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TRANSCRIPT
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Assessment andTreatment Strategies for
Psychiatric Patients in the
Emergency Department
Sara Gilbert, RN, CEN, MACPCheshire Medical Center
Keene, NH
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Objectives
Recognize the importance of symptom management
for psychiatric patients Gain understanding of psychiatric diagnoses and
associated symptoms
Identify patients at high risk for suicidality, self-harmand acting out behaviors
Learn specific strategies for dealing with a variety ofbehavioral issues
Identify characteristics of special populations
Gain insight regarding therapeutic rapport,nonjudgmental attitude and alliance
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I d on t have a n a t tit ude !
THE IMPORTANCE OF SYMPTOM MANAGEMENT
Anxiety drives many problematic behavioral symptoms
Anxiety Agitation Aggression
Symptom management reduces anxiety, acting out, need forrestraints and enhances cooperation of patient and family
Avoid the attitudes and behaviors that increase patient
anxiety and frustration dont REACT:
R: restrict
E: escalate
A: avoid
C: coerce
T: threaten
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The Importance of Symptom
Management
Ant ic ipa t ionof symptoms based on diagnosis andinitial nursing assessment of pt.
Preventionof symptoms by use of early intervention,building trust, conveying nonjudgmental attitude,establishing therapeutic rapport and alliance with
patient
Man a g eme n t of symptoms saves time, energy andresources; reduces chaos, noise; improves patient
outcomes and satisfaction Goa l is to keep patients and staff safe by enlisting
cooperation of pt. to stay in control
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What sYOURYOUR p ro b lem ?
Common Psychiatric Disorders
Borderline Personality Disorder
Bipolar Disorder (Manic Depression)
Psychosis/Schizophrenia
Depression (Major Depressive Disorder) Anxiety Disorders
**Sym p tom s c a n ra ng e from m ild to sev ere .
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Can I lea ve , so I c a n g o hom e a nd k ill m ysel f?
Borderline Personality Disorder
Commonly occurs in individuals with traumaticchildhood abuse or neglect
Rigid or fixed perception of the world
Characterized by poor self-image, chaotic personal
relationships, emotional dysregulation, intensereactions to situations, extreme fear of abandonmentand ineffective coping skills in crisis
Women are more often diagnosed with BPD (75%)
Often occurs with co-morbidities e.g. eating disorders,substance abuse, depression
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Borderline Personality Disorder
Behaviors/Thinking
Manipulation, power struggles, passive-aggressivecommunication
Tend to want you to know what they want, withouttelling you directly
Unpredictable, gamey around safety issues,attention-seeking, dramatic, provocative
Can be argumentative; have difficulty takingresponsibility for behaviors e.g. may blame dissociation
or voices High risk for self-harming behaviors Can be chronically suicidal with many attempts Black and white thinking
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Borderline Personality Disorder
Emotions:
Angry, labile, depressed, overwhelmed, needy
Hypersensitive to rejection, criticism, negativeattitude
Easily frustrated, agitated
Anxiety around being poorly treated, ignored, etc iscommon trigger for acting out
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Borderline Personality Disorder
Specific Strategies: AVOID POWER STRUGGLES!
Give choices as often as possible; clear, reasonable limits Dont react emotionally to behaviors, know your own
buttons No punitive treatments, threats, ultimatums or excessive
restrictions-they will give the patient a reason to escalate Spend time (if you can) talking with the patient to find out
what they need and want; try to accommodate them if youare able (explain why if you cant)
Be aware of non-verbal communication Explain the process involved, try to decrease anxiety as
much as possible Check back with the pt. often Expedite process of evaluation
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Who ne ed s sle ep ????
