Mental Health Emergencies CEN Study Guide

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Mental Health Emergencies CEN Study Guide

Aggressive and Violent Behavior

Characteristics

• Aggressive or violent behavior in patients may occur for many reasons, including:
• crisis or psychosis
• altered mental status
• influence ofdrugs or alcoho
• underlying organic processes
• traumatic brain injuries
• urosepsis, especially in patients > 65
• acute dementia or Alzheimer’s disease

Management

• Management ranges from verbal de-escalation to mechanical restraint of the violent patient.
• De-escalation strategies:

1. verbal redirection
2. allowing the patient to express needs
3. allowing the patient to exercise
4. decreased environmental stimulation (quiet room time)
5. PRN medication administration (as requested by patient)

• Restraints may be used.

1. should be used conservatively
2. only for patients whose behavior cannot be controlled through less restrictive measures
3. require frequent assessment (every 5-15 minutes depending on organizational policy)
4. check vitals, assess pain, assess circulation and skin integrity of all restrained extremities, and address restroom needs
5. should be removed as soon as they are deemed unnecessary for patient and staff safety

• In patients with acute agitation, medications can be administered: olanzapine (Zyyrexa), haloyeridol (Haldol), or risperidone (Risperdal)

Anxiety Disorders

Characteristics
Anxiety is feelings of fear, apprehension, and worry that can be characterized as mild, moderate, or severe (panic). Physical manifestations of anxiety include palpitations or chest pain, dyspnea, diaphoresis, and/or nausea.
Anxiety will impact other functions such as the respiratory, cardiac, and gastrointestinal systems. A key nursing consideration is to assess for organic causes for reported symptoms, as other life-threatening illnesses may present with similar symptoms.

Management

• Treatment of anxiety should be targeted at the level of anxiety the patient presents with (mild to panic).
• Non-pharmapacological interventions include:

1. Place patient in calm environment.
2. Encourage rhythmic breathing.
3. Offer social support if possible.

• Pharmacological interventions (fast-acting anxiolytics) include:

1. benzodiazepines (diazepam [Valium], lorazepam [Ativan])
2. antihistamines (hydroxyzine)

Mood Disorders

Characteristics
Mood disorders can include mania and/or depression. Depression is a mood disorder characterized by feelings of sadness and hopelessness. Patients may also report feelings of suicidality. Depression can manifest as an exacerbation of bipolar disorder or as its own disease process. Depressive behaviors include:

• deep or intense feelings of sadness, worry, or anxiety
• decreased energy levels with associated decreased activity
• sleep and appetite disturbances
• suicidal ideation or focus on death

Bipolar disorder (previously called manic-depressive illness) is characterized by shifts in mood accompanied by manic behaviors or depressive behaviors. Manic behaviors include:

• feelings of elation
• high levels of energy and increased activity
• difficulty sleeping; may not sleep for several days
• increased rate of speech
• engaging in high-risk activities (e.g., excessive spending, risky sexual activity)

Management

• Rule out possible medical causes for depression or mania (e.g., metabolic disorders).
• Assess for and treat conditions related to manic or depressive behaviors (e.g., dehydration, trauma injuries).
• Depression:

1. Screen for depression per protocols.
2. Evaluate for suicidal ideation (discussed in detail below).
3. Management of depression is long-term treatment with antidepressants and therapy.

• Bipolar disorder:

1. Treatment in ED addresses exacerbations (i.e., patients "in crisis").
2. Medications to treat symptoms of exacerbations include mood stabilizers, atypical antipsychotics, and antipsychotics.
3. Patients with extreme or long-term mania should be admitted to the hospital.

Homicidal and Suicidal Ideation

Characteristics

Homicidal ideation is characterized by feelings of intent to harm other people, either groups or individuals.

Suicidal ideation is characterized by considering suicide, thoughts of attempting suicide, or planning suicide. Patients exhibiting suicidal ideation may have vague thoughts without a distinct plan, or they may have a specific plan and the means to carry it out.

A situational crisis is an acute change or event in a patient's life that may lead to feelings of anxiety, fear, depression, or other mental or emotional illness concerns. Examples of a situational crisis can include:

• divorce
• rape or sexual assault
• domestic violence or abuse
• loss of a job/retirement from a job
• loss of a family member
• any event that creates crisis from a patient's perspective

Nurses should understand that the crisis is as problematic as the patient perceives it to be. The key distinction is not the nature of the event, but the patient's response to the event. Patients may self-refer for situational crises, or the ED nurse may discover that the patient is experiencing a situational crisis during the course of the ED visit.

Management

• Screen for depression and suicidal ideation.

1. Ask directly if the patient is considering suicide or has recently or in the past attempted suicide.
2. If the patient is having thoughts of suicide, do they have a concrete plan to carry it out?
3. Determine the presence of risk factors such as a history of substance abuse or chronic pain.
4. Assess the presence of social supports for the patient.

• Interventions for patients with suicidal ideation:

1. Secure a contract of safety that states they will remain safe while in the hospital and in the future.
2. Create a safe environment (e.g., removing dangerous items from the room).
3. Establish a 1:1 watch or line-of-sight supervision for the patient.
4. Have the patient evaluated by a psychiatrist before discharge.

• Homicidal ideation:

1. Assess level of intent.
2. Determine per local protocols if report to law enforcement is required.

Thought Disorders

Characteristics

A patient experiencing an episode of psychosis will have delusions, hallucinations, paranoia, suicidal or homicidal ideation, and disturbances in thinking and perceptions. Psychosis can be the result of organic illnesses or an exacerbation of an existing or new-onset mental illness such as schizophrenia or bipolar disorder.

Schizophrenia is a chronic psychotic condition that is characterized by bouts of psychosis, hallucinations, and disorganized speech. Positive symptoms of schizophrenia are those not normally seen in healthy persons, and negative symptoms are disruptions of normal behaviors.

Positive symptoms:

1. delusions and hallucinations
2. disorganized speech
3. odd or confusing behavior

Negative symptoms:

1. social withdrawal
2. paranoia
3. flattened affect
4. poverty of speech

Management

• Rule out organic causes for behavior.
• Test for alcohol and recreational drugs.
• Patients with known history of schizophrenia should be tested to rule out lithium toxicity.
• Antipsychotics (e.g., risperidone or haloperidol) and/or benzodiazepines can be administered for acute exacerbations.

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• Mental Health Emergencies CEN Practice Test