PSYCHIATRIC EMERGENCIES

PRESENTED BY
DIKSHA KAIWART
M.Sc. NURSING 2ND
YEAR
 DEFINITIONS

“A condition in which the client will have disturbances in thoughts,

affect and psychomotor activity that leads to threat either to himself
or his existence, Ex: 1) suicide; threat to people in the environment;
2) homicide; which needs immediate attention and care”.

“A sudden onset of an unusual, disordered inappropriate behaviour

caused by an emotional and physiological situation”.
—Bimla Kapoor, 2002
 CONCEPT AND MEANING

Acute form of alteration in behaviour, emotion of thought which

requires immediate intervention to safeguard the life of patient by
bringing down the behavioural manifestation and promoting emotional
security to the client and others in his surroundings.
 COMMON PSYCHIATRIC EMERGENCIES
1.Suicidal attempt and committing suicide
2.Violent, aggressive behaviour
3.Excitement or overactive patient
4.Panic attack
5.Stupor and catatonic syndrome
6.Withdrawal symptoms
7.Overdose of alcohol or drug abuse
8.Severe depression
9.Hysterical attacks, hyperventilation
10.Under active patient
11.Transient Situational disturbance
12. Delirium tremens, status epilepticus, drug toxicity or iatrogenic
emergencies, e.g. lithium toxicity- organic conditions

13. Abnormal response to stressful situation

14. Disasters, e.g. natural or manmade

OBJECTIVES OF PSYCHIATRIC EMERGENCY
INTERVENTION

a)To safeguard the life of patient

b)To reduce the anxiety
c)To promote emotional security of client and the family members
d)To educate the client and his family members the ways of dealing
emergency situation by utilizing adaptive coping strategies and
appropriate problem solving techniques.
CHARACTERISTICS OF PSYCHIATRIC EMERGENCIES

a)Certain conditions or stressors predisposes the Client and his family

members to seek immediate intervention, as they feel more discomfort
b)Disharmony between client and his environment
c)Sudden, unexpected, disorganization in person
d)Unable to cope up with the stressful situation or failure in handling the
stressors
 ASSESSMENT
Immediate Assessment
a) The clients behaviour and how the client is brought to hospital
b) The physical environment and its safety Availability of trained persons
c) Mental status examination
d) Search for availability of instruments and collect it
e) Identify the stressor which predisposing the events
f) Level of adjustments or coping abilities prior to the problem
g) Main complaints of present illness
h) H/O any psychiatric illness
i) Thorough physical examination has to be conducted to exclude physical illness
j) Assist for laboratory investigations.
 MANAGEMENT OF PSYCHIATRIC EMERGENCIES

1. Handle the cases tactfully

2. Provide calm and watchful environment
3. Emergency cases has to be shifted as early as possible where he will be
safeguarded against injury either to himself or to the others
4. Clients disturbed mood will disturb the other clients, hence immediately nurses
has to shift them to the calm areas with adequate safety and supervision
5. Provision of care in meeting the client’s needs accordingly
 EXAMINATION
Psychiatric History from both the patient and the informant(s).
Informant(s) may be more coherent
1.Chief complaint: elaborate, with emphasis on dating of onset and
progression.
2.Recent life-changes, such as any losses (real or imagined); any
physical illnesses.
3.Level of adjustment, prior to the psychiatric emergency,
4.Past history (briefly) of any physical or psychiatric disorder(s).
5.Family history (briefly) of any physical or psychiatric disorder(s).
6.Drug and alcohol history, prescription drugs, street drug(s) or alcohol
dependence/abuse.
 DETAILED GENERAL PHYSICAL AND
NEUROLOGICAL EXAMINATION
1.secondary psychiatric disorders, with particular emphasis on the
presence of any head injury.
2.Mental Status Examination
3.Screen for organicity (most important). Test for higher mental (or
cognitive) functions, such as consciousness, orientation, attention,
concentration, memory, intelligence, abstract thinking, insight and
judgement.
4.Brief mental status examination, to diagnose or rule out any psychiatric
disorder(s).
5.presence of ideas of self-harm or suicide, or of harming others .
SUICIDE
 Definition:-
 
"A murderous attack on an internalized object which has
become a source of ambivalence".

