Psychiatric
emergencies
in med-surg patients:
Are you prepared?
All nurses—not just psych nurses—
are likely to encounter patients experiencing
psychiatric emergencies.
By Marlene Nadler-Moodie, MSN, APRN, PMHCN-BC
RODNEY,
AGE
47, was admitted
to the hospital 2 days ago with rib
and femur fractures and facial contusions. He appears well nourished
and well groomed. The previous
shift’s report indicates he had a
restless night, requested pain medications, and seemed anxious. His
chart reveals a routine course with
restlessness and anxiety throughout multiple shifts.
Halfway through your shift, you
observe that Rodney is restless, is
moving about in bed, and has hand
tremors. When you walk into his
room, he is frantically brushing the
bedsheets with his hands and arms
in sweeping motions. Despite a reasonably cool room temperature,
he’s sweating profusely.
Toward the end of your shift,
you find Rodney in a panic, trying
to get out of bed. He complains of
nausea and has vomited a small
amount into an emesis basin. He is
sobbing, and yells,“There are bugs
all over the sheet!” He can’t stop
shaking.
You suspect he is in acute alcowww.AmericanNurseToday.com
hol withdrawal and needs immediate intervention to manage his
delirium tremens.
Psychiatric disorders and related
problems are common in med-surg
patients, and scenarios like this one
occur every day in acute-care hospitals. One source estimates that in
2007, 46% of the U.S. population
experienced such mental-health disorders as anxiety, impulse control,
and substance abuse. In 2006, psychosis was the third-highest-volume
CE
1.7 contact
hours
L EARNING O BJECTIVES
1. Describe how to assess patients
for potential psychiatric problems.
2. Identify signs and symptoms of
common psychiatric emergencies
on the med-surg unit.
3. Discuss appropriate interventions
for common psychiatric
emergencies.
diagnostic-related group (DRG).
This DRG (430) includes major personality disorders, such as schizophrenia, catatonia, bipolar affective
disorders, and paranoia.
People with psychosis or substance use disorders are at risk for
the same health problems as any
other population subset. What’s
more, even patients without preexisting mental disorders may become anxious and apprehensive
when hospitalized, which may alter their behavior. Consequently,
aberrant social behaviors may increase in the hospital setting.
Bottom line: You don’t have to
be a psych nurse to encounter patients experiencing psychiatric
emergencies. That’s why all nurses
should have a basic knowledge of
psychiatric nursing, regardless of
the setting they work in.
Identifying psychiatric
emergencies
On med-surg units, common psychiatric problems include psychosis, substance abuse and withMay 2010
American Nurse Today
23
Hallmarks of psychosis
Psychosis is a state of being out of touch with reality. Key signs and symptoms include hallucinations and delusions.
• Hallucinations manifest as reports of false sensory input, such as seeing visions,
hearing voices, smelling and tasting various sensations, and tactile disturbances.
In some cases they’re a hallmark of a frank psychiatric disorder. In others, they
arise secondary to such conditions as infection, high fever, drug toxicity, and
brain anomalies.
• Delusions are false fixed beliefs with no basis in reality—for instance, the belief
that “there’s a conspiracy against me.” A patient may claim that “all the doctors in
this hospital want to experiment with my brain and send it to outer space for future dealings with aliens.” As with hallucinations, delusions can stem from a psychiatric disorder or result from delirium or medical-surgical complications.
drawal, delirium, anxiety, aggression, bipolar disorder, personality
disorders, and suicidal behavior or
ideation. To ensure appropriate intervention, these problems need to
be identified early and their cause
must be determined. (See Hallmarks of psychosis.)
Signs and symptoms of psychiatric problems cross over into
many diagnostic categories. Nurses
skilled in early assessment of
these disorders are best prepared
to intervene. During your assessment, seek corroboration from
family members, look for a history
of such problems in the patient’s
medical record, or document the
patient’s report that he or she has
a known psychiatric disorder.
Generally, psychiatric disorders
are long-term problems with exacerbations and remissions. Knowing
if your patient’s current psychotic
symptoms are secondary to an ongoing psychiatric disorder can
guide interventions.
