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Psychiatric Emergencies: Caring for People in Crisis

Persis Mary Hamilton, RN, CNS, MS, EdD

Wild Iris Medical Education is an approved provider for paramedic and EMT continuing education in California by the California Emergency Medical Services Agency: EMS CE Provider #49-0057.
Wild Iris Medical Education is an approved provider (#0007) of continuing education by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS).
This course is appropriate for EMTs, paramedics, and first responders.

This course discusses psychiatric emergencies from the perspective of crisis intervention. It describes the assessment, diagnosis, planning, intervention, and evaluation by clinicians of people in crisis with mood, anxiety, anger, substance use, and mental disorders.

PSYCHIATRIC EMERGENCIES AS CRISIS EVENTS

A psychiatric emergency is a cluster of conditions in which the capacity of the individual to cope is overwhelmed by acute mental and emotional distress arising from situational and maturational stressors. Clinicians most often encounter individuals in crisis in emergency departments and on crisis hotlines. These individuals are experiencing severe disturbances of mood, thought, and behavior and require immediate care. Of particular concern are people in crisis who suffer from disorders of mood, anxiety, anger, substance use, and mental illness.

Characteristics of Crises

Crises are experienced by people of all ages, cultures, and socioeconomic conditions, and may not be related to a specific mental disorder. Crises begin with a precipitating event and intensify into feelings of fear and emotional disequilibrium.

Because people in crisis are so uncomfortable, they seek to resolve the issue as soon as possible, usually in less than six weeks. During that time they become increasingly sensitive to the influence of others and grasp at almost any solution, whether or not the remedy lessens their distress or improves the quality of their lives (Aguilera, 1998).

SOURCES

Although crises arise from many different sources, most caregivers agree there are at least two major causes of crises: maturation and situation.

Maturational crises have to do with the predictable transitions people experience as they move from one stage of human development to another. Erik Erickson identified these stages in terms of the developmental tasks of infancy, early childhood, preschool, school-age, adolescent, young adult, mature adult, and late adulthood (1963). For example, a toddler is developing autonomy and self-esteem and may have a temper tantrum when he does not get what he wants. An adolescent is learning identity and intimacy and may show inappropriate sexual behavior toward someone of the same or opposite sex.

Situational crises are events or circumstances that threaten an individual's physical, social, and psychological integrity. They may originate in the physical body as a result of disease, injury, substance use, or emotional distress. Sometimes maturational and situational crises occur at the same time and, on occasion, one crisis triggers another, compounding the problem.

A teenage boy and girl are attracted to one another and experiment with sexual intimacy. When the girl's menstrual period is late, both adolescents are thrust into a state of emotional disequilibrium as they experience both the developmental crisis of adolescence and the situational crisis of a potential pregnancy. The action they take to resolve the crisis may thrusts them into yet another crisis.

PHASES

In 1965, Caplan noticed that crises develop in four predictable phases, as follows:

• Initial threat. People are faced with a problem or conflict. In an effort to lower their anxiety, they employ various defense mechanisms, such as compensation (using extra effort), rationalization (reasoning), and denial. If the problem is resolved, the threat disappears, and there is no crisis.
• Continuing threat becomes a crisis. If the problem persists, people in crisis become increasingly distraught and their anxiety grows to serious levels. In crisis now, they become disorganized and have difficulty thinking, sleeping, and functioning. They initiate trial-and-error efforts to solve the problem and restore emotional equilibrium.
• Crisis intensifies to panic. When trial-and-error attempts fail, their anxiety intensifies to severe and panic levels and the person is immobilized with fear. Some people in crisis redefine the problem, attack it from a new angle, and try again to find a solution.
• Serious disorganization and assault. If the problem is not resolved and new coping skills are ineffective, anxiety may overwhelm the person and lead to serious disorganization, depression, confusion, violence against others, or suicidal behavior. (Varcarolis et al., 2006)

BALANCING FACTORS

In her seminal work on crisis, Aquilera (1998) noted that the equilibrium of people in crisis is significantly affected by three balancing factors: their perception of an event, support system, and coping mechanisms.

• Perception of an event refers to the importance of a problem to the person in crisis and includes such things as health, career, financial status, and reputation.
• Support system refers to the resources possessed by the person in crisis, such as the people they trust who can provide support and assistance during a time of need.
• Coping mechanisms are skills or methods people use to reduce anxiety and solve problems, such as reasoning, meditation, physical exercise, sleep, and denial. (Aguilera, 1998)

RESOLUTION

When a crisis is resolved and emotional equilibrium restored, individuals again face the everyday issues of life. Ideally, as a result of a crisis, they learn new coping skills, gain greater self-confidence, enlarge their support system, and raise their level of functioning. The goal of crisis intervention is to restore the pre-crisis level of functioning and, when possible, raise it to a higher level than before the crisis. An important part of all crisis interventions, whether they take place over a hotline or in a counseling session, is anticipatory guidance, whereby clients learn how to avoid repetition of a crisis event.

Triage Considerations

When individuals who are in distress call a telephone hotline or go to an emergency department (ED), caregivers assess the person and the problem, identify the precipitating event, consider the influencing factors, plan what actions are needed, take those actions, and evaluate the effectiveness of the actions. Initial triage considers safety concerns, immediacy challenges, ethical principles, and legal issues.

SAFETY CONCERNS

The most urgent concern of caregivers is the safety of people in crisis as well as others who may be in danger. Clinicians gather information about:

• The presence of guns, knives, explosives, or other harmful devices
• Threats of violence to self or others by the person in crisis
• History of harm to self or others by the person in crisis
• Intoxication of the person in crisis or others through various substances
• Environmental hazards that might complicate interventions (fire, wind, water, trauma, toxic fumes, random gunfire)

IMMEDIACY CHALLENGES

The immediacy of danger to a person in crisis and others in the vicinity is described as either emergent, urgent, or nonemergent (Antai-Otong, 2004).

• Emergent crises require immediate action. These situations include such crises as imminent suicide, drug toxicity, and violent or threatening behavior toward others. After making an assessment, the clinician intervenes at once.
• Urgent crises require attention, but are not life-threatening emergencies. These situations include such behavior as suicidal gestures, intoxication, bizarre gestures, and acute agitation. After making a physical examination and mental status assessment, the caregiver takes appropriate action.
• Nonemergent situations do not require immediate attention but should not be ignored. These situations include such things as mild to moderate anxiety, questions about medications, and a need to talk about personal problems. After making an initial assessment, the caregiver refers the client to appropriate resources for care.

ETHICAL PRINCIPLES

Healthcare providers follow ethical standards of care, whether or not a client is in crisis. These principles are based on ethics, the branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects (Hamilton, 2006).

Ethical principles are fundamental concepts by which people make decisions. These principles serve as criteria against which people measure behavior. Laws flow from ethical principles and consist of rules about specific situations. These rules are enforced by an authority with the power to see that they are obeyed. Unlike laws, ethical principles serve as general guides for behavior. Five ethical principles mark the practice of healthcare professionals: (1) respect for human life and dignity, (2) beneficence, (3) honesty, (4) justice, and (5) autonomy.

