PSYCHIATRIC EMERGENCIES

1. Aggressive and violent patients

2. Acute panic attacks

3. Patient with suicidal behavior

4. Alcoholic withdrawal delirium (Delirium Tremens)

5. Acute dystonia

AGGRESSIVE AND VIOLENT PATIENTS

This is Emergency nursing intervention aimed at controlling and

providing safety to patients, staff and others due to patient’s inability

to exercise effective coping patterns when overwhelmed by anxiety,

disordered thoughts and perceptual processes.

Aggressive means quarreling without reason.

Signs and Symptoms of Aggression

 Anxiety.
 Moodiness.
 Agitation.
 Disorientation or memory problems.
 Depression or flat affect.
  Trouble with concentration and attention.
 Trouble thinking in an organized manner,
 Poor communication skills due to overt negative affect.

REASONS FOR AGGRESSION

1. Mental state of patient

2. A dirty ward, linen, utensils etc.

3. Improper preparation and serving of meals

4. Unnecessary seclusion

5. Denial of basic needs

6. Prolonged confinement in hospital

7. Staff inconsistency

8. A significant change in medication

MINIMIZING VIOLENCE AND AGRESSION

1. Good observation skills to enable the nurse to note early signs of

aggression e.g clenched fists, a wrinkled eye brow, jerky

movements and lack of eye contact.

2. Try to interact with patient to find out what is disturbing him

3. Allow patient to express his or her feelings freely.

4. Engage patient on activities that consume energy eg playing

volleyball

5. Sedate patient in the absence of support personnel when it is not

possible to calm him down through interaction and other activities.

In caring patients with aggressive and violent behaviour;

- Assess previous violent and aggressive behaviors to predict

outcome of current behavior and plan for appropriate interventions.

- Assess the number, gender and level of preparation of staff to deal

with such emergencies. This determines need for more staff

required to handle patient.

- Assess the environment for dangerous items that can be used by

the patient. To safe guard patient, other patients and staff from

being injured.
- Asses the level of motor agitation and verbal aggression to

determine when to exercise restraint measures and the type of

restraint technique to apply.

- Assess psychiatric nursing interventions that may be antecedent to

aggression to minimize further provocation.

- Perform self-assessment for the presence of accessories that can be

destroyed or can cause harm to self and patient. Accessories may

include staff’s long fingernails, long hair left hanging and pens,

labels, bangles and ear rings to determine the need to remove them

so as to minimize risk of injury to self, other staff and patient.

- Do not handle an aggressive patient alone

- Remove all dangerous items such as chairs, utensils and stones.

- Ensure a clear and easily accessible exit from the situation

- Be prepared to move out quickly as a violent patient can strike out

suddenly

- Ensure that the patient has no weapons

- Inform ward Dr to review the patient

- Approach patient carefully keeping at arm’s length. This is to

ensure safer margin and avoids encroaching upon patient’s

personal space.

- Address patient by name. This helps orientate patient and

demonstrate respect and minimizes provocation.

- Request other patients to leave the room. This is to maintain a safe

environment for all patients and avoids aggravating the situations

further.

- Keep verbal communication brief when talking with patient; don’t

fold arms maintain an open posture. This demonstrates acceptance

and encourages verbalization.

- Talk calmly, clearly and firmly keeping voice neutral; ask open

question using ‘how’ and ‘where’ to help clarify the problem.

- Show the patient that you don’t have anything in your hands. Helps

the patient feel that he is not being pursued thus reducing tension.

- Adopt an attentive expression but do not stare at the patient.

Staring can be interpreted as an attempt to dominate the patient.

- Call for assistance by shouting, using any signaling system or

request another patient to summon help.

- Ask colleagues to lead other patients away when the patient is

being restrained. Violent incidents may distress other patients.

- Organize staff and identify a leader who gives direction on how to

contain the situation.

- One psychiatric nurse to prepare and administer prescribed

parental antipsychotic or benzodiazepines. This helps to calm

down the patient. (Haloperidol, modicate/Fluphenazine)

- Give clear instructions on how to restrain the patient. To facilitate

efficiency in full immobilization of the patient.

