Psychiatric Emergencies

  1. Definition: sudden onset (days or weeks, not years) of unusual (for that individual), disordered (without pattern or purpose), or socially inappropriate behavior caused by emotional or physiological situation. Examples include suicidal feelings or attempts, overdose, acute psychotic reaction, acute alcohol withdrawal, acute anxiety.

  2. General characteristics:
    1. Assessment: the presence of great distress without reasonable explanation; extreme behavior in comparison with antecedent event.
      1. Fear - related to a particular person, activity, or place.
      2. Anxiety - fearful feeling without any obvious reason, not specifically related to a particular person, activity, or place (e.g., adolescent turmoil).
      3. Depression - continual   pessimism, easily
      4. moved to tears, hopelessness, and isolation (e.g., student despondency around exam time, middle-aged crisis, elderly hopelessness).
      5. Mania - unrealistic optimism.
      6. Anger - many events seen as deliberate insults.
      7. Confusion - diminished awareness of who and where one is; memory loss.
      8. Loss of reality contact - hallucinations or delusion (as in acute psychosis).
      9. Withdrawal - neglect or giving away of belongings and neglect of appearance; loss of interest in activities; apathy.
    2. Analysis/nursing diagnosis: ineffective individual coping related to degree of seriousness:
      1. Life-threatening emergencies - violence toward self or others (e.g., suicide, homicide).
      2. Serious emergencies - confused and unable to care for or protect self from dangerous situations (as in substance abuse).
      3. Potentially serious emergencies - anxious and in pain; disorganized behavior; can become worse or better (as in grief reaction).
    3. General nursing care plan/implementation:
      1. Remove from stressful situation and persons.
      2. Engage in dialogue at a nonthreatening distance, to offer help.
      3. Use calm, slow, deliberate approach to relieve stress and disorganization.
      4. Explain what will be done about the problem and the likely outcome.
      5. Avoid using force, threat, or counterthreat.
      6. Use confident, firm, reasonable approach.
      7. Encourage client to relate.
      8. Elicit details.
      9. Encourage ventilation of feelings without interruption.
      10. Accept distortions of reality without arguing.
      11. Give form and structure to the conversation.
      12. Contact significant others to gain information and to be with client, including previous therapist.
      13. Treat emergency as temporary and readily resolved.
      14. Check every half hour if cannot remain with client.

