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Psychiatric emergencies
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- 2. Introduction • An emergencyis defined as an unforeseen combination of circumstances which calls for an immediate action. • A psychiatric emergency is a disturbance in thought, affect, and psychomotor activity leading to a threat in his existence or threat to the people in the environment.
- 3. Contd. • Edwin Shneidmanproposed that victims of suicide suffer unbearable psychological pain, a sense of isolation, and the perception that death is the only solution to their situation. Individual feels that there is no way out. • This condition needs immediate intervention to safeguard the life of the patient, bring down the anxiety of the family members and emotional security to others in the environment.
- 4. Common psychiatric emergencies •Attempted suicide • Excitement and violence • Stupor and catatonic syndrome • Severe depression • Panic attacks • Dissociative convulsion • Neuroleptic malignant syndrome • Lithium toxicity • Drug and alcohol withdrawal
- 5. ANGER, AGGRESSION ANDVIOLENCE Anger-An emotional state that may range in intensity from mild irritation to intense fury and rage. It is an emotional response to something that has happened or is happening.
- 6. Contd. Aggression-The act ofinitiating hostilities, a feeling of hostility that arouses thoughts of attack and disposition to behave aggressively.
- 7. Contd. Violence- Is definedas an unjust, unwarranted, or unlawful display of force to inflict harm upon, damage or violate.
- 8. Etiology a) Social factors:childhood aggression, alcohol and substance abuse, poor socioeconomic status, male gender and young age b) Neurobiological factors: structural damage to the limbic system, low central serotonin function has been correlated to aggression and impulsive activities
- 9. Contd. c) Genetic linkage d)Psychiatric disorders: common in mania, depression, drug and alcohol dependence, epilepsy, acute stress reaction, organic psychotic reaction.
- 10. Signs and symptoms •Angry • Irritable • clenched teeth • Hyperactive • Increasing anxiety and tension • Verbal abuse • Loud voice • Intense eye contact • Stone silence
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- 12. Pre-assaultive stage • Duringthe pre-assaultive stage the patient becomes increasingly agitated. • Staff require training in both verbal techniques of de-escalation and physical techniques to restrain without harm.
- 13. Contd. 1. Pay attentionto the angry behavior and respond as early as possible 2. Assess personal safety and provide self-care Leave door open Choose a quiet place If you are uncomfortable have another staff nearby Always use more space if the patient is anxious. Know where panic buttons and alarms are located Never turn your back on an angry patient.
- 14. Contd. 3. Appear calmand control- the perception that someone is in control can be comforting and calming to an individual who is beginning to lose control 4. Do not try to speak when aggressive patient is yelling. It will only escalate the anger and violence 5. Speak softly in a nonprovocative, nonjudgmental manner 6. Demonstrate genuineness and concern- do not treat individual in a humiliating manner 7. Set clear, enforceable limits on behavior. “It’s okay to be angry with Ramesh, but it is not okay to threaten him.”
- 15. Contd. 8. If patientis willing, both nurse and the patient can sit in a 450angle. Do not tower over or stare at the patient. 9. When the patient begin to talk, listen. Use clarification. 10.Acknowledge the patients need regardless of whether expressed needs are rational or irrational, possible or impossible to meet.
- 16. Assaultive stage • Inthis stage, the patient shows violence. • If the patient progresses to assaultive stage then the nurse should immediately respond. • Generally a team approach with at least 5 members is advisable. Only leader speaks to the patient and instruct the members of the team.
- 17. Assaultive stage Contd. •The intervention includes medication, seclusion or physical restraint. • APNA 2002 Seclusion and Restraint Standards of Practice- Any staff providing care to persons at risk of harming others and themselves and who participate in seclusion and restraint shall have received training and demonstrate current competency in all aspects of dealing with behavioral emergencies. • Be sure to know the hospital protocol for seclusion and restraints in whatever part of the hospital you choose
- 18. Contd. • Medications- antipsychotics,benzodiazepines. Haloperidol is the first choice among antipsychotics and lorazepam is the choice among BZD.