Respect for human life and dignity is one of the most basic of ethical principles. It asserts that "individuals must be treated as unique beings, equal to every other individual. Special justification is required for interference with an individual's own purposes, privacy, and behavior" (Rawls, 1971). When applied to psychiatric emergencies, respect for human life and dignity means caregivers:

• Refrain from abuse, harassment, or discrimination
• Respect the personhood, lifestyle, and belief system of clients
• Demonstrate regard for physical, psychological, and socioeconomic well-being
• Strive to sustain human life and dignity
• Respect and hold in confidence all personal information

Beneficence means doing good for the benefit of others. Although some writers separate beneficence (doing good) from nonmaleficence (not doing harm), Frankena (1973) suggests the ethical principle of beneficence is a continuum, from a neutral not harming to a positive doing good. At a minimum, beneficence means maintaining professional competence. Ideally, it means acting in ways that demonstrate care and nurturance. When applied to psychiatric emergencies, beneficence means caregivers:

• Give accurate empathy, nonpossessive warmth, and genuineness (Rogers, 1961)
• Relate to clients professionally and objectively
• In consultation with other clinicians, follow treatment plans
• Give unconditional positive regard even when it is necessary to set boundaries, apply physical restraints, or limit movement (Carkhoff, 1977)

Honesty means being truthful in word and deed, even when you must convey unwelcome advice or information about a condition or treatment. Clinicians must be truthful, yet compassionate, withholding information only when the client is a minor child or an adult with a legal guardian. When applied to psychiatric emergencies, honesty means caregivers:

• Accurately report and record critical data
• Place the welfare of clients above personal or professional gain
• Keep promises and abide by contracts
• Provide factual, scientific, relevant information about treatment, including benefits and risks

Justice implies fairness and equality and requires impartial treatment of clients. Like other ethical principles, justice is based on respect for human life and dignity. The historic image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources will be distributed equally, using the same criteria for everyone.

When applied to psychiatric emergencies, justice means clinicians:

• Assess all clients' needs with equal diligence and professionalism
• Attend to the needs of clients, no matter how difficult their personality, complex their disorder, or challenging their behavior
• Evaluate and communicate information about treatment options without prejudice

Autonomy means respecting the right of self-determination, independence, and freedom. In psychiatric emergencies, to prevent injury clinicians may need to choose between actions that support autonomy (freedom) and those that support beneficence (safety). Clinicians may need to restrain clients, administer tranquilizing drugs, or lock them in seclusion against their will.

Laws governing involuntary commitment address the ethical dilemmas created by this conflict of ethical principles. Except for legally defined situations, when applied to psychiatric emergencies, autonomy means caregivers:

• Inform clients about treatment options and risks and make sure they understand
• Respect and accept decisions made by clients about their personal care
• Implement and evaluate interventions chosen by clients
• Hold in confidence all personal information, only divulging it when clients or their legal guardians give permission

LEGAL ISSUES

In the past, people could be hospitalized under the flimsiest of pretexts by almost anyone for nearly any length of time. Unbelievably, it took nearly 200 years for the Fifth Amendment to the U.S. Constitution to be applied to people who are mentally ill. The amendment says "No person shall…be deprived of life, liberty, or property without due process of law."

In Humphrey v. Cady, 1972, the court recognized that involuntary civil commitment to a mental hospital was a "massive curtailment of liberty" and required "due process protections."

In recent years, the number and scope of state, federal, and case laws that affect the treatment of people with psychiatric disorders has increased dramatically. Of special interest to those who care for people in crisis are laws concerning civil rights, confidentiality, patient rights, treatment decisions, restraints, seclusion, and hospital confinement.

Civil Rights

Under federal and state laws, people with mental illness are guaranteed the same civil rights as every other citizen in the land. These laws guarantee the rights of all people to humane care, to interact socially, to press charges against others, to vote, speak, enter into contractual relationships, make purchases, meet requirements for a driver's license, follow religious practices, participate in legal activities, and travel within the United States.

Confidentiality

In 2003, to protect the privacy of individuals and the confidentiality of patient records, the U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA). It provides that, without the prior consent of patients, medical records may not be read or copied.

Though the act greatly complicates the storage and transmission of records and in some cases delays the treatment of people in crisis, it affirms the right to privacy and supports the concept of respect for all human beings.

Patient Rights

When people are confined to a healthcare facility for treatment, they must be cared for with respect and dignity. No longer can authorities put them on display like animals in a zoo. Neither can people be locked away for indefinite periods of time without medical care, as Luther Osborne described in his personal story The Insanity Racket (1939).

People have the right to receive medical and dental care, entertain visitors, receive uncensored mail, and be free from excessive medication, isolation, or physical restraints. Individuals have the right to refuse to participate in research studies or experimental treatment and they cannot be discriminated against on the basis of gender, age, religion, disability, or ethnic origin.

If people do not speak English or can use only sign language, they must have access to an interpreter. Individuals cannot be forced to work for a healthcare facility without remuneration. Finally, people have a right to voice grievances without fear of punishment (Varcarolis et al., 2006).

Treatment Decisions

The Hospitalization of the Mentally Ill Act of 1964 required that all patients in public hospitals have a right to treatment. Prior to that time, patients could be hospitalized for decades without treatment. Since then the courts have ruled that clients must be cared for by qualified and sufficient staff, in a humane environment, following individualized care plans (ICPs).

In other rulings, the courts have ruled that patients have the right to refuse treatment (eg, electric convulsive therapy [ECT] or antipsychotic medications). Furthermore, clients have the right to prepare an "advance care directive" in case they should become incapacitated.

Restraints and Seclusion

When people in crisis become so distressed that they are a danger to themselves or others, it may be necessary to placed them in restraints or to isolate them. Because history is replete with accounts of the excessive use of restraints and seclusion, current state laws and recent court decisions affirm that the least restrictive measures must be used.

Restraints and seclusion may be used only when absolutely necessary and on the rare occasion when a person in crisis requests seclusion to reduce sensory stimulation. If these measures are essential, a physician must prescribe them and specify the length of time they may be used (eg, 2 hours).

Caregivers must review and document the condition of the client at specific intervals (eg, every 15 minutes). These measures may be reauthorized by the physician, but the same time restrictions must be followed. In addition, restraints and seclusion may not be used for the convenience of the staff or to punish clients (Simon, 2001).

Hospital Confinement

Admission to the hospital may be either voluntary or involuntary. Voluntary means the patient is in control and decides when to enter the facility and when to leave. Though a few states require patients to submit a written notice to the hospital before they may leave, most do not. Furthermore, in most states a client can institute a court proceeding seeking a judicial discharge through a writ of habeas corpus (a "right to the body"). Habeus corpus provides a constitutional means to challenge the unlawful detention of individuals.

Emergency involuntary commitment, also called civil commitment, of people in crisis is controlled by state statutes specifying the conditions under which people can be held against their will. In general, involuntary admission is permitted when people are a danger to themselves, a danger to others, or are unable to provide for basic human needs (eg, are "gravely disabled").

Many states give police officers, physicians, and certain mental health professionals authority to hospitalize such people and indicate the specific length of time (often 72 hours) that they can be held against their will. During that period of time, the person must be evaluated and a plan devised for their care.

Civil commitment for observation, also called temporary involuntary hospitalization, is for a longer period of time than emergency hospitalization. Its primary purpose is observation, diagnosis, and treatment of people who have a mental illness or pose a danger to themselves or others. The length of time is specified by statute and varies markedly from state to state. Application for this type of commitment can be made by a guardian, family member, physician, or other public health officer and may require a certificate affirming mental illness.

