MANAGEMENT OF A CLIENT

WITH
PSYCHIATRIC EMERGENCY

MENTAL HEALTH AND

PSYCHIATRIC NURSING (MHP 026)
L.N.H MUKENDI
RN. BSc. COMM.HPSY
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• INTODUCTION

• Psychiatric emergencies are conditions in which

there is altered behavior ,emotion or thought
processes presenting in an acute form and
requiring immediate attention and care.
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• Emergency presentations may include:
• People with suicidal ideation
• People experiencing psychosis
• People in situational crisis
• People with a delirium
• People Intoxicated with Substances
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1. Suicidal attempts
Suicide is the intentional taking of ones own life .

Attempted suicide is any act of self-harm with the

intension of self destruction/ taking ones life. The
act is commonly referred to as parasuicide,
pseudocide or non fatal deliberate self-harm
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• Etiology of Suicide
• Genetics has been proved with increased familial
incidence of psychiatric illnesses. E.g. depression etc.
• Biological e.g. people with lower levels of CSF-HIAA or
increased levels of 17-oh corticosteroids in urine.
• Mental ill health e.g. drug abuse, adjustment disorders

• Physical illness like HIV, dementia, epilepsy, cancer etc.

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• Psychological mechanisms
• Suicide is an out come of displaced form of
autoplastic aggression in a dependent or helpless
person caught in a frustrating interpersonal situation.
• An individual humiliated or ashamed of a given act
would commit suicide as a way of avoiding public
humiliation “ face saving”
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• Durkheim's three types of social suicide
• Egoistic suicide
• is a response by an individual who feels apart from
the main stream. E.g. family, church or society at large.
The individual lacks ability to integrate.
• Anomic suicide
• occurs as a result of social changes in an individual’s
life that disrupts feelings of relatedness to the group. E.
g. loss of job, property or divorce.
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• Altruistic suicide

• This is a form of suicide in which the individual is

excessively integrated with the group such that they
are ready to sacrifice own life for the sake of the
group which is governed by cultural, political or
religious ties to which individuals express strong
allegiance.
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• Risk Factors
• Include the above mentioned causes and coexisting
conditions such as Mental Ill Health, alcoholism and drug
abuse
• loss of social relationships
• Unwillingness to seek mental health services
• Isolation
• Access to lethal methods e.g. guns or poison.
• It is apparent then that suicide is a common outcome of
various mental illnesses as well as social situations.
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• Signs and symptoms
• No longer making plans
• Seems to have given up, no longer discussing or trying
to sort out problems
• Expressing hopelessness or helplessness
• Talking about what life will be like without them
• Tidying up personal affairs
• Becoming secretive about actions
• Has written goodbye note
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• Therapeutic interventions
• Psychoanalytic oriented psychotherapy.

• Cognitive behavior therapy for suicide prevention

(CBT-SP)
• Dialectics therapy

• TASA C treatment adolescent suicide attempts study.

• Medical mgt. - According to other underlying

conditions
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• Nursing Management
• Immediate Nsg. Mgt. is dependent on case
presentation on admission considering the various
causes outlined above. Management of a suicide
case calls for crisis intervention resulting from; e.g.
alcohol intoxication, drug abuse or depression.
• Goal is to;
• 1. Resuscitate as necessary according to
presentation or cause;
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• Nursing action will be based on findings following a
primary survey that answers the following patient situation;
• Airway
• B – breathing
• C - circulation
• Physical and mental health state
• A – appearance/affect
• B – behaviour e.g. agitated or delirious
• C – cognition / conversation
• History provided.
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• 2. Manage the underlying social or mental ill health
condition
• 3. prevent further self harm by:

• Open communication method (therapeutic ) that

allows the nurse to listen to the client’s physical
concerns that may actually be the method by
which client expresses desires to commit suicide.
E.g. feelings of being alone.
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• 3. Signing a suicide contract in which a client agrees to
communicate feelings of suicide with the staff.
• Observing unit precaution for prevention of suicide such
as;
• frequent client observation for mood changes, interest in
personal care
• Safety measures by checking and ensuring
inaccessibility for harmful objects such as razor blades
or ropes bed sheets or poisonous material etc.
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AGGRESSIVE BEHAVIOR
VIOLENCE
AND
ANGER
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• ANGER
• Anger is an emotional response to frustration of
desires, a threat to one’s needs (emotional or
physical needs).
• Anger is a normal emotional expression which is
positive only if expressed in a healthy way. But
viewed negatively if expressed in a violent manner
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AGRESSION
• This is an action or behavior that results in a physical
attack.
• While aggression is used synonymously with violence,
aggression is not always inappropriate as it
sometimes is necessary in self protection
VIOLENCE
• On the other hand violence is an objectionable act that
involves intentional use of force that has potential/
results in injury to another person
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PREDISPOSING FACTORS
Organic psychiatric disorders
Delirium
Dementia RISK
Other psychiatric disorders such as;
Paranoid Schizophrenia Mania
Agitated depression
Withdrawal from alcohol and drugs
Antisocial personality disorder
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ETIOLOGY
Psychological factors
According to the behaviorists responses such as anger,
were learned responses to environmental stimuli that is
perceived as a threat.
This cognition leads to the emotional and physical
arousal necessary to take action. Though the alert is
understood as an alert to physical danger, perceived
danger to physical domain such as, values, moral codes
and protective values can lead to anger
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The Social learning theory (context)

