evidence & practice / acute care

PATIENT ASSESSMENT

Using a systematic approach to

assess an acutely unwell patient
with catatonia: a case study
Dixon M (2018) Using a systematic approach to assess an acutely unwell patient with catatonia: a case study. Nursing
Standard. 32, 27, 44-52. Date of submission: 19 March 2017; date of acceptance: 1 February 2018. doi: 10.7748/ns.2018.e10870

Martha Dixon Abstract

Clinical nurse specialist Patients in acute settings may present with a variety of signs and symptoms; however, the
in orthogeriatric care, principles of assessment are applicable to all acutely unwell patients. This article details a
Homerton University case study of a patient who presented to the author’s medical ward in a catatonic state,
Hospital, London, England and was assessed using the ABCDE (airway, breathing, circulation, disability, exposure)
approach. Catatonia is a disturbed mental state in which a patient exhibits abnormal
Correspondence behaviour, such as the inability to speak and non-responsiveness to stimuli, alongside
marthadixon@hotmail. immobility. Although catatonia is a rare condition, it is important that nurses can identify
co.uk its signs and symptoms, because it can be fatal if not treated appropriately and rapidly.
Thus, it is crucial for nurses to be able to systematically assess acutely unwell patients,
Conflict of interest including those with catatonia, using the ABCDE approach.
None declared
Keywords
Peer review ABCDE assessment, acute care, assessment, catatonia, clinical observations, mental health,
This article has been neurological observations, neurology
subject to external
double-blind peer
review and checked THIS ARTICLE PRESENTS a case (inflammation of the brain), delirium,
for plagiarism using study of a patient with the signs and stroke, metabolic disturbances or
automated software symptoms of neurological compromise benzodiazepine withdrawal (American
in the form of a catatonic state, who was Psychiatric Association 2013). It is crucial
Online admitted to an emergency department to rule out these physiological causes
For related articles visit and transferred to the medical ward before assuming that a patient’s
the archive and search where the author worked. Catatonia is a catatonic state indicates a psychiatric
using the keywords. disturbed mental state in which a patient condition (Jaimes-Albornoz and Serra-
Guidelines on writing for exhibits abnormal behaviour such as the Mestres 2012). Furthermore, prompt
publication are available inability to speak and non-responsiveness and accurate assessment of a patient’s
at: rcni.com/writeforus to stimuli, alongside immobility. Although neurological status can prevent further
rarely encountered in acute settings, it is deterioration.
important that nurses can identify the signs Evidence suggests that catatonia has
and symptoms of catatonia and distinguish a prevalence of 8-38% in patients with
it from other conditions through effective psychiatric conditions, and the prevalence
assessment, because it can be fatal if left is increased in people with schizophrenia
untreated (Bhati et al 2007). (Kleinhaus et al 2012). It is thought that
Catatonia is associated with various men and women with schizophrenia
psychiatric conditions, including are equally at risk of catatonia
schizophrenia, major depression (Kleinhaus et al 2012). It is estimated that
and bipolar disorder (Jinkerson and 20-30% of patients with bipolar disorder
Morris 2010). It can also be caused by may experience a catatonic state at some
physiological issues such as encephalitis point (Bhati et al 2007).

44 / 28 February 2018 / volume 32 number 27 nursingstandard.com

Signs and symptoms of catatonia
The main signs and symptoms of catatonia
include (Brasic 2017):
»» Mutism – inability to speak.
»» Stupor – a motionless state where
the individual exhibits a lack of
motor activity and does not react to
external stimuli.  is often inappropriate or delayed.
»» Negativism – lack of response to external
stimuli.
»» Echopraxia – repeating the movements
of others.
»» Echolalia – repeating the words of others.
»» Waxy flexibility – allowing oneself to
be positioned by another person and
maintaining that position.
»» Posturing – maintaining a physical
posture for an extended period of time.
A particularly harmful form of catatonia is
malignant catatonia, which is characterised
by an acute onset of excitement, fever,
autonomic instability and delirium, and
is highly fatal. A person with catatonia is
unlikely to be able to respond to questions
about their medical history; therefore,
other sources such as medical records and
the patient’s family and friends should
be used to provide information. It is
also important that nurses can identify
other potential causes of neurological
impairment, including (Brasic 2017):
»» Neuroleptic malignant syndrome –
a rare but life-threatening reaction to
antipsychotics (neuroleptics).
»» Encephalitis – brain inflammation.
»» Non-convulsive status epilepticus –
a persistent change in behaviour and/
or mental processes, without the major
motor disturbances associated with
epilepsy.
»» Acute psychosis – a brief episode of
psychosis characterised by delirium,
hallucinations and incoherent speech.