Long-term commitment for involuntary hospitalization is intended to give clients extended care and treatment. As with clients who undergo observational involuntary hospitalization, extended involuntary hospitalization can occur only with judicial or administrative action and medical certification. This type of involuntary hospitalization may be for 60 to 180 days or, under some circumstances, for an indeterminate period of time.

Involuntary outpatient commitment is a relatively new legal category of care that was initiated in 1990. Its purpose is to provide an alternative to involuntary long-term inpatient commitment. Recently, states have begun using involuntary outpatient commitment as a preventive measure to ward off psychiatric emergencies and the need for a court-ordered inpatient commitment.

Usually, involuntary outpatient commitment is tied to the receipt of services and goods provided by social welfare agencies, including disability benefits and housing. To receive these benefits, clients must participate in the treatment plan (Chan, 2003).

Doctrine of least restrictive alternative is another important concept that applies to the care of patients. This doctrine affirms that caregivers must use the least restrictive means to achieve a specific end. For example, if four-point restraint of both arms and both legs is enough to protect disturbed patients from harming themselves or others, they must not be placed in five-point restraint of the waist, both arms, and both legs.

Discharge from the hospital depends on the status of clients at the time they were admitted. In general, those who entered voluntarily have the right to be released voluntarily unless their condition changes significantly during their hospitalization. Some states provide a conditional release of people who were admitted voluntarily. Such a provision allows physicians or administrators to arrange for ongoing treatment on an outpatient basis.

THE NURSING PROCESS AND THE PERSON IN CRISIS

Assessment

When the safety of a person in crisis is secured, the formal data-gathering process begins. It is conducted in person or by telecommunications and starts with an assessment interview. Of course, the interview is modified to match the circumstances, age, and cognitive ability of the person in crisis.

Data collection is enhanced by information gathered from family members, other healthcare providers, and authorities such as police officers. The purpose is to assess the mental and physical status of the person and the problem. Professionals may find the influencing (balancing) factors of crises a useful framework for an assessment interview, specifically the client's (1) perception of the event, (2) situational supports, and (3) coping skills.

1. Perception of the event. Something has happened to create a crisis in a person's life, motivating the person to seek help from a crisis hotline or ED. By gaining information about the precipitating event, both caregivers and individuals in crisis gain a better understanding of the problem. Questions clinicians might ask about a precipitating event are:
• What happened to make you so upset?
• How are you feeling right now?
• How does this event affect your life?
• How will this event affect your future?
• What needs to be done to fix the problem?
2. Situational supports. The support system of a client includes the resources available to the person in crisis. Family and friends, social clubs, church groups, and networks of professional associates are all sources of support. When these resources are not available, caregivers act as a temporary support system for the client. The plan of care should include the identification of a support system. Some questions a clinician might ask about a support system are:
• With whom do you live?
• When you feel lonely and overwhelmed by life, who do you talk to?
• Is there someone in you life whom you trust?
• In the past, during difficult times, who did you want to help you?
• Where do you go to school (to worship, to have fun)?
3. Coping skills. In crisis situations, it is important to evaluate the person's level of anxiety and their usual coping methods. Some people drink, some eat, some sleep, and some gamble. Others engage in physical activity, work harder, pick fights, and talk to friends. Some questions clinicians may ask about coping skills are:
• Have you thought of killing yourself or someone else?
• How would you go about doing this?
• Did you try it this time? If so, what was different this time?
• What do you usually do to feel better?

MENTAL STATUS EXAMINATION (MSE)

The mental status examination is used to evaluate critical areas of cognition and emotion. The MSE, in psychiatry, is "analogous to the physical examination in general medicine" (Varcarolis et al., 2006). Caregivers use their findings to diagnose unmet needs, identify desired goals, and create a plan of care. Though an emergency requires that clinicians modify the examination to fit the situation, a complete MSE includes the following items.

Personal Information

• Age
• Sex
• Marital status
• Religious preference
• Ethnic background
• Employment
• Living arrangements

Appearance

• Grooming and dress
• Hygiene
• Facial expression
• Height, weight, nutritional status
• Unique body markings: scars, tattoos, piercings
• Age related to appearance

Behavior

• Body movement: excessive or reduced
• Peculiar movement: scanning, gesturing, balance, gait
• Abnormal movement: tremors, teeth chattering
• Eye contact

Speech

• Rate: slow, rapid, normal
• Volume: loud, soft, normal
• Disorganized, rapid

Affect and mood

• Affect: flat, bland, animated, angry, withdrawn, appropriate to context
• Mood: sad, labile, euphoric

Thought

• Process: coherent, flight of ideas, neologism, thought blocking, circumstantiality
• Content: delusions, obsessions, suicidal ideations

Perceptual disturbances

• Hallucinations: auditory, visual
• Illusions: perceptual misinterpretations

Cognition

• Orientation as to time, place, person
• Level of consciousness: alert, confused, clouded, stuporous, unconscious, comatose Memory: remote, recent, immediate
• Fund of knowledge
• Abstractions: performance on tests, involving similarities, proverbs
• Insight into problems
• Judgment

PHYSICAL STATUS EXAMINATION

A basic physical examination is essential at the initial in-person interview because medical conditions may mimic psychiatric ones and people who suffer psychiatric disorders are more likely than others to have medical, cognitive, or substance-related disorders. When the interview is conducted by telephone, the clinician may urge the caller to obtain a physical examination and should refer the person to such services.

If a physical examination suggests the person in crisis has a medical disorder or is experiencing an acute drug reaction, the client should be referred for treatment immediately. A minimal physical examination includes the following.

Physical Examination

• Measurement of temperature, pulse, respirations, blood pressure (abnormal vital signs suggest an underlying medical or drug-related condition)
• Review of body systems: cardiovascular, gastrointestinal, pulmonary, genitourinary, musculoskeletal, integumentary, endocrine, and neurosensory
• Names of prescribed and nonprescribed drugs
• Date and provider of last physical examination
• Laboratory tests: complete blood count, alcohol and sugar levels, thyroid panel, urinalysis, hematocrit, hemoglobin, chemistry profile, folate and thiamine levels, STDs, hepatitis, electrocardiogram, liver and renal function, drug toxicology screen, pregnancy as appropriate (Antai-Otong, 2004)

Diagnosis

After assessing the person in crisis, clinicians make a tentative diagnosis, using one of three major diagnostic classification systems, all of which identify the client's problem or unmet need, the probable cause or etiology, and signs and symptoms or other supporting data. The classification systems are taken from:

• International Statistical Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), published by World Health Organization (WHO)
• The Diagnostic and Statistical Manual of Mental Disorder-IV-TR (DSM-IV-TR), published by American Psychiatric Association
• NANDA Nursing Diagnoses: Definitions and Classifications 2005–2006 (NND), published by NANDA International

The ICD-9-CM classifies both psychiatric and medical syndromes (clusters of symptoms) using a number and a word or phrase, such as 295.30 Schizophrenia, paranoid, or 577.1 Pancreatitis, chronic. The code number facilitates research studies, demographic data collection, and the reimbursement of providers.