1. Explains aggressive behavior as learned

from exposure to aggressive models

(i.e. in the family, gangs, TV, movies, video

games) or as the result of random positive

reinforcement or direct experience

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2. Environmental and situational determinants
• Dehospitalization and deinstitutionalization have
resulted in thousands of MH displacements.
• There is a great need for a supportive social
network after discharge.
• Dehospitalization and unsupervised patients in the
community may become involved in antisocial acts
and violence.
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• The Neurobiological (Biological) theory

• Research, through brain neuroimaging, has found that

neurobiological deficits or injuries in the limbic
system or frontal or temporal lobes of the brain are
related to aggressive behavior.
• Aggressive behavior, personality changes & irritability
have been seen incases of limbic tumors & frontal
lobe lesions. Rabies, encephalitis & some brain
injuries are associated with loss of impulse control.
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• The Neurobiological (Biological) theory

• Studies have found that patients who attempted

suicide had the lowest CSF levels of 5-HIAA.

• MAO activity may also be linked to behavioral

expression of aggression à MAO metabolizes

serotonin & thus contributes to decreased serotonin

levels in the brain

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• The Neurobiological (Biological) theory

• Neurotransmitter Dysregulation

• Low Serotonin Syndrome – refers to, conditions of

low serotonin or low 5-hydroxyindoleacetic acid (a.k.a.

5-HIAA) a little ol’ metabolite of serotonin in the CSF.

• This is characterized by episodes of mood changes

and/or impulsive behavior.

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The Cognitive view (or theory)
refers to how a person thinks or interprets
situations and events and consequently determines
whether or not they become aggressive.
• A person uses their attitudes, beliefs & appraisals to
explain or interpret events that happen.
• If a person appraises an event or situation as
aversive and anger inducing à then it is likely that
they will react with anger.
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RISK ASSESSMENT
Assess for previous history of aggression
Assess for presence hallucinations, delusions and
impulsivity or predisposition to irritability
Assess client for
a plan
Wish or intent to harm
Means available to carry out a plan
For lack of coping skills such as assertiveness
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• Clinical Features
• Physical - Increased or prolonged restlessness, body
tension, pacing

• General over-arousal of body systems (increased

breathing and heart rate, muscle

• twitching, dilating pupils

• Affect - Facial expressions tense and angry

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• Clinical Features

• Increased volume of speech, erratic movements

• Prolonged eye contact

• Discontentment, refusal to communicate, withdrawal

• Reporting anger or violent feelings

• Blocking escape route

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• Clinical Features
• Cognition - Thought processes unclear, poor
concentration
• perception - Delusions or hallucinations with
violent content
• Verbal threats or gestures

• Replicating, or behaviour similar to that, which

preceded earlier disturbed/violent episodes
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• Tools (scales or tests) used to measure aggressive
behavior
• Overt aggression scale (OAS)

• This is used to document behaviors and

interventions during an aggressive episode.

• It helps to justify the use of medications and is a

way to compare other facilities to one another in
terms of using seclusion, restraints and PRN meds.
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• Tools (scales or tests) used to measure aggressive
behavior cont.
• The Minnesota Multiphasic Personality Inventory
measures general psychopathology through a variety
of tests.

• The Brief Anger Aggression Questionnaire is a six-

item measure (test) used for quick assessment of
irritability and tendency toward aggressive or violent
behavior.
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• Management of an aggressive client

• Is dependent on case presentation and related

history.
• Forms of intervention

• 1. Restraining

• Chemical, physical and geographical restraining

• 2. De-escalation
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• Management of an aggressive client

• Excessively aggressive clients require medication (e.

g. Largactil) in order to settle them and prevent harm
to self and others, even as further nursing
interventions are planned.
• During state of heavy sedation (chemical restraints),
basic ADL will be met for the patient in the form of;
• Ensure adequate nutritional and fluid needs including
any known treatment that patient may be taking;
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• Excessively aggressive clients

• Elimination by catheter and use of diaper;

• Maintenance of self esteem by meeting patients

personal hygiene etc.

Three strategies in psychiatric Emergencies

• Form of Restraining

• Chemical

• Physical

• Geographical
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• Chemical Restraint
• The specific properties or risks of the individual drugs
should be taken into consideration.