BipolarDisorder
Also known as Manic-Depressive illness, characterized bycycles of extreme mood swings and behaviors
Involves disruption in normal brain chemistry, often with afamilial component
Not curable, can be managed
Young, undiagnosed Bipolar patients often self-medicate Manic behaviors can result in loss of job, relationships, etc.
which can increase instability
High risk for accidentally or intentionally killing self
May not be taking medications
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BipolarDisorder
Behaviors/Thinking (manic phase):
Delusions of grandiosity, may feel invincible
Impulsiveness with little regard for personal safety orconsequences of actions; high risk behaviors
Racing thoughts, tangential thinking make it difficult tofollow directions or complete tasks e.g. giving UA
Grandiose, delusional, paranoid, may see some psychosis;perceive themselves as being superior
Poor boundaries, inappropriate language; loud, frequent
change of subjects, interrupting Often have little intent to be disruptive or oppositional
Poor sleep, hygiene and nutrition in acute manic phase
Rapid, pressured speech
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BipolarDisorderEmotions:
Euphoric, energized, confident
Labile, anxious, paranoid, feeling invincible to harmand superior to others
Impatient, easily frustrated when process is slower thanthey think it should be
Confusion as to why others are concerned about them
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BipolarDisorder
Specific strategies:
Low stimulus, keep directions/statements short andsimple (may have to repeat them)
Dont argue with the pt.; say youre right as much aspossible in order to make it easier to set limits when
necessary Medicate early for agitation, get a reliable sitter
New onset mania needs medical workup and
probably hospitalization Assume pt. will be unpredictable and plan for it
Check medication levels
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I think tha t d o c tor is from the C IA !
Psychosis/Schizophrenia
Characterized by disorganization in thinking, delusions/hallucinations and some emotional flatness
Schizophrenia onset typically late adolescence, early20s
Psychosis can be drug induced or related to other
disorders such as Bipolar or depression Typically dont realize that their thinking is delusional or
irrational ; may not understand what is happening tothem
New onset vs. established diagnosis?
New onset: families can often be in denial
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Psychosis/Schizophrenia
Behaviors/Thinking:
Paranoid, hyper-vigilant, responding to voices, religiousreferences, delusions
May extend their paranoia to include staff
May believe that that others are reading their thoughts,
secretly plotting against them
Socially withdrawn, focused on delusions
Not typically violent/aggressive to others
Could be self-harming or suicidal, if having commandhallucinations
May be uncooperative with an aggressive approach
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Psychosis/Schizophrenia
Emotions:
Can be very frightened, anxious
Emotionally withdrawn, suspicious, paranoid
May not be willing to share what they are feeling;
affect may be blunted
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Psychosis/Schizophrenia
Specific Strategies:
Approach slowly, using non-threatening body language
Dont feed into delusions, but dont directly contradict themeither e.g. That sounds very frightening.
Ask about voices, what they are saying, how the patient
feels about them (some are friendly voices) Assess cognitive functioning to determine level of
disorganization
If the patient is there due to safety issues, ask what would be
helpful to them to feel safe in the ER Low stimulus, medicate for agitation, consider medical
etiology if new symptoms
New onset? Plan for hospitalization and family education
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I really think my kids would be better off without me.
Depression
Acute vs. chronic (Major Depressive Disorder,dysthymia)
MDD can be a progressive illness; if left untreated canlead to SI with loss of ability to perceive situations inrational, objective way
Multiple stressors, recent trauma (especially with PTSDissues), perceived loss of control, difficulty inrelationships, medical issues can be precipitants
Genetics, personality, environment can make a personmore susceptible
Physical symptoms e.g. fatigue, headaches, nausea
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Depression
Behaviors/Thinking:
Usually cooperative in the ER, especially if no other psychissues involved (e.g. personality disorder, substance abuse)
Tend to not ask for what they need/want , believe they are aburden or that they cant trust others to care for them
May or may not have intent to hurt self, may or may notwant hospitalization vs. being set up with services
Poor sleep/ hygiene, inability to function, impaired judgment,lack of motivation, difficulty making decisions
May be trying to please others vs. caring for themselves; maynot assert themselves around getting the care they need
Negative, unrealistic thinking
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Depression
Emotions:
Affect can be flat, sad, tearful
Overwhelmed, anxious, scared, guilty, sad, insecure,hopeless
May be angry at someone, usually dont take it out onus
Can easily shut down if they perceive negativity from
staff
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Depression
Specific Strategies:
Ask what they need from ER visit, explain options e.g.connect with services
Assess extent of depression to avoid excessive restrictions
Be kind, explain what is happening; give reassurance thatyou want to help them
Offer food, warmth, comfort; may need to ask more thanonce
Ask about stressors, supports, therapists, allow family/friends ifpatient wants them
Ask about SI (vague thoughts vs. plan with intent, can helppinpoint how far the depression has progressed)
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Anxiety sets off a cascade of physical, emotional and cognitivesymptoms that can overwhelm pt.
