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Week 2: Req Readings: Boland, R., & Verduin, M. L. (2022). Kaplan and Sadock's synopsis of psychiatry (12th ed.). Wolters Kluwer.
- Ch. 28 High-Risk Clinical Situations The United States is facing an increasing burden of psychiatric emergencies due to the rise in mental illness, provider shortages, and a decline in access to mental health treatment options. Over one-third of Americans live in a mental health professional shortage area, and those that live outside of a shortage area often report access and utilization barriers to mental health care (Health Resources & Services Administration, 2022). This shifting landscape has led to an increasing percentage of psychiatric emergencies outside the psychiatric inpatient setting (Becker & Forman, 2020). During psychiatric emergencies, clients are often in a state of crisis that has overwhelmed their coping mechanisms. Other psychiatric emergencies involve life-threatening side effects associated with psychiatric medications. All clients experiencing psychiatric symptoms must be evaluated and screened with a validated suicide assessment tool for risks of harm to self or others to reduce harm and the risk of suicide. Stabilization must be attempted using the least restrictive interventions. When possible, clients should be engaged in the decision-making process. Some clients may require inpatient services, while others may benefit from outpatient services. As frontline mental health specialists, psychiatric mental health nurse practitioners (PMHNPs) play a critical role in providing psychiatric emergency services and ensuring clients' safety. Risk Factors in Suicide Some important risk factors for suicide
- History of substance abuse
- Physical disability or illness
- Losing a friend or family member to suicide
- Ongoing exposure to bullying behavior
- Mental health condition
- Recent death of a family member or a close friend
- Access to harmful means
- Relationship problems
- Previous suicide attempts Ask suicide-screening questions (ASQ) suicide risk screening tool Review the ASQ suicide risk screening tool
https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq- toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf Psychiatric Emergency Services and Crisis Intervention Background Psychiatric emergencies are situations that involve acute disturbances in thought, mood, behavior, or social interactions that negatively impact a client’s ability to function in their environment and require immediate intervention to keep the client and others from harm. During psychiatric emergencies, clients are often in a state of crisis that has overwhelmed their coping mechanisms. Psychiatric emergencies occur when a client is (Zeller, 2021):
- a danger to self
- a danger to others
- unable to meet their own basic needs for food, clothing, or shelter due to a psychological impairment Psychiatric emergency services and crisis intervention may be provided in a hospital, psychiatric facility, or community setting. Psychiatric emergencies often present in a hospital emergency department (ED), creating unique challenges due to limited privacy. Common Psychiatric Emergencies
- Suicidality
- acute psychosis
- agitation and aggression
- mania
- substance-related concerns
- decompensation related to personality disorders
AEIO Risk Assessment: A gitation/Arousal: Is the client able to sit still? Are they pacing? Are they demonstrating aggressive behaviors? E nvironment: Is the client in a safe location? Identify potential exits, equipment in the room, and the distance of the room from the rest of the unit. I ntent: Does the client have thoughts of harming themselves or others? Is the client having psychotic experiences that may cause them to harm themselves or others? O bjects: Does the client have access to firearms, blades, medications, lighters, or clothing items that could be used to harm themselves or others? Psychiatric risk in each category may be measured as low, moderate, or high. The higher the number of moderate or high-risk assessments, the greater the number of staff are required to ensure client safety, and the higher the likelihood of needing physical or chemical restraints (ALSG, 2020). Deficiency Needs A hungry, tired, overstimulated, isolated client may become aggressive. Clients with deficiency needs may require additional support to offset aggression. Similar to Maslow’s hierarchy, the needs may include physiological (food, hydration, sleep, ability to see/hear normally), followed by safety (access to personal items, pain medication), belonging (family members, physician-client relationship), and esteem (clarifying the client’s wishes). Deficiency Needs
- Self-actualization
- Esteem needs
- Love & belonging
- Safety & security
- Physiological needs De-Escalation De-escalation is a first-line response to potential violence or aggression in healthcare settings (The Joint Commission [TJC], 2021). De-escalation is also known as conflict resolution or crisis management and involves strategies and techniques to reduce a client’s agitation or aggression. De-Escalation Techniques:
- Clear, calm, empathetic, nonjudgmental communication
- Respect for personal space
- Non-confrontational approach
- Non-threatening nonverbal communication
- Response to client’s expressed problem or condition
- Clear limits
- Environmental controls such as minimizing light, noise, and loud conversations Source: (TJC, 2021; Crisis Prevention Institute [CPI], 2021) Discover More Learn more about de-escalation tips for healthcare professionals: https://platform.crisisprevention.com/CPI/media/Media/Resource-Center/Free- Resources/PDF_DTHC.pdf?_gl=11t7rsnw_gcl_aw*R0NMLjE2NTIxOTkwNDcuQ2owS0NRandtdWlUQm hEb0FSSXNBUGl2Nkw4c2lHVGVNWk93Wi1RR2hKUGt5OEhWNzg4U01iTjRHYXhLN0tDSzRmMjRXY0hmV 3U2WGVtY2FBaUhhRUFMd193Y0I. When aggression is unavoidable, prioritize security, sedation, and supervision. Medication, restraints, and seclusion may be necessary until the client is stabilized. The least restrictive means of safe intervention should be employed.
