CHAPTER 26 Psychiatric/Psychosocial Emergencies

Lynne Gagnon, RN, BSN, MS, CPHQ

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Specific Psychosocial Emergencies

Eating Disorders

Anxiety and Panic Reactions

Ineffective Coping and Situational Crisis

Depression

Grief

Psychotic, or Brief Psychotic, Behavior

Bipolar Disorder

Suicide or Suicidal Behavior

Homicidal or Violent Behavior

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)

2. Focused assessment

a. Subjective data collection

1) History of present illness/chief complaint: patient’s perspective and that of significant others

a) Behavioral changes

b) Somatic symptoms

c) Hallucinations or thought disturbances

d) Thoughts of harming oneself or others

e) Precipitating event

f) Mechanism and time of injury (see Chapter 30)

(1) Unintentional

(2) Intentional

g) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current or preexisting diseases/illness (especially affecting neurologic function or mental status)

(1) Diabetes

(2) Alcoholism/drug dependency

(a) Recent use

(b) Recent/past withdrawal history: seizures or delirium tremens (DTs)

(3) Central nervous system (CNS) disorders such as Guillain-Barré syndrome, multiple sclerosis, and amyotrophic lateral sclerosis

(4) Mental illness history

b) Head trauma

c) Previous similar episodes

d) Previous hospitalizations: determine chronicity and frequency of disturbances

e) Substance and/or alcohol use/abuse

f) Last normal menstrual period: female patients of childbearing age

g) Current medications

(1) Prescription

(a) Psychotropic drugs

(b) Anticonvulsants

(c) Hypoglycemic agents

(2) Over-the-counter/herbal

h) Allergies

i) Immunization status

3) Psychological/social/environmental factors

a) Family history of mental illness

b) Biochemical imbalances

c) Recent personal difficulties

d) Lack of social support system

(1) Broken family relationships, recent relationship losses/crisis

(2) Gang membership

(3) Disintegration of social relationships

e) Lack of knowledge and availability of community support or rehabilitative services

f) Loss of control/violence

(1) Possible/actual assault, abuse, intimate partner violence situations (see Chapter 3)

g) Fear

h) Guilt or anger

i) Poor self-image or self-esteem

j) Unhealthy work life

k) Spiritual values

l) Cultural influences

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Vital signs

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection

a) Tics or tremors, which may be evidence of dystonic reaction

b) Pupils: size and reactivity

c) Coordination and movement

d) Obvious injuries

3) Auscultation

a) Breath sounds

b) Heart sounds

c) Bowel sounds

4) Palpation/percussion

a) Extremity range of motion

b) Deep tendon reflexes

c) Areas of tenderness

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

3) Serum and urine toxicology screen and therapeutic drug levels

4) Thyroid function tests

5) Liver function tests

6) Urinalysis; pregnancy test in female patients of childbearing age

7) Arterial blood gas (ABG)

8) Erythrocyte sedimentation rate (ESR)

b. Imaging studies

1) Head computed tomography (CT) scan

2) Head magnetic resonance image (MRI)

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Anxiety

2. Impaired verbal communication

3. Ineffective coping

4. Chronic/situational low self-esteem

5. Interrupted family processes

6. Disturbed sleep patterns

7. Disturbed sensory perception

8. Disturbed thought processes

9. Imbalanced nutrition: less than body requirements

10. Dysfunctional grieving

11. Risk for suicide

12. Risk for other-directed/self-directed violence

13. Deficient knowledge

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluids/blood products/medications

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plan as appropriate

3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatrics

a. Growth or development related

1) Appropriate behavior varies with age

2) Many disorders have age-specific onset; others cross all age groups or occur at various points along age continuum

b. “Pearls”

1) It is often difficult to determine whether a child’s behavior is abnormal or merely part of normal adjustment to life’s developmental challenges. If behavior seriously interferes with personal, family, or social adjustment, it is most likely deviant and in need of attention

2) Many children and adolescents rely on acting-out behaviors to express emotions. This situation may signify a problem when behaviors are socially or culturally unacceptable. These children or adolescents may come to the attention of emergency department personnel when they are brought in by police, school, or family

2. Geriatrics

a. Aging related

1) Declining health may be contributory

2) Most common problems include depression, suicide potential, suspiciousness and altered perceptions, anxiety, situational crisis, and sleep pattern disturbances

b. “Pearls”

1) Assessment should include determination of drug/alcohol abuse and suicide risk

2) Thorough assessment of prescribed medication therapy and dosing schedules: certain drugs can cause depression (e.g., propranolol [Inderal], chloral hydrate, digitalis, corticosteroids, and sulfonamides)