Anxiety is a more difficult emotion to handle than anger ordepression
Patients often self-medicate with drugs, etoh
Panic attacks, phobias, PTSD-related anxiety can quickly becomemedical problems if not managed
During panic attacks, patients are unable to process what is beingsaid to them
Anxiety is a strong component of many other disorders e.g.depression, schizophrenia
Physical symptoms can include nausea, chest tightness, dizziness,headache etc
Im p re t ty sure Im ha v ing a hea rt a t tac k!
Anxiety/Anxiety Disorders
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Anxiety/Anxiety DisordersBehaviors/Thinking:
Repetitive, irrational thoughts; inability to control
anxious thoughts
Difficulty concentrating or making decisions
Can be difficult to redirect, restless, impatient
May escalate if physical symptoms are dismissed ornegated
Impulsive, poor judgment; avoidance as coping
May react out of proportion to staffs interactions
Excessive worrying, may repeatedly ask the samequestions
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Anxiety/Anxiety Disorders
Emotions:
Feelings of dread, sense of impending doom
Irritable, edgy, preoccupied with physical symptoms
Anxious about being anxious
Overwhelmed, easily frustrated, feeling of powerlessness; lack oftrust in staff
Frightened, may feel like they are losing control
Can escalate to anger, which may be easier for them to tolerate
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Anxiety/Anxiety Disorders
Specific Strategies:
Recognize, treat the physical symptoms as real
Assess the pt.s understanding of what is happening
Offer reassurance e.g. I know you are frightened but we
are going to take care of you. Specifically ask what would be most helpful to them
Needle phobias, hyperventilation
Ask what has worked for them in the past when dealing withtheir anxiety
Family/friends involvement
Humor, distraction are helpful with mild-moderate anxiety
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Assessing Suicidal Risk
Variations in Suicidal Ideation:
Chronic vs. acute
Fleeting vs. vague vs. specific
No intent vs. passive intent vs. clear intent
Impulsive vs. planned
Self-harm vs. gesture vs. attempt
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Assessing Suicidal Risk
RED FLAGS:
Planned attempt, no regret
Did not tell anyone
Unhappy about being alive
No future plans
Very irrational thinking
Specific plan, with means
Lethality of attempt
Can not contract for safety
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Assessing Suicidal Risk
Specific Strategies:
Assess level of SI Do not minimize/dismiss lethality of attempt or patients
stressors, feelings
Do not attempt to talk pt. out of it
Avoid backing suicidal pt. into a corner
Listen in a nonjudgmental way, avoid offering advice
Check with pt. before allowing visitors, phone calls
? Safety contract Explain to pt. what the process involved in formal
assessment
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Special Populations
Geriatric Patients:
Assess past history of mental health issues
Unlikely to develop personality disorders, bipolar disorder orschizophrenia past age 60
High risk for depression/suicide, esp. males, but depression is not anormal part of aging
Illness, losses, financial problems, caring for incapacitated spouse mayincrease risk of mental health issues (either exacerbation of chronic ornew onset)
May have difficulty identifying their own depression, or asking for help
Ask What is most difficult for you right now? to begin discussion
Evaluate support systems, access to services, changes in level offunctioning
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Special PopulationsAdolescents:
Rapport with parent and patient is crucial to management; avoidauthoritarian approaches
Assess safety, ability to cooperate with and understand process,relationship with parents
Common stressors for teens that lead to SI include parentaldivorce/conflict, relationship breakups, bullying, school problems
Speak to adolescent first; avoid asking about what you already know
Separate parents from kids when appropriate; do not take sideswith parent or adolescent
Ask about self-harming , SI without parent present
Allow adolescent to save face, have some control, modesty
Avoid taking behaviors personally
Remember, bribery (aka neg o t ia t ion)is underrated
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Special Populations
Medical-Psych
Both medical and psych illnesses can exacerbate each other;
important to maintain awareness
Assess psych illness with pt.s cooperation, e.g. ask abouteffectiveness of medications, sleep, stress level, supports;Please let us know if anything changes
Medications/NPO status
Educate patients about mental health issues that may resultfrom medical illnesses
Avoid dismissing physical symptoms as part of psych illness,
without appropriate assessment
Consistency among shifts with difficult pts. (?need for careplan)
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Special Populations
Substance Abusers:
Can be high risk for self-harming, suicidal behaviors
May have co-morbid psych illnesses, which will complicate treatment(e.g. bipolar disorder, borderline personality)
Self-medication for anxiety, depression, anger issues
Assess how far pt. is into addictive process; ask about effects onsupports, functioning, finances
Avoid judgmental attitudes and behaviors
Avoid direct suggestions e.g. AA
Explain sequence of tolerance, dependence, addiction
Limit education to most important thing Educate family about caring for themselves, when necessary (e.g.