- Explain to each staff what part of the patient to hold and from

where to approach the patient.

- Allocate one member of the group whom the patient is more

familiar with to talk with him /her throughout the procedure. This

is for sustaining a therapeutic communication and conveys to

patient that restraint is not punitive.

- Minimize force used for restraint to be appropriate to the degree of

resistant.

- Nurse the patient in a comfortable and isolated room.

- Ensure that the restraint is realized gradually by releasing one limb

at a time.

- Observe patient’s respiration rate half hourly and change gradually

until the condition improves

- Withdraw staff from the patient gradually

- Withdraw patient from isolation as soon as he is no longer violent.

- When the patient calms down discuss the incident with him/her.

This helps the patient to verbalize experiences and identify

provoking factors; promotes planning for interventions that prevent

repeat of violence and aggression.

- Inform the patient that destructive anger is not acceptable

- Observe the patient continuously for subsequent violent behavior

- Offer him food or drink if available.

HANDLING A PATIENT WITH A WEAPON

1. Call for assistance

2. Call patient by name

3. If patient does not acknowledge, restrain him by using a blanket

and snatch the weapon.

4. Give tranquilizers e.g modicate (Fluphenazine) as prescribed by

the Dr.

5. Leave patient to sleep comfortably in a single room

6. Look around the ward for dangerous weapons e.g stones, brooms,

etc.

ACUTE PANIC ATTACKS

- This is the nursing interventions given to a patient in intense

apprehension (worry that something unpleasant may happen) and

severe fear or terror associated with feelings of impending doom.

SIGNS AND SYMPTOMS OF ACUTE PANIC ATTACKS

Panic attacks typically include some of these signs or symptoms:

1. Sense of impending doom or danger.

2. Fear of loss of control or death.
3. Rapid, pounding heart rate.
4. Sweating.
5. Trembling or shaking.
6. Shortness of breath or tightness in your throat.
7. Chills.
8. Hot flashes.

The causes of unexpected panic attacks

It is not yet known what causes panic attacks but certain factors may play

an important role, including;

1. Genetics

2. major stress or having a predisposition to stress.

3. Panic attacks are typically experienced as a result of misinterpreting

physical symptoms of anxiety.

- Care is given to control the hyperactivity of autonomic nervous

system associated with high levels of anxiety while promoting

patients’ safety and enhancing effective coping mechanisms.

- Asses the patient’s mental state and the environment. This aids to

determine intervention required and over stimulating environment

is likely to worsen the panic attack; dangerous equipment are a

threat to patient and staff’s safety

- Take vital signs to determine monitoring autonomic nervous

system dysfunction

- Nurse the patient in a quiet room with minimum stimulation and

explain to patient all actions being taken.

- Remove any dangerous items within the environment

- Stay with the patient and encourage him /her to discuss his/her

experiences.

- Maintain calmness and patience when attending to patient.

- Take vital observations 2 hourly and reduce to 4-hourly as

appropriate.

- Administer the prescribed anxiolytics and B-adrenergic receptor

antagonists. Anxiolytics are GABA agonists resulting in calmative

and sedative effects; B-adrenergic receptor antagonists reduce

anxiety symptoms by reducing sympathetic stimulation.

- Assess patients mental status every 4 hours

- Use simple brief words and messages spoken calmly and clearly.

In extreme anxiety patients only comprehend elementary

communication
- Reinforce reality if distortions occur. High levels of anxiety

obscure the client’s awareness of physical needs.

- When levels of anxiety are reduced, explore reasons of occurrence.

Recognition of precipitating factors helps in planning interventions

for preventing future re-occurrences.

- Teach patient signs of escalating anxiety and how to interrupt

them. This include; Relaxation, refrain from caffeine, engage in

exercises, psychotherapy and cognitive behavioral therapy.

PATIENT WITH SUICIDAL BEHAVIOR

- This is the nursing intervention for a client/patient who is at high

risk of committing suicide or deliberate self-harm.