  3. Categories of psychiatric emergencies:
    1. Acute nonpsychotic reactions, such as acute anxiety attack or panic reaction.
      1. Assessment includes differentiating hyperventilation that is anxiety - connected from asthma, angina, and heart disease.
      2. Nursing care plan/implementation in hyperventilation syndrome - goal:  prevent paresthesia, tetanic contractions, disturbance in awareness; reassure client that vital organs are not impaired.
        1. Increase CO2 in lungs by rebreathing from paper bag.
        2. Minimize secondary gains; avoid reinforcing behavior.
        3. Health teaching: demonstrate how to slow down breathing rate.
      3. Evaluation/outcome criteria: respirations slowed down; no evidence of effect of hyperventilation.
    2. Delirium - conditions produced by changes in the cerebral chemistry or tissue by metabolic toxins, direct trauma to the brain, drug effects, or withdrawal.
      1. Acute alcohol intoxication.
        1. Assessment: signs of head or other injury (past and recent), emotional lability, memory defects, loss of judgment, disorientation.
        2. Nursing care plan/implementation:
          1. Observe, monitor vital signs.
          2. Prevent aspiration of vomitus by positioning.
          3. Decrease environmental stimuli:
            1. Place in quiet area of emergency department.
            2. Speak and handle calmly.
          4. Give medication (diazepam [Valium]) to control agitation.
        3. Evaluation/outcome criteria: oriented to time, place, person; appears calmer.
      2. Hallucinogenic drug intoxication - LSD, mescaline, amphetamines, cocaine, scopolamine, and belladonna.
        1. Assessment:
          1. Perceptual and cognitive distortions (e.g., feels heart stopped beating).
          2. Anxiety (apprehension —> panic).
          3. Subjective feelings (omnipotence —> worthlessness).
          4. Interrelationship of dose, potency, setting, expectations and experiences of user.
          5. Eyes: red - marijuana; dilated - LSD, mescaline, belladonna; constricted - heroin and derivatives.
        2. Nursing care plan/implementation:
          1. “Talk down.”
            1. Establish verbal contact, attempt to have client verbally express what is being experienced.
            2. Environment - few people, normal lights, calm, supportive.
            3. Allay fears.
            4. Encourage to keep eyes open.
            5. Have client focus on inanimate objects in room as a bridge to reality contact.
            6. Use simple, concrete, repetitive statements.
            7. Repetitively orient to time, place, and temporary nature.
            8. Do not moralize, challenge beliefs, or probe into lifestyle.
            9. Emphasize confidentiality.
          2. Medication (minor tranquilizer-diazepam [Valium], chlordiazepoxide HCl [Librium]):
            1. Allay anxiety.
            2. Reduce aggressive behavior.
            3. Reduce suicidal potential; check client every 5-15 min.
            4. Avoid anticholinergic crisis (precipitated by use of phenothiazines, belladonna, and scopolamine ingestion) with 2-4 mg IM or PO of physostigmine salicylate.
          3. Hospitalization: if hallucinations, delusions last more than 12-18 hr; if client has been injecting amphetamines for extended time; if client is paranoid and depressed.
        3. Evaluation/outcome criteria: less frightened; oriented to time, place, person.
      3. Acute delirium - seen in postoperative electrolyte imbalance, systemic infections, renal and hepatic failure, oversedation, metastatic cancer.
        1. Assessment:
          1. Disorientation regarding time, at night.
          2. Hallucinations, delusions, illusions.
          3. Alterations in mood.
          4. Increased emotional lability.
          5. Agitation.
          6. Lack of cooperation.
          7. Withdrawal.
          8. Sleep pattern reversal.
          9. Alterations in food intake.
        2. Nursing care plan/implementation:
          1. Identify and remove toxic substance.
          2. Reality orientation - well-lit room; constant attendance to inform repetitively of place and time and to protect from injury to self and others.
          3. Simplify environment.
          4. Avoid excessive medication and restraints; use low-dose phenothiazines; do not give barbiturates or sedatives (these increase agitation, confusion, disorientation).
        3. Evaluation/outcome criteria: oriented to time, place, person; cooperative; less agitated.
    3. Acute psychotic reactions - disorders of mood or thinking characterized by hallucinations, delusions, excessive euphoria (mania), or depression.
      1. Acute schizophrenic reaction.
        1. Assessment:
          1. History of previous hospitalization, no illicit drug ingestion; use of major tranquilizers and recent withdrawal from them or alcohol.
          2. Auditory hallucinations and delusions.
          3. Violent, assaultive, suicidal behavior directed by auditory hallucinations.
          4. Assault, withdrawal, and panic related to paranoid delusions of persecution; fear of harm.
          5. Disturbance in mental status (associative thought disorder).
        2. Nursing care plan/implementation.
          1. Hospitalization.
          2. Medication: phenothiazines.
          3. Avoid physical restraints or touch when fears and delusions of sexual attack exist.
          4. Allow client to diffuse anger and intensity of panic through talk.
          5. Use simple, concrete terms, avoid figures of speech or content subject to multiple interpretations.
          6. Do not agree with reality distortions; point out that client’s thoughts are difficult to understand but you are willing to listen.
        3. Evaluation/outcome criteria: does not hear frightening voices; less fearful and combative behavior.
      2. Manic reaction.
        1. Assessment
          1. History of depression requiring antidepressants.
          2. Thought disorder (flight of ideas, delusions of grandeur).
          3. Affect (elated, irritable, irrational anger).
          4. Speech (loud, pressured).
          5. Behavior (rapid, erratic, chaotic).
        2. Nursing care plan/implementation:
          1. Hospitalization to protect from injury to self and others.
          2. Medication: lithium carbonate.
          3. Same as for acute schizophrenic reaction, except do not encourage talk, because of need to decrease stimulation.
          4. Provide food and fluids that can be consumed while “on the go.”
        3. Evaluation/outcome criteria: speech and activity slowed down; thoughts less disordered.