Medication reconciliation can
yield valuable clues. Has the patient been taking psychiatric medications routinely? If so, which
ones? Did she recently stop taking
such drugs? If so, when? Is she
taking the prescribed dosage at
the prescribed frequency? Some
psychiatric medications can be
dangerous if they build up to a
toxic blood level; for example,
toxic levels of lithium exceed 1.5
mEq/L. Finding out if the patient’s
24
American Nurse Today
taking too much or too little of a
prescribed medication can help
the healthcare team stabilize the
drug regimen as soon as possible.
If the patient has no known
psychiatric disorder, continue to
assess all aspects of the current
situation to determine what might
be causing the signs and symptoms. Alleviating the cause may
resolve the problem. In other cases, short-term use of antipsychotic
drugs can calm the patient and reduce agitation.
General goals of care
While each type of psychiatric
emergency requires specific nursing interventions, these general
care goals apply to all:
• Assess the problem or potential
problem early.
• Maintain a safe environment.
• Intervene appropriately using
all available resources.
• Ensure an appropriate followup plan, if needed.
Know that good communication
and interpersonal skills are crucial
when dealing with patients experiencing psychiatric emergencies.
(See Key communication tips.)
Substance intoxication and
withdrawal
As with Rodney in the opening
scenario, substance intoxication or
withdrawal can pose a psychiatric
emergency. Intoxication with various substances can cause aggres-
Volume 5, Number 5
sive behavior. Especially during
physical assessment, patients may
believe you are going to harm
them and may become combative
or assaultive.
Acute alcohol withdrawal is
common in med-surg patients and
must be treated. But be aware that
some patients aren’t truthful about
their alcohol intake. Alcohol withdrawal may not occur for 24 to 72
hours after the last drink, so withdrawal symptoms may come as a
surprise to caregivers a few days
after a patient’s admission.
Alcohol withdrawal signs and
symptoms include high blood
pressure, tachycardia, fever, hand
tremors, insomnia, nausea and
vomiting, anxiety, generalized tonicclonic seizures, and transient visual, tactile, or auditory hallucinations. Progression to delirium
tremens includes disorientation,
delusions, severe agitation, profuse perspiration, and fever. The
most serious phase of alcohol
withdrawal, delirium tremens has
a mortality of 5% to 30%.
Intervention
Alcohol withdrawal symptoms can
be managed fairly easily with immediate and consistent care. Early,
continuous treatment promotes
rapid stabilization. Benzodiazepines, such as chlordiazepoxide
or lorazepam, routinely are given
every 4 to 6 hours; patients receiving these drugs should be monitored closely.
A common, easy-to-administer
tool for assessing alcohol withdrawal and guiding management
is the Clinical Institute Withdrawal
Assessment—Alcohol, Revised (CIWA-AR). It takes about 5 minutes
to administer and yields
a score indicating the severity of
the patient’s withdrawal symptoms. To use it, the examiner asks
specific questions or makes specific observations.
The primary care goal for patients in acute alcohol withdrawal
www.AmericanNurseToday.com
Key communication tips
Keep in mind that patients with behavioral or psychiatric problems may be unable to think clearly and may
lack good judgment and decision-making skills. When
speaking with them, use short sentences with short
words, and avoid long or complicated messages. A rule
of thumb is to use words with five or six letters in sentences containing five or six words. For example, “Stay
calm and rest here” or “Please drink this water now,
slowly.”
Avoid arguing with a patient who has psychotic
symptoms. If she is hallucinating or reports that others
are conspiring against her, don’t state, “There are no bats
flying around the room” or “There’s no conspiracy.” The
patient’s reality tells her you’re wrong. Instead, say, “I believe you, but I don’t see the bats.” That way, you’re not
suggesting the patient is lying or that you don’t believe
her; you’re simply letting her know her reality isn’t your
reality. This may give her reason to question whether her
hallucinations are real.
is to promote safe withdrawal
without injuries or medical complications. Nursing care includes:
• monitoring vital signs
• maintaining a quiet, calm environment
• offering support and reassuring
the patient he or she is safe
• instituting fall precautions
• addressing pain caused by medical-surgical conditions (and not
withholding analgesia)
• promoting good hygiene
• monitoring food and fluid intake
• encouraging supportive family
members and others to stay at
the bedside
• promoting use of relaxation
techniques, such as soft music,
controlled breathing, and visualization.
