the patient is taking medication at the time of admission for a psychiatric emergency and to evaluate lab values, since many psychiatric drugs have a narrow range of therapeutic levels (Lithium, Dilantin, etc.). Some patients may come to the psychiatric emergency room exhibiting behavior that is the direct result of over- or under-medication.
It is important for the nurse to become familiar with each of the drugs currently available to treat psychiatric emergencies. However, there has been an explosion in recent years in the number of new drugs available as well as new uses for older medications. If you are not familiar with a particular drug or indications for its use, refer to the Physician's Desk Reference, telephone the hospital pharmacy, or ask a physician or nurse who is immediately available. The information on psychiatric pharmacology is too extensive to be covered in detail here. If the nurse is to become a safe practitioner in psychiatric emergency care, she or he must develop a comprehensive understanding of psychiatric pharmacology. Many continuing education classes, lectures, seminars and medical manuals are available to assist.

You have Finished Part 4 of 5. Click on Part 5 to continue.

Table of Contents …Review Part 1 …Review Part 2 …Review Part 3 … Part 5 … Independent Analysis … Evaluation