Freud, 1957
"Ultimate act of self destruction". Clayton, 1985
 Epidemiological Factors:-

 Approximately 30000 person in the United States end their

lives each year by the
Suicide.
 These statistics have established suicide as the third leading
cause of death among young Americans ages 15 to 24,
 the fifth leading cause of death for ages 25 to 44
 And eights leading cause of death for individual ages 45 to 64.
Gender and suicide:-

In the Western world, males die much more often by means of suicide
than do females, although females attempt suicide more often.

Season and suicide:-

 People die by suicide more often during spring and summer.

 Some studies have found that elderly people are more likely to
commit suicide around their birthdays.
Co-morbidity:-
Comorbidity is common among suicide victims; .
1. Psychiatric disorders - Depression, alcoholism and drug
dependence, Schizophrenia
2. Physical disorder : Cancer, AIDS and painful physical illness.
3. Psychosocial factors - Failure in exam, failure in love.
Illegitimate pregnancy, loss of loved one, occupation etc.
 Risk factors:-
1. Marital status
Unmarried, widowed, divorced, separated and lonely living
2. Gender.
Women attempt more than men. Women 70% and men 30%.
3. Socio-economic status.
Suicidal rates were observed more in high and low social classes than middle
class.
4. Occupations
Lawyers, law enforcement officers, insurance agents, dentist, musicians,
physicians etc.
5. Race
More in whites than non whites
6. Residence
High in cities than in villages.
7. Religion
Higher rates of suicide in Catholics and Jews.
8. Ethnicity
Higher rates of suicide in Americans, African American, Asian Americans.
Etiology:-
Suicide may occur for a number of reasons, including depression, shame, guilt,
desperation, physical pain, emotional pressure, anxiety, financial difficulties, or
other undesirable situations.
General causes:-
 It is the way out to the problem or crisis
 Isolated stressful and traumatic events and experience
 Constant failure to the use of normal coping strategies
 Presence of multiple risk factors
 Significant losses.
 Perceived abuse
 Biochemical factors
When low level of neurotransmitters, eg serotonin causes depression
 Physical Disorder:-

 physical illness is present in 25 to 75 percent of all suicide victims;

 Cancer of the breast or genitals is found in 70 percent of women
with cancer who commit suicide.
 There are seven diseases of the central nervous system that
increase the risk of suicide: epilepsy, multiple sclerosis, head
injury, cardiovascular disease, Huntington's disease, dementia, and
acquired immune deficiency syndrome (AIDS).
 Neurotransmitter Theory:-
 Diminished central serotonin plays a role in suicidal behaviour
 
 Low concentrations of the serotonin metabolite 5-hydroxy
indoleacetic acid (5-HIAA) in the lumbar cerebrospinal fluid (CSF)
were associated with suicidal behavior. This finding has been
replicated many times and in different diagnostic groups.
Low Cholesterol-
Psychological Factors
Aaron Beck stated that Hopelessness and dichotomous thinking increases
risk for suicide
Sociocultural Factors Durkheim's Theory-
1. Egoistic suicide is determined by a lack of meaningful family ties or
social interactions.
 
2. Anomic suicide is committed by those who experience severe
disorientation from society. Anomic suicide occurs when the relationship
between an individual and society is broken by social or economic
adversity.
3. Altruistic suicide results from excessive integration in society.
Marital Status-
Employment-
Psychiatric Disorders-
 Depressive Disorders
 Male sex is a risk factor for suicide among depressed subject
 Schizophrenia
Alcohol Use Disorders
Other substance use disorders drug dependence
Other substance use disorders drug dependence
Panic Disorder, Social causes-
 CLASSIFICATION
 

1. Egoistic suicide
One who lost social integration with the social group? It may result from
excessive individualism and from the decreasing influence of social
norms. It s the response of the individual who feels separated and apart
from the main society. For e.g. divorcé

2. Altruistic suicide
Results from a response to a cultural expectation

 
3. Anomic suicide
Occurs in response to the changes that occur in an individual's life.
e.g. divorce loss of job

4. Samsonic suicide or suicide of revenge

To spite others or experiencing as being unfriendly, for eg if husband
is unfaithful to his wife, she may attempt to commit suicide to take
revenge
 METHODS OF COMMITTING SUICIDE
 