Treatment of catatonia
Many healthcare organisations do
not have a specific policy for the
identification and treatment of patients
with catatonia; however, nurses should
be aware of the treatment options
available for the condition. National
Institute for Health and Care Excellence
(NICE) (2009) guidance mentions that
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treatment of catatonia includes the use of KEY POINT
benzodiazepines; however, these guidelines Bhati et al (2007) stated
do not provide any information on the that catatonia is reversible
assessment or nursing care of patients with treatment, although
with the condition. Bhati et al (2007) its initial treatment
stated that catatonia is reversible with is often inappropriate
treatment, although its initial treatment or delayed
Treatment options for catatonia include
(Sienaert et al 2014):
»» Discontinuation of antipsychotics – in
most cases, antipsychotics should be
stopped since they can exacerbate the
patient’s catatonic state and lead to
neuroleptic malignant syndrome.
»» Benzodiazepines – the first-line treatment
for catatonia, irrespective of the
underlying cause.
»» Electroconvulsive therapy (ECT) – this
could be considered in patients with
catatonia who have not responded to
benzodiazepines. ECT should also be
considered when rapid treatment is
required for life-threatening catatonic
presentations such as malignant
catatonia. Fatality rates have
significantly decreased following the
widespread use of ECT as a standard
psychiatric treatment for catatonic
states (Bhati et al 2007)
Case study
Jane (pseudonym used to ensure
anonymity), a 43-year-old woman, was
admitted to the author’s medical ward
from the emergency department in a
suspected catatonic state. Her partner had
called an ambulance because Jane had
stopped eating and drinking. Jane’s cousin,
who was later contacted by telephone
to establish a thorough patient history,
reported that Jane had been diagnosed
with schizophrenia in her 20s, but that
her engagement with community mental
health services had been infrequent and
her adherence to her medication was often
suboptimal. Jane’s partner also had mental
health issues.
Jane had been experiencing a cycle
of admission to hospital with physical
health conditions such as lower respiratory
tract and urinary tract infections; being
detained under the Mental Health Act 1983
volume 32 number 27 / 28 February 2018 / 45
evidence & practice / acute care
KEY POINT (amended in 2007) while a general hospital
Lung crackles can be inpatient; subsequent admission to a mental
indicative of pulmonary health unit; eventual discharge to the
consolidation (where community; and readmission to a general
an area of the lung fills hospital. Jane had become increasingly
with liquid) or pulmonary isolated in recent years, in part because of
oedema; therefore, this her lack of engagement with the community
necessitates an urgent mental health team, and because she only
chest X-ray and monitoring left her house on rare occasions since her
for signs of infection partner undertook household tasks such
(Coviello 2014) as shopping.
Jane was admitted to the medical ward
at the weekend, and had been on the
ward in a seemingly unconscious state for
approximately 36 hours when the author
took over her care. Jane was unable to
speak, her eyes were tightly shut, she
was unable to eat or drink, and her body
was rigid. She had been catheterised on
admission to the emergency department
because she was incontinent of urine.
In accordance with the NICE (2009)
guidance for treating catatonia, Jane
had been prescribed 2mg intravenous
(IV) lorazepam four times per day by
the psychiatric team who reviewed her
on her admission to the medical ward.
However, because lorazepam can have
sedative effects, including drowsiness and
respiratory depression (British National
Formulary 2017), the medical ward nurses
initially omitted it because of concerns
that it could worsen Jane’s catatonic state.
Jane was also prescribed IV paracetamol to
address any underlying pain, and IV fluids
because she was not eating or drinking.
This article details the clinical
and neurological observations and
investigations the author performed as
part of an ABCDE (airway, breathing,
circulation, disability, exposure) assessment
of Jane, with the support and guidance of
the critical care outreach team.
ABCDE assessment
On taking over Jane’s care, the author and
the critical care outreach team commenced
an ABCDE assessment, which involves
systematically assessing the symptoms of
an acutely unwell patient (Resuscitation
Council (UK) (RCUK) 2015). In an acute
setting, using the ABCDE approach can
quickly identify any life-threatening signs
46 / 28 February 2018 / volume 32 number 27
and symptoms. It is essential that nurses in
these settings are able to undertake thorough
clinical and neurological observations for
any acutely unwell patient, irrespective
of the underlying cause of the patient’s
condition, as part of the ABCDE assessment.
Airway
Jane’s airway was patent and self-maintained.
However, there were ‘gurgling’ sounds
coming from her mouth, so the author
checked inside her mouth for any visible
obstructions and used piped suction to
remove any excess saliva (RCUK 2015).
Jane’s head was supported in an upright
position and 3-5mL of saliva was removed
using suction.
 
Breathing
Concerns were raised regarding Jane’s
breathing, because she exhibited audible
chest sounds. On auscultation, there were
‘crackling’ sounds in both lung bases (the
concave lower sections of the lung that
rest on the diaphragm). Lung crackles can
be indicative of pulmonary consolidation
(where an area of the lung fills with liquid)
or pulmonary oedema; therefore, this
necessitates an urgent chest X-ray and
monitoring for signs of infection
(Coviello 2014).
