MAMATA COLLEGE OF NURSING KHAMMAM Date: Time: SUBJECT: CLINICAL SPECIALTY PSYCHIATRY- II TOPIC : PSYCHIATRIC EMERGENCIES GUIDE: MRS.

ASHA KUMARI ASST. PROFESSOR PRESENTED BY: UDAYA SREE.G M.Sc. (N) II YEAR MASTER PLAN ON PSYCHIATRIC EMERGENCIES INTRODUCTION Psychiatric emergencies are the conditions wherein the patient needs immediate intervention to safeguard the life of the patient, bring down the anxiety of the family members and enhance emotional security to others in the environment. It may be resulting from either psychiatric disorders or due to medical conditions related to environment. For example, natural disasters or manmade disasters. It is the combination of circumstances which needs immediate attention. DEFINITION A condition in which the client will have disturbance in thought, affect and psychomotor activity that leads to threat either to himself or his existence. Example suicide-threat to people in the environment, homicide- which need immediate attention and care. -R.Sreevani A sudden onset of an unusual, disordered inappropriate behavior caused by an emotional and physiological situation -Bimla Kapoor, 2002 It is a stress induced pathologic response, which physically endangers the affected individual, disrupts the functional equilibrium of the individual and his environment. COMMON PSYCHIATRIC EMERGENCIES Suicidal attempt and committing suicide Violent, aggressive behavior and excitement Panic attacks Catatonic stupor Hysterical attacks Transient situational disturbances

Organic psychiatric emergencies are Delirium tremens Epileptic furor Acute drug induced extra pyramidal syndrome Drug toxicity OBJECTIVES OF PSYCHIATRIC EMERGENCY INTERVENTION To safeguard the life of patient To reduce the anxiety To promote emotional security of client and the family members To educate the client and his family members the way of dealing emergency situation by utilizing adaptive coping strategies and appropriate problem solving technique client CHARACTERISTICS OF PSYCHIATRIC EMERGENCIES Certain conditions or stressors predisposes the client and his family members to seek immediate intervention, as they feel more discomfort Disharmony between client and his environment Sudden, unexpected, disorganization in person Unable to cope up with the stressful situation or failure in handling the stressors. ASSESSMENT Immediate assessment The client behavior and how the client is brought to hospital The physical environment and its safety Availability of trained persons Mental status examination Search for availability of instruments and collect it Identify the stressors which predisposing the events Level of adjustments or coping abilities prior to the problem Main complaints of present illness H/O any psychiatric illness Thorough physical examination has to be conducted to exclude physical illness Assist for laboratory investigations Management of psychiatric emergencies Nurses have to assume overall in charge for interventions and seeks guidance from the psychiatrist whenever necessary Handle the cases tactfully Provide calm and watchful environment

 Emergency cases has to be shifted as early as possible where he will be safeguarded against injury either to himself or to the others Clients disturbed mood will disturb the other clients, hence immediately nurses has to shift them to the calm areas with adequate safety and supervision Provision of care in meeting the clients needs accordingly. SUICIDAL THREAT In psychiatry a suicidal attempt is considered to be one of the commonest emergencies. Suicide is a type of deliberate self- harm and is defined as an intentional human act of killing oneself. Etiology Psychiatry disorders Major depression Schizophrenia Drug or alcohol abuse Dementia Delirium Personality disorder Physical disorders Patient with incurable or painful physical disorders like, cancer and AIDS Psychosocial factors Failure in examination Dowry difficulties Marital difficulties Loss of loved object Isolation and alienation from social groups Financial and occupational difficulties Risk factors for suicide Age Males above 40 years of age Female above 55 years of age Sex Men greater risk of completed suicide Suicide is 3 times more common in men than in women Women have higher rate of attempted suicide Being unmarried, divorced, windowed or separated