 Low lethal methods: self poisoning by pill ingestion, wrist cutting

 High lethal methods: gun shooting
• Hanging & drowning
• Car crash
• Fire arms
• Jumping from height
• Ingestion of poisons - 35%, hanging 23%, drowning 9%, jumping in
front of train - 4% and burning 12%.
RECOGNITION OF SUICIDAL IDEAS
OR FACTS-
a) Behavioural clues
• Ingestion of small amount of some potentially lethal drugs
• Keeping affairs in order
• Giving away prized possessions
• Writing suicidal notes
• Sudden changes in mood
b) Verbal clues
• Passing negative statement like
• I want to die
• I am not useful
• Everything going bad
 
c) Situational clues
• life experiences associated with major stress due to death of loved ones
 
d) syndromic clues
• Constellation of emotion that is commonly associated with suicide. For
example depression, delirium and other psychotic disorders.
 
e) Non-verbal clues
• Addiction, sleeping too much or too little.
f) Emotional and behaviour changes associated with suicide.
• Sad, social association, recurring suicidal thoughts
 MANAGEMENT
 

MLC:
Sec. 309 of IPC, states that whoever attempts to commit suicide and
does any act towards the commission of such offense, shall be
punishable for a term which may extend to one year and shall also be
liable to fine".
 
Preventable:
suicide prevention centres. Crisis intervention centres, psychiatric
emergency services, medical emergency services, social welfare
centres, even at home.
Important steps for preventing suicide are:-
1. Take all suicidal threats;
2. Inspect physical surrounding and remove all means of committing
suicide, like sharp objects, ropes, drugs, etc.
3. Acute psychiatric emergency interview.
4. Counselling and guidance.
5. Treatment with medication of ECT
6. Follow up

World Suicide Prevention Day 10 September By WHO

Assessment:
-It include demographic assessment
 Presenting symptoms/ medical-psychiatric diagnosis 
 Suicidal act or ideas
• How serious the intent and plan, means, is the first time or second
 Interpersonal support system
 Analysis of the suicidal crisis like
• Precipitating event, Relevant history, Life stage issues
 Psychiatric / medical/ family history
Diagnosis: Risk for suicide, Ineffective coping, Disabled family coping,
Hopelessness
Intervention
Primary intervention 
Secondary intervention
Tertiary intervention
Basic level intervention:-
In the hospital or community setting the basic level registered nurse
utilizes counselling, health teaching, case management and
psychobiological interventions.
Evaluation:
Evaluation of suicidal clients is an ongoing part of assessment. The
nurse must be constantly alert to the changes in the suicidal patient's
mood, thinking, and behaviour.
ANGER, HOSTILITY, AGGRESSIVE
BEHAVIOUR
Anger ‘is an emotional response to perceived frustration of desires or
needs or challenges’. —Wanda K Mahr, 2006
  
Hostility or verbal aggression ‘is an emotion expressed through
verbal abuse, lack of cooperation, violation of rules or norms of
threatening behaviour’. —Schultz and Videbeck, 2005
 
