Managing Psychiatric Symptoms & Challenging
Behaviors in the Medical-Surgical Patient:
Evidence-Based Strategies &
‘Tools for your Trade’
Dr. Kim Cox MSN, DNP, ANP-BC, APNP-BC
Assistant Professor, University of San Francisco
School of Nursing & Health Professions
April 17, 2015
Learning Objectives
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Identify common, difficult behaviors & psychiatric symptoms &
conditions presenting in the medical-surgical patient.
Describe current barriers, health care consequences &
complications that occur with patients with behavioral health
symptoms & psychiatric conditions.
Identify common medical conditions that place patients at high-risk
for psychiatric & behavioral health symptoms.
Assist the medical-surgical nurse to identify high risk behavioral &
psychiatric symptoms & management strategies.
Describe evidence-based strategies (‘Tools’) that medical-surgical
nurses can add to their ‘Toolbox’ to use ‘in-the-moment’ & at-thebedside with patients to better identify & manage a variety of
common psychiatric symptoms & behavioral health problems.
Terms & Goals
‘Difficult’, ‘Challenging’, ‘Problem’ behaviors (bx’s)
‘Psychiatric symptoms’(sxs)
‘Psyche diagnoses’ (dx’s)
‘Psychiatric conditions’
ANY
‘Psychiatric diseases’ (dz’s)
‘Behavioral health disorders’
Patient!!
‘Crisis’ etc.
Goals (regardless of psychiatric ‘diagnosis’ or not):
 Manage Symptoms & Behaviors (NOT diagnoses or labels)
Prevent, Minimize, Stabilize
 To safely, effectively & efficiently manage (minimize
& stabilize) patient problems to provide the best
care possible; reduce risks & complications.
 less problems, smoother shifts.
Understanding Behavior
Crisis:
An experience of anxiety, aberrant/unusual behavior or symptoms
that go beyond a person’s typical coping;
– Many hospitalized patients are ‘in crisis’.
• may act out, regress to earlier stages of development, express
atypical, odd, or difficult behaviors &/or just behave differently than
their usual selves.
• In general, med-surg patients are sicker, increasingly more complex,
& have more co-morbidities.
– ANY hospitalized patient (regardless of diagnosis) can have
behavioral symptoms &/or be ‘in-crisis’.
CAN be a BARRIER to quality care & make nursing job harder.
TOOL 1:
ABCD’s
Recognize BEHAVIORS
Identify Common ‘Difficult’ Behaviors, ‘Crisis’
• Anxious
– Stressed, feels out of control, may be severe…Panic, Paranoia etc…
• Angry / Acting out
– Complaining, Frustrated, Hostile
– Aggressive, Agitated to Assaultive / Violent
• Manic, Psychotic, Delirious, Demented, SUDs, Personality Disordered (PD)
• Bored / Overwhelmed (Under-stimulated or Over-stimulated)
• Confused / Disorganized
• Demented, Delirious, Mood Disorders, Anxious, Substance-Using/Detoxing - AWS
• Dependent ‘needy’, regressed or child-like behavior
• Anxious, Depressed, Personality Disordered (PD)
• Depressed, unmotivated, non-adherent pt
– Suicidal
– Manic, Depressed, Eating Disorders, Anxious, Substance-Using/Detoxing, PD
Common Medical Conditions associated with Psychiatric Symptoms
MIND - BODY CONNECTION
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Cancer- depression may precede a diagnosis, comorbid anxiety, depression
CVD (Endocarditis, HTN, Obesity, Dyslipidemia) - directly associated with Depression
DM /Metabolic Syndrome - depression, sleep, memory (heart healthy - brain healthy)
Chronic Pain conditions/Skeletal-Connective Tissue dz’s - depression, anxiety, PTSD, SUDs, PD’s
Dementia & Parkinson’s Disease - anxiety, depression are early signs; personality changes, lack of
motivation, sleep disruption, memory /concentration problems, hypersexuality, inappropriate bx’s.
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Delirium - confusion, combativeness, sleep-wake disruptions, hallucinations.
Dental Disorders - CVD associations- Substance use disorders (SUDs)
Gastrointestinal (Eosophageal, GERD) - SUDS, EDS
Intellectual / Developmental disabilities - anxiety, depression, personality issues.
Respiratory infections (PNA/Influenza/TB, COPD) - acute & chronic anxiety, depression
Skin infections (sepsis, wounds, poor healing) - IDU
Infectious Disease (HIV, Syphilis, fever, rash, seizures) - IDU
Pancreatitis- Alcohol, Alcohol Withdrawal Syndrome (AWS)
Liver Disease (Hepatites, Cirrhosis) - fatigue, depression, SUDs
MS - co-morbid anxiety, depression, sleep, memory
Traumatic injuries, TBI’s, Falls, Fractures - Anxiety, PTSD, Depression, SUDs, sleep, memory disruptions.
TOOL 2: Recognize Barriers
Understanding can improve nursing care for
patients with psychiatric symptoms!
Prevalence:
Psychiatric symptoms, conditions & histories are COMMON:
• 1 in 3 adults in any 12 mos pd.
• 1 in 2 individuals in lifetime.
• Often undiagnosed / unrecognized (esp. in medical, pre & post-surgical pts) … until problems.
• These patients admitted to hospitals may arrive sicker!
Poorer Outcomes & Quality of Life (QOL) & Generally less healthy; Less Supports:
- Increased Morbidity rates, Premature Mortality
- problems navigating HC system, may not have PCP / regular care
Discharge Planning:
- Poor Communication, acute & chronic conditions- adds to difficulty with placements, transitions, follow-up
care  longer, more costly, complicated hospital LOS.