Amir Amir is a 28-year-old who was brought to the ED by law enforcement after his mother called 911 due to his bizarre behaviors. When the police arrived, Amir was agitated and wandering the street naked. He refused to follow directions and became combative with officers when approached. He was handcuffed and transported by a squad car. Before transfer, his mother told police that Amir had a history of schizophrenia with treatment nonadherence and marijuana use. During the ride to the ED, Amir was calm and cooperative. He was transferred to a gurney in the triage area without incident, but after transfer to an exam room, Amir began screaming and threatening the PMHNP and staff member. Amir tried to punch and spit at them when they approached the bedside. Which of the following are the most appropriate management strategies for Amir? Select all that apply.
- begin the involuntary admission process
- use de-escalation techniques (Correct answer)
- request additional staff support (Correct answer)
- medicate with intramuscular lorazepam 0.5 mg (Correct answer)
- remove objects from the room, such as monitors, tray tables, or other equipment, that the client may use to injure himself or others (Correct answer)
- request that law enforcement restrain the client
- provide one-to-one observation Rationale: Amir presents a risk of harm to self and others due to his combative behavior; therefore, the most appropriate management strategies for Amir include the use of de-escalation techniques, request for additional staff support, intramuscular lorazepam 0.5 mg, and the removal of objects from the room, such as monitors, tray tables, or other equipment, that he may use to injure himself or others. Chemical restraint may be necessary. Additional staff should be requested to provide support, and de-escalation techniques should be attempted. Items the client may be used to injure himself or others should be secured or removed. Physical restraints may be necessary and should be applied by the emergency department team, not law enforcement.
Madison Madison is a 30-year-old who was brought to the ED by police. She was apprehended at a local shopping center after several drivers called the police to report that she was shouting and making crude gestures at their cars. Madison is alert, oriented, and cooperative; she denies any past medical or psychiatric history, and no medical records are found in the system. She admits that she does not have a home, and he has been panhandling with little success. When the emergency department attending physician asked her to submit a blood and urine sample, she became agitated and verbally threatened the phlebotomist. A psychiatric consult is initiated. Which of the following are the most appropriate management strategies for Madison? Select all that apply.
- begin the involuntary admission process
- use de-escalation techniques (Correct answer)
- request additional staff support (Correct answer)
- medicate with intramuscular lorazepam 0.5 mg
- remove objects from the room, such as monitors, tray tables, or other equipment, that the client may use to injure herself or others
- initiate 4-point restraints
- provide one-to-one observation
- ask Madison if she would like a meal or snack (Correct answer) Rationale: At this time, Madison’s behaviors do not create an imminent threat to staff, but caution is warranted. The most appropriate management strategies for Madison include de-escalation techniques, requesting additional staff support, and asking Madison if she would like a meal or snack. Madison has indicated that she has been panhandling without success. Offering her a meal or snack may help to reduce her aggressive behavior.