• Oral medication should be offered first before

parenteral medication.

• The dignity of the patients must be respected during

sedation, and the reasons for using medications
explained as much as possible.
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• Chemical Restraint

•Staff must be trained for basic resuscitation.

A crash cart must be available and a doctor
available to attend an alert by staff.
• Following sedation patients should have the
opportunity to document their account, and
their care plans updated if necessary
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• Examples of chemical restraints

• Intervention with medication in managing aggression:


when the patient does not respond to verbal

intervention.


Medications may not be advisable if the assaultive
patient is believed to be under the influence of an

unknown drug..
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
Haloperidol and diazepam are most commonly used
PRN for sedation and calmness. Works within 30
minutes and provides a "calm settle" within 1 hour.


Lithium (lithium is an antimanic) is effective in
decreasing aggression, irritability, manipulation,
persecutory delusions and hostile behaviors.


Also decreases aggression and self-injurious behavior
in children however it may increase aggression in
patients with temporal lobe epilepsy.
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
Sedative and anxiolytics such as benzodiazepines
(Ativan), barbiturates, and chloral hydrate decrease
aggression by sedating è use short-term only. (Ativan
and Benadryl)


A nonbenzodiazepine anxiolytic is buspirone (Buspar)
which does not sedate, relax muscles or have
anticonvulsant activity.


Antidepressants – have also been used to decrease
aggression. (Elavil, Desyrel, Prozac, and Zoloft)
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• Antipsychotics are the most commonly used for
aggression in acute psychosis the sedative effect
decreases the aggression (Haldol, Thorazine, Clozaril
and Risperdal).
• Rapid tranquillization may be used

• Anticonvulsant, such as carbamazepine (Tegretol and

Valproic Acid) is used, Side effect: BONE MARROW
DEPRESSION, aplastic anemia and hepatotoxicity.
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• Physical Restraint
• Done preferably by trained staff

• Avoid pressure to neck, thorax, abdomen, back and

pelvic area.

• Prop prone patients up so they can breathe more

easily

• Make one team member responsible for ensuring

that airway and breathing are not compromised
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• Physical Restraint

• Restrain patients for the shortest period possible (this

will depend on access to alternatives such as

seclusion and tranquilization)

• Deliberate use of pain can be used in exceptional

circumstances
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• Geographical Restraint
• moving the patient to a quieter place
• for patients medicated before being moved, the
risks associated with rapid tranquillization
• a more secure ward or seclusion increase the
risk of suicide hence ensure a safe
environment
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• According to Task Force of the American Psychiatric
Association indications for use of seclusion and restraint are:
• A. To prevent harm to patient and others if no others means
are effective.
• B. Prevent serious disruption of treatment program or damage
to environment.
• C. As part of an ongoing behavior treatment program.
• D. On patients request (for seclusion, used for violence, patient
on the verge of exploding).
• E. Seclusion and restraint should be viewed as important as
CPR in mental health .
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• When the decision for use of seclusion and restraint is made,

the staff:

• approaches client with 4 members behind the team leader in a

calm, helpful and non provocative manner

• informs patient what is happening and why

• if patient refuses to walk with or without help progress as such;

• Each team member holds a limb and transports patient to

seclusion or to apply restraints, (include wrist and ankle) cuffs,

sheet restraints and camisoles (straight jackets).

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•if this occurs, document all other interventions that
failed to help the patient maintain control.

Criteria for release from seclusion or restraints:

•decreased psychomotor agitation- decreased
restlessness, lowered BP and pulse rate
•stabilization of moods- absence of physical threats,
lowered anxiety level, consistency of verbal and
nonverbal behavior and feelings of trust in staff.
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• cognitive processes – signs of insight and
ability to look at the incident in an objective
manner, increased ability to concentrate and
improved reality testing
• Staff discussion occurs after the incident to
discuss what happened, what would have
prevented it, the rationale for the seclusion/
restraint and the reactions of the patient and staff
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•Behavior Therapy
A behavior therapy program requires target behaviors


be clearly stated.
Terms such as assaultive or violent should not be


used but rather use pushing, shoving, hitting, pulling

hair and throwing chairs.
Limit setting and behavioral management techniques


by use ofbehavioral contracts, token economics or

seclusionary
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A behavioral contract or no-harm contract is a


statement signed by the patient that he/she will

not harm themselves or others
Token economy: Is probably the most commonly


used behavioral management strategy. A desired

behavior results in receipt of tokens while
undesired behavior results in token loss
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
Reinforcing patient positive social behaviors can
proactively decrease hostile and aggressive response
on inpatient units and decrease aggressive episodes


Time-out- removes patients who are exhibiting socially
inappropriate behavior from over stimulating and
reinforcing situations. It is effective with people who
experience loss as a negative consequence. E.g. in a
case where others are free to roam while one is locked
away or denied participation in social activities.