Increased Symptoms & Complications:
- Worsen medical conditions, healing, treatment adherence & communication.
• Some surgical patients stop psychiatric meds->Worse underlying symptoms & Discontinuation
syndromes - may worsen nausea, other sxs (not necessary to stop psych meds completely)
• ‘Dual diagnosis’
• Changing demographics / Aging population-
Essential Elements
– Nurses are in optimal position to offer:
“Symptom (or Behavioral) Management” (includes medications)
(aka Comfort Care, Palliation/Palliative Care & Risk Prevention)
YOU = most important “Tool”!
– No special certifications.
– Ongoing education, Awareness, Motivation
– Fundamental nursing skills:
» Assessment & Communication
» Patience & Open-mind
» Confidence & Flexibility
– Not every tool works with every patient or problem every time but,
– More strategies for “TOOLBOX”
» increases options & flexibility as pts, sxs & situations change.
TOOL 3:
Don’t be a hammer!
Psychiatric conditions = generally chronic with exacerbations & remissions
- May be life-long patterns of behavior or just temporary ‘crisis’ – same goals
- Patients in crisis, h/o traumas etc-- sensitive to voice, tone, energy levels
- Heavy handed approaches, adv ice-giving, convincing - do not work
- Realistically, we are cannot, nor should we try, to fix all pts or every problem.
- Resist the urge to address every problem or issue, or to force issues…
- If we enter into power struggles with pts, we lose - not aligned with them.
It’s not about the Nail…
► 1:42
It's Not About The Nail – YouTube
www.youtube.com/watch?v=-4EDhdAHrOg
Goals:
-Manage
-Minimize
-Stabilize!
TOOL 4:
Empathy
What works?
LISTEN / Empathy
– “Resist urge to ‘fix-it’. Sit on your hands & Listen.”
‘Less FIXIN’, More LISTENIN’
(Berg-Smith, S. 2013, Dec. MINT training)
– Understand big picture meaning of what is communicated.
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• Patient’s perspective
• Connect to underlying emotions - Sadness, Fear, Anger/Frustration
Offer Genuine Empathic responses (not questions):
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“This is really frustrating for you.”
“I can see …. how hard this is for you.”
“I can hear …… that you are really struggling with this.”
“I can understand…”, “I get how painful…”
“You feel...”
Decreases Resistance - reduces problematic behaviors, defuses
risky situations, improves feelings, symptoms & situations.
TOOL 5:
Positive Framing
• Motivation:
– Influences behaviors & change.
– Everyone has basic needs, drives & desires (motivations).
– We can all relate to needs for comfort, safety, to feel in control, be free of
pain, thirst, hunger, fatigue, nausea…
‘What is it that you need?’ & ‘What is bothering you?’
• Communication:
– Recognize & Offer Empathy (connect to motivations).
– Partner with patient: reduces ‘us-them’ mentality/ resistance; Use words
that tap into pts needs/motivations to improve symptom options &
adherence.
“This medication will help you to feel more comfortable, calm your mind, help
with your thinking, memory, sleep, to feel more relaxed, more like your old
self…” etc.
TOOL 5:
Positive Framing
Positive Framing - Communication:
 improves hope, pt self-beliefs/abilities,
willingness, adherence & motivation =
adherence … improves care!
• Responsibility onto patient; empowers pt, builds self-efficacy
• May prompt healthier mindset (‘mind-over-matter’ or
‘placebo’ response- real physiological improvements).
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Anxiety, insomnia – can worsen pain / coping …
Least amount of medication to get the job done.
Offering ways to manage sxs improves pain perception & coping.
May reduce need for medications, complications etc.
CASE
‘Communication Crisis’
A 65 y/o Caucasian male s/p right THR day...
The patient is progressing well & adhering to
treatment plan. Is restarting his typical home med
regimen. Pt c/o of N/V/D & dizziness. Pt’s adult
daughter has come to visit & is at the bedside.
The nurse takes VS, offers scheduled
medications. VS elevated. Pain: 6/10.
Nurse: “This is your pain pill & this is your antidepressant.”
Pt immediately appears flustered;
Angrily states:
“I don’t have depression. Those aren’t my pills. I
think you made a mistake. I don’t take that!”
(refuses medication).
Which behavior(s) are occurring?
Which barrier(s) are playing out?
Impact of
Stigma:
Recognize Barriers
… especially those that can be changed…
1) Pt’s SHAME, EMBARRASSMENT (or feelings of being out of control, anger)
2) Pt’s Mistrust of System: “Us-Them” increases resistance = non-adherence.
-i.e. BIB Police or in handcuffs… use of restraints… adds to ‘crisis’ behaviors
3) Symptoms themselves: depression, anxiety, insomnia --> lack of ability,
interest/willingness/motivation, memory, concentration, decision-making problems
 NON-Adherence & poor management are common (r/t less willingness or ability to
admit symptoms/seek treatment/adhere to care plans; denial or refusal care).
4) Our FEARS, FEELINGS, ATTITUDES  poor care & pt satisfaction, longer LOS.
5) Labels-‘crazy’, ‘manipulative’, ‘med-seeking’, ‘non-compliant’ pt avoidance, risks)
6) Communication - misunderstanding symptoms or causes
-Psych Med. Withdrawal & underlying behavioral health symptoms
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Nurses can improve trust, communication & adherence by being aware of barriers.
Checking in with patients, family, providers & colleagues.
Using pts’ words for symptoms & treatments improves adherence & care.
(communication/medication education)
TOOL 6:
Self-Check (Be aware)
Nurses commonly report these sentiments:
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“Psych scares me.”