Hailey Hailey is a 20-year-old brought to the emergency department by EMS to evaluate a laceration. Her roommate found her sitting on their sofa with blood streaming down her arms and a knife beside her. Her roommate immediately called 911 and applied pressure to the wound. The triage nurse assessed the wound as superficial. After dressing the wound, the PMHNP was called to perform a psychiatric evaluation. On exam, she is awake and alert but appears withdrawn and hesitant to speak. She continues to repeat, “I don’t know why this keeps happening.” Hailey denies medical or psychiatric history; the PMHNP notes bilaterally linear scarring on her arms. Hailey admits to self-injury behaviors and states she has been using cutting as a coping mechanism for years. She confirms that she did not intend to kill herself today and has never experienced suicidal ideations. Which of the following is the most appropriate recommendation to the care team for Hailey’s treatment and disposition?
- discharge to home with resources for crisis care and recommendations for outpatient psychiatric services (Correct answer)
- 23 - hour observation in the ED with Q15 minute checks
- one-to-one observation in the ED
- recommend voluntary admission
- involuntary admission Rationale: The client did not have suicidal thoughts during the self-harm episode. The self-harm episode was not lethal in nature, nor was there intent for lethality. The client should be provided psychiatric care resources for follow-up.
Mary Ellen Mary Ellen is a 42-year-old who presents to the clinic with low energy and “feeling down.” She states she has been increasingly fatigued for the past two months since she was laid off from her job due to downsizing. She reports that she presented for care because she felt “down in the dumps” as it was her sister’s death anniversary. She had thoughts about harming herself somehow over the past few days but denied specific plans, stating, “sometimes it just seems like it would be easier not to be here.” She has a previous history of a suicide attempt as a teenager, after which she received several years of therapy; she has not received mental treatment for about 20 years. She also reports using occasional marijuana and alcohol socially; she currently appears sober. Mary Ellen lives with her husband with whom she states she has a poor relationship; he has not been supportive of her mental health needs in the past. She is concerned that returning to their home might exacerbate her symptoms of depression. Which of the following is the most appropriate recommendation for Mary Ellen’s treatment and disposition?
- schedule a follow-up appointment for 48-72 hours and provide crisis resources
- begin fluoxetine 20 mg daily
- transfer to ED for additional evaluation
- recommend voluntary admission (Correct answer)
- involuntary admission Rationale: Mary Ellen has had suicidal thoughts, and she does not have a plan; she has a history of suicide attempts and has a lack of support resources. Currently, she may benefit from voluntary admission for evaluation and treatment.
Antonia Antonia is a 26-year-old who presents to the ED with acute suicidal thoughts for several days. She denies a plan at this time. She has a history of major depressive disorder (MDD) and generalized anxiety disorder (GAD), for which she takes paroxetine 20 mg daily and clonazepam 0.5 mg as needed. She endorses a suicide attempt by taking “a handful” of medications at age 16. Antonia reports recent stress in her life, including a breakup with her girlfriend and an unstable work environment. She states that she came to the ED tonight because she “wasn’t feeling like I could trust myself 100%.” Click each section below to assist Antonia. Antonia: Part One Which of the following is the most appropriate recommendation to the care team for Antonia’s treatment and disposition? Select all that apply.
- discharge to home with resources for crisis care and recommendation for follow-up
- increase sertraline to 75 mg daily
- 23 - hour observation in the ED with Q15 minute checks
- recommend voluntary admission (Correct answer)
- involuntary admission Rationale: Antonia has had suicidal thoughts, and she does not have a plan; she has a history of suicide attempt and MDD and GAD. She is also under acute stress. At this time, she may benefit from voluntary admission for evaluation and treatment. Antonia: Part Two Antonia agrees to voluntary admission for evaluation and treatment. After searching the hospital system, the PMHNP finds that there is not an available inpatient bed for Antonia and that a bed may not be available for 24 hours or longer. Antonia states that she is not willing to remain in the emergency department for that long, and she instead wants to schedule an appointment with her counselor for the next day. Antonia states that she is willing to stay with her brother and his family in their home and will give him her prescriptions so that she does not have access to the bottles. Which of the following is the most appropriate recommendation for Antonia?