DSM-IV-TR classifies psychiatric disorders using five axes or elements:

• Axis I: ICD-9-CM code number and name of psychiatric disorder, such as 309.81 Posttraumatic stress disorder
• Axis II: ICD-9-CM code number and name of a personality disorder or type of mental retardation, such as 301.6 Dependent personality disorder and 317 Mild mental retardation
• Axis III: ICD-9-CM code number and name of general medical condition such as 530.3 Esophageal stricture
• Axis IV: Psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of the mental disorder, such as "problems with the primary support group, social environment, housing, and education"
• Axis V: Global assessment of functioning scale using "100" to indicate "superior functioning in a wide range" and "1" to indicate "persistent danger of severely hurting self or others or persistent inability to maintain minimal personal hygiene" such as 60 to 51 "moderate symptoms or moderate difficulty in social, occupational, or school functioning." (APA, 2000).

NANDA describes "psychosocial responses or potential responses to health problems and life processes" (2005). A complete nursing diagnosis states a response to a health problem related to a medical or psychiatric disorder, as evidenced by signs and symptoms exhibited by the patient. For example, risk for suicide, related to depressed mood, as evidenced by dangerous behavior such as drinking and driving.

Nurses make NANDA diagnoses and use them in the nursing care plans required by all accredited hospitals and agencies. Nurses must also be familiar with the other two diagnostic systems because healthcare organizations and government agencies use ICD-9-CM and DSM-IV-TR codes to pay clinicians for professional services.

Planning

When clinicians make an assessment of a person in crisis and diagnose the problem, they and the client decide what goals and outcomes are desirable and feasible. They then determine the process by which each outcome can be achieved. Naturally, outcomes depend on the setting and condition of the person in crisis.

For a client who hears voices telling him to hurt himself, a NANDA diagnosis might be disturbed thought processes related to schizophrenia, paranoid type, as evidenced by persecutory hallucination. The outcome criteria might be to consistently refrain from doing what the voices command.

Intervention

Interventions are the actions caregivers take to achieve identified outcomes. Such actions are based on the clinical knowledge, judgment, and skill of the caregiver, how acceptable the intervention is to the person in crisis, and whether the action is feasible under the circumstances.

When a person is a danger to self or others, as with a client who hears voices telling him to hurt himself, it may be necessary to call the authorities for "emergency involuntary commitment" whereby the individual is restrained and taken to a locked facility for evaluation and treatment.

Emergency departments and telephone crisis centers often develop standardized procedures called clinical protocols to assist caregivers in giving more appropriate and effective emergency care to people in crisis. For example, when a victim of sexual assault comes to an ED, clinicians implement the rape protocol.

The protocol will include such interventions as "provide emotional support and privacy, stay with the client, label and save all clothing, collect vaginal or rectal secretions, examine the victim's body for cuts and bruises, refer the person to a rape advocacy program, and document every aspect of care."

Evaluation

The effectiveness of an intervention is judged by its outcome. If outcome goals were met, the crisis was resolved, and the person in crisis was returned to a prior level of functioning, we can rightfully say the intervention was successful. Ideally, as a result of the intervention, individuals who have been in a crisis learn new coping skills, increase their social support network, and as a result are better equipped to overcome future disruptive events.

CRISIS-PRODUCING EMERGENCIES

Crisis-producing emergencies can be grouped into five categories: (1) mood-related (mania, depression, and suicide), (2) anxiety-wrought, (3) anger-generated, (4) substance use, and (5) mental illness. All of the conditions require immediate assessment and knowledgeable interventions from caring professionals.

Mood-Related Emergencies

All people experience a range of moods, from great joy to profound sadness, expressing these moods in an array of behaviors, from laughter and smiling to weeping and withdrawal. When moods become exaggerated at either end of the emotional spectrum they become disorders, limiting the ability of the person to function socially or occupationally.

In their extremes, mood disorders produce the frenzy of mania and exhaustion and the melancholy of depression and suicide. When people experience mood disorders and seek help in EDs or on crisis hotlines, clinicians need to recognize typical symptoms, identify their cause, plan a course of action, implement the plan, and evaluate its effectiveness.

MANIA

Manic episodes are periods of extreme elevation of mood when people feel expansive, energetic, grandiose, and, sometimes, irritable and ill-tempered. Typical behaviors of mania are:

• Inflated self-esteem or grandiosity
• Decreased need for sleep (feels rested after only 3 hours of sleep)
• More talkative than usual or pressured to keep talking
• Subjective experience that thoughts are racing or flight of ideas
• Distractible, attention easily drawn to unimportant or irrelevant external stimuli
• Intense goal-directed activity, socially, sexually, and occupationally
• Hyperactive behaviors and symptoms occur in episodes of a week or more
• Excessive involvement in pleasurable activities with a high potential for painful consequences, such as unrestrained buying sprees, foolish business investments, and sexual indiscretions (DSM-IV-TR, 2000)

Hypomanic episodes last less than a week and are more moderate than manic episodes. The symptoms, though noticeable, are not severe enough to keep the person from functioning. During these times many individuals are exceptionally creative, productive, and focused, often becoming successful standup comedians, performers, inventors, and artists. As with people who experience manic episodes, those who experience hypomanic episodes commonly abuse substances.

Assessment

Caregivers assess the potential danger of these people in crisis to themselves and to others and their need for hospitalization. Often people experiencing a manic episode may not have eaten or slept for many days and have poor impulse control, resulting in harm to themselves and others. They may become exhausted to the point of death. Thus, clinicians need to assess the following:

• Medical status, by performing a physical examination to determine if mania is primary or secondary to a medical condition or to substance disorder
• Other psychiatric conditions, such as anxiety disorder and schizoaffective disorder
• Understanding by the client and the family about bipolar disorder and their knowledge of prescribed medications, support groups, and organizations

Diagnosis

Medical Diagnoses

Because depression often precedes and follows hypomanic and manic episodes, the disorder was once called manic-depression. Now, however, it is called bipolar disorder. Currently, the American Psychiatric Association identifies mania as a symptom in all of the following diagnoses:

• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Bipolar Disorder, Not Otherwise Specified (NOS)
• Mood Disorder due to a medical condition
• Substance-induced Mood Disorder
• Mood Disorder, NOS (DSM-IV-TR, 2000).

Nursing Diagnoses

Because clients exhibit constant and excessive motor activity, poor judgment, difficulty evaluating reality, probable dehydration, and lack of impulse control, the following NANDA diagnoses may be appropriate: risk for injury, risk for other-directed violence, risk for self-directed violence, risk for suicide, ineffective coping, defensive coping, ineffective coping, disturbed thought processes, impaired verbal communication, impaired social interaction, imbalanced nutrition, deficient fluidvolume, self-care deficit, and disturbed sleep pattern (NANDA, 2005).

Planning

The goal of care for clients in an acute manic episode is to prevent injury and instill hope for the future. Therefore, outcome criteria for the client are as follows:

• Be well hydrated
• Maintain or obtain stable cardiac status
• Maintain or obtain tissue integrity
• Get sufficient sleep and rest
• Demonstrate thought self-control
• Make no attempt at self harm (Moorhead, Johnson, & Maas, 2004)

Intervention

To meet outcome criteria and ensure safety, medical stabilization, and external control, people in crisis manifesting manic symptoms need hospitalization. If they will not cooperative and are a danger to themselves or others, emergency involuntary commitment may be necessary. (See Legal Issues, above.) To gain their cooperation and communicate more effectively, clinicians:

• Use short and concise statements and explanations
• Use a calm but firm approach
• Remain neutral, avoiding power struggles
• Coordinate care with other staff members to avoid manipulation

Medications such as antianxiety agents (anti-anxiolytics), antipsychotics, and antidepressants may be prescribed. Furthermore, mood stabilizers such as lithium and valproic acid are considered lifetime maintenance therapy for bipolar clients (Preston, O'Neal, & Talaga, 2005). Because the incidence of substance use disorders is exceptionally common with bipolar disorder, treatment for mood disorder and substance abuse should proceed at the same time when appropriate (APA, 2000).