“Psych makes me uncomfortable.”
“Psych is too ‘touchy-feely’.”
“Psych nurses don’t do ‘real’ nursing.”
“Psych doesn’t use ‘real’ skills.”
“I didn’t go into psych for a reason.”
“I don’t know what to say to ‘psych patients’.”
When working with patients with psychiatric symptoms &/or difficult behaviors,
nurse often describe feeling:
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‘ineffective’
‘scared’
‘anxious’
‘unsafe’
‘overwhelmed’
‘manipulated’
‘fatigued’
‘disrespected’
‘angered’
‘incompetent’
‘stressed’
‘frustrated’
‘irritated’
‘used’
‘exhausted’
‘unappreciated’
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You are not alone if
you have ever felt
this way!
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CASE
The ‘Psyched Out ‘Psych Nurse!
Patients with psychiatric / behavioral sxs can be difficult,
draining!
Nursing Barriers from the evidence:
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Increased work-load, fatigue, & burnout
Time-management, organizational / budgetary restraints
Lack of support, resources, knowledge, skills & training.
Communication problems & non-adherence to treatments, resulting complications.
added stress & challenges of providing care are common.
Our fears & feelings are common… But they can be ‘Contagious’!
 can worsen behavior!
- Many complex reasons exist as to why nurses feel inadequate or challenged
when caring for patients with psychiatric symptoms & difficult behaviors.
*Identification & Awareness of barriers, problems & discomforts are
important initial steps to improving the ability to effectively manage
& care for challenging patients.
“We need to be honest about our thoughts, beliefs, attitudes toward people … with
psychiatric disorders”.
-Boylan & Waite (2013). Psychiatric Comorbidities in Med/Surg.
TOOL 7:
Take a Moment
‘Take your Temperature!’ (virtual temp)
(Identify how you are feeling / SELF- AWARENESS)
Self-Check:
1. ‘Take a Moment’ BREATHE…
2. Try to let go of any stress, frenetic energy etc… before addressing pt.
3. “Let it Go”…
(ongoing self-care is key: seek supports, outside interests, vent etc)
– Learn to recognize personal feelings when working with patients.
– Identify Barriers (stigma, crisis, communication, labels, fears, feelings etc) that may be
WORSENING patient sxs or behaviors.
– Sometimes, it’s the small, simple things that make the biggest differences!
TOOL 8:
“Don’t let them see you sweat”
(like many things… it’s in the approach)
Approach patient with a calm, even, confidence:
PROJECT
CONFIDENCE
Even if you are not 100% confident inside…
Try to project / present yourself with confidence:
-Exhibit (model) the behavior that you want the patient to do:
-Nurse actions, behaviors & words should communicate:
“I am calm, in-control, safe, appropriate and respectful”.
What have we learned thus far…
CASE
‘Petite Paranoid Polly’
A middle-aged female is admitted for medical complications r/t
malnourishment & dehydration. Nurse approaches her to start an
IV. Patient appears guarded with a piercing glare towards the nurse.
Her eyes dart nervously around the room & towards the hallway.
States the doctors are trying to poison her and are part of a
conspiracy with her family & landlord to ‘punish & evict’ her.
Pt asks: “See those two doctors out in the hallway? “
Nurse looks & responds that she sees two hospital employees wearing
scrubs & conversing in the hallway. She starts the IV set up.
Patient asks: “What are you doing? I thought you said that you see
them? Can’t you understand? They are all trying to kill me! Don’t you
dare touch me. I don’t want any of that (poison)!”
Patient starts to continuously move her arm in an up & down motion
to keep the nurse from proceeding with the IV.
Aggressive Behaviors / Violent or
Assaultive Behaviors:
Understand the Barriers & Behaviors & BE Self-aware (Tools 1 & 2)
Delusions: false fixed beliefs
(no logic or reasoning will change them; don’t argue or try to convince the patient otherwise).
Paranoia:
• Extreme form of anxiety & self-protection (like the cornered animal who lashes
out in self-defense)…
• Any lack of awareness &/or anxiety can be ‘contagious’…
• Patient may sense anxiety (and/or that we don’t understand the seriousness of
threats against them) & perceive the situation as unsafe.
• This can result in acting out, striking in self-defense… potentially assaultive bx.
Key points:
Confidence, Awareness
Listen/Connect to meaning – Trust
Empathy – validates pt experience (validation is recognition of their experience… not the
specific threats or the exact content of their words)
CASE
‘Petite Paranoid Polly’
What might happen if the nurse:
A) avoids or ignores what the patient communicated?
- may escalate & the problem does not go away
B) colludes or agrees with the patient’s specific delusions or beliefs?
-erroneous thinking & non-adherent bx are reinforced; creates split
C) disagrees, argues or refutes the delusions or beliefs?
-you are now part of the conspiracy, patient may escalate
D) What other issues or barriers might be playing out?
-communication, extreme anxiety, underlying risks from non-adherence
E) What is the patient communicating?
F) What might be the possible impact of the nurse’s approach, tone, &
feelings convey?
TOOL 9:
Limit-Setting
• What is limit-setting?
– Assertive communication (respect for self & patient) “I” statements.
– Describes & explains in simple, clear & direct manner what behavior is
expected.
– Consistently holds pt. to expectations for appropriate behavior.
• Who does it work best with?
– Patients with personality disorders, those with ‘manipulative’,
‘needy/dependent’ , difficult or inappropriate behaviors; Substance
Users, Potentially Violent or Aggressive patients.
• Examples:
– “I need you to lower your voice and tell me what it is that you need.”