- discharge to home with resources for crisis care and recommendation for follow-up (Correct answer)
- increase sertraline to 75 mg daily
- 23 - hour observation in the ED with Q15 minute checks
- involuntary admission Rationale: Antonia’s symptoms indicate that she might benefit from voluntary admission; however, since there is no appropriate inpatient bed, keeping her indefinitely in the ED for observation is not
appropriate. Antonia can be discharged to the care of her brother with a safety plan, crisis resources, and a follow-up plan. Antonia: Part Three Antonia is discharged to the care of her adult brother and his family. Her girlfriend broke up with her by text that night and posted comments about Antonia’s mental illness on social media. Antonia took her brother’s car and left his house unnoticed. After hours of binge drinking, she parked her car on the expressway ramp and laid down on the highway. She took a video of herself lying on the highway and sent it to her girlfriend just as she was fatally struck by two cars. The care team is notified of the death by suicide, and the PMHNP is asked to lead a crisis debriefing and postvention or intervention after the suicide to support Antonia’s family and friends. Discover More Learn more about immediate and long-term postvention: file:///Users/hannahmarcum/Downloads/Hemha-postvention-guide.pdf Now, explore these resources for supporting postvention in the workplace and community: https://sprc.org/wp-content/uploads/2022/12/Spotlight_Postvention_ResourceSheetv03.pdf Other Psychiatric Emergencies Background Some psychiatric emergencies involve life-threatening side effects associated with psychiatric medications. Emergencies include serotonin syndrome, neuroleptic malignant syndrome, agranulocytosis, and lithium toxicity. Rapid response is required to prevent permanent harm. In many cases, collaboration with an emergency management team may be necessary. Serotonin Syndrome Serotonin syndrome occurs when medications that alter the way serotonin is produced or metabolized by the body cause excessive levels of serotonin to build up in the body. Many medications may be implicated in serotonin alteration, including antidepressants, illicit drugs, lithium, and antibiotics. When serotonin transmission is increased due to one or more medications, symptoms of serotonin syndrome may occur. Clinical symptoms may range from mild to fatal and typically occur within several hours of beginning a new medication or increasing the dose of an existing medication.
Treatment Treatment for serotonin syndrome initially involves discontinuing the causative medication. The intensity of supportive treatment depends on the severity of symptoms. Mild cases typically resolve within 24 hours, while more severe cases may require hospitalization for stabilization. Neuroleptic Malignant Syndrome Neuroleptic malignant syndrome (NMS) is a rare, life-threatening adverse effect caused by antipsychotic medications. The syndrome may occur due to disruption of dopamine receptors in the anterior hypothalamus or due to direct toxicity to muscle cells (Kuhlwilm et al., 2020). Psychological stressors that activate the autonomic nervous system may also play a role in triggering NMS. Typical and atypical antipsychotic medications have been implicated in NMS. The classic presentation of a client with NMS may involve mental status changes including agitation, confusion, catatonia, muscle rigidity (sometimes called “lead pipe” rigidity), hyperthermia, excessive salivation, and autonomic instability as evidenced by labile blood pressure and heart rate. Serum creatine kinase (CK) levels are typically elevated. The onset of symptoms may occur 1-2 weeks after starting or changing the causative medication. Treatment Treatment includes immediate intervention to stabilize vital signs, reduce fever, and control agitation. Clients are frequently admitted to the intensive care unit for management. The causative agent should be discontinued immediately; symptoms typically resolve 1-2 weeks after treatment is initiated. Learn More Misdiagnosis of emergency psychiatric syndromes is common as many symptoms overlap. Serotonin Syndrome Both NMS Dilated pupils Agitation Drooling Headache High blood pressure Catatonia Shivering High fever Rapid changes in blood pressure Dysrhythmias Confusion Increased serum creatine kinase (CK) Hyperreflexia Rigid muscles Hyporeflexia