An accepted range for a patient’s
respiration rate is 12-20 breaths per
minute, and an elevation in the respiration
rate can be one of the earliest clinical
signs of deterioration (Cretikos et al 2008,
RCUK 2015). Jane’s respirations were
monitored for 60 seconds (Carlisle 2012),
and her respiration rate was 22 breaths
per minute, which indicated tachypnoea
(abnormally rapid breathing). Jane’s
oxygen saturations were measured using
pulse oximetry and were 94%, which
was within the accepted range of 94-98%
(O’Driscoll et al 2017).
On identification of the audible chest
sounds and tachypnoea, the author and
critical care outreach team nurses assisted
Jane to adopt a sitting position, and they
requested a portable chest X-ray to assess
whether she had aspirated (taken food or
saliva, for example, into her airways) or
developed pneumonia (Coviello 2014).
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Jane’s chest X-ray indicated small areas
of consolidation in the lower lobes of
both lungs.
 
Circulation
Jane’s blood pressure was 102/75mmHg,
which was at the lower end of the normal
range, thus requiring closer monitoring
for hypotension. Her heart rate was
82 beats per minute, which was well within
the accepted range of 70-100 beats per
minute (British Heart Foundation 2017).
Jane’s capillary refill time was checked and
was timed at under two seconds, which
indicates an optimal level of perfusion
(RCUK 2015). Capillary refill time is
typically checked by applying pressure to
a patient’s nail bed until it blanches, then
counting how many seconds it takes for the
person’s normal skin colour to return.
Blood tests were undertaken to identify
any signs of infection, specifically elevated
levels of C-reactive protein (CRP) (an
inflammatory marker) and white cell
count (Treas and Wilkinson 2014). A CRP
level over 10mg/L is indicative of illness,
while the normal white cell count range
in women is 3.9-11.1 x 109/L (Dougherty
and Lister 2015). Jane’s CRP level was
240mg/L and her white cell count was
13.2 x 109/L. It is useful to consider
CRP and white cell count together when
assessing infection because CRP can be
elevated by several other factors, including
rheumatoid arthritis, inflammatory
bowel disease and myocardial infarction
(Landry et al 2017). A raised white cell
count can assist the nurse to make a
differential diagnosis. Jane’s blood test
results also demonstrated that her urea
and creatinine levels, both measures of
kidney function, were within the normal
ranges (NICE 2013).
A urine dipstick analysis was
undertaken, which tested positive for
the presence of ketones (an acidic waste-
product of metabolised fat) – possibly
indicating Jane was malnourished – as
well as for leucocytes and blood, which
may be indicative of urinary tract trauma.
There were no nitrites present in the urine
sample – these would usually be present
if the patient had developed a urinary
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tract infection. On discussion with the KEY POINT
medical team, it was decided that since While there is little
Jane had been catheterised, the presence evidence on the aetiology
of leucocytes and blood in her urine of catatonia, its prevalence
were likely to have been caused by minor is increased in patients
urinary tract trauma rather than infection. with schizophrenia, and
Jane had a catheter in situ because she it is less responsive to
was incontinent of urine. The catheter benzodiazepines in
had been inserted on admission to the this patient group
emergency department since, because of (Rosebush and
her rigidity, it was challenging for the Mazurek 2010)
nurses to manage her personal hygiene and
to protect her skin integrity. An adequate
urine output is 0.5mL/kg/hour (RCUK
2015). Jane’s weight was estimated to be
85kg and she was passing approximately
40-50mL of urine per hour, which was
adequate. However, her fluid intake
was being supplemented with IV fluids
because she was not eating or drinking.
Sepsis guidelines recommend
commencing antibiotics within one hour of
suspecting sepsis, after undertaking a septic
screen that includes chest X-ray, blood tests
and urine dipstick analysis (NICE 2017a,
Rhodes et al 2017). Therefore, in response
to Jane’s test results and the pulmonary
consolidation identified on X-ray, a course
of broad-spectrum IV antibiotics was
commenced immediately.
Disability
Jane’s level of consciousness was a
significant concern. When a catatonic
state is suspected, it is important to identify
the cause. Following her admission to
the medical ward, Jane had been seen by
a medical consultant who suspected that
she had become catatonic because of her
underlying mental health issues. While
there is little evidence on the aetiology of
catatonia, its prevalence is increased in
patients with schizophrenia, and it is
less responsive to benzodiazepines in
this patient group (Rosebush and
Mazurek 2010).