– “I cannot hear you (or help you etc) if you are screaming at me. I need you
to _____ bring your behavior under control so that I can help you.”
TOOL 10:
Distraction
• What is distraction?
– Tool to divert or focus one’s attention onto something completely
different or new to stop a problematic behavior. (usually ignores the
underlying problem)
• Who does it work best with?
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Delirious, Demented (middle-later stages), Anxious
Disorganized Thinking, Delusional
Developmentally Disabled, Depressed, Daring’-Manic
Pain… any patient with childlike behaviors (regressed, kids).
• Examples:
– Attention on pain is distracted by listening to music, watching tv,
having a conversation, laughing, prayer etc.
– Remember mind-body connection…. We can also distract physical
pain-hypnosis, offer different sensation (pressure, massage etc).
TOOL 11:
Refocus - Redirection
• What is Redirection?
– Focusing attn, energy or impulse onto something similar but safer & more
appropriate.
– Channels pt’s current action/behavior into alternative, more appropriate action.
– Offers opportunities for pt to learn better ways to manage feelings, urges, &
impulses.
• Who does it work best with?
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Angry/Frustrated
Anxious, needy-dependent
Manic & those with inappropriate or child-like behaviors.
Hallucinating
• Examples:
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Child hits sibling with a bat; is redirected to hit a ball instead.
Throws / hits things; Offer paper/art/journal to write/draw/vent feelings. Cry, hit pillow.
Excessive energy can be re-directed into doing PT, walking halls if appropriate.
… or mental energy to a crossword puzzle etc.
Sexually inappropriate / hypersexual- Offer appropriate times to ‘take care of business’.
TOOL 12:
Praise!
• What is it?
– Point out in a specific, obvious way what the pt is genuinely doing well
or right.
• Sometimes patients cannot see what is right in front of them.
• Other times thinking is disrupted & overly concrete so they cannot make
inferences or draw conclusions.
• Builds patient up; enhances trust, motivation & self-esteem.
– EX’s: “Great job with …(be specific)”, “I’m impressed with how well you
are handling…”
– Positive reinforcement!
• ‘Carrots’ are more powerful than ‘sticks’ (negative
reinforcement/punishment).
• Every moment is an opportunity to reinforce behavior that you want & to
build up (scared, frustrated, unmotivated) patient- even when angry with
you.
• Anger & Conflict are opportunities for improvement.
• Works with ANY patient.
• Stress Verbalization (role model the behavior you seek)
– EX: “You communicated so clearly how angry you are feeling.”
CASE
‘Angry Annie’
An ambulatory, angry, elderly female patient is observed ranting & raving
to herself in the hallway on a busy, crowded unit. She is creating a
commotion. The patient directs words to a nurse. The words are unclear
but it sounds like she may be speaking in either Russian or a similar
language. The nurse tries asking the patient to repeat herself but the
patient’s words are still garbled & incomprehensible. Another nurse, who
speaks Russian tries to communicate with the patient but the difficulties
continue & frustrate the patient. The nurses discuss that she seems
“crazy, psychotic”. She begins waving her arms, raising her voice to a yell
& appearing more frantic. The nurses become concerned & calmly move
away from the patient to take a moment to consider next steps and
whether or not security may be needed.
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What are the barriers? Behaviors?
What would you do next?
What might you say to the patient?
Is there any behaviors to be concerned about?
CASE
‘Angry Annie’
(This was a real case & is actually quite ‘textbook’)
Apply Safety/Violence precautions:
-Awareness of barriers:
-communication, stigma, providers’ fears, patient’s body language, environment
-Awareness of behaviors:
-risky- Safety Stance: know exits, environment, protocols
-Awareness self: calm, confidence, position self
- Communication:
– Voice – gets quieter as patient gets louder.
– Limit-Setting- explain expectations: “I need you to…______”
– Use clear, simple, direct, assertive “I statements____”
»  Patient response: “What?” - Got attention.
» Repeat expectations as needed.
» Ask: ‘What is it that you need?’
» Not realistic to fix every problem, demand, need in the moment…
» KISS– Empathy, Listening, Caring attitude
» Distraction (or redirection & symptom-management)
Aggressive Behaviors / Violent
or Assaultive Behaviors:
Do NOT typically occur ‘out of the blue’, suddenly or
without warning.
-Missed warning signs can escalate patient behavior quickly.
Goals: SAFETY is PRIORITY ( self, others, & patient)
Identify –
Recognize & pay attention to the hairs on your neck/red flags.
Trust your intuition (gut feelings).
Do not avoid or ignore these instincts/feelings.
Prevent / Minimize – de-escalate before it explodes .
Prioritize Safety Nurses who were assaulted reported afterward having known
that something was ‘off’ or wrong, but ignored their instincts.
TOOL 13:
“ARM PAIN”
Identify High Risk / Potentially Patients
Identification of Violence/ Assaultive / Aggressive Behaviors:
- Assess for current escalating behaviors, threats, *risk factors.
- Assess for past history of harm to others, assaultive behavior.
-Document & Communicate “Violence triggers” with team.
-SAFETY is PRIORITY!
*Risk factors for Violence:
‘ARM PAIN’:
Altered consciousness- intoxicated
Repeated attacks; +h/o violence
Male gender
Paranoia
Age– younger & impulsive
Incapacity- d/t brain injury, DD/IDIntellectual Disability (with low IQ), or Psychosis
Neurologic Dz’s- Dementia, Huntington’s Chorea
TOOL 14:
PREVENT & MINIMIZE-
De-Escalation of Anger, Potential Violence
Summary Strategies/Tool Kit:
(Try Behavioral / Least restrictive measures 1st )
1) Approach with Calm Confidence, firm voice (Self-checks, awareness)
-Convey that you are calm, controlled, open, caring & non-threatening.