Evaluation

Caregivers achieve treatment goals when they meet outcome criteria, clients are safe, and families are informed of resources for ongoing assistance. If these goals were not met, caregivers need to analyze where they failed and make changes for the future.

DEPRESSION AND SUICIDE

Depression is a "dis-ease" in a true sense of the word. Those who experience depression feel sad, joyless, empty, and that life is not worth living. This tragic condition is the fourth leading cause of disability in the United States and a major health problem of older adults. Depression is twice as common in women as it is in men and is not related to education, income, ethnicity, or marital status. Two-thirds of those who suffer from the disorder also suffer from anxiety. Typical symptoms of major depression are:

• Depressed mood most of the time
• Lack of interest or pleasure in almost everything, most of the time
• Significant weight gain or loss when not dieting
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue and loss of energy
• Feelings of worthlessness and inappropriate guilt
• Diminished concentration and indecisiveness
• Recurrent thoughts of suicide and death, but without a specific plan
• Morbid preoccupation with worthlessness and guilt
• Symptoms are not better accounted for by bereavement
• Clinically significant distress or impairment in social, occupation, and other areas of functioning (DSM-IV-TR, 2000)

Dysthymic episodes of depression means the sufferers have fewer of the identified symptoms of major depression and their episodes occur over a shorter period of time (<2 years). Even so, dysthymia causes significant distress in every area of life (DSM-IV-TR, 2000).

Assessment

Numerous screening tools have been devised to identify people who are depressed. However, in psychiatric emergency situations, there is little time for testing. Caregivers know that 10% to 15% of depressed persons eventually commit suicide (Dhossche, 2000). For this reason, clinicians in the ED take depression seriously and screen people in crisis for suicide ideation. They know that asking if someone has thought about committing suicide does not make them do it!

Direct questions to ask of people who are at risk for suicide are:

• Have you ever felt that life was not worth living?
• Have you been thinking about death recently?
• Do you ever think about suicide?
• Have you ever attempted suicide?
• Do you have a plan for committing suicide?
• If so, what is that plan? (APA,2003)

Areas of inquiry include the following:

• Feelings: Helpless, worthless, hopeless, and anger, generated by profound helplessness
• Thought processes: Difficulty concentrating or making up one's mind
• Affect: Seeing the world through gray-colored glasses
• Communication and comprehension: Slow speech and understanding
• Delusional thinking: Believe false and denigrating things about the self (God wants me dead, I'm not worth anything, anyway)
• Typical behaviors: Poor personal hygiene, psychomotor agitation, weeping, substance abuse, changed sleep patterns, constipation, reduced sexual interest (Varcarolis et al., 2006)

Guidelines for assessing depressed clients include the following:

• Always evaluate the client's risk of harm to self or others. In some cultures, there is a high correlation with anger, especially self-anger and suicide (Hamilton, 1997).
• A thorough medical and neurologic examination helps determine if the depression is primary or secondary to another disorder or to drugs. Evaluate whether the client is psychotic, has taken drugs or alcohol, has medical conditions, or has a history of psychiatric syndromes.
• Ask if the person has a history of depression.
• Assess support systems, family, significant others, and need for referral.

Guidelines for assessing suicidal clients include the following:

• Assess risk factors, including history of suicide, degree of hopelessness and helplessness, and lethality of plan (gun, poison, hanging).
• If there is a history of suicide attempt, assess intent, lethality, and injury.
• Determine whether the client's age, medical condition, or psychiatric diagnosis puts the client at higher risk.
• Note whether a client's mood changes suddenly from sadness to a happier state. Often a decision to commit suicide gives a feeling of relief and calm.
• If the client is to be managed on an outpatient basis, assess social supports and knowledge of potential suicide signs.

Diagnosis

Medical Diagnoses

The American Psychiatric Association (2000) recognizes three types of depressive disorders that do not have manic features (note that there is no medical diagnosis of "suicide risk"). The three types of depressive disorders are:

• Major Depressive Disorder
• Dysthemic Disorder
• Depressive Disorder NOS (not otherwise specified)

Nursing Diagnoses

Because depressed individuals have many needs and may suffer from other psychological and physical disorders, numerous nursing diagnoses may be appropriate. However, risk for suicide is always considered. Other diagnoses may be: hopelessness, ineffective coping, social isolation, self-care deficit, ineffective coping, powerlessness, chronic low self-esteem, constipation, and sexual dysfunction.

Planning

The planning of care for depressed individuals in crisis is based on the circumstances that bring them to emergency care. Outcome criteria for the nursing diagnosis risk for suicide might be: Individuals will (1) value and nurture themselves and (2) refrain from hurting themselves. When depressed clients are judged to be a danger to themselves or others, clinicians must consider the need for emergency hospitalization.

Intervention

There are three phases in the treatment and recovery of persons with major depression:

1. Acute phase (6 to 12 weeks). The goal of treatment is to reduce depressive symptoms and restore psychosocial and work function. Hospitalization during this phase may be necessary.
2. Continuation phase (4 to 9 months). The goal of treatment is to prevent relapse with pharmacotherapy, education, and depression-specific psychotherapy.
3. Maintenance phase (1 or more years). The goal of treatment is to prevent further episodes of depression.

Medical treatment for depression is either first-line or second-line. First-line treatment includes:

• Selective serotonin reuptake inhibitors (SSRIs)
• Atypical antidepressants
• Cyclic antidepressants (eg, tricyclic antidepressants TCAs)

Second line treatment includes:

• Monoamine oxidase inhibitors (MAOIs)
• Electroconvulsive therapy (ECT)

Nursing interventions for severely depressed clients include providing food and fluids, suicide precautions, personal hygiene, supportive communication, and psychotherapy using cognitive-behavioral, psychodynamic, and interpersonal approaches. If a person is hospitalized because deemed at risk for suicide, staff implement Suicide Risk Precautions as follows:

1. Search client and belongings for harmful objects.
2. Make sure visitors do not leave potentially harmful objects or gifts in client's room.
3. Keep electric cords to minimal length.
4. Hang-proof and jump-proof bathrooms.
5. Provide plastic eating utensils.
6. Do not assign client to private room.
7. Lock utility rooms, kitchens, stairwells, windows, and offices.
8. Conduct one-to-one nursing observations and interaction 24 hours a day.

Evaluation

Treatment of depressed persons is considered successful if, after treatment, they are able to think clearly, behave appropriately, and express greater hope and self-esteem. For example, an individual who came to the ED considering suicide, now is able to state alternatives to suicide, explore thoughts and feelings that preceded those impulses, and function successfully in the environment.

ANXIETY-WROUGHT EMERGENCIES

In the United States, anxiety-wrought conditions are the most common of all disorders that cause people to seek help in EDs or through crisis hotlines (Anxiety Disorders Association of America, 2003). Consequently, clinicians need to understand anxiety and its many manifestations and be prepared to assess, diagnose, plan, intervene, and evaluate the effectiveness of their actions.