Having a definite suicidal plan History of previous suicidal attempts Recent losses MANAGEMENT Be aware of certain signs which may indicate that the individual may commit suicide, such as Suicidal threat Writing farewell letters Giving away treasured articles Making a will Closing bank accounts Appearing peaceful and happy after a period of depression Refusing to eat or drink, maintain personal hygiene Monitoring the patients safety needs Take all suicidal threats or attempts seriously and notify psychiatrist Search for toxic agents such as drugs/ alcohol Do not leave the drug tray within reach of the patient, make sure that the daily medication is swallowed Remove sharp instruments such as razor blades, knives, glass bottles from his environment Remove straps and clothing such as belts, neckties Do not allow the patient to bolt his door on the inside, make sure that somebody accompanies him to the bathroom Patient should be kept in constant observation and should never be left alone Have good vigilance especially during morning hours Spend time with him, talk to him, and allow him to ventilate his feelings Encourage him to talk about his suicidal plans/ methods If suicidal tendencies are very severe, sedation should be given as prescribed Encourage verbal communication of suicidal ideas as well as his/ her fear and depressive thoughts. A no suicidal pact may be signed, which is a written agreement between the client and the nurse, that client will not act on suicidal impulses, but will approach the nurse to talk about them. Enhance self esteem of the person by focusing on his strengths rather than weakness. His positive qualities should be empathized with realistic praise and appreciation. This fosters a sense of self-worth and enables him to take control of his life situation

VIOLENT OR AGGRESSIVE BEHAVIOR OR EXCITEMENT This is severe form of aggressiveness. During t his stage, patient will be irrational, uncooperative, delusional and assaultive. Etiology Organic psychiatric disorders like, delirium, dementia, wernicke-Korsakoffs psychosis Other psychiatric disorders like schizophrenia, mania, agitate depression, withdrawal from alcohol and drugs, epilepsy, acute stress reaction, panic disorder and personality disorders. Management An excited patient is usually brought tied up with a rope or in chains. The first step should be to remove the chains. A large proportion of aggression and violence is due to the patient feeling humiliated at being tied up in this manner. Talk to the patient and see if he responds. Firm and kind approach by the nurse is essential. Usually sedation is given. Common drugs used are: diazepam 10- 20 mg, IV; haloperidol 10-20 mg; chlorpromazine 50-100mg IM. Once the patient is sedated, take careful history from relatives; rule out the possibility of organic pathology. In particular check for history of convulsions, fever, recent intake of alcohol, fluctuations of consciousness. Carry out complete physical examination Send blood specimens for hemoglobin, total cell count ect. Look for evidence of dehydration and malnutrition. If there is severe dehydration, glucose saline drip may be started. Have less furniture in the room and remove sharp instruments, ropes, glass items, ties, strings, match boxes, ect. From patients vicinity. Keep environmental stimuli, such as lighting and noise levels to a minimum; assign a single room; limit interaction with others possibility of an accident. Stay with the patient as hyperactivity increases to reduce anxiety level and foster a feeling of security. Redirect violent behavior with physical outlets such as exercise, outdoor activities Encourage the patient to talk out his aggressive feelings, rather than acting them out. If the patient is not calmed by talking down and refuses medication, restrains may become necessary Following application of restraints, observe patient every 15 minutes to ensure that nutritional and elimination needs are met. Also observe for any numbness, tingling or cyanosis in the extremities. It is important to choose the least restrictive alternative as far as possible for these patients. Guidelines for self-protection when handling an aggressive patient Never see a potentially violent person alone

Keep a comfortable distance away from the patient ( arm length) Be prepared to move, a violent patient can strike out suddenly Maintain a clear exit route for both the staff and patient. Be sure that the patient has no weapons in his possession before approaching him. If patient is having a weapon asks him to keep it on a table or floor rather than fighting with him to take it away. Keep something like a pillow, mattress or blanket wrapped around arm between you and the weapon Distract the patient momentarily to remove the weapon ( throwing water in the patients face, yelling ect.) Give prescribed antipsychotic medications PANIC ATTACKS Episodes of acute anxiety and panic can occur as a part of psychotic or neurotic illness. The patient will experience palpations, sweating, tremors, feeling of choking, chest pain, nausea, abdominal distress and fear of dying, paresthesias, chills or hot flushes. Management Give assurance first Search for causes Diazepam 10 mg or lorazepam 2 mg may be administered. CATATONIC STUPOR Stupor is a clinical syndrome of akinesis and mutism but with relative preservation of conscious awareness. Stupor is often associated with catatonic signs and symptoms (catatonic withdrawal or catatonic stupor). The various catatonic signs include mutism, negativism, stupor, ambitendency, echolalia, echopraxia, automatic obedience, posturing, mannerisms, stereotypes, ect. Management o Ensure patent airway o Administer IV fluids o Collect history and perform physical examination o Draw blood for investigations before starting any treatment. o Other care is same as that for an unconscious patient.