-Modulate your voice to pt’s (If patient gets loud, your voice gets quieter).
2) Maintain safe personal space & exit strategy for self.
- Place self near exits- have exit plan before you enter; Know protocols.
- Do not approach alone.
3) Model Behavior that you want patient to do (ie. respect, calm)
4) Ask pt: “What is it that you need?”
5) Stress Verbalization (over action) & Praise Positive Behaviors
-Pt uses words (not actions) to express anger; calms down... Notice & point out +’s.
6) Allow client opportunities to vent, discuss feelings, anger (offer options)
7) Set clear & firm expectations for patient (requires team communication).
-Offer examples of what is appropriate.
-Share information about what may happen/consequences.
-When patient is calm: Initiate a contract : “I (pt ___ ) agree to call you if I have the urge to___... I will
do ___ first (deep breathe, count to 10, listen to music, journal etc…”.
8) Demonstrate respect for patient & patient’s personal space.
-EMPATHIZE; Explain & ask permission first especially whenever need to touch patient.
9)
Offer symptom management options- for sleep, nausea, pain;
- Minimize distractions & Cluster care
10) More Restrictive Measures
-Medications, seclusion
& restraint may be necessary, 1: 1, security etc.
TOOL 15:
Patient Tools
What works?
Symptom-Management Overview
(Palliation, Comfort care)
- Healthy ways to cope with, calm or reduce, a disturbing or uncomfortable experience.
- Any symptom … Be flexible & creative! OFFER OPTIONS
- Even patients with serious/severe symptosm can learn to better control them (eg. voices)
(MOST Psychiatric Symptoms –THERE IS NO PERMANENT or quick CURE)
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Partner with patient to understand needs, symptoms
Patient Responsibility & Empowerment
Enhances self-esteem & belief in self (patients feel more able & in control)
Reduces anxiety & symptoms
Patient teaching - Sharing information & Decision-making/ Offer Choices
Practice alternatives
What is it that you need? (id. motivations)
• ASK about (assess/identify/clarify) Symptoms
• Assess possible causes:
– meds, side effects, anxiety, pain?
• What usually works for patient? What makes you feel better?
• What is currently working for you? (Build on these)
• What is not working?
GOALS:
1. Manage-to reduce frequency & severity of problematic symptoms & behaviors.
2. Minimize- to improve nurses’ ability to provide the most optimal care that is possible.
3. Stabilize- to enhance patient’s role & efficacy in self-care.
PRACTICAL
APPLICATION
Symptom management
(Auditory Hallucinations)
Tools – offer a common language & can be a sign of worsening symptoms.
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Assess Symptom frequency, intensity, duration, type:
“Are you hearing (or seeing) anything that others cannot (right now)?” or
“Are you experiencing any noises or voices that others cannot hear?”
Many Symptom types:
– Prodromal - precursor (early sign, may not be full-blown/partial symptoms)
– Acute illness (full symptom)
– Trigger or Relapse (a cause)
– Withdrawal, Medication side effects, other interacting factors
Treatment Manual of Behavioral Strategies for Managing Distressing Voices:
EBP - Buccheri & Trygstad ‘s research (2006, 2013)
1. Self-monitoring---paying attention to what makes the voices better or worse
2.Talking with someone---engaging with another helps
3. Listening to music/radio---having an IPod helps, because the choices are personal
4. Watching TV or something else that is enjoyed and does not make for anxiety
5. Saying “stop” and ignoring the voices or refusing to do what one is told to do
6. Using an earplug
7. Using relaxation exercises built into a routine
8. Keeping busy, helping others
9. Taking prescribed medications
10. Avoiding drugs and/or alcohol
11…. Add patient’s own….
ANXIETY
PRACTICAL
APPLICATION
And those with:
Generalized or Chronic Anxiety; Stress
Acute Anxiety/Panic Attacks; PTSD;
Hallucinations; Paranoia,
Substance Use or Withdrawal, some Personality
Disorders
Identification:
anxiety attacks, crying, shaking, tearfulness, elevated vitals, sweating, SOB,
hyperventilation, regressive behavior to an earlier stage of development, sleep
disruption, anger, irritability, or even outwardly calm/internally panicked.
Nursing Tool Box /Action Plan:
-VS.
-Offer paper bag for acute anxiety / hyperventilation to reduce fall & injury risks- (safety)
-Believe patient (Pt is the ‘expert’ & not all anxiety looks alike).
-Communication: Reassure with your presence, calm voice.
Simple sentences. “I am here. You are safe. You are having an anxiety attack. It will
pass soon. You are okay. You will be fine. No one has ever died of an anxiety attack.”
After an Attack & for Non-acute, generalized Anxiety:
1) Assess symptoms & existing coping.
2) “What do you think might work?”
3) Offer symptom management options:
-Can be anything; (CAMs, breathing, prayer, listening to music, distraction, PRN meds)
-Be creative & individualize: one psychotic patient calmed AH’s & anxiety by brushing
her teeth; another said rubbing a smooth ocean rock reduced his voices & panic.
PRACTICAL
APPLICATION
Patients with:
Boredom / Under-stimulated or
Confusion / Over-stimulated Patient
and/or
Disorganized Thinking
Identification:
- Speech / Thinking:
-Words, sentences, thoughts do not string together in organized/coherent way.
-You are confused or filling in the blanks to make sense of words.
- Memory deficits, confusion, distractibility, poor decision-making,
inappropriate or odd behaviors.