Anxiety is a feeling of uncertainty and dread, resulting from real or imagined threats. Unlike fear, which is a reaction to a specific danger, anxiety is a vague apprehension that invades the "central core of the personality, eroding ones feeling of self-esteem and personal worth" (Varcarolis et al., 2006).

Normal anxiety is a natural response to the demands of life. It provides energy to achieve goals and carry out the activities of daily living. It energizes people and helps them manage the usual demands of life, including such things as arriving for work on time, fulfilling commitments, and pursuing worthwhile goals.

Acute anxiety, or state anxiety, is a sudden, intense feeling of fear, caused by an imminent threat to ones' sense of security. It is the feeling new graduates experience as they sit for a licensing examination, singers experience as they walk to the microphone to audition for a leading role, and patients feel as they climb onto the dentist's chair.

Chronic anxiety, or trait anxiety, is a long-lasting, fear-based condition that persists over many years. Children with this condition appear apprehensive and high-strung. Adults with the disorder experience unrelenting angst and may develop all manner of physical and emotional disorders such as insomnia or chronic fatigue syndrome.

Anxiety disorders frequently occur with other psychiatric disorders, especially depression and substance abuse. Genetic, biological, psychological, and cultural factors all play a part in their development.

Like other emotions, the intensity of anxiety varies with the situation, ranging from mild to panic. Mild anxiety actually improves performance, sharpens focus, increases attention, and helps people grasp information. However, as anxiety increases to moderate, the perceptual field narrows and people are less able to see, hear, and grasp information. They experience selective inattention and notice only a few things in the environment. The ability to think clearly lessens and the body responds with profuse perspiration, and rapid pulse and respirations.

As anxiety intensifies to severe, people feel dazed and confused, unable to solve problems or focus on more than one thing at a time. They may feel dizzy, have a sense of impending doom, and behave automatically. Panic is the most extreme level of anxiety. In this state, people lose touch with reality and are unable to process what is going on around them. They feel confused, behave erratically and impulsively, and experience false sensory perceptions.

Assessment

As with everyone who comes to an emergency facility for help, a physical examination and at least a modified mental status examination should be performed. Although all anxiety disorders are fear-based, the symptoms they display differ greatly, as described by The American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders (2000):

• Panic disorder: Sudden onset of extreme apprehension, with or without agoraphobia, a fear of being in a place from which escape is difficult or impossible.
• Phobia: A persistent, irrational fear of a specific object, activity, or situation, leading to a desire to avoid certain objects.
• Obsessive-compulsive disorder (OCD): Obsessions are repeated thoughts, impulses, and images. Compulsions are repeated ritualistic behaviors over which the sufferer has no control, even though the person knows they are excessive and unreasonable.
• Generalized Anxiety Disorder (GAD): Excessive anxiety and worry about many different things for six months or more. Sufferers experience restlessness, poor concentration, irritability, tension, sleep disturbance, and fatigue.
• Posttraumatic Stress Disorder (PTSD): Repeated re-experience of a highly traumatic event to which the person responds with intense fear, helplessness, or horror. These flashbacks may begin within three months or be delayed for years. The person avoids stimuli associated with the trauma, becomes hypervigilant, and experiences a feeling of detachment from others.
• Acute Stress Disorder (ASD): Symptoms occur within one month of exposure to a highly traumatic event. The person displays three of the following dissociative symptoms: subjective sense of numbness, detachment, absence of emotional responsiveness, derealization, depersonalization, or loss of memory. ASD resolves within four weeks.
• Substance-induced Anxiety Disorder: Symptoms of anxiety, panic attacks, obsessions, and compulsions develop with the use of a substance within a month of stopping use of the substance.
• Anxiety due to medical condition: Symptoms of anxiety are a direct physiologic result of a medical condition such as hyperthyroidism, asthma, hypoglycemia, pulmonary embolism, and Parkinson's disease.

Assessment guidelines for anxious individuals in crisis include the following:

1. Assess for potential self-harm, because people with high anxiety are more likely to become desperate and suicidal.
2. Conduct a physical and neurologic examination to determine whether the anxiety is the cause or the result of substance use or a medical or psychiatric disorder.
3. Assess for psychosocial and environmental problems that may be affecting the client, such as a stressful relationships, recent loss of job, and economic pressures.
4. Consider cultural differences that may affect the way a person exhibits anxiety.

Diagnosis

Medical Diagnoses

The American Psychiatric Association (APA) recognizes eleven anxiety disorders, as follows:

• Panic disorder without agoraphobia
• Panic disorder with agoraphobia
• Agoraphobia without history of panic disorder
• Specific phobia
• Social phobia
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Acute stress disorder
• Generalized anxiety disorder
• Anxiety disorder due to medical condition (state medical condition)
• Substance-induced anxiety disorder (state substance)

And, finally, anxiety disorder NOS (not otherwise specified).

Nursing Diagnoses

Although many anxiety disorders described by the APA differ markedly from one another, NANDA diagnoses may appear in all of the anxiety conditions. For example, ineffective coping, fatigue, anxiety, disturbed sleep pattern, and chronic low self-esteem are common to all of the anxiety disorders.

Planning

People in crisis with anxiety disorders usually do not require hospitalization. However, clinicians encounter these people in homes, clinics, and acute and skilled nursing facilities. Caregivers encourage people with symptoms of anxiety to participate in planning their treatment. For example, if the nursing diagnosis is "self-control of anxiety," the outcome criteria might be: "client will monitor the intensity of anxiety and use relaxation and regular exercise to decrease anxiety."

Intervention

Medical Interventions

Both psychotherapy and medications are used to treat anxiety disorders. In cognitive therapy, clients learn to recognize behaviors and take action to change them. Therapists teach cognitive restructuring or reframing (replacing irrational negative statements and beliefs with positive statements), relaxation to help reduce anxiety, systemic desensitization to overcome phobias, and thought-stopping to reduce obsessions.

Medications prescribed for anxiety include antidepressants such as selective serotonin reuptake inhibitors (SSRIs), tricyclics, monoamine oxidase inhibitors (MAOIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs), and anxiolytics such as benzodiazepines and nonbenzodiazepine, antihistamines, and anticonvulsants.

Nursing interventions for anxious people include:

1. Teaching behavioral therapy techniques to reduce anxiety.
2. Teaching relaxation techniques, cognitive reframing (changing negative thoughts to positive ones).
3. Offering counseling, milieu therapy, self-care, and health teaching.
4. Referral to appropriate community resources such as OCD support groups.

Evaluation

The treatment of anxiety disorders is considered successful if symptoms of anxiety in clients are reduced and they are able to live a happier, less fearful life.

ANGER-GENERATED EMERGENCIES

Anger-generated emergencies that involve assault and battery are well-known to clinicians in EDs and crisis hotlines. In recent times, violence has become a serious public health issue, affecting individuals, families, and entire communities. For this reason it is essential that healthcare providers understand anger and aggression, recognize its signs and symptoms, plan appropriate interventions, and evaluate those interventions. The goal of such care is to ensure safety for everyone concerned.

In his classic study of human emotions, Robert Plutchik (1991) identified anger as one of the primary emotions, an inborn response to the frustration of desire. The purpose of anger is to remove what is blocking fulfillment of human needs or wants.

Aggression is the physical or verbal action people take to overcome obstacles that block their desires. As with other emotions, a stimulus event evokes a feeling and the feeling motivates the person to respond. The decision to express anger aggressively depends on many factors, including cultural influences, genetic predisposition, low serotonin levels, and brain abnormalities, especially in the limbic system.