Despite the various physical
investigations that had been undertaken,
including blood tests, urine dipstick
analysis, and a chest X-ray, verifying
the exact cause of Jane’s catatonic state
remained challenging, particularly since
the ward staff were unable to ask her any
volume 32 number 27 / 28 February 2018 / 47
evidence & practice / acute care
KEY POINT
If there are any
concerns regarding the
patient’s pupillary reflexes,
a full set of physiological
observations should be
undertaken, including
respiration rate, oxygen
saturation, systolic blood
pressure, pulse rate, level
of consciousness or new
confusion and temperature
(RCP 2012, 2017)
48 / 28 February 2018 / volume 32 number 27
questions. A computed tomography (CT)
scan was also undertaken; however, this
did not reveal any acute neurological
changes that could have caused catatonia.
Level of consciousness
The AVPU tool (Royal College of
Physicians (RCP) 2012) can be used to
rapidly evaluate a patient’s responsiveness,
indicating their level of consciousness. This
has four possible outcomes (RCP 2012):
»» A – the patient is alert.
»» V – the patient responds to verbal
stimuli, such as speech prompts.
»» P – the patient responds to painful
stimuli, for example applying pressure to
the bed of one fingernail.
»» U – the patient is unresponsive.
It should be noted that the AVPU tool
has since been revised to the ACVPU tool
(RCP 2017), with the C representing ‘new
confusion’. Healthcare professionals can
use the AVPU or ACVPU tool (RCP 2012,
2017) to assess level of consciousness,
as part of the patient’s initial clinical
and neurological observations. Jane was
unresponsive when pressure was applied to
the bed of one of her fingernails; however,
she later responded to painful stimuli when
a nasogastric tube was inserted.
If the patient is classified as anything
other than ‘alert’, the healthcare assistant
should refer the patient to a nurse who will
undertake a Glasgow Coma Scale (GCS)
assessment (Teasdale and Jennett 1974). The
GCS is a commonly used tool that assesses
a patient’s level of consciousness by
determining how responsive they are to
stimuli in three areas: eye opening, motor
responses and verbal responses. The scores
of each of these areas are added together
to give a total score out of 15. The lowest
score is 3/15 (indicating unconsciousness)
while the highest score is 15/15 (indicating
full alertness and orientation) (Teasdale
2014). A low GCS score may be considered
a medical emergency because many patients
are unable to protect their airway and are
therefore at risk of aspiration (Holbery and
Newcombe 2016).
On initial assessment, Jane’s GCS score
was 3/15, since she was unresponsive to
pain and made no verbal sounds. However,
when a nasogastric tube was inserted to
improve Jane’s nutritional intake, she raised
her arm and attempted to speak, but did
not open her eyes. This resulted in a GCS
score of 8/15 (1 point for eye-opening;
2 points for verbal response; 5 points for
motor response). NICE (2017b) guidelines
for patients with head injury recommend
that any patient with a GCS score of 8 or
below is intubated and ventilated. However,
in Jane’s case, her catatonia was not
thought to be impairing her airway reflexes,
so she was not intubated (Jevon et al 2008).
This decision was made by the critical
care outreach team and the on-call doctor,
who undertook a full assessment of Jane’s
airway to ensure that her reflexes enabled
her to maintain a patent airway and
breathe normally.
 
Raised intracranial pressure
Pupillary reflex observations enable the
nurse to assess the functioning of the third
cranial nerve (oculomotor nerve) (Jevon
2008). When this nerve is constricted, the
pupils become non-reactive and dilated,
which can indicate raised intracranial
pressure (Jevon 2008). Raised intracranial
pressure can be caused by bleeding,
swelling, oedema or encephalitis, among
other complications (Dolan and Holt
2013). Bleeding was unlikely because Jane
was not reported to have fallen and the
CT scan had ruled it out. However, since
assessing her limb power and movement
was challenging, it was important to
undertake a pupillary reflex examination
to enable early identification of any
cerebral changes.
When Jane’s pupils were tested by
shining light into her eyes with a pen torch,
they both constricted immediately and
remained equal in shape and size (3mm in
diameter), indicating that she was unlikely
to have raised intercranial pressure. If
there are any concerns regarding the
patient’s pupillary reflexes, a full set of
physiological observations should be
undertaken, including respiration rate,
oxygen saturation, systolic blood pressure,
pulse rate, level of consciousness or new
confusion and temperature (RCP 2012,
2017). Altered respiration, hypertension
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and bradycardia – collectively referred to
as Cushing’s triad – are important signs of
raised intracranial pressure, and medical
assistance should be sought immediately if
this is suspected (Jevon et al 2008).  become unresponsive (Jevon et al 2008). It
Hourly evaluations
It was important to perform hourly
evaluations of Jane’s observations,
including GCS assessments, to:
»» Establish a pattern for the psychiatric
team to follow on discharge.
»» Determine if Jane’s level of consciousness
was decreasing over time, which could
have indicated that her mental state was
deteriorating and would require an
urgent review.