HYSTERICAL ATTACKS A hysteric may mimic abnormality of any function, which is under voluntary control. The common modes of presentation may be Hysterical fits Hysterical ataxia Hysterical paraplegia All presentations are marked by a dramatic quality and sadness of mood Management Hysterical fit must be distinguished from genuine fits As hysterical symptoms can cause panic among relatives, explain to the relatives the psychological nature of symptoms. Reassure that no harm would come to the patient Help the patient to realize the meaning of symptoms, and help him find alternative ways of coping with stress Suggestion therapy with IV Pentothal may be helpful in some cases TRANSIENT SITUATIONAL DISTURBANCES These are characterized by disturbed feelings and behavior occurring due to overwhelming external stimuli Management Reassurance Mild sedation if necessary Allowing the patient to ventilate his/ her feelings Counseling by an understanding professionals ORGANIC PSYCHIATRIC EMERGENCIES DELIRIUM TREMENS Delirium tremens is an acute condition resulting from withdrawal of alcohol Management Keep the patient in a quiet and safe environment Sedation is usually given with diazepam 10mg or lorazepam 4mg IV, followed by oral administration Maintain fluid and electrolyte balance Reassure patient and family

EPILEPTIC FUROR Following epileptic attack patient may behave in a strange manner and becomes excited and violent. Management Sedation : diazepam 10mg IV or inj. Luminal 10mg IV followed by oral anticonvulsants Haloperidol 10mg IV help to reduce psychotic behavior ACUTE DRUG INDUCED EXTRA PYRAMIDAL SYNDROME Antipsychotics can cause a variety of movement related side effects, collectively known as extra pyramidal syndrome (EPS). Neuroleptic malignant syndrome is rare but most serious of these symptoms and occurs in a small minority of patients taking Neuroleptic, especially high potency compounds. Management The drug should be stopped immediately. Treatment is symptomatic and includes cooling the patient, maintaining fluid and electrolyte balance and treating inter current infections. Diazepam can be used for muscle stiffness. Dantrolene, a drug used to treat malignant hyperthermia, bromocriptine, amantadine and L- dopa have been used DRUG TOXICITY Drug over- dosage may be accidental or suicidal. In either case all attempts must be made to find out the drug consumed. A detailed history should be collected and symptomatic treatment instituted. A common case of drug poisoning is lithium toxicity. The symptoms include drowsiness, vomiting, abdominal pain, confusion, blurred vision, acute circulatory failure, stupor and coma, generalized convulsions, oliguria and death. Management Administer Oxygen Start IV line Assess for cardiac arrhythmias Refer for heamodialysis Administer anticonvulsants.

SUMMARY Psychiatric emergencies are the conditions wherein the patient needs immediate intervention to safeguard the life of the patient, bring down the anxiety of the family members and enhance emotional security to others in the environment. It may be resulting from either psychiatric disorders or due to medical conditions related to environment. For example, natural disasters or manmade disasters. BIBLIOGRAPHY KP. Neeraja. Essentials of mental health and psychiatric nursing, Volume-1 ; Jayapee brothers publication, 2008 Bimla Kapoor. Psychiatric nursing, Volume-2, Pearsons publications, 2005 Sreevani. Psychiatric nursing, Volume-1, Suresh Kumar publications 2004 Mary C. Townson. Psychiatric and mental health nursing, Jayapee brothers publications, 2009 Madhavi K. Essentials of mental health and psychiatric nursing for nurses, Vijams series publications, 2009

MAMATA COLLEGE OF NURSING KHAMMAM Date: Time: SUBJECT: CLINICAL SPECIALTY PSYCHIATRY- II TOPIC : PSYCHIATRIC EMERGENCIES GUIDE: MRS.ASHA KUMARI ASST. PROFESSOR PRESENTED BY: UDAYA SREE.G M.Sc. (N) II YEAR MASTER PLAN ON PSYCHIATRIC EMERGENCIES I. II. III. IV. V. VI. VII. Introduction Definition Common types of emergencies Objectives of interventions Characteristics of interventions Assessment Management Suicidal attempt and committing suicide Violent, aggressive behavior and excitement Panic attacks Catatonic stupor Hysterical attacks Transient situational disturbances Organic psychiatric emergencies are Delirium tremens Epileptic furor Acute drug induced extra pyramidal syndrome Drug toxicity Summary Bibliography

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