- This care is indicated to patients;

1. Who have verbalized desire to commit suicide

2. Suffering from depressive illnesses

3. Suffering from severe anxiety or agitation

4. Actively abusing alcohol or substances.

5. With history of attempted suicide

 6. With terminal /chronic illnesses.

- Give and receive report about the client/patient to include; findings

of suicide assessment.

- Allocate specific nurses to attend client/patient during the crisis

period until the patient gains self-control.

- Search the patient’s and his roommates belongings and remove all

items considered unsafe

- Encourage client/patient to verbalize and explore feelings. This

promotes feelings of acceptance, improves self -esteem with

subsequent ability to evaluate options and develop problem solving

skills.

- Secure a “no suicide contract’’ from the patient. This will

demonstrate the patient /clients’ commitment to abide by

therapeutic decisions made by both client /patient and nurse.

- Discuss with client/patient’s and give a message of hope that life is

worth living.

- Assign clients/patient recreational activities such as volley balls to

reduce tension
 - Ensure client/patient is always within view of the nurse at all time.

- Do not seclude nor allow the patient to sleep alone. Staying with

other people reduces the possibility of attempting suicide.

- Maintain suicide precaution card observations and recordings

including 15-minute visual check on the client/patient; carefully

observe and record mood and suicide indicators. Signs and

attempts of suicide are recognized early and appropriate

interventions carried out promptly.

- Physically hand over client/patient at end of shift. Evidence of

close monitoring and assurance of client/patient safety/security.

ALCOHOLIC WITHDRAWAL DELIRIUM (DELIRIUM

TREMENS)

- This is the nursing interventions for clients/patients suffering from

acute confusion states and autonomic nervous system hyperactivity

occurring within 40 hours -1 week after cessation of or reduction

in long term heavy alcohol ingestion.

CLINICAL PRESENTATIONS

1.

- This is to minimize and correct autonomic nervous system effects

within the shortest duration and ensure client/patient safety.

- It’s indicated in patients in acute confusion states and autonomic

nervous system hyperactivity following alcohol withdrawal.

- Assess own feelings, fears and anxiety related to handling the

situation

- Assess procedure on emergency management of acute alcohol

withdrawal delirium

- Assess the patients’ understanding of his/her current experiences

- Assess physical psychological/ emotional social and spiritual needs

- Assess the safety of the environment

- Assess the amount of light in the room. This is to plan for adequate

light that reduces risk of illusions common in alcoholic delirium.

- Remove dangerous objects with the patient or in the environment

- Administer anxiolytics/antipsychotics. Anxiolytics have sedation

and calming effects due to their GABA minegic actions;

antipsychotics help to control hallucinations through their

dopamine antagonist effects.

- Assign a staff to stay with the patient.

- Conduct and record mental status examination and vital signs

observations four hourly.

- Explain to patient the experiences he had and the interventions

carried out.

- Obtain an informed consent from the patient once they can

understand what is expected of them.

- Organize for individual/group counseling

ACUTE DYSTONIA

- Emergency nursing intervention for patients experiencing life

threatening muscles contractions/spasms of the neck, tongue, face,

jaws, eyes and laryngeal/pharyngeal tract.

- Care is given to control contractions/spasms, ensure patent airway

and manage anxiety associated with the dystonic experience.

- Its indicated for patients experiencing;

i) Oculogyric crises - concerned with severe movements of the

eye

ii) Torticollis also known as wryneck- it is an irresistible turning

movement of the head that becomes more persistent, so that

eventually the head is held continually to one side. It may be

caused by birth injury to the sternomastoid muscle (twisted

neck/facial spasms),

iii) Trismus – it is spasm of the jaw muscles, keeping the jaws

tightly closed. This is the characteristic symptom of tetanus

but it also occurs as a sensitivity reaction to certain drugs and

in disorders of the basal ganglia.

iv) Tongue protrusions

v) Extrapyramidal side effects of antipsychotic drugs

- Assess the patency of airway and breathing patterns to determine

the need for oxygen since spasms of the larynx and pharynx affect

air way.