As with other crises, anger and aggression are mediated by three balancing factors: (1) the perception of an event, (2) the availability of a support system, and (3) coping mechanisms. On feeling angry, some people use aggression as their primary coping mechanism. Such a response is common in disorders like substance abuse, mania, antisocial personality, and cognitive deficit.

Assessment

Because of the danger to themselves and others who may be nearby, it is important for clinicians to recognize common predictors of violence, including:

• A history of recent acts of violence
• Intoxication with alcohol or drugs
• Possession of a potential weapon
• Situations that lead to violence: overcrowding, arbitrary rules, apparent favoritism
• Signs and symptoms of violence: hyperactivity, restlessness, clenched jaw, fierce facial expression, increasing tension, mumbling to self, clenched fist, profanity, loud voice, soft voice, argumentative, avoidance of eye contact, and intense eye contact

Guidelines caregivers can use to assess a client's anger and violence include:

• History of violence
• Hyperactive, irritable, impulsive behavior
• Risk factors: wish or intent, plan to harm, means to carry out plan
• Demographic factors: male aged 14 to 24, low socioeconomic status, lack of support system, limited coping skills, frequent use of intimidation to meet needs
• Intolerance of limit-setting by authorities

Guidelines caregivers can use to assess their own response to anger:

• Personal triggers, such as physical characteristics of clients or situations
• Sense of personal competence in a situation of potential conflict
• Ability to ask for assistance

Diagnosis

Medical Diagnoses

Although impulse control and aggression are symptoms of many neurobiologic conditions, the American Psychiatric Association has identified only one discrete disorder in which aggressive episodes are not better accounted for by other mental disorders; it is Intermittent Explosive Disorder (APA, 2000).

Nursing Diagnoses

NANDA diagnoses for clients who display aggressive behavior include: Risk for self-directed violence, risk for other-directed violence, aggression self-control, and ineffective coping.

Planning

Without question, de-escalation of anger and prevention of violence is the primary outcome criteria for interventions with angry clients. Such planning takes into account resource availability and situations in which violence may occur, is occurring, or has occurred.

In planning interventions, it is important to consider the stages of violence. These are the pre-assaultive stage, assaultive stage, and post-assaultive stage, when clients return to their usual disposition (Mason & Chandley, 1999).

Intervention

Pre-assaultive stage interventions focus on de-escalation of anger and require that clinicians:

1. Analyze clients and their situation and reassure them of your concern and expectation that they will stay in control of themselves.
2. Use deescalating communication and remain calm and nonthreatening.
3. Demonstrate respect for personal space of clients, giving them adequate space and decreasing intimidation. Sit if the client is sitting and stand if the client is standing.
4. Interact with clients respectfully, in a low, nonthreatening voice, honestly verbalizing options. Encourage them to assume responsibility for the choices they make and acknowledge the difficulties they have in making choices.
5. Use time wisely, giving adequate time for depressed or suicidal clients to consider options, but set limits with manipulative clients.
6. Interact with clients in a quiet place that is in plain view of other caregivers.
7. Secure personal safety:
• Avoid dangling jewelry.
• Alert other caregivers.
• Eliminate hazards caused by furniture or other objects.
• Stand to the side of clients, not directly in front of them in a threatening way.
• If clients begin to escalate, provide feedback, assuring them they will be safe.
• Avoid confrontation and "show of force" by security guards.

Assaultive stage interventions include application of restraints, administration of medication, and seclusion. These measures should be used only after alternative interventions have been tried (eg, verbal intervention, medication, decreased sensory stimulation). Restraints, medications, and seclusion are used only when clients present a clear and present danger to themselves or others, have been legally detained for involuntary treatment and escape risk, or when they request seclusion.

When physical restraint is necessary, a team of practiced staff members use management of assaultive behavior (MAB). When restrained, physician-prescribed sedatives are administered and the client is placed in a quiet, secluded area.

Postassaultive stage interventions begin when the client has become calm. These measures include establishing rapport with the client, engaging in a therapeutic discussion of stressors, and teaching alternative coping behavior. When available, clients are referred to longer-term counseling and anger management group therapy.

Evaluation

After an assault by a client, caregivers need time to regroup and regain a sense of personal safety, control, and security. They need time to debrief, to discuss what happened, what went right, what went wrong, and what they will do in future situations. All incidents of violence are reported and documented according to agency protocol.

SUBSTANCE-USE EMERGENCIES

We are a drug-oriented society, using substances of every kind to reduce pain, lessen anxiety, induce sleep, increase energy, restore health, create feelings of euphoria, and enhance alertness. At least two-thirds of the U.S. adult population consume alcohol regularly and more than half of those with mental illnesses use or have used mind-altering substances (Smith-Dijulio, 2006).

Because of the widespread use of substances, clinicians in EDs and on crisis hotlines must assess, diagnose, plan, intervene, and evaluate not only physical but also psychiatric disorders, including substances-use disorders. When more than one disorder presents, clients are described as suffering from dual diagnoses or co-morbid conditions. Some common dual diagnoses are:

• Alcohol addiction and generalized anxiety disorder
• Cocaine addiction and major depression
• Polydrug addiction and schizophrenia
• Episodic polydrug abuse and borderline personality disorder (Negrete, 2003)

Terminology

• Physical dependence: Physiologic adaptation to a drug, confirmed by the appearance of a signs and symptoms that occur if the drug is withheld. (See Psychological dependence.)
• Psychological dependence (addiction): Compulsive and maladaptive dependence on various substances such as methamphetamine, cocaine, and tobacco. (See Withdrawal syndrome.)
• Polysubstance abuse: The simultaneous use of many legal and illegal mind-altering, addictive substances.
• Substance abuse: The repeated use of mind-altering substances, resulting in a failure to meet obligations at home, work, or school.
• Substance use: The ingestion of a chemically active agent, such as legally prescribed medication, alcohol, tobacco, or illegally obtained drug.
• Tolerance: A condition in which people take progressively higher doses of a substance to achieve a desired effect; withdrawal symptoms appear when individuals stop taking the substance.
• Withdrawal syndrome: A group of symptoms that occur when a drug is discontinued or when its effect is counteracted by a specific antagonist.

Assessment

People in crisis often resort to mind-altering substances to dull their senses, lift their spirits, or in some way relieve their discomfort. When individuals come to a ED because they are suffering substance withdrawal symptoms or have taken a mind-altering drug and fear its effects—or have come for some other reason and exhibit bizarre behavior suggesting substance use—clinicians interest themselves in the following:

• History of substance abuse: What substance have you taken, how long ago, what symptoms? Have you had blackouts, overdoses, complications, recent accidents, head trauma? Do you have a family history of substance abuse?
• Medical history: What medical disorders do you have? What medicines do you take?
• Psychiatric history: Have you ever thought about ending your life or hurting yourself? Have you tried to end your life? When, and under what circumstances?
• Psychosocial issues: Do you have a family or friends? What do you do for a living? What do you do to make yourself feel happy? Have you had a crisis in your life recently?