Common Causes:
-Delirium (fever, infection, post-op, meds, SUDS, AWS etc)
-Dementia (Alzheimers, Parkinson’s Dz)
-TBI, Tumors, Medications, Anxiety, Depression, Psychosis
TOOLS:
- Introductions with each contact
- Orientation- Reminders (calendars, photos, personal memorabilia)
- Distraction for inappropriate, angry, escalating behaviors
- Manage Environment & Boredom (offer activities, engage/empower pt in care
- Reminiscence
- Be aware of escalating behaviors… Safety stance, exit strategies, prevention!
Special & High risk situations:
Substance Use Symptoms
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Substance-induced disorders (Depends on drug specifics, route of use):
Assess: drug taken, amount, route & time of last use whenever possible.
• ST Risks: drug’s direct effects (ST body damage-IDU, nasal, skin
infections, endocarditis etc.)
• Intoxication
• What drug may be cut / mixed with
• Overdose (OD)
• Withdrawal- General rule: Whatever the drug’s effect, the opposite
effects occur during Detox / Withdrawal
• LT/Chronic effects: Opiates & Depression; Cirrhosis, Pancreatitis &
Alcohol, Depression
• Alcohol Withdrawal Syndrome (AWS)- Can be life-threatening
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Benzodiazepine & Barbiturate withdrawal also require medical support.
Assess VS; Recognize signs & intervene early.
Contact provider.
Apply medications as per orders, CIWA scales, detox plans & protocols.
Monitor for complications. Support discharge plans, referrals, supports.
Special & High risk situations:
Depressed / Unmotivated Patients
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Motivation = part of the problem & therefore can be part of the key.
– Try to figure out what the motivation is? (Do they want to be more in control, comfortable?)
– Every patient has motivations--even those, who on some level, like or want to remain miserable, have
things that they wish could be different, change or improve.
Maintain Care Balance between gently pushing patient & too much ‘fixing’:
– Start small - ADL’s; assist as needed, encourage small talk / social interactions with family.
– Discomfort can be strongest motivation to do something to feel better… (take meds, get out of bed etc)
Offer Empathic Reflection responses
– Aligns self with pt complaints.
Use light Approach & Humor… Communicate that world is OK; Its hard to feel bad when you smile or laugh!
Recognize Symptoms & Support Physical Needs
– sleep, food/fluids, memory issues that can be involved or impacting healing, adherence etc.
Offer Symptom Management Tools (CAMs etc)
– “What’s one thing that you can do to feel better right now? “Is there one thing you are feeling okay
about doing today?” (Gratitude, Prayer, Breathing, Distraction, Music).
Reframe Problems & Negative Mindset - through actions & examples (not just words):
– “I cannot do this___” (self-defeating words) etc.
– Do NOT argue; Listen & Empathize: “This is hard for you.” Assist patient.
– Praise /Build-up patient (point out successes, progress of pt’s own actions)
“You did a great job getting up to the bathroom today. I know that was difficult for you but I’m
impressed how you well managed it despite the pain. You are doing well today.”
Special & High Risk Situations-
Suicide
NOT MISS- priority for Psychiatric Consult, Referral
• Emergency Situations:
– Suicide
• Stigma, embarrassment, lack of med adherence etc can heighten suicide risk:
• JCAHO found in 2010 that over 14% of all inpt suicide occurred in general hospital settings
that were non-behavioral health units (including med/surg units).
• Report concluded that med-surg nurses needed to be aware of safety issues esp. admits with
depression or post-suicide attempt.
• Risk factors for suicide: Elderly Cauc Males > 75 yrs (highest risk group)
• Chronic pain/illness, Depression, Substance Use Disorders.
TOOL KIT:
Assess Suicide risks
• ASK! Directly / Recognize: “Are you having any thoughts of wanting to hurt yourself today?”
– Do you have a specific Plan? Are you serious about it? Do you intend to carry plan out?
Does pt have access or a means to follow-through with their plan soon?) Yes 1:1
(remove hazards)
• Seek Psychiatric Consult
• Initiate No-Harm Contract : “I (pt _) agree to call you if I have the urge to harm myself”
• Maintain options for adequate sleep (minimize distractions/cluster care /offer PRN’s etc).
• Manage symptoms like pain, nausea - prn’s, CAMs…
• Discuss Mindset– Find Connections (to someone or something… a pet, person, provider, higher
power — spirituality).
• Summary-- Listen, Empathize, Support, Assist with ADL’s.
CASE
“The Walking Wounded”
(Putting it all together … )
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35 year old female admitted to a med-surg unit for surgical treatment &
debridement of LLE osteo-myelitis. Patient has a h/o of an unspecified mental
illness, drug addiction & prostitution to support her drug habit. She has been living
on & off the streets for years. She is smoker & was seen putting cigarettes out in
her wound. She admits to this with some degree of pride. She has a history of past
admission for pancreatitis .
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Patient complains constantly about the care she is ‘not getting’ including
insufficient pain meds. Nurses comment she is ‘med-seeking’ analgesics. Her
mood shifts rapidly from tearful to angry. Generally, she is hostile, critical, entitled
& demanding. She impulsively throws emesis basins at anyone whom she
perceives is not adequately meeting her needs. She has a history of threatening
suicide & the nurses suspect that she has been intentionally sabotaging the
healing process of her wound while in the hospital to get more medication. She is
discussed in report as being very ‘manipulative’.
•
A psych & pain management consult have been requested but have not yet been
completed. The behavior is making the nursing staff very uncomfortable & caring
for her challenging. The nurses admit to being somewhat afraid of this patient &
avoid entering her room unless absolutely necessary. The latest is that the patient
is threatening to sue the hospital for what she perceives as sub-par care.