»» Monitor Jane for signs of physiological
deterioration such as temperature
changes, decreased blood pressure
or elevated heart rate. These signs
could indicate several physiological
conditions such as sepsis, hypovolaemia,
dehydration or acute kidney injury
(Jevon et al 2008).
It is important for nurses to remember that
a patient suspected to be in a catatonic
state is also at risk of developing other
physiological conditions, which might not
be initially recognised (Jaimes-Albornoz
and Serra-Mestres 2012).
 
Blood glucose levels
Another clinical observation required in
acutely unwell patients is an assessment
of their blood glucose levels using a
finger-prick blood test. Hypoglycaemia
(low blood glucose level) is a primary
cause of impaired consciousness and it
is important to rule this out in patients
presenting with signs and symptoms of
catatonia (RCUK 2015). Jane’s reduced
oral intake also meant that she was at risk
of hypoglycaemia (Jevon et al 2008).  (Abbey et al 2004); this was recommended
The normal range for blood glucose
levels is 4-7mmol/L (NICE 2016a).
However, when a patient’s nutritional
intake is suboptimal, the body begins
to metabolise stored complex fats to
release energy (Dudek 2013). While this
can maintain the body’s blood glucose
at a level conducive to cell respiration,
it leads to an elevated level of ketones in
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the blood and urine (Dudek 2013). If the KEY POINT
patient’s blood glucose levels fall below Hypoglycaemia (low
4mmol/L, they can begin to exhibit signs blood glucose level) is a
of confusion and disorientation and can primary cause of impaired
consciousness and it is
is important to monitor the patient’s blood important to rule this out
glucose levels alongside any neurological in patients presenting with
observations to ensure that their symptoms signs and symptoms of
of catatonia are not obscuring the catatonia (RCUK 2015)
development of hypoglycaemia (RCUK
2015). Jane’s blood glucose level was
4.2mmol/L, which was within the accepted
range (NICE 2016a).
Patients with catatonia are at increased
risk of malnutrition (Clinebell et al
2014, Fletcher 2015), and the author
was concerned that, because Jane was
not eating or drinking, her nutritional
requirements were not being met. The
critical care outreach team and the
on-call doctor were informed, and it was
agreed that a nasogastric tube should
be inserted (Fletcher 2015). Since there
was no dietitian available at the time,
an out-of-hours feeding regimen was
commenced, which provides a minimal
level of nutritional input until a tailored
nutritional programme can be put in place
by a dietitian.
 
Pain
As with any patient, it was important
that any signs that Jane might have
been experiencing pain were monitored.
This can be challenging in patients
who are unresponsive, and there is also
evidence that patients with schizophrenia
may have reduced responsiveness to pain,
which can also make an accurate pain
assessment challenging (Bonnot et al
2009). It was possible to attempt a pain
assessment when Jane’s GCS score was
at its highest, using the Abbey pain scale
in the local healthcare organisation
policy to assess pain in patients who
cannot verbalise. However, the Abbey pain
scale is recommended primarily for patients
with dementia (Abbey et al 2004), and,
furthermore, reduced mobility, withdrawal,
unintentional facial expressions and a lack
of verbal expression all indicate pain on the
Abbey pain scale, but can also be signs of
volume 32 number 27 / 28 February 2018 / 49
evidence & practice / acute care
KEY POINT catatonia (Abbey et al 2004, Jinkerson and
Patients experiencing Morris 2010).
catatonia are at The pain assessment was completed
increased risk of deep twice, but subsequently discontinued
vein thrombosis (DVT), because it was deemed that Jane’s catatonic
pulmonary embolism state prevented an accurate assessment.
(PE) and pressure No recommended pain assessment
ulcers (Clinebell et al tools could be found for patients with
2014). Symptoms of DVT catatonia, and further research in this area
usually develop in the is required. Because it was challenging to
patient’s calves and assess Jane’s pain levels, IV paracetamol was
include redness, swelling, administered to address any underlying pain.
tenderness and
a sensation of warmth Exposure  repositioning, and the use of appropriate
on the skin (NICE 2016b) Patients experiencing catatonia are at
increased risk of deep vein thrombosis
(DVT), pulmonary embolism (PE) and
pressure ulcers (Clinebell et al 2014).
Symptoms of DVT usually develop in
the patient’s calves and include redness,
swelling, tenderness and a sensation
of warmth on the skin (NICE 2016b).
Symptoms of a PE include an acute
drop in oxygen saturations, sharp pain,
tachycardia, tachypnoea and sweating
(Dolan and Holt 2013). Patients
experiencing catatonia may also be
susceptible to infection or bleeding,
particularly if they begin to develop
pressure ulcers. Untreated pressure ulcers
are prone to deterioration and can have
adverse effects such as sepsis, loss of limbs
and, in some cases, death (Cox 2011).