- Assess level of pain to determine the type of analgesia needed

- Assess level of anxiety because experience of acute dystonia may

be frightening to the patient.

- Assess intensity of contractions/spasms to determine type of

muscle relaxants (benzodiazepines) and anticholinergics

(Benztropine, Trihexyphenidyl) required.

- Assess the presence of dangerous equipment in the patient’s

surrounding to ensure patient and staff safety.

- Administer oxygen if necessary

- Administer I.V benzodiazepine and anticholinergics as appropriate.

- Perform vein puncture and administer IV fluids.

- Take vital signs half hourly, gradually changing to one hourly until

dystonia is over and vital signs are normal.

- Conduct mental status assessment as the patient recovers

- Discuss with the patient his/her experience

 - Explain to the patient that acute dystonia is a side effect of

antipsychotic drugs

- Explain to the patient how to recognize its early signs, the need to

notify the nurse and how to control it with anticholinergics (artane)

and muscle relaxants.

- Evaluate patient’s level of consciousness, effectiveness of the

treatment given, patient feeling of the experience and patient

feeling of how he was managed during the experience

Alcohol Intoxication:

What is alcohol intoxication?

Acute alcohol intoxication is a condition associated with drinking too much

alcohol in a short amount of time.

It’s also called alcohol poisoning.

Alcohol intoxication is serious.

It affects ones temperature, breathing, heart rate, and gag reflex.

It can also sometimes lead to coma or death.

Both young people and adults can experience alcohol poisoning.

The condition is usually linked to drinking too many alcoholic beverages.

But in some cases, people with this condition might have accidentally or

intentionally drank household products containing alcohol, such as mouthwash or

vanilla extract.

Alcohol intoxication is considered a medical emergency.

Symptoms of alcohol intoxication

Alcohol intoxication can occur quickly over a short amount of time. When a

person is consuming alcohol, you might notice different symptoms. These

symptoms are associated with different levels, or stages, of intoxication.

The stages of intoxication differ from person to person because they’re based on

age, sex, weight, and other factors.

But generally, the seven stages of alcohol intoxication and their symptoms include

the following:

1. Sobriety or low-level intoxication

If a person has consumed one or less drinks per hour, they’re considered to be

sober, or low-level intoxicated.

At this stage of intoxication, the person’s behavior will be normal with no visible

signs of intoxication, such as slurred speech or delayed reaction time.

Their blood alcohol content (BAC), which measures how much alcohol is in the

bloodstream, will be very low at 0.01 to 0.05 percent.

2. Euphoria

If a person has generally consumed two to three drinks as a man or one to two

drinks as a woman in an hour, they’ll enter the euphoric stage of intoxication.

Some symptoms include:

 an increase in chattiness and confidence

 a delayed reaction time

 decreased inhibitions

Most people call this stage of intoxication being “tipsy.”

A person’s BAC at this stage might range from 0.03 to 0.12 percent.
In Kenya, the Traffic Act states that the legal Blood Alcohol concentration limit

for driving is 0,8 grams per litre of blood or 0.35 grams per litre of breath.

Note that a BAC of 0.08 percent is the legal limit of intoxication in the United

States.

A person can be arrested for driving with a BAC above this limit.

3. Excitement

At this stage, a man might have consumed three to five drinks in an hour, or two to

four drinks for a woman. At this time, a person will begin to experience emotional

instability and a significant loss of coordination.

Other symptoms include:

 a loss of judgment and memory

 vision problems

 loss of balance

 drowsiness

A person will appear visibly “drunk” at this stage.

They’ll have a BAC of 0.09 to 0.25 percent.

4. Confusion

If a man consumes more than five drinks or a woman more than 4 drinks in an

hour, they’ll enter the next stage of intoxication: confusion.

This stage of intoxication is marked by emotional outbursts and a major loss of

coordination.

The person may not be able to stand up, may stagger when walking, and will likely

be extremely confused about what’s going on.