Aggressive behaviour ‘may manifest as verbal aggression, physical
aggression or both against objects, people or self with a potential
towards destruction or intent to cause harm’. -Anderson and
Bushman, 2002
 AGGRESSION CYCLE
a) Triggering Phase : Stimuli in the environment initiates the client’s response.
Manifestations: Restlessness, anxiety, irritability, pacing, muscle, tension, rapid
breathing, perspiration, loud voice, anger.
b) Escalation Phase: Client’s responses indicate movement towards a loss of
control.
Manifestations: Flushing or paleness in the face, yelling, swearing, agitated,
threatening, demanding, clenched fists, threatening gestures, hostility, loss of
ability to think clearly or to solve problems.
c) Crisis Phase: Client loses control during emotional and physical Crisis.
Manifestations: Throwing objects, kicking, hitting, spitting, biting, scratching,
screaming, shrieking, and inability to communicate clearly.
d) Recovery Phase: Client will regain physical and emotional control.
Manifestations: Lowering of voice, decreased muscle tension, clearer more
rational communication, physical relaxation.
e) Post Crisis Phase: Client attempts reconciliation with others and returns to
the level of functioning before the aggressive incident and its antecedents.
Manifestations: Remorse, apologies, crying, quiet, withdrawn behaviour
 AETIOLOGY
1. Neurobiological Factors
 serotonin plays a major inhibitory role in aggressive behaviour, hence low
serotonin levels may lead to increased aggressive behaviour.
 Increased levels of dopamine, norepinephrine in the brain is associated with
violent behaviour.
 Structural change in the limbic system and the frontal, temporal lobes of brain
may alter the person’s ability and causes aggressive behaviour.
2. Psychological Consideration
 Lower socioeconomic status
 Toddler with temper tantrums
 Broken family, Culture bound syndromes
 Low educational attainment, inferiority feelings
 Poor nutrition, Drug abuse, alcoholism .
3. Psychological Factors
 Adults at risk for adjustment problems had experienced difficult temperaments
4. Inpatient Factors
 Postoperative confusion
 Unwanted treatment, Delayed treatment, Client assault
 Post-traumatic stress responses.
5. Psychiatric Disorders
6. Medical Conditions
7. Cognitive Theory aggressive disposition and expectations that result in negative
self fulfilling prophecies.
8. Socio-environment Factors
9. Legal Issues
10.Treatment
 If interventions fails, physical seclusion and restraint.
 STRATEGIES
1. Verbal Intervention:
• Verbal communication can prevent aggressive behaviour from escalating steps:
make contact.
2. Limit Setting
 Authority reminds clients of the boundaries of acceptable behaviour and sets
limits as warranted 
3. Cognitive Interventions
 Client learns to use more positive and assertive responses in interactions with
others.
Techniques
i) Guided Discovery/Cognitive Reframing or Cognitive Restructuring indications
Depression, anger
ii)Anger Management in Groups
1. Behaviour Therapy: Token Economy
2. Group and Family Therapy
3. Pharmacotherapy
For acute psychosis
Haloperidol - 0.5-5 mg bd or TID Or
Chlorpromazine - 10-25 mg —50 mg at PRN For 3—4 days
Clozapine - 300-900 mg OD (Schizophrenia)
Risperidone (Risperidal) - 3—6 mg/day (for Hallucinations and Delusion).
 Anti-convulsant
Carbamazapine (tegretol)-100—200 mg/12hr; daily increase 200 mg maximum
dose - 1200 mg
 β - Blockers;
Propranolol (inderal)-20 mg TID.
 
4. Restraint and Seclusion
 NURSING MANAGEMENT OF THE CLIENT WITH AGGRESSIVE
BEHAVIOUR
Assessment
Nursing Diagnosis
Interventions
• Close supervision of the client is always essential.
• Engage the hostile person in dialogue is most effective to prevent the behaviour
• Encourage the client to talk about the events or issues freely when he to calm.
• Engage him in therapeutic activities to participate actively.
• Show concern for clients thoughts and feelings.
Evaluation : Observe whether the client has regained normative behaviour or not; if
not, modified strategies has to be adopted until the client regains control over his
behaviour.
 VIOLENT BEHAVIOUR
 
