Psychiatric Emergencies & Nursing Action

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

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Environmental Interventions in Psychiatric Emergencies

There have been many changes over the last ten years in the facilities and resources available for treatment of patients with acute psychiatric problems. As mentioned, emergency rooms and designated crisis clinics have become both screening and treatment centers. General hospitals have developed psychiatric units or integrated admissions to medical units. The trend in most inpatient psychiatric units is short-term treatment based on the crisis intervention model.
Communities have developed a variety of other resources, which include residential programs as alternatives to hospitalization, halfway houses, day-or-night treatment centers, non-medical detoxification programs for alcohol and drugs, and crisis intervention centers.
If a patient in the general hospital develops a psychiatric emergency, there may be a service there that can help. In some hospitals, psychiatric clinical nurse specialists are available to help staff with difficult patients. This is often preferable to transferring the patient to a psychiatric unit that is generally ill equipped to deal with acute physical problems in medical and surgical patients.
Another approach to a crisis problem could be to remove a family member from an explosive situation and have him or her spend the night with friends or in a hotel. Getting a person physically out of a problem situation may help to de-escalate matters. Follow-up work is generally needed. Some cities offer residential refuge to wives and children of physically abusing men. Rape services also offer temporary housing as well as all other aspects of crisis intervention and support.
Despite the growing number of alternatives, however, the best interests of the patient in a psychiatric emergency may require hospitalization. Hospitalization is a very important decision that should never be taken lightly. The very fact of hospitalization will significantly affect the person in the future in terms of jobs, government opportunities, and later treatment by medical and psychiatric personnel. Hospitalization may be voluntary or involuntary. The laws and criteria for involuntarily holding a person for psychiatric reasons vary in different states. They generally include some aspects of danger to self and others; being gravely disabled (unable to care for basic needs); and being acutely psychotic but not dangerous.
Criteria for admission to a psychiatric inpatient unit can include one or more of the following:

1. The person is a danger to self or others, as identified by a suicide or homicide/violence evaluation.
2. The person's disturbed behavior (bizarre, inappropriate, agitated, regressed, depressed or aggressive) has become intolerable to those around him or her.
3. In addition to disturbed behavior, the patient has physical problems, such as withdrawal from alcohol or drugs, which must be treated.
4. Medication or other treatments cannot be safely administered on an outpatient basis or the person is unreliable or uncooperative in following necessary regimens.
5. There are no other resources - family, friends, community agencies - or the person needs to be temporarily removed from a highly disturbing interpersonal setting.

Factors which are against psychiatric hospitalization include the determination that:

1. The person is already in treatment and needs to work out problems and plans with the therapist or agency.
2. Hospitalization is sought - primarily to evade responsibilities.
3. The family or person is requesting admission, but the circumstances do not warrant inpatient treatment.
4. Other facilities are more appropriate - medical unit, nursing home, day program, specialized drug or alcohol programs.
5. The person only needs housing, not psychiatric treatment.
6. Hospitalization would increase problems for the person and family through disruption in roles, financial burden, job change, time adjustments, childcare.
7. The social stigma and consequences may outweigh the benefits.

Whether or not the person is hospitalized, the ongoing process of crisis intervention is used to handle the psychiatric emergency.
Regardless of the setting, administration of medication to a highly agitated, uncooperative or aggressive person requires that safety precautions be taken. There is a reason for having a special "holding" room in emergency facilities and treatment centers where the patient can be adequately medicated and supervised; this may extend over a period of hours. The room is a physically safe place where potential for injury to self and others is lessened. Even if the patient will be hospitalized, arrangements take time. In the meantime, the patient needs protection and relief from overwhelming anxiety. If it becomes necessary to restrain the patient, several people will be required from among the staff and security forces on the scene. Five people - one for each extremity and one to give the medication - is the usual rule. The team must be prepared to hold the patient until the medication takes effect or the person becomes calm. In extreme situations, mechanical restraints may be used.