People in this stage of intoxication are very likely to forget things happening

around or to them. They might “black out” without actually losing consciousness

and may not be able to feel pain. This makes them at risk of injury.

At this stage, a person’s BAC is very high. It’ll range from 0.18 to 0.30 percent.

5. Stupor

At this stage, a person no longer responds to the things happening around or to

them.
A person won’t be able to stand or walk. They may completely pass out or lose

control over their bodily functions, becoming incontinent or vomiting

uncontrollably.

They may also experience seizures or have blue-tinged or pale skin. Their

breathing and gag reflexes will likely be impaired.

This stage can be very dangerous and even fatal if a person chokes on their vomit

or becomes critically injured.

Any of these symptoms are signs that immediate medical attention is necessary. At

this stage, a person’s BAC will range from 0.25 to 0.4 percent.

6. Coma

This stage is extremely dangerous. A person’s breathing and blood circulation will

be extremely slowed. Their motor responses and gag reflexes are nonfunctional,

and their body temperature drops. A person at this stage is at risk of death.

Their BAC will measure in at 0.35 to 0.45 percent. Emergency medical attention is

necessary at this point to avoid death and severe health problems.

7. Death
At a BAC of 0.45 percent or above, a person is likely to die from alcohol

intoxication.

It may seem like a person has to drink a lot to get to this stage. But if a person

drinks very quickly, they can get to this stage before long.

Factors affecting ones risk of alcohol intoxication include:

 Body type and weight. Larger people absorb alcohol more slowly than

smaller people.

 Health status. Having certain health issues can put you at greater risk of

alcohol poisoning.

 Whether or not one has eaten. Having food in your stomach before

drinking can slow your body’s absorption of alcohol.

 Whether one has combined alcohol with other drugs. Consuming certain

drugs before drinking can increase your risk of alcohol poisoning.

 The percentage of alcohol in the drinks. Drinks with a higher percentage

of alcohol will raise your BAC more quickly than drinks with a lower

percentage of alcohol.

 Rate and amount of alcohol consumption. Drinking many drinks quickly

puts you at risk of alcohol poisoning.

  Level of alcohol tolerance. People who regularly drink are better able to

tolerate alcohol than people who are only occasional drinkers.

Management of alcohol intoxication

- Treatment for alcohol intoxication involves supportive care while the body

tries to process the alcohol.

- You must seek emergency medical treatment for a person who’s showing

symptoms of alcohol poisoning.

At home you should:

 If they’re unconscious, gently turn the person on their side to prevent them

from choking on vomit.

 If they’re conscious, encourage the person to lay on their side in a safe place

until help arrives.

 If they’re able to swallow, encourage the person to drink water.

Misconceptions: It’s a myth that a person can recover from alcohol

intoxication by sleeping, taking a cold shower, going for a walk, or drinking

black coffee or caffeine. In fact, doing these things can put an intoxicated

person at greater risk of injury and death.

Medical technicians will take the intoxicated person to the hospital. They will:

 carefully monitor vital signs

 prevent breathing or choking problems with a breathing tube that opens the

airways

 give oxygen therapy

 give intravenous (IV) fluids to prevent dehydration

 give vitamins and glucose (sugar) to prevent complications

 fit a catheter, which allows urine to drain into a bag, so they don’t wet

themselves

 pump the stomach (gastric lavage) to minimize the body’s absorption of

already ingested alcohol

 give activated charcoal to further minimize the body’s absorption of alcohol

- After an episode of alcohol intoxication, it takes time to recover.

- The person will be hospitalized until their vital signs return to normal.

- This may take days, up to weeks.

- During the recovery period, a person may experience a depressed mood and

appetite, discomfort, and memory problems.

- Even after a person is released from hospital care, it can take up to a month

for them to feel normal again.

 - It’s possible to survive alcohol intoxication if appropriate medical treatment

is given promptly.

TREATMENT OF SEXUAL AVERSION

1. Sensate focus
2. Systemic desensitization
3. Squeeze technique
4. Modelling