Delirium
Many med-surg patients experience delirium secondary to stroke,
intracranial tumors, trauma, surgical complications, fever, infection,
heart failure, substance toxicity or
withdrawal, sedative drugs, or excessive or deficient stimuli. Among
the elderly, delirium is common
with or without mental illness.
Whatever its cause, delirium
may result in:
• perceptual disturbances
www.AmericanNurseToday.com
•
•
•
•
•
•
•
disorientation
restlessness
reduced level of consciousness
disorganized thinking
decreased attention span
memory impairment
sleep disturbances.
Delirium resembles dementia to
some extent. However, signs and
symptoms of delirium tend to be
labile (in some cases, unpredictably so) while those of dementia are less likely to fluctuate. (See
Differentiating dementia and
delirium.)
Intervention
The behavioral problems that can
accompany delirium may interfere
with routine nursing care, causing
frustration for care providers. Also,
patients with delirium may be unable to participate in their care.
Nursing actions should include
providing structure, as routines are
helpful to patients with disorganized thinking. Maintain an orderly
environment, keeping items in the
same place and within the patient’s view. Because of fluctuating
signs and symptoms, finding the
right time for certain interventions
can promote a better outcome.
Be aware that you may have to
repeat yourself when speaking to
the patient. And sometimes you
may need to back off and wait until the patient is calmer and more
receptive. Also, finding distractions
from the task at hand can be helpful if the patient is particularly disturbed or distraught by your interventions. Remember—if you don’t
insist emphatically, the patient
isn’t likely to resist. In light of the
disorganized thinking caused by
delirium, giving patients some
space and options can help you
gain their cooperation.
Violent behavior
Violent behavior may result from
such problems as substance intoxication, disordered or paranoid
thinking and beliefs, and anger.
Violent patients are a threat to
their own safety as well as that of
staff members, other patients, and
visitors.
Generally, violent outbursts
don’t occur suddenly without
warning. For example, agitated patients experience an inner tension
that may manifest as hyperactivity
and behavioral disorganization. So
stay alert for violent tendencies.
Trust your own judgment and tell
others of your concerns.
Intervention
If a patient becomes violent, maintaining the safety of everyone involved—the patient, yourself, other staff members and patients, and
anyone else in the immediate
area—takes priority. Don’t approach the patient alone. Ask colleagues to remain nearby; no one
should be isolated or left in a vulnerable space with a potentially
violent patient.
Make sure you can’t be trapped
away from an exit. Check the environment for dangerous objects.
Stay out of the patient’s physical
space while keeping the patient
within view at all times.
Many hospitals have an emergency procedure for managing violent persons. Nursing staff must
receive training on how and when
May 2010
American Nurse Today
25
Differentiating dementia and delirium
Dementia is sometimes confused with delirium, but with adequate knowledge and
assessment skills, you can differentiate the two disorders and help ensure appropriate intervention. Patients with dementia lack full cognitive capacity. Like those with
delirium, their memory and judgment may be impaired. However, dementia signs
and symptoms are less dramatic then those of delirium and are less likely to fluctuate. Also, dementia has a slow, steady insidious onset and progression, whereas
delirium has a rapid onset.
to initiate this procedure. Enacting
periodic mock scenarios helps
prepare staff for a true emergency.
Staff members should use deescalation techniques and crisis
communication to avert aggressive
behavior. (See Managing a psychiatric crisis.) All healthcare facilities
should implement and provide
staff education in violence deescalation. Well-known programs
include those from the Crisis Prevention Institute, Mandt System,
and Pro-ACT. Some facilities have
designed their own de-escalation
programs.
Early identification of and interventions for violent behavior promote appropriate care planning
and improve communication
among team members, who can
share their perception of what
works and what doesn’t. For instance, staff members can alert
each other to potential violence
triggers.