It is a severe form of physical aggression by one individual to
other individual. Violent clients are always not psychiatrically
ill.
RISK FACTOR PROFILE
1. Demographic
2. History
Violence to self or others
Antisocial behaviour
Criminal act performance
Family violence
Cruelty to others or to animals.
3. Medical
Traumatic brain injury
Central nervous system dysfunctions.
4. Socio-environmental
Association with antisocial elements or
peer group
Financially dependent on family
members
Living in violent milieu
Access to lethal weapons.
5. Cognitive
Negative perceptions
Aggressive and anger inducing
behaviour.
6. Behavioural
Poor impulse control
Escalating anger or agitation
Coercive
Exploitative interaction style
AETIOLOGY
10. Severe depression
1. Personality disorders, e.g. Antisocial
11. Acute stress reaction
and paranoid behaviour
12. Panic disorder
2. Organic psychiatric disorders, e.g.
13. Psychotic disorder.
Delirium, dementia, Wernicke’s -
Korsakoff’s psychosis
3. Drug intoxication
4. Withdrawal effects of alcohol, drug
abuse
5. Mental retardation
6. Epilepsy
7. Domestic violence
8. Schizophrenia
9. Mania
MANIFESTATIONS
1. Uncooperativeness
2. Irrational
3. Delusions
4. Violent or assault behaviour
5. Feels humiliated.
MANAGEMENT
a. Medical Management
• Avoid giving tablets or capsules (Drugs)
• Chlorpromazine - 50—150 mg IM
• Promethazine - 25—SO mg I.M (May or may not based on situation and need)
• Haloperidol - 20 mg IL-V 20 minutes once to a maximum of 120 mg/day till the
violent behaviour is controlled
• Trifluoperazine - 10-30 mg IM
• Diazepam - 10-40 mg LV slowly (If epileptic attacks are associated)
• ECT may be given to help him controlled
a. Nursing Management
• Minimal stimulating
• Limit interaction of the client with others.
• Have essential things in client’s room,
• Avoid to keep hazardous or toxic agents in the client’s room.
• Collect history, physical examination
• Try to explore the probable causes.
• Comfortable distance has to be maintained
• Prepare to move, as client can strike out suddenly.
• Keep the doors open.
• Maintain a clear exit route
• Do not wear neck tie or jewellery.
• Do not keep any provocative (family member or relative) individual near to the
client. Do not sit close or back to the patient, do not confront with him.
• Assist for prescribed or investigative procedures.
• Encourage the client to redirect the behaviour with physical outlets, e.g.
performing exercises, outdoor activities.
• Motivate the client to ‘talk out’ rather than ‘acting out’.
Physical Restraints
 If the client is not talking out or rapport not established withholding himself or
not taking drugs, behaving aggressively restraints may be necessary
 HYSTERIA
Definitions
“It is a somatoform and conversion disorder in which repressed inner
conflicts are unconsciously converted or transformed into physical
symptoms without organic basis”.
—Bimla Kapoor, 2002
“It is a type of neurosis characterized by somatic and psychological
manifestations without any organic basis”.
—LP Shah and Hemashah, 1997
 AETIOLOGY
 Deprived or abnormal parent  Significant psychological
child relationship distress
 Dissatisfied environment in  Prolonged physical illness or
childhood head injury
 Broken families  Lower resistance
 Hysterical personality, e.g.  Impaired social and
dramatizing, exhibiting, attention occupational functioning
seeking, immature, shallow and  Excessive medical help
superficial emotional relationship seeking behaviour.
 Maladaptive environmental
factors
Incidence
 Peak between 20-30 years, may continue for years
 Children and old people also manifest high incidence
 Women will exhibit more than in men
 Low intelligence people suffer more.
Psychopathology
 Personal inadequacy
 According to DSMIV, a combination of pain, GIT symptoms,
sexual and pseudo neurological; symptoms exist
 Exaggerated symptoms in the presence of a sympathetic audience
 Manifestations will change qualitatively and quantitatively with
different examiners and on repeated examinations.
SYMPTOMS
1. Symptoms of Conversion Reaction
a. Motor symptoms,
b. Sensory symptoms
 Anaesthesia, hypothesia, hyperaesthesia, paraesthesia
 Sensation related to touch, pain, temperature will be affected
 Blindness
 Deafness
 Analgesia or diminished ability to feel pain
 Feel like to punish others
c.Visceral symptoms
 Nausea, vomiting, choking sensation, hiccoughs
 Feeling of lumps in the throat
 Dyspnoea, dysphagia
 Aphonia
 Anorexia nervosa
 Labelle indifference to symptoms
2. Symptoms of Dissociation
 Anxiety
 Desire to escape or flee from stress
 Guiltiness
 Somnambulism and somniloquy
 Amnesia, i.e. circumscribed and cover up the psychological traumatic event
 Trance, i.e. altered state of consciousness lasting for a few minutes to few hours,
in which client will suspends all physiological function
 Fugue, e.g. the patient travels long distances over a period of days and has
amnesia for the entire episode
 Multiple personality
 Ganser’s syndrome, client c/o pseudodementia, circumstantiality
 Repressed conflicts.
3. Behavioural Manifestations
 Subtle behaviour
 Low self-esteem
 Self dramatization
 Impulsive behaviour
 Exhibitionism
 Attention seeking tendency
 Narcissism
 Self centred approach
 Emotionalism inappropriate, exaggeration of symptoms
 Manipulativeness
 Suggestible and child like behaviour.
4. Hysterical Fits or Pseudo-seizures