The nurses undertook a head-to-toe skin
check (RCUK 2015), and were particularly
vigilant in observing for signs of blood
clots because Jane was unable to report
pain. Jane’s skin was found to be intact.
While she did not exhibit any signs of
clotting, a course of enoxaparin sodium
subcutaneous injections at a prophylactic
dose was commenced as a precautionary
measure (Lois et al 2014); this drug is
used in the prevention and management
of thromboembolism.
The Waterlow score was used, which
can identify patients at risk of developing
pressure ulcers and assist nurses in deciding
if any preventative equipment is required
(Waterlow 2005, Thorn et al 2013). The
Waterlow score incorporates various
assessments of the patient, including
(Waterlow 2005):
50 / 28 February 2018 / volume 32 number 27
»» Build or weight for height (body mass
index).
»» Skin type and visual risk areas.
»» Sex and age.
»» Malnutrition Screening Tool.
»» Continence.
»» Mobility.
Jane’s Waterlow score was 16, which
meant she was considered to be at high risk
of developing pressure ulcers; therefore,
preventative measures were undertaken.
Optimal prevention of pressure ulcers
involves regular skin checks, regular
preventative equipment such as support
mattresses and cushions (Clinebell et al
2014). A pressure mattress was provided
and a turning schedule was commenced,
which involved turning Jane every four
hours onto her left side, her right side and
her back. Pressure ulcers can also develop
if catheter bags are not positioned correctly
and the skin area around the bag is not
checked regularly (Sivaraman Nair et al
2001, Vaidyanathan et al 2002). Therefore,
since Jane had a catheter in situ, the nurses
closely monitored the skin in this area.
Discussion
After three days of treatment with IV
lorazepam, Jane gradually regained
consciousness. She was supported by
a mental health nurse throughout her
three-week stay on the medical ward,
before being discharged to a mental
health unit. When Jane was discharged,
she was able to eat, speak and mobilise
using a walking frame. However, Jane’s
case was complex and the medical team
was uncertain about Jane’s diagnosis of
catatonia and how several of her presenting
symptoms were caused by physiological
rather than psychiatric factors.
This case study reinforces the importance
of not making assumptions in clinical
practice. For example, the nurses on the
medical ward initially omitted lorazepam
because they thought it was contraindicated,
even though there is a clear evidence base
for administering benzodiazepines in the
treatment of catatonia (NICE 2009).
However, the psychiatric team had not
documented clearly in the patient’s notes
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that lorazepam was to be administered
specifically to treat Jane’s catatonic state.
Therefore, it was necessary for the author to
seek advice about whether to reinstate the
lorazepam from the clinical site manager,
the critical care outreach team and the on-
call doctor. However, the on-call doctor had
not treated a case of catatonia before, while
the critical care outreach team nurse had not
assessed a patient with catatonia recently
and could not be sure of the accuracy of
his knowledge. The clinical site manager
advised the author to administer lorazepam,
in line with the evidence base (NICE 2009).
On later discussion with the psychiatric
consultant, it was discovered that
lorazepam had been prescribed specifically
to treat Jane’s catatonic state. The
psychiatric consultant acknowledged
that the use of lorazepam specifically for
catatonia should have been documented
clearly for the benefit of healthcare
professionals who were not experienced in
treating patients with this condition.
This case study also demonstrates the
importance of nurses being aware of a range
of physiological and psychiatric conditions,
which, in this case, included patients with
catatonia and/or mental health issues who
might be admitted to a medical ward.
The nurses’ lack of knowledge potentially
delayed Jane’s recovery when they omitted
lorazepam because they believed it to be
contraindicated and did not seek the advice
of senior colleagues. This demonstrates the
importance of providing evidence-based care.
The fact that Jane’s seemingly
unconscious state did not immediately
prompt the medical ward nurses to escalate
Jane for further assessment, such as airway
reflexes and hourly GCS assessments,
demonstrates that education and support
for nurses in caring for patients with
reduced consciousness is required. This
case study also shows the importance
of addressing Jane’s low GCS score and
investigating its underlying cause, rather
than accepting it as a consequence of her
catatonic state. Any diagnosis that a nurse
is unsure about should be escalated, even
if the patient’s medical history includes
similar presentations.  as pain and pressure areas, which might be
In many healthcare settings, healthcare
nursingstandard.com
assistants routinely undertake clinical KEY POINT
observations, including some neurological Catatonia is not a well-
observations; however, in this case it was understood condition and
crucial that a registered nurse undertook further research into its
the neurological observations. Although management is required
healthcare assistants routinely undertake to optimise patient care.
tasks such as clinical observations, research Support and training for
has found that many feel they have acted nurses is also required
outside of their remit and training at some since many may not have
time (Clews 2010, Emergency Nurse 2013). adequate knowledge of
It should be noted that the competency how to manage a patient
and knowledge among ward-based who is in a catatonic state
healthcare assistants varies; however, the
author’s experience suggests that many
healthcare assistants may not be confident
in assessing and escalating abnormal
neurological observations. While this should
be judged on an individual basis, nurses
must only delegate tasks to healthcare
assistants who understand the task and
have the skills to complete it (Nursing
and Midwifery Council 2015, Royal
College of Nursing 2017). Where nurses
do undertake neurological observations,
this can support the prompt identification
and escalation of patient deterioration. The
author suggests that nurses should always
undertake neurological observations unless
the healthcare assistant has completed the
required competencies.