Agranulocytosis Clozapine-induced agranulocytosis (CLIA) occurs in less than 1% of clients prescribed clozapine; however, CLIA is potentially life-threatening. Although the cause of CLIA is unknown, research indicates that there may be a genetic component to the reaction (Mijovic & MacCabe, 2020). Clinical symptoms of CLIA include fever and chills, increased heart rate, sudden hypotension, muscle weakness and fatigue, mouth ulcers, and sore throat. Diagnosis occurs when absolute neutrophil counts (ANC) are less than 100/mcL. Onset of symptoms may occur at any time following initiation of clozapine but is most common after 4 to 5 weeks of drug therapy. Treatment Treatment involves immediate discontinuation of clozapine, supportive care for infection, and consultation with hematology. Prevention of CLIA involves serial lab draws weekly during the first 18 weeks of treatment with clozapine, then biweekly until one year, and then monthly for the duration of treatment (Mijovic & MacCabe, 2020). Lithium Toxicity Lithium has a narrow therapeutic range. Too much lithium can quickly cause toxicity, which can lead to acute kidney injury and death (Heyda et al., 2021). Lithium toxicity may occur due to excessive intake related to overdose or dosage modifications. it may also occur from impaired excretion; when clients experience sodium and fluid depletion from vomiting, diarrhea, fever, or a low sodium diet, lithium is reabsorbed by the kidneys which increases serum levels of the drug (Heyda et al., 2021). Early symptoms of lithium toxicity include nausea, vomiting, diarrhea, hand tremors, slurred speech, and vision changes. Chronic toxicity may present without gastrointestinal symptoms. Later symptoms include hyperreflexia and muscle spasms, nystagmus, dysrhythmias, confusion, and delirium. Seizures and death may occur if serum lithium concentration exceeds 3.5 mEq/L. Treatment Treatment involves discontinuing lithium and supportive care. Acute overdose is treated with gastric lavage. Clients should be admitted for cardiac monitoring, intravenous fluids, and serial lithium levels. Hemodialysis may be required for clients with severe toxicity.
Question 2 Which diagnostic tests are required to help clarify or confirm the diagnosis?
- diagnosis is made using clinical presentation alone
- complete blood count
- lithium level
- serum CK (Correct answer) Rationale: Yousef’s symptoms are consistent with NMS. An elevated serum CK will help diagnose the disorder. Question 3 Which of the following are the most appropriate emergent management strategies for Yousef? Select all that apply.
- admission to a medical unit (Correct answer)
- discontinuation of psychiatric medication (Correct answer)
- neutropenic precautions
- hematology consult
- hemodialysis Rationale: The most appropriate emergent management strategies for Yousef include discontinuing the neuroleptic medication and admission to a medical or intensive care unit for monitoring, stabilization of vital signs, and management of fever. Question 4 Once stabilized, which of the following is the most appropriate management strategy for Yousef?
- reassess the need for medication therapy
- begin a different antipsychotic medication after a 2-week washout (Correct answer)
- order serial serum medication levels
- order serial complete blood counts Rationale: Once Yousef is stabilized, the most appropriate management strategy for Yousef is to begin antipsychotic medication again after a 2-week washout period; close monitoring and client education are essential once a new medication is prescribed (Kuhlwilm et al., 2020).
Aiofe Aiofe is a 24-year-old who presents to the emergency department with complaints of a high fever, agitation, and confusion. Triage Vital Signs
- BP: 161/90 mm Hg
- HR: 104 beats per minute (bpm)
- RR: 22 b/min
- Temperature: 101.6 F
- Pulse oxygenation: 98%
- Height: 5' 5"
- Weight: 57 kg Past medical history
- Major depressive disorder
- Recent urinary tract infection Allergies
- No known drug allergies Medications
- paroxetine 20 mg daily
- ciprofloxacin 500 mg twice daily (BID) for 7 days Aiofe was transferred to a private room where she was examined by an emergency room resident. The resident requested a consult with the PMHNP due to Aiofe’s confusion and agitation. The resident reports that he noted hyperreflexia and dilated pupils on the physical exam. Upon entering the room, the PMHNP finds Aiofe shivering, sweating, and oriented to person only. Complete the activity below to assist with Aiofe's case. Question 1 Which of the following is the most likely diagnosis for Aiofe?
- neuroleptic malignant syndrome
- serotonin syndrome (Correct answer)
- agranulocytosis
- lithium toxicity
- tardive dyskinesia