3) Evaluation must rule out organic cause of mental health manifestations

4) Personal losses and socioeconomic stressors, frequently seen with the older adult, can precipitate emotional disorders

II. SPECIFIC PSYCHOSOCIAL EMERGENCIES

A. Eating Disorders

Although not commonly thought of as an emergency, patients with eating disorders often reach an emergency condition before they are diagnosed. Physical results of this disorder may include starvation, binging-purging, suicide, or self-mutilation, and these are the presentations that may be seen in the emergency department. These individuals often require admission to the intensive care unit (ICU) for electrolyte imbalance. The disorder is more common in female patients, particularly athletes whose sports emphasize thinness. Major depressive disorder or dysrhythmia is diagnosed in 50% to 75% of patients with anorexia nervosa or bulimia nervosa. Anorexia nervosa carries a significant risk of death and suicide. Any adolescent or young adult female patient presenting to the emergency department with low body weight, amenorrhea, yellow skin (hypercarotenemia), muscle weakening, constipation, cool skin on the extremities, and dehydration should be assessed for possible eating disorders. Immediate care in the emergency department is directed by the physiologic symptoms that brought them to the emergency department, but the plan of care should consider the underlying cause as that of an eating disorder.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Appetite and weight changes

b) Exercise patterns

c) Pain (see Chapter 9)

d) Vomiting, diarrhea

2) Past medical history

a) Current or preexisting diseases/illness

(1) Psychological disorders

(2) Anorexia/bulimia

b) Substance and/or alcohol use/abuse

c) Laxative and/or diet pill use

d) Last normal menstrual period: female patients of childbearing age

e) Current medications

(1) Prescription

(2) Over-the-counter/herbal

f) Allergies

g) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: possible depression

(2) Possible hypotension, tachycardia, orthostasis

(3) Moderate to severe distress/discomfort

b) Inspection

(1) Thinness

(2) Dry, brittle hair

(3) Yellow skin

(4) Tooth enamel erosion

(5) Cardiac dysrhythmias on monitor

c) Palpation/percussion

(1) Diminished deep tendon reflexes

(2) Cool, dry skin

(3) Poor skin turgor

2) Diagnostic procedures

a) CBC with differential

b) Serum chemistries including glucose, BUN, and creatinine

(1) Hyponatremia

(2) Hypoglycemia

(3) Hypokalemia

(4) Hypomagnesemia

(5) BUN: possible elevation

c) ABGs

(1) Metabolic alkalosis with prolonged vomiting

(2) Metabolic acidosis with laxative abuse

d) ESR: if elevated, possible organic cause

e) Serum and urine toxicology screen

f) Urinalysis; pregnancy test in female patients of childbearing age

g) Thyroid function tests

h) ECG

2. Analysis: differential nursing diagnoses/collaborative problems

a. Imbalanced nutrition: less than body requirements

b. Situational/chronic low self-esteem

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluids/medications

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Assist with obtaining psychological consultation

3) Assist with possible hospital admission

e. Administer pharmacologic therapy as ordered

1) Electrolyte replacements

f. Educate patient and significant others

1) Importance of nutritionally balanced diet

4. Evaluation and ongoing monitoring (see Appendix B)

a. Hemodynamic status

b. Cardiac rate and rhythm

B. Anxiety and Panic Reactions

Anxiety is a subjective individual experience ranging from vague discomfort to a feeling of impending disaster or death. It can be a normal response to certain events or a symptom of some underlying disease. Anxiety occurs as a result of a threat to self, self-esteem, or identity and can be manifested as apprehension in response to known or unknown threats. Levels of anxiety range from mild to severe, including a state of panic (panic reaction), with corresponding symptoms ranging from mild discomfort to a lack of functional capability. Anxiety may heighten in the following circumstances: during developmental changes; when extreme effort is needed to cope with a situational crisis; or with use of caffeine, iatrogenic agents such as inhaled beta₂-agonists, alcohol, amphetamines, or narcotics. The symptoms range from jumpiness, nervousness, and apprehension to panic states. Anxiety disorders have been associated with familial patterns. A panic reaction is defined as extreme anxiety with personality disorganization and lack of functional abilities.