Restraint Guidelines for Psychiatric Emergencies
There are specific laws in most states regarding the use of mechanical restraints to control a patient. Nursing and medical policies, documentation guidelines, and forms used in hospitals and psychiatric facilities are developed to reflect the laws of each state. In general, a physician's order is required, describing the specific type of restraint ordered. The time must be entered on the order sheet, and the order must be renewed every 24 hours.
If a patient verbally threatens to strike other patients, staff or visitors, the nurse should chart the patient's behavior and verbal threats in the nursing documentation. The patient must be structured by staff (cued and redirected to more appropriate behavior) and medicated without results before he/she can legally be placed in restraints. How the patient was "structured" must be clearly documented. For example, "Mr. Smith, it is important that you try to control yourself. Hitting people is not a good way to express your anger. It is better to tell someone that you feel angry and that you want some help." It is a good idea to assign a staff member to talk the patient through his or her feelings about hostility and anger. The nurse continues to observe the patient's behavior and document relevant information. Remember: It is not legal to restrain a patient without following and documenting the above steps.
If a patient has actually hit or struck another person, the patient is legally considered a danger to self or others, and a restraint may be applied at that time. A physician's order is required, as is appropriate documentation. The documentation must include a description of the patient's behavior, any prn medication given, doctor notification, restraints applied, type of restraints, circulation status of extremities, and patient's vital signs. Other data should be recorded, including circulation checks at least every two hours, fluids and food given, and care for personal hygiene. Specific considerations in the proper use of restraints are summarized in Figure 6.

How to Use Restraints Properly

Under federal guidelines, health care institutions should have a policy on the use of restraints. Such a policy should describe:

1. alternatives to attempt before resorting to restraints
2. indications that restraints are necessary
3. how long (time frame) the client should be restrained
4. how and when the restrained client should be assessed

You must have a physician's order now that restraints are considered "prescription devices." (Some states authorize other licensed health care professionals to prescribe restraints.) The caregiver should consult the institution policy and find out what procedures to follow in an emergency.
The federal government is also requiring the manufacturers of restraints to develop better labeling and to modify their equipment so that it meets new regulations. Look for labels that say "prescription only" and provide graphic instructions on how to apply the restraints.
What can you do to make restraints safer? Always follow the Food and Drug Administration's (FDA's) guidelines as follows:

A.Assess why you are considering the use of restraints, and try alternatives first.
B.Make sure restraints are used only under the supervision of a licensed health care provider, such as yourself, for a strictly defined period.
C.When you have to use restraints, tell the patient and family members why and obtain informed consent from the patient or guardian. (Consult your institution's policy to find out what to do when you cannot obtain informed consent.)
D.Attend a staff-development program on how to use restraints. The program should include a demonstration on how to properly apply them, and an opportunity for supervised practice.
E.Before applying restraints, read and follow the manufacturer's directions.
F.Display the instructions on how to use restraints in a highly visible location and translate them, as necessary, into languages other than English.
G.Select restraints that are appropriate to the patient's condition.
H.Use the correct size restraint.
I.Carefully apply the restraint and adjust it properly so that it maintains body alignment and assures patient comfort.
J.Secure bed restraints to the bedsprings or bed frame, never to the mattress or bed rails. If the bed is adjustable, secure restraints to parts of the bed frame that will move with the patient.
K.Tie knots with appropriate hitches so they can be released quickly.
L.Check on the restrained patient frequently.
M.Remove the restraints at least every 2 hours (more if necessary), and allow for activities of daily living.
N.Continue to assess the patient regularly and remove the restraints as soon as possible. Restraints should be considered only a temporary solution to a problem.
O.Clearly document the medical reason for using restraints, the length of time they were used, and any alternatives that were tried.
P.Know and follow local and state laws on the use of restraints.
Q.Make sure all deaths and injuries associated with the use of restraints are reported to the FDA.

It is generally the goal of all care facilities to minimize the use of physical restraints as much as possible consistent with patient safety. Studies in gerontological nursing have determined that any effort to change restraint practices must include the nursing staff as a main target for change. The studies concluded that, following education and implementation of a restraint-reduction program, the majority of nursing staff participants found restraint use to be less critical in caring for the elderly. The changes were most notable immediately following in-service education, however, and were most accepted by RNs and LVNs with more years of experience. Ongoing education was recommended to decrease feelings of frustration and stress, and to provide staff with workable alternatives to the use of restraints.
In geriatric settings, the most frequently restrained patients were older, new on the unit, demonstrated altered thought processes and high risk for injury, and required extensive nursing care. The type of restraint used most often was the vest (posey) restraint and was intended to prevent falls; however, the rationale for restraint use was often not charted. Nursing home residents often become more agitated after the application of restraints, and this must be taken into consideration in the overall care plan.
Psychiatric nurses who have much experience caring for aggressive and assaultive patients offer some tips for coping with violent behavior. They suggest planning and practicing the specific intervention before approaching the patient whenever possible. Use six staff members to apply restraints: one for each ­extremity, one for the body and one for the head. This will minimize possible injury to staff. If the patient starts to bite, put a towel over his face. Whenever the patient is to be transported, be sure he is placed in the prone position to prevent grabbing of staff. Always have one staff member coordinate the transport to avoid confusion.