Do any elements of this case sound familiar?
Personality Disordered patients commonly present challenging bx’s.
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CASE
What made a difference…
(Putting it all together … )
• No medical treatment or any increased pain meds!
– Opiates & other narcotic analgesics can exacerbate psychiatric symptoms such as
worsening depression & difficult behaviors like hers.
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Nurse took < 5 minutes each shift to sit & listen.
Patient felt more “heard”.
Nurse consistency was “reassuring” to patient.
Nurse presence & a few empathic statements.
Staff noted significant improvement; less “difficult behavior”,
patient smiled.
• Patient NEEDED to vent her fears, sense of powerlessness.
– Ultimately, dx was Borderline Personality Disorder with long trauma history.
– BPD - indicates lifelong pattern of problematic behavior
– Characterized by an internal sense of chaos or emptiness; poor boundaries,
will test you or size you up (they need to know that you are present and will
be there. Nurses need to push back through presence, assertive limit-setting),
impulsivity, very erratic (labile—all over the place) moods, threats of suicide /
self-harm to get needs met / avoid being abandoned.
CASE
What made a difference…
(Putting it all together … )
Patients with Personality Disorders (difficult entrenched behavior patterns):
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Understand behavior- as COPING, long-standing maladaptive coping (but coping
nonetheless); a wall to keep people from hurting her (long h/o victimization)
No need to try to fix-it.
Understand behavior – as ‘real’ pain (physical &/or psychic)
– It is real to HER. She is ‘expert’ of her experience.
– Avoiding or rejecting patient prove her fears; that she is powerless.
Once calm, RN was able to be present & explain what could be expected; & to offer
additional tools to manage anxiety & pain.
- Alternative more appropriate PRN meds for agitation & anxiety were offered.
- Enhanced patient’s sense of control & reduced anxiety.
- Do NOT just state: “No” or “Don’t do ___”, or “This is not appropriate…”
EXPLAIN
– EX’s: (assertive respectful communication)
• “I understand that you are in a lot of pain…& that you feel scared & that we are not
giving you the best care. I want to give you the best possible care but in order to do
so, I need you to stop throwing things at me. I am here to listen & help when you are
able to show me that you can speak calmly to me.”
• Patient is part of the behavioral plan (has some responsibility)
• “I am showing you respect & I need for you to do the same. I cannot help you if you
are (yelling, screaming, throwing items..)”
Summary Toolkit Remarks
1) Pursue Education: √ check (good for YOU!)
• Ongoing educ. in-services, seminars, conf’s to understanding mental health issues.
• Helps identify Barriers, Common Behaviors that can impact nursing care- Tools 3, 4
– Document patient’s report of psychiatric symptoms / conditions
– Reconcile medications / substances taken (what is pt taking? Could meds be
toxic? Withdrawing? Meds, recently stopped?)
• Awareness improves identification & care, reduces problems & keeps you safer!
2) Self-Aware Approach: (Take a Moment), “Face your fears” - Tools 5, 6, 7
• Assess Self- Be honest, identify personal beliefs, thoughts & attitudes towards patients.
• Project Calm, Confident Approach, Model the behavior you seek.
3) Establish Trust: ‘Less Fixin’ - More Listening’; ‘Don’t be a hammer’- Tools 1, 2
4) Praise Patient: Tools 8, 12
• Enhances motivation, empowers patient
• Positive reinforcement of desired behaviors (align self with patient needs)
Conclusion
Summary Toolkit
Remarks
5) ‘Take team approach’:
• Communication & Consistency (reassuring to patients) ALL Tools
• Team huddles, Consults, Case Management can improve care & reduce symptoms.
6) Partner with Patient for Symptom Management of Common Symptoms:
(“View patient as member of the team” ) Tools 9- 12, 15
• Listen to patients as ‘experts’ of their experience.
• Partner with them to understand Needs, Motivations AND to Manage Symptoms.
– Ask patients about how they cope when experiencing … (anger, voices, stress,
feeling out of control etc…)
– enhances their sense of control (& responsibility)
– reduces problematic behaviors / sxs.
• Apply current Symptom-Management tools: Ask ‘What makes (it) better? ‘
• Offer AND Practice new choices for managing symptoms.
• Share information with patient - supports therapeutic decisions.
• Set-limits for expected appropriate behaviors- Tool
• Identify HIGH Risk patients & behaviors- remain calm.
Summary Toolkit Remarks
7) Safety - Identify & Manage High Risk Patients & Behaviors: Tools 9-15
Violence typically does not occur without warning signs.
– Priority - Maintain Safe Environment (for self, patient, others)- Starts with you.
A) Identify
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Identify risks / early signs to prevent, minimize problems
B) Prevent / Minimize/ Stabilize
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ASK: What it is that you need? (Assess motivations, needs)
Apply least restrictive Behavioral Methods first:
• Use of self, environment, distraction, de-escalation, redirection, symptom management.
• Safety stance- prevention; remove hazards to self & patient.
• 1:1; Meds (chemical restraints) & Physical restraints (follow policies) as needed.
• Team approach–document & communicate regularly with team
• Access information & supports including outside resources, providers & family etc.
Limit-setting:
• Describe what do you need the patient to do in simple, clear ways (expected behaviors)
• Model Assertive Communication:
– “I can see that you are upset. I want to help, but first I need you to…”
C) Access Supports
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Intervene with all appropriate resources, team approach
• Advocate for Psychiatric Consults.
Provide appropriate follow-up as needed.
• Seek collateral data/ confirmation from family, chart, regular case managers & health care
providers, review history to determine if symptoms are possibly r/t psychiatric condition.