Use of restraints
Violent patients who pose an immediate danger to themselves or
others may need to be physically
restrained for a brief period until
they can gain self-control. However, patient injuries and litigation
risks associated with physical restraints are well documented, so
restraints should be avoided whenever possible. Use them only as a
last resort for the shortest time
needed and in the least restrictive
manner possible—and only if
you’ve been trained in the proper
application technique. The restrained patient should be moni26
American Nurse Today
tored closely and appropriate interventions followed. Several regulatory agencies, such as the Centers
for Medicare & Medicaid Services
and the Joint Commission, have
established guidelines for restraint
use. Most likely, your facility has a
policy and procedure that comply
with these guidelines. All nurses
applying restraints need to be familiar with these.
Medications
Medications may be given to calm
a violent patient and promote selfcontrol. Work with the physician
to identify the need for medication. Encourage the patient to ac-
Suicidal patients
Some med-surg patients have suicidal thoughts or exhibit suicidal behavior. Patients may be hospitalized
after a failed suicide attempt, such
as an intentional drug overdose,
hanging, or a nonfatal gunshot
wound. Other med-surg patients
may become suicidal when hospitalized for other reasons. A 2007
Patient Safety Goal of the Joint
Commission was to identify patients
with suicidal ideation. Although that
goal applies mainly to patients being treated for mental illness in psychiatric settings, acute-care general
hospitals can adopt it to assess for
this potential problem.
Intervention
For a patient with known or suspected suicidal tendencies, take
appropriate precautions. Med-surg
units can pose a danger to such a
patient; even psychiatric units
aren’t completely safe. As a rule of
thumb, assume no place is completely safe. Patients can hang or
strangle themselves with sheets,
se de-escalation techniques and
crisis communication to avert
aggressive behavior. Some facilities
have designed their own
de-escalation programs.
U
cept the recommended drug, and
administer it before the patient’s
behavior escalates. Medications
commonly used to reduce agitation include lorazepam (alone or
in combination with haloperidol)
and atypical antipsychotics, such
as risperidone, olanzapine, and
ziprasidone. These drugs are available orally; some can be given intramuscularly. Haloperidol (lactate
form only) is available for I.V. use.
Volume 5, Number 5
towels, bedclothes, tubing, or
cords. They may take large doses
of drugs (legal or illegal) that they
have brought with them or saved
up. Also, sharp objects abound in
hospitals, and even plastic cutlery
can prove dangerous to those intent on harming themselves.
The best approach is to closely
monitor the patient’s environment
and behavior. Patients at high risk
for suicidal behavior should receive
www.AmericanNurseToday.com
Managing a psychiatric crisis
If your patient experiences a psychiatric crisis, use the following
techniques to help de-escalate the situation.
• Maintain a calm demeanor.
• Speak in a soft, clear voice.
• Convey empathy. For instance, ask, “How can I help you?”
• Allow the patient to vent.
• Listen to the patient; then reflect back what she has said so she
knows you’ve been listening. This may make her more likely to be
receptive to you.
• Use appropriate problem-solving techniques.
• Offer reassurance and support. Let the patient know you’re trying
to ensure her safety.
• Avoid a power struggle.
• Don’t argue with the patient.
• Keep your options open by avoiding definitive statements.
one-on-one care. The staff member
should stay within arm’s reach of
the patient at all times and never
leave, even for a break, until directly relieved by another staff member.
Special skill sets
If you work in a setting where
many patients pose behavioral
problems, consider obtaining further education in psychiatric problems and crisis management. For
instance, emergency departments
see more psychiatric emergencies
than other hospital areas. Patients
in intensive care units have a
higher acuity and thus may require different approaches and interventions in psychiatric emergencies. If you work on a pediatric
unit, you may require a specialized skill set to care for children
and adolescents with psychiatric
or emotional problems. A maternity nurse may encounter patients
with severe postpartum psychiatric
emergencies that call for interventions encompassing the mother,
newborn, and family.
Psychiatric emergencies can occur in any healthcare setting—
acute-care, hospice, long-term
care, and outpatient clinics as well
as psychiatric facilities. Nurses caring for patients from all walks of
life with any type of healthcare
problem can expect to encounter
patients who are at risk for or are
experiencing a psychiatric crisis.