1. Assessment

a. Subjective data collection

1) History of present illness/injury/chief complaint (Table 26-1)

a) Previous episodes

b) Precipitating event

c) Measures already taken by patient that have or have not helped

d) Family history of organic disease and anxiety disorders

e) Occurrence during developmental cycle

(1) Children: separation from parents

(2) Adolescents: extreme peer pressure, perceived loss of love, failure to achieve

(3) Adults: midlife crisis, marriage, divorce, menopause, failure to achieve goals

(4) Elderly: loss of significant other, loss of home, increased dependence, death of friends

f) Physical ailments causing pain or impairment in function

g) Impaired communication abilities resulting from stroke, hearing impairment, blindness, lack of language fluency

h) Insufficiency of previously used coping patterns

i) Acute changes in health

j) Lack of knowledge regarding available resources

k) Inadequate parenting patterns with maltreatment (see Chapter 3)

l) Recent life change (e.g., occupation, relationships, responsibilities)

m) Difficulty with sleep

n) Events causing anger

o) Passivity in face of threats

p) Feeling of impending doom, including sensation of heart attack or choking

q) Reports of sexual difficulties, including impotence, lack of desire, dyspareunia (abnormal pain during sexual intercourse)

2) Past medical history

a) Current or preexisting diseases/illness

(1) Anxiety disorder

(2) Conversion disorder

(3) Post-traumatic stress disorder

b) Phobias

c) Hyperventilation syndrome

d) Substance use/abuse

e) Medications

f) Allergies

g) Immunization status

b. Objective data collection

1) Physical examination (see Table 26-1)

a) General appearance

(1) Level of consciousness, behavior, affect: agitation, hyperalertness

(2) Tachycardia, hypertension, hyperventilation

(3) Possible elevated temperature

(4) Moderate to severe distress/discomfort

b) Inspection

(1) Pupillary dilation

(2) Ptosis (drooping of upper eyelids) may be caused by muscle fatigue, oculomotor nerve dysfunction, chronic eyelid edema

(3) Skin hair erect

(4) Nystagmus: eye movements that result from stimulation of semicircular canals and reflect oculovestibular and cerebral cortex functioning

(5) Tremors: tense musculature

(6) Startle reaction

(7) Pacing

(8) Cardiac dysrhythmias on monitor: premature ectopy

c) Auscultation

(1) Breath sounds: normal

(2) Bowel sounds: normal to hyperactive

d) Palpation/percussion

(1) Increased reflex responses and clumsy movements

(2) Abdominal distention: sympathetic nervous system stimulation

(3) Skin cool and clammy

2) Diagnostic procedures

a) CBC with differential

b) Serum chemistries

c) Serum and urine toxicology screen

d) ECG

2. Analysis: differential nursing diagnoses/collaborative problems

a. Anxiety/fear

b. Impaired gas exchange

c. Impaired verbal communication

d. Ineffective individual or family coping

e. Risk for injury

f. Deficient knowledge

g. Disturbed thought processes

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Provide supplemental oxygen as indicated

1) If patient is hyperventilating, encourage slow, diaphragmatic breathing with breathing retraining or possible rebreathing bag over mouth and nose and/or use behavioral techniques such as breath control and relaxation exercises, after ruling out organic cause

c. Establish IV access for administration of crystalloid fluids/medications as needed

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Build trusting relationship

a) Introduce self and explain role to patient

b) Enhance acceptance and self-esteem by acknowledging patient’s anxiety and offering reassurance

c) Provide for safety and security needs

3) Communicate in calm manner

a) Explain all procedures in simple, understandable terms

b) Convey attitude of acceptance

4) Assist patient in recognizing causes and effects of anxiety

5) Direct patient to refocus attention to begin problem-solving process

a) Facilitate patient’s expression of feelings

b) Emphasize realistic perceptions

6) Assist patient with problem-solving activities

a) Identify precipitating event

b) Determine measures already taken to resolve problem

c) Determine usual coping measures

7) Determine options available

a) Select most desirable option

b) Offer direct assistance

c) Verbally acknowledge and comment positively on appropriate problem solving by patient

8) Assist patient in determining source of fear and identify means of allaying fear

9) If there is potential for injury related to poisoning or trauma, refer for crisis evaluation and suicide risk assessment

10) Place patient in area where he or she can be closely observed

11) If thought processes are altered, orient patient to current reality; refer for psychiatric evaluation to determine whether judgment is impaired; help make appropriate and safe discharge disposition

12) Work with health care team to determine whether discharge is appropriate or supportive environment is necessary until acute stage of anxiety abates

e. Administer pharmacologic therapy as ordered

1) Antianxiety

a) Diazepam (Valium): long acting

b) Chlordiazepoxide (Librium): medium acting

c) Lorazepam (Ativan): short acting

2) Antipanic

a) Clonazepam (Klonopin)

f. Educate patient and significant others

1) If patient has altered health maintenance, identify type of impairment and refer for appropriate follow-up care

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