Conclusion
Catatonia is not a well-understood
condition and further research into its
management is required to optimise patient
care. Support and training for nurses is
also required since many may not have
adequate knowledge of how to manage
a patient who is in a catatonic state.
Similarly, training in caring for patients
with mental health issues is required in
many acute settings.
It may be beneficial for nurses to use the
ABCDE approach to systematically assess
acutely unwell patients, including those
with catatonia, and doing so may improve
patient outcomes and care. Undertaking
an ABCDE assessment can assist nurses to
consider the patient as a whole, rather than
focusing only on their presenting condition.
This can enable them to address issues such
neglected in acutely unwell patients.
volume 32 number 27 / 28 February 2018 / 51
evidence & practice / acute care
References
Abbey J, Piller N, DeBellis A et al (2004) The
Abbey pain scale: a 1-minute numerical
indicator for people with end-stage dementia.
International Journal of Palliative Nursing.
10, 1, 6-13.
American Psychiatric Association (2013)
Diagnostic and Statistical Manual of Mental
Disorders. Fifth edition. American Psychiatric
Publishing, Washington DC.
Bhati MT, Datto CJ, O’Reardon JP (2007)
Clinical manifestations, diagnosis and
empirical treatments for catatonia.
Psychiatry. 4, 3, 46-52.
Bonnot O, Anderson GM, Cohen D et al (2009)
Are patients with schizophrenia insensitive
to pain? A reconsideration of the question.
Clinical Journal of Pain. 25, 3, 244-252.
Brasic JR (2017) Catatonia. emedicine.
medscape.com/article/1154851-overview
(Last accessed: 20 February 2018.)
British Heart Foundation (2017) Your Heart
Rate. www.bhf.org.uk/publications/heart-
conditions/medical-information-sheets/
your-heart-rate (Last accessed: 20 February
2018.)
British National Formulary (2017) British
National Formulary. No. 74. BMJ Group and
the Royal Pharmaceutical Society of Great
Britain, London.
Carlisle S (2012) Nursing and Health. Essential
Clinical Skills. Survival Guide. Routledge,
Abingdon.
Clews G (2010) Healthcare Assistants Carry
Out Nursing Tasks. www.nursingtimes.net/
healthcare-assistants-carry-out-nursing-
tasks/5019391.article (Last accessed:
20 February 2018.)
Clinebell K, Azzam PN, Gopalan P et al (2014)
Guidelines for preventing common medical
complications of catatonia: case report
and literature review. Journal of Clinical
Psychiatry. 75, 6, 644-651.
Coviello JS (2014) Auscultation Skills: Breath
& Heart Sounds. Fifth edition. Lippincott,
Williams & Wilkins, Philadelphia PA.
Cox J (2011) Predictors of pressure ulcers in
52 / 28 February 2018 / volume 32 number 27
adult critical care patients. American Journal
of Critical Care. 20, 5, 364-375.
Cretikos MA, Bellomo R, Hillman K et al (2008)
Respiratory rate: the neglected vital sign.
Medical Journal of Australia. 188, 11, 657-659.
Dolan B, Holt L (Eds) (2013) Accident and
Emergency: Theory into Practice. Third
edition. Ballière Tindall, London.
Dougherty L, Lister S (2015) The Royal
Marsden Manual of Clinical Nursing
Procedures. Ninth edition. Wiley Blackwell,
Chichester, West Sussex.
Dudek SG (2013) Nutrition Essentials for
Nursing Practice. Seventh edition. Lippincott
Williams & Wilkins, Philadelphia PA.
Emergency Nurse (2013) Healthcare nurses
working outside their role endanger patients.
Emergency Nurse. 21, 1, 4.
Fletcher J (2015) Giving nutrition support to
critically ill adults. Nursing Times. 111, 12, 12-16.
Holbery N, Newcombe P (2016) Emergency
Nursing at a Glance. John Wiley & Sons,
Chichester.
Jaimes-Albornoz W, Serra-Mestres J (2012)
Catatonia in the emergency department.
Emergency Medicine Journal. 29, 11, 863-867.