Take home messages…
• Slow down for brief moments throughout your
day, breathe, recalibrate…
Smallest things… can pay often pay off the most in many cases!
• Try a tool & if at first you don’t succeed, “Be
bendy”, draw from toolbox & try another…
• You will learn most from practice, and yes,
making mistakes… but as long as you keep trying,
your flexibility, style, confidence & efficacy will
improve…
• Questions?
References
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Berg-Smith, S. (2013, Dec). Motivational Interviewing Approaches; conference materials.
Boylan, C. & Waite, R. (2013). Psychiatric Comorbidities in Med/Surg; Advance Health for Nurses. Retrieved 03/2015.
http://nursing.advanceweb.com/ Merion Matters. King of Prussia, PA. www.advanceweb.com
Bronheim, H.E., Fulop, G., Kunkel, E. J., Muskin, P.R., Schindler, B.A., Yates, W.R., Shaw, R., Steiner, H., Stern, T.A. &
Stoudemire, A. (1998, August). Practice Guidelines for Psychiatric Consultation in the General Medical Setting. Academy of
Psychosomatic Medicine,39, S8-S30.
Buccheri, R.K., Trygstad, L.N., Buffum, M.D., Lyttle, K., & Dowling, G. (2010, March). Comprehensive Evidence-Based Program
Teaching Self-Management of Auditory Hallucinations on Inpatient Psychiatric Units. Issues in Mental Health Nursing, 31,(3),
223-231.
Buccheri, et al., (2006). Long-term effects of teaching behavioral strategies for managing persistent auditory hallucinations in
schizophrenia. Journal of Psychosocial Nursing & Mental Health Services, 42 (1), 18-27.
Esposito, N. & Vanacore, D. (2015). Strategies for Improving Symptoms in Patients With Major Depression CE. Medscape
Nurses, www.medscapenurses.com
Fulop, G, Strain, J. J>, Vita, J., Lyons, J. S., & Hammer, J.S. (1987). Impact of psychiatric comorbidity on length of stay for
medical/surgical patients: a preliminary report. American Journal of Psychiatry, 144(7), 878-882.
Frost, M.(2006). The Medical Care of Psychiatric Inpatients: Suggestions for improvement. The Internet Journal of
Healthcare Administration. 4,3.
Levenson, J.L. (2007). Psychiatric issues in surgical patients part 1: general issues. Primary Psychiatry, 14 (5), 35-39.
McIntyre, R.S. (2013). Using measurement strategies to identify and monitor residual symptoms. J Clin Psychiatry,74:14-18.
MacKusick C. I. & Minick, P. (2010, Nov/Dec). Why are nurses leaving? Findings from an initial qualitative study on nursing
attrition. Research for practice. MEDSURG Nursing, 19, 6.
Nadler-Moodie, M. (2010, May). Psychiatric emergencies in med-surg patients: Are you prepared? American Nurse Today, 5
(5), 23-28, www.AmericanNurseToday.com
Parks, J., Svendsen, D., Singer, P., & Foti, M. E. (2006). Morbidity and mortality in people with serious mental illness. National
Association of State Mental Health Program Directors Medical Directors Council.(NASMHPD) www.nasmhpd.org
Siegel, V. Outside the bedside comfort zone. Caring for a patient with psychiatric illness on a med/surg unit poses a unique
set of challenges for nurses. Advance for NPs & PA’s. http://nurse-practitioner-and-physician-assistants.advanceweb.com
Merion Matters. King of Prussia, PA. www.advanceweb.com
Siegel, V. (2014). Examination of Three Case Studies of Caring for Psychiatric Patients on a Medical Surgical Unit. Open
Journal of Nursing, 4 (13), Article ID:52121, 4 pages. 10.4236/ojn.2014.413096
Common psychiatric / behavioral health problems in Med-Surg pt:
Majority are Chronic problems with waxing & waning
symptomsAnxiety disorders, PTSD
Mood Disorders- Depression, Bipolar
- Suicidal ideation & behaviors
Psychoses- Schizophrenia
Personality Disorders (PD’s)
may manifest as a lack of cooperation
Aggression / Violent Behavior
Delirium
r/t infections, fever, post-op, polypharmacy, stroke,
intracranial tumor, heart failure, substance toxicity,
sedative drugs, excessive or deficient stimuli.
Substance Use Disorders (SUDs):
Intoxication / Complications (pancreatitis in alcoholics)
Withdrawal / Detox (alcohol withdrawal syndrome, AWS)
Pain management in the Opioid-dependent patient.
Problems that commonly lead to requests for
Psychiatric Consultation in the medical-surgical setting
Acute stress reactions
Aggression or impulsivity
Agitation
AIDS or HIV infection
Alcohol & drug abuse (including withdrawal states)
Anxiety or panic
Assessment of psychiatric history
Burn sequelae
Change of mental status
Child abuse
Coping with illness
Death, dying, and bereavement
Delirium
Dementia
Depression
Determination of capacity & other forensic issues
Eating disorders
Electroconvulsive therapy
Ethical issues
Factitious disorders
Family problems
Geriatric abuse
Hypnosis
Malingering
Pain
Pediatric psychiatric illness
Personality disorders
Posttraumatic stress disorder
Pregnancy-related care
Psychiatric care in the intensive care unit
Psychiatric manifestations of medical & neurological
illness
Psychological factors affecting medical illness
Psychological & neuropsychological testing
Psycho-oncology
Psychopharmacology of the medically ill
Psychosis
Restraints
Sexual abuse
Sleep disorders
Somatoform disorders
Suicide
Terminal illness
Transplantation issues