- 19. Contd. • Seclusion- Itis the voluntary confinement of a person alone in a room or an area where a person in physically prevented from leaving. Used for management of violent self-destructive behavior.
- 20. Contd. • Restraints- Itrefers to any manual method, mechanical device or equipment attached or adjacent to a patient’s body where they cannot move their arms, legs, body or head freely. * Seclusion and restraints is only used after alternative interventions have been attempted (e.g. medication, verbal intervention, decreased sensory stimulation, removal of a stimulus, and use of sitter who provides one to one 24 hours observation of the patient).
- 21. Contd. • Seclusion andrestraints are used in the following circumstances - The patients presents a clear danger to self and others - The patient is legally detained for involuntary treatment and is thought to pose an escape risk. - The patient requests to be secluded or restrained.
- 22. Contd. - Once inrestrain the patient must be protected from all sources of harm. - Each team member is trained with a correct use of physical restraining maneuvers as well use of physical restraints. - Before approaching the patient, the team is prepared with the correct number and size of restraints and with medication, if ordered. - The team leader explains to the patient in a straightforward manner exactly what the team is about to do and why. - Face to face observation is made every 15 mins and reintegration occurs gradually.
- 23. Post assaultive stage Whenthe patient returns to the baseline • Critical incident debriefing- staff analysis of an episode of violence is crucial. To ensure that quality care was provided to the patient. Prevent long term psychological sequel.
- 24. Contd. • Documentation ofviolent episode- assessment of the behaviors, nursing interventions, evaluation of the interventions used, patient’s response to those interventions, interventions performed while the patient was in seclusion room. • Anticipating increased anxiety and anger in other hospital settings • Use of anxiety reduction techniques • Psychotherapy
- 25. STUPOR AND CATATONICSYNDROME Stupor- Is defined as a syndrome of mutism and akinesis but with relative preservation of conscious awareness. Stupor is a condition in which a person is motionless for a long period of time and may appear to be in coma. Catatonia- Is defined as extreme abnormal motor behavior. It can be either excited, withdrawn or mixed.
- 26. Etiology • Neurological disorderslike epilepsy, cerebral malaria, neoplasms, • Systemic and metabolic disorders-DKA, pellagra, hyperparathyroidism, SLE, membranous glomerulonephritis
- 27. Contd. • Drugs andpoisoning- anti psychotics, ACTH, aspirin, ethyl alcohol, lithium toxicity • Psychiatric disorders- catatonic schizophrenia, depressive stupor, manic stupor, conversion and dissociative disorder, reactive psychosis, during hypnosis • Onset is abrupt and the prognosis is favorable.
- 28. Clinical features ofexcited catatonia • Increase in psychomotor activity- restless, agitation, excitement, aggressiveness, violent at times. • Increase in speech production • The person may run ceaselessly and without purpose leading to exhaustion and cardiac difficulties or physical collapse. • Automatic obedience, mannerism, impulsiveness, excitement, nudism. • Extreme motor agitation
- 29. Clinical features ofretarded (stuporous) catatonia • Mutism - complete absence of speech • Rigidity- maintenance of rigid posture against all commands and efforts to be moved. The person does not move or eat, thus becoming vulnerable to pressure ulcers, contractures and malnutrition
- 30. Contd. • Negativism- resistanceto all commands and attempts to be moved, doing just the opposite • Posturing – voluntary assumption of bizarre posture such holding arms or legs rigidly or bent at severe angle for a long period of time. • Stupor- akinesis with mutism with evidence of relative preservation of consciousness
- 31. Contd. • Echolalia- mimickingof phrases or words • Echopraxia- mimicking of actions • Waxy flexibility- parts of the body can be placed in positions that will be maintained for a long period of time, even if very uncomfortable. • Other behavior like automatic obedience, mannerism
- 32. Treatment Treatment of underlyingcause Ensure patency of airways and oxygenation Check cardiac activity and vital signs Provide IV fluids for possible fluid and electrolyte imbalance Maintain circulation
- 33. Contd. Treat hypoglycemia Benzodiazepines arethe first line of therapy for catatonic syndrome Use of antidote for drugs poisoning Electroconvulsive therapy is sometimes used Rarely restraining