Alanon, CODA, Alateen)
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The Therapeutic Relationship
Main components:
Therapeutic Rapport: consistency, reliability,confidentiality, safety, trust, respect
Nonjudgmental attitude: acceptance, validation,compassion, empathy
Alliance: support, meeting of needs, working with pt.to achieve goals
Esta b lish ing a the ra p eutic re la tio nship d oe s no t mea n
c ond on ing , a llow ing unhea lthy o r p rob lem b eha v io rs
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The Therapeutic Relationship
Establishing a therapeutic relationship is KEY to symptommanagement
Nonverbal communication
Appropriate humor
Physical needs e.g. pain control, warmth, food
Respect: avoid stripping, cathing, threats, ultimatums
Clear, reasonable, enforceable limits; give choices
Educate vs. lecture; timing is important
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The Therapeutic Relationship
What not to say:
If yo u re g o ing to a c t like a c hild , I ll t re a t you tha t w a y.
I m g o ing to c a ll the p o lic e if yo u d o n t stop tha t , he re I g o .
See ? I m hea d ing to the p hone .
I know how you fe e l.
I d o n t ha ve t im e fo r th is.
I ha ve w o rse p ro b lem s tha n you a nd I m no t su ic id a l.
Yo u ha ve a lo t to live fo r.
Yo u re c a using yo ur ow n p ro b lem s.
Are you he re a g a in?
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The Therapeutic Relationship
And what to say instead:
Tha t so und s like it is re a lly sc a ry/ d if f ic ult / o ve rw he lm ing fo ryou.
I m so rry th is is ha p p e ning to yo u.
Yo u re rig ht o r I a g re e w ith yo u.
Wha t c a n I d o to he lp you w h ile yo u a re he re ?
Wha t w o u ld b e m o st he lp fu l to yo u?
Wha t is w o rry ing yo u the m o st rig ht no w ?
It so und s like yo u m a d e the rig ht d e c isio n to c om e he re .
The se a re yo ur o p tio ns
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Summary
Both patients and staff benefit when we:
Understand psychiatric diagnoses
Anticipate, manage and prevent symptoms
Avoid punitive, controlling strategies
Increase cooperation by establishing a therapeuticrapport and alliance
Questio ns o r c omm ents
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And finally
References:
Gilbert, Sara Barr. Psychiatric Crash Cart: TreatmentStrategies for the Emergency Department. AdvancedEmergency Nursing J ournal. 31(4):298-308,October/December 2009.
Stefan, Susan, Emergency Department Treatment ofthe Psychiatric Patient: Policy Issues and LegalRequirements, Oxford University Press, 2006.
National Alliance for Mental Health, www.nami.org
Psychiatric Services,www.psychservices.psychiatryonline.org
Help Guide, www.helpguide.org/mental
http://www.psychservices.psychiatryonline.org/http://www.psychservices.psychiatryonline.org/http://www.helpguide.org/mentalhttp://www.helpguide.org/mentalhttp://www.psychservices.psychiatryonline.org/