Make sure you have a fundamental understanding of psychiatric
problems, including their identification and intervention.
✯
Selected references
Allen M, Currier GW, Hughes DH, Reyes-
CE POST-TEST —
Psychiatric emergencies in med-surg patients:
Are you prepared?
Instructions
To take the post-test for this article and earn contact hour credit,
please go to www.AmericanNurseToday.com/ContinuingEducation
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If you are unable to take the post-test online, complete the
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Harde M, Docherty JP. The Expert Consensus
Guidelines™: Treatment of Behavioral Emergencies. A Postgraduate Medicine Special Report. New York, NY: McGraw-Hill; 2001.
Fossett B, Nadler-Moodie M, Thobaben M.
Psychiatric Principles and Applications for
General Patient Care. 4th ed. Brockton, MA:
Western Schools; 2004.
Gilbert SB. Psychiatric crash cart: Treatment
strategies for the emergency department.
Adv Emerg Nurs J. 2009;31(4):298-308.
Hermanns MS, Russell-Broaddus CA. “But I’m
not a psych nurse!” RN. 2006;69(12):28-31.
Kerrison SA, Chapman R. What general emergency nurses want to know about mental
health patients presenting to their emergency
department. Accid Emerg Nurs. 2007;15:48-55.
Ramadan M. Managing psychiatric emergencies. Internet J Emerg Med. 2007;4(1). http://
www.ispub.com/ostia/index.php?xmlFilePath
=journals/ijem/vol4n1/psycho.xml. Accessed
March 10, 2010.
Stokowski L. Alternatives to restraint and
seclusion in mental health settings: Questions and answers from psychiatric nurse experts. Medscape Nurses. May 5, 2007. http://
www.medscape.com/viewarticle/555686. Accessed March 10, 2010.
Sullivan JT, Sykora K, Sneiderman J, Naranjo
CA, Sellars EM. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWAAR). Brit J Addict. 1989;84:1353-1357. www3
.interscience.wiley.com/journal/119445441/
abstract. Accessed March 10, 2010.
Marlene Nadler-Moodie is a clinical nurse specialist
in psychiatry and mental health nursing at Sharp
Mesa Vista Hospital and Scripps Mercy Hospital in
San Diego, California. The planners and author of
this CNE activity have disclosed no relevant financial
relationships with any commercial companies
pertaining to this activity.
Provider accreditation
The American Nurses Association Center for Continuing Education and Professional Development is accredited as a provider of continuing nursing education
by the American Nurses Credentialing Center’s Commission on Accreditation.
ANA is approved by the California Board of Registered Nursing,
Provider Number 6178.
Contact hours: 1.7
Expiration: 12/31/13
Post-test passing score is 75%.
ANA Center for Continuing Education and Professional Development’s accredited provider status refers only to CNE activities and does not imply that
there is real or implied endorsement of any product, service, or company referred to in this activity nor of any company subsidizing costs related to the
activity. This CNE activity does not include any unannounced information
about off-label use of a product for a purpose other than that for which it
was approved by the Food and Drug Administration (FDA).
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CE
POST-TEST • Psychiatric emergencies in med-surg patients: Are you prepared?
Earn contact hour credit online at www.americannursetoday.com/ContinuingEducation.aspx (ANT100501)
Please circle the correct answer.
1. Which statement about psychiatric problems is
correct?
a. Psychiatric disorders in med-surg patients are rare.
b. People with psychoses are at lower risk for health
problems than other population subsets.
c. Psychosis is the seventh-highest-volume diagnosticrelated group.
d. Nearly half of Americans have experienced mentalhealth disorders.
2. Which strategy for early identification of psychiatric
problems in med-surg patients is not appropriate?
a. Seek corroboration from family members as
needed.
b. Determine if the patient is taking psychiatric
medications.
c. Assume that psychiatric disorders are short-term
problems.
d. Assess for possible causes if the patient has no
known psychiatric disorder.