General Guidelines for Nursing Action in Psychiatric Emergency Situations

What the specific nursing action will be in a psychiatric emergency situation depends on what the emergency is, where it occurs and the actions of other members of the health team. Specific nursing action for patients with suicidal, violent and anxious behaviors has been described in previous sections. General guidelines are:

1. Nurses participate in the identification of a psychiatric emergency through observation and anticipation of stressors. They contribute to the immediate treatment plan and carry out activities such as preparing and administering medication. They report and record changes in behavior, especially decompensation and improvement.
2. Nurses are available to patients as interested, caring helpers who stay with them, provide structure and reality testing, help meet immediate physical and social needs, and talk with them about the current crisis.
3. Nurses provide a safe environment where the patient is protected from loss of impulse control toward self or others. Enough staff are used to establish safety and security.
4. Nurses along with other team members maintain a treatment program where patients can increase impulse control, decrease anxiety, raise self-esteem and reestablish hope. Patients can learn to express anger and other feelings in constructive ways, and they gradually resume responsibility for themselves.
5. Nurses are aware of the many feelings that are aroused by psychiatric emergencies. They are conscious of the effects on them and on other patients and significant others. They discuss and learn from each situation to be more effective in the future.
6. Nurses recognize the importance of other people in crisis situations. They establish rapport with families and significant others and include them in treatment and discharge planning. The nursing staff should be familiar with community resources in order to make appropriate referrals.
7. Nurses know the laws and hospital policies in regard to involuntary hospitalization, use of seclusion and restraints, and restriction of patients' rights. They are aware of the malpractice implications of nursing action. If court action is initiated as the result of a psychiatric emergency, the nursing staff should consult with supervisors and legal counsel for the hospital before making any responses to inquiries, requests or subpoenas.
8. Nurses recognize the importance of teamwork, especially during psychiatric emergencies. They support each other and other members of the health team, during the crisis and afterward. They apply the principles of crisis intervention to their on-going work.

ACUTE PSYCHIATRIC SITUATIONS

Diagnosis

Acute alcoholism; Delirium tremens; Acute drug reactions; Drug withdrawal; Epilepsy; Hyperventilation syndrome; Metabolic/endocrine disorders; Brain tumor; Subdural hematoma; Infectious/exhaustive disorders; Porphyria; Dementia

Suicide attempt

Schizophrenic disorders; Paranoid; Catatonic excitement or stupor; Paranoid disorders; Schizophreniform disorders; Borderline personality

Suicide attempt

Affective disorders; Depression: retarded or agitated; Manic depressive disorder; Manic or depressed

Suicide attempt

Interpersonal Crisis: family or significant other;

Acute disorganization; Fights and violence;

Suicide attempt; Possible psychiatric disorder in one or more members

Acute grief reaction

Other: Victims of rape and assault; Dissociative states; Fugue; Amnesia; Panic; Malingerer; Munchausen Syndrome; Drug seeker; Resourceless person; Explosive personality; Disaster victim

Sleep disorder; Eating disorder; Regulation of energy; Stupor/agitation; Exhaustion; Anxiety/depression; Guilt/anger; Confusion/Delusions; Grandiosity; Poor impulse control; Suicide; Combative; IPR; Socioenvironmental

Anxiety;
Depression;
Anger;
Grandiosity;
Guilt

Action

Detain legally if necessary.

Mobilize safety measures: personal, family, temporary restraint, locked room.

Diagnose correctly, through physical examination; lab tests, psychiatric history and mental status exam.

Institute immediate appropriate treatment; medicate as indicated; hospitalize in med/surg; psychiatric; alcohol or drug unit.

Confer with family, significant others.

Treat suicide attempt if necessary mobilize safety, functions, personnel, family locked room, rest.

Assess and diagnose through ruling out physical causes.

Psychiatric history and mental status exam.

Medicate if needed antipsychotic drugs, hospitalize, voluntary and involuntary if needed.

Alternative to hospital;

Confer with significant others.

Treat suicide attempt and detain legally if needed.

Assess suicide lethality.

Arrange for treatment.

Hospitalize voluntary or involuntary.

Alternate treatment.

Refer to MD to be started on anti-depressants or lithium treatment.

Treat suicide attempt.

Begin crisis intervention.

Arrange temporary environmental changes.

Medicate short-term.

Referral to appropriate facility.

Contact appropriate authorities in child abuse cases.

Sodium amytal interviews.

Institute appropriate treatment.

Refuse treatment if indicated.

Refer to social service agencies.

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