Characterized convulsive movements and partial loss of consciousness; aura will
be unusual, purposive body movements, 20—800 seconds, partial amnesia; never
occurs during sleep; occurs in safe places, absence of postictal confusion and
neurological science.
PROGNOSIS
 Low intelligence, immature and hysterical personality, presence of physical
defects will have poor prognosis.
 Environmental manipulation may relieve the stress, ameliorate the
manifestation and promotes long lasting recovery.
TREATMENT
1. Remove the client from pathogenic environment
2. Hospitalization may be required
3. Visitors were not allowed to meet the client
4. Placebo therapy, e.g. I.M injections of distilled water may be helpful
5. Injection chlorpromazine-50 mg TID, inj. Diazepam-10 mg TID; 2—3 days
6. Relieve the psychological stress and strain
7. Abreactive therapy by 100-200 mg IV, pentothal sodium
1. Hypnosis—suggestibility, e.g. client will be able to improve through therapist
suggestions
2. Supportive psychotherapy
3. Case work or social work
4. Family therapy
5. Role play or psychodrama.
NURSING MANAGEMENT
6. Provide comfortable environment.
7. Don‘t give concentration for physical symptoms of the client, actively listen to
the client.
8. Show concern, sympathy, attention, firm with the client.
9. Develop and establish therapeutic relationship with the client.
10.Record the symptoms expressed by the client or observable behavioural changes.
1. Explore the feeling of the client by history collection or ventilation
2. Help him to identify and follow adoptive behaviour.
3. Teach the client the adaptive coping strategies
4. Assist him to take independent decisions,
5. Give some useful tasks,
6. Provide supportive psychotherapy.
7. Encourage the client to participate in religious rituals, social work.
8. Encourage the family members to provide love, affection and discourage
dependency.
 5.Withdrawal Behaviour
Definitions
“Removed from immediate contact or easy approach, isolated,
unresponsive and socially detached”,
— Webster's Dictionary
“A clients retreat from relating to the external world”
—Sreevani R, 2004
Associated Conditions
 Schizophrenia
 Mood disorders
 Suicidal behaviour
 Organic mental disorders
 Delusional disorders
 Personality disorders
 Physical handicap
 Mental disharmony
 Ageing
 Physical illness like cancer
 Alcoholism
 Drug abuse.
Psychodynamics
 Disinterested in communicating
 Flattened inappropriate emotions; apathetic, Sometimes talking to self
 Persecutory delusions, grandeur delusions , Hallucinations
 Poor judgement skills, Remains mute, Impaired ego functioning
 Not responding to environmental stimuli
 Likes to live in isolation
 Assuming uncomfortable positions by sitting in corners
 Difficulty in expressing his feelings a, Ambivalent tendency
 Disorganization in thought process, e.g. unable to think properly, disturbed in
thinking process, jumbling of words, unable to concentrate, thought block
 The client will be living in his own world; with his own thoughts
 Sleep disturbances
 Not interested in eating, in dressing or meeting hygienic needs, Regression.
Nursing Diagnosis
1. Decreased activity related to disinterest
2. Alteration in thought process related to failures/ preoccupied behaviour/guilty
feeling
3. Ineffective communication due to thought block
4. Non compliance to treatment with ineffective understanding
5. Alteration in perception process
6. Poor socialization
7. Low performance in self care activities
8. Self harming tendency due to poor coping strategy
9. Alteration in sleep pattern.
Nursing Management
1. Expertised skills are necessary for nurses in handling situation
2. Establish one-to-one Therapeutic Nurse-Patient relationship
3. Make the client to understand reality and work in it
4. Enhance the social interaction pattern of the client with his environment and by
friendship pattern
5. Provide opportunity for the client that he can trust the nurse
6. Nurses should not be authoritative, demanding type; they have to be tolerative
and silent
7. Assist the client to handle the situation
8. Don’t probe or interrogate the client
9. Meet the needs of the client by assisting him is general care activities
10.Provide sensory stimulated environment Promote physical or daily having
activities of the client by his own
1. Assist the client in regular evacuation of bladder and bowel
2. Fiber rich diet
3. Sit with the client and interact with him during eating; maintain intake and
output chart
4. When the client does simple task effectively, provide positive reinforcement, to
encourage him to perform in a better manner
5. Provide calm and safe environment to ensure sleep, ask him to avoid ‘nap’ in
day time
6. Avoid condemnation of clients feeling, never hurt him; if the behaviour is not
acceptable, slowly explain him and make him to understand
7. Protect the client from self injury or harm, e.g. by removing sharp articles
beside the client
8. Discourage an excited client to talk to a severely withdrawn patient
1. Explain the client the importance of social interaction, communication of his
problems outwardly; discuss positive points; and the procedure for
overcoming destructive ideas
2. Engage the client to participate in religious activities, according to their
interest
3. Provide discharge advises, e.g. compliance to the treatment, follow-up
services (if needed).