3. When communicating with patients with psychiatric
problems who can’t think clearly or who lack good judgment and decision-making skills, you should:
a. contradict the patient’s skewed view of reality.
b. agree with the patient’s skewed view of reality.
c. use words of 8 to 10 letters in sentences containing
six to eight words.
d. use words of five or six letters in sentences containing five or six words.
4.
Which statement about hallucinations is accurate?
a. They manifest as reports of false sensory input.
b. They do not stem from such conditions as infection
or drug toxicity.
c. They involve beliefs that have no basis in reality.
d. They manifest as reports of conspiracies against the
patient.
5.
Which statement about delusions is true?
a. They are fixed beliefs with no basis in reality.
b. They do not arise from a psychiatric disorder.
c. They do not arise from med-surg complications.
d. They manifest as seeing visions or hearing voices.
6. Alcohol withdrawal may not occur until how many
hours after a person’s last drink?
a. 6 to 10 hours
b. 10 to 20 hours
c. 24 to 48 hours
d. 24 to 72 hours
7. A common, easy-to-administer tool for assessing
alcohol withdrawal and guiding treatment is the:
a. Clinical Institute Withdrawal Assessment—Alcohol,
Revised.
b. National Institute Withdrawal Assessment—Alcohol,
Edited.
c. National Alcohol Withdrawal Assessment—Revised.
d. Clinical Alcohol Withdrawal Assessment—Edited.
8. Which of the following is a sign or symptom of
alcohol withdrawal?
a. Absence seizures
b. Bradycardia
c. High blood pressure
d. Sleepiness
9.
Which statement about dementia is accurate?
a. Dementia has a rapid onset.
b. Patients with dementia have full cognitive capacity.
c. Patients with dementia lack full cognitive capacity.
d. Dementia signs and symptoms are dramatic.
10. Which statement about delirium is accurate?
a. Delirium does not impair the patient’s memory.
b. Delirium has a rapid onset.
c. Delirium signs and symptoms are not dramatic.
d. Delirium progresses steadily.
Evaluation form (required)
1. In each blank, rate your achievement of each objective from 1 (low/poor) to 5
(high/excellent).
(1.) Describe how to assess patients for potential psychiatric problems. ____
(2.) Identify signs and symptoms of common psychiatric emergencies on
the med-surg unit. ____
(3.) Discuss appropriate interventions for common psychiatric emergencies. ____
Purpose/goal: To help med-surg nurses identify and manage
CE: 1.7 contact hours
11. Which intervention might be appropriate for a
patient with delirium?
a. Avoid an orderly environment for a patient with disorganized thinking.
b. Avoid routine for a patient with disorganized thinking.
c. Frequently change the location of items in the room.
d. Distract a distraught patient from the task at hand.
12. To de-escalate a psychiatric crisis, you should:
a. maintain a calm demeanor.
b. speak in a firm, loud voice.
c. prevent the patient from venting.
d. interrupt to distract the patient.
13. Which strategy is appropriate when dealing with a
patient who has become violent?
a. Approach the patient alone.
b. Don’t approach the patient alone.
c. Ask colleagues to stay far away.
d. Move into the patient’s physical space.
14. Which statement about the use of restraints for a
patient with violent behavior is correct?
a. Restraints rarely are associated with a risk of
litigation.
b. Once applied, keep restraints on the patient for at
least 4 hours.
c. Regulatory agencies typically don’t issue guidelines
on restraint use.
d. Restraints should be avoided whenever possible.
15. Patients at high risk for suicide should be:
a. receiving one-on-one care.
b. left alone for no more than 5 minutes.
c. restricted from access to plastic cutlery.
d. left alone for no more than 10 minutes.
Also rate the following from 1 to 5.
2. The relatedness and effectiveness of the purpose, objectives, content, and
teaching strategies. ____
3. The author(s)’competence and effectiveness. ____
4. The activity met your personal expectations. ____
5. The application to and usefulness of the content in your nursing practice. ____
6. Freedom from bias due to conflict of interest, commercial support, product
endorsement or unannounced off-label use. ____
7. State the number of minutes it took you to read the article and complete the
post-test and evaluation. ____
psychiatric emergencies
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