Jevon P (2008) Neurological assessment
part 2 – pupillary assessment. Nursing Times.
104, 28, 26-27.
Jevon P, Humphreys M, Jevon B (2008)
Nursing Medical Emergency Patients. John
Wiley & Sons, Chichester.
Jinkerson J, Morris M (2010) Catatonia: An
Analysis and Examination of the Validity of
Current Diagnostic Trends. Verlag Dr. Müller,
Saarbrücken, Germany.
Kleinhaus K, Harlap S, Perrin MC et al
(2012) Catatonic schizophrenia: a cohort
prospective study. Schizophrenia Bulletin.
38, 2, 331-337.
Landry A, Docherty P, Ouellette S et al (2017)
Causes and outcomes of markedly raised
C-reactive protein levels. Canadian Family
Physician. 63, 6, e316-e323.
Lois SG, Sato M, Geraci T et al (2014)
Correlation of missed doses of enoxaparin
with increased incidence of deep vein
thrombosis in trauma and general surgery
patients. JAMA Surgery. 149, 4, 365-370.
National Institute for Health and Care
Excellence (2009) Guidance on the Use
of Electroconvulsive Therapy. Technology
appraisal guidance No. 59. NICE, London.
National Institute for Health and Care
Excellence (2013) Acute Kidney Injury:
Prevention, Detection and Management.
Clinical Guideline No. 169. NICE, London.
National Institute for Health and Care
Excellence (2016a) Type 1 Diabetes in
Adults: Diagnosis and Management.
Clinical guideline No. 17. NICE, London.
National Institute for Health and
Care Excellence (2016b) Venous
Thromboembolism in Adults: Diagnosis
and Management. Quality standard No. 29.
NICE, London.
National Institute for Health and Care
Excellence (2017a) Sepsis: Recognition,
Diagnosis and Early Management. NICE
guideline No. 51. NICE, London.
National Institute for Health and Care
Excellence (2017b) Head Injury: Assessment
and Early Management. Clinical guideline
No. 176. NICE, London.
Nursing and Midwifery Council (2015) The
Code: Professional Standards of Practice
and Behaviour for Nurses and Midwives.
NMC, London.
O’Driscoll BR, Howard L, Earis J et al (2017)
BTS guideline for oxygen use in adults in
healthcare and emergency settings. Thorax,
72, 1, i1-i90.
Resuscitation Council (UK) (2015) The ABCDE
Approach. www.resus.org.uk/resuscitation-
guidelines/abcde-approach (Last accessed:
20 February 2018.)
Rhodes A, Evans LE, Alhazzani W et al, (2017)
Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and
Septic Shock: 2016. Intensive Care Medicine.
43, 3, 304-377.
Rosebush PI, Mazurek MF (2010) Catatonia
and its treatment. Schizophrenia Bulletin.
36, 2, 239-242.
Royal College of Nursing (2017) Accountability
and Delegation: A Guide for the Nursing Team.
www.rcn.org.uk/professional-development/
publications/pub-006465 (Last accessed:
20 February 2018.)
Royal College of Physicians (2012) National
Early Warning Score (NEWS): Standardising
the Assessment of Acute-Illness Severity in
the NHS. RCP, London.
Royal College of Physicians (2017) National
Early Warning Score (NEWS) 2. www.
rcplondon.ac.uk/projects/outputs/national-
early-warning-score-news-2 (Last accessed:
20 February 2018.)
Sienaert P, Dhossche DM, Vancampfort D et al
(2014) A clinical review of the treatment of
catatonia. Frontiers in Psychiatry. 5, 181.
doi: 10.3389/fpsyt.2014.00181.
Sivaraman Nair KP, Taly AB, Roopa
N et al (2001) Pressure ulcers: an unusual
complication of indwelling urethral catheter.
Spinal Cord. 39, 4, 234-236.
Teasdale G (2014) Forty years on: updating
the Glasgow Coma Scale. Nursing Times,
110, 42, 12-16.
Teasdale G, Jennett B (1974) Assessment
of coma and impaired consciousness: a
practical scale. The Lancet. 2, 7872, 81-84.
Thorn CC, Smith M, Aziz O et al (2013) The
Waterlow score for risk assessment in
surgical patients. Annals of the Royal College
of Surgeons of England. 95, 1, 52-56.
Treas LS, Wilkinson JM (2014) Basic Nursing:
Concepts, Skills & Reasoning. F.A. Davis
Company, Philadelphia PA.
Vaidyanathan S, Soni BM, Bingley J et al
(2002) Prevention of pressure sore caused by
indwelling urinary catheters. Spinal Cord. 40,
9, 489. doi:10.1038/sj.sc.3101356.
Waterlow J (2005) The Waterlow Score. www.
judy-waterlow.co.uk/waterlow_score.htm
(Last accessed: 20 February 2018).
nursingstandard.com