When people do not know or will not tell caregivers what substance they have taken, clinicians look for typical signs of stimulants, depressants, inhalants, hallucinogens, intoxicants, opiates, and other drugs. Signs and symptoms of the most common are:

• Central nervous system (CNS) stimulants (eg, cocaine, crack, amphetamines): Tachycardia, dilated pupils, elevated blood pressure, nausea and vomiting, insomnia, assaultive, grandiose, impaired judgment, impaired social and occupational functioning, euphoria, increased energy, severe to panic levels of anxiety, paranoia with delusions, visual, auditory, and tactile hallucinations
• Opiate intoxication (eg, opium, heroin, meperidine, morphine, codeine, fentanyl, methadone, hydromorphone): Constricted pupils, decreased respiration, drowsiness, decreased blood pressure, slurred speech, psychomotor retardation, initial euphoria followed by impaired judgment, attention, and memory
• Hallucinogen intoxication (eg, lysergic acid diethylamine [LSD], mescaline, psilocybin): Pupil dilation, tachycardia, diaphoresis, palpitations, tremors, and elevated temperature, pulse, and respirations
• Phencyclidine piperidine (PCP) intoxication, or hallucinogens: Vertical or horizontal nystagmus, elevated blood pressure, pulse, temperature, ataxia, muscle rigidity, seizure, blank stare, chronic jerking, agitation repetitive movements, belligerence, impulsiveness, impaired judgment and functioning
• Inhalant intoxication (volatile solvents that vaporize at room temperature): Excitement, then drowsiness, agitation, and lack of self-control.
• Nitrates (room deodorizers): Enhanced sexual pleasure, euphoria
• Anesthetics (nitrous oxide): Giggling
• CNS depressants (eg. alcohol, benzodiazepines, barbiturates): Slurred speech; unsteady gait; drowsiness; decreased blood pressure; impaired judgment, memory, and occupational function; irritability; and aggressiveness
• Alcohol withdrawal: These signs usually develop within a few hours after the last drink, peaking sometime between 24 and 48 hours. The person becomes irritable, hyperalert, exhibits jerky movements called "shakes," and then symptoms gradually disappear.
• Complicated alcohol withdrawal with delirium tremens (DTs): occur 48 to 72 hours after the last drink. These include disorientation, agitation, tremors, anxiety, visual and tactile hallucinations, paranoid delusions, fluctuating levels of consciousness, hypertension, tachycardia, diaphoresis, fever (100°F–103°F), and death, if untreated (Webb et al., 2000).

Diagnosis

Medical Diagnoses

In the Diagnostic Criteria from DSM-IV-TR, the American Psychiatric Association lists a staggering number of substance-related disorders: 16 alcohol, 13 amphetamine, 4 caffeine, 9 cannabis, 13 cocaine, 11 inhalant, 11 hallucinogen, 3 nicotine, 12 opioid, 10 phencyclidine, 16 sedative, 1 poly-substance, and 15 other individual substance disorders (APA, 2000).

Nursing Diagnoses

Many nursing diagnoses are appropriate to substance abusers, indicating just how dysfunctional their lives may be. Some common diagnoses are: disturbed sleep pattern, ineffective health maintenance, imbalanced nutrition, deficient fluid volume, disturbed thought processes, hopelessness, nonadherence to healthcare regimen, anxiety, self-care deficit, ineffective coping, dysfunctional family processes, and risk for suicide (NANDA, 2005–2006).

Planning

The goal of immediate care of substance-using individuals is to provide immediate, life-saving measures, identify the drug or drugs the individual has taken, and give supportive emotional care. The goal of long-term care is to encourage abstinence from substance abuse, meet physical and emotional needs, restore self-respect, and assist clients to establish a support system and become economically independence.

Interventions

In the ED, interventions for a substance-abusing individual include identifying the specific drug or drugs they have taken, giving immediate life-saving care, providing food and fluid, and transporting clients to inpatient care or referring them to outpatient care. Sadly, many substance abusers are homeless and friendless and afflicted with serious co-morbid conditions. Some communities provide shelter and drug treatment facilities, but people must agree to the rules and regulations of such facilities. Many refuse, preferring to live on the street until another crisis sends them back to an ED.

Evaluation

Caregivers in EDs evaluate how well they have met the immediate needs of clients, even though they may find it difficult to remain sympathetic because these clients return to the ED again and again. Nonetheless, caregivers must strive to give every client "genuineness, accurate empathy, and nonpossessive warmth" (Rogers, 1961).

MENTAL ILLNESS EMERGENCIES

When precipitating events occur in the lives of people with mental illnesses they may become so distressed they seek help in an ED or through a crisis hotline. This is not surprising, since the coping skills of these individuals may be scarce and their support systems limited. Clinicians need to assess the signs and symptoms of such clients, diagnose their disorders, plan their care, intervene appropriately, and evaluate the effectiveness of these interventions. Some of the more common mental illnesses seen in EDs are:

• Delirium (acute confusional state): A disturbance of consciousness and change in ability to think that develops within a few hours or days. It is caused by numerous metabolic and toxic disorders and substances such as anticholinergic drugs and alcohol ((Beers & Berkow, 1999).
• Dissociative disorders: Disturbance of memory (amnesia) or confusion about personal identity; in dissociative fugue, person suddenly and unexpectedly travels away from home; in dissociative identity disorder, individual exhibits two or more distinct personalities (APA, 2000).
• Mania: Individual exhibits a period of expansive or irritable mood, lasting at least a week. The person is talkative, grandiose, sleeps very little, experiences flight of ideas, psychomotor agitation, and excessive involvement in pleasurable activities (APA, 2000).
• Panic disorders: Intense fear develops suddenly, reaching a peak within 10 minutes, with rapid heart rate, palpitations, sweating, tremor, shortness of breath, feelings of being smothered or choked, fear of going crazy or dying, and dizziness. Symptoms gradually subside (APA, 2000).
• Posttraumatic stress disorder: An overwhelming traumatic event is reexperienced repeatedly, causing intense fear, helplessness, horror, and avoidance of stimuli associated with the trauma (Beers & Berkow, 1999).
• Schizophrenia: Loss of contact with reality with hallucinations (false perceptions), delusions (false ideas), illusions (false interpretations of real objects), abnormal thinking, flattened affect, diminished motivation, and disturbed work and social functioning (Beers & Berkow, 1999).

Assessment

When individuals with psychotic symptoms come to the ED, caregivers interview them and, when possible, interview relatives, associates, and other caregivers. Initial information may suggest the need for laboratory or other diagnostic studies. When clients have been hospitalized recently, those records may be available. If clients are agitated and assaultive, it may be necessary to restrain or seclude them for a limited period of time, as described in Legal Issues earlier in this course.

Diagnosis

Clinicians consider carefully the signs, symptoms, history, medical record, and laboratory test results in diagnosing each client. They use standard medical reference codes found in the following.

Medical Diagnoses

• The International Statistical Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), published by the World Health Organization
• The Diagnostic and Statistical Manual of Mental Disorder-IV-TR (DSM-IV-TR, published by the American Psychiatric Association

Nursing Diagnoses

• The NANDA Nursing Diagnoses: Definitions and Classifications 2005—2006 (NND), published by NANDA International

Planning

Individuals must have an individualized plan of care (IPC) that includes their immediate needs as well as ongoing needs. Many will require medications, some will need hospitalization, and most will need referral to outpatient care. The goal for all clients is stabilization and appropriate ongoing interventions.

Interventions

Immediate interventions for individuals suffering from the disorders listed above are carried out in the ED. Ongoing interventions are provided by either the hospital staff or family members and other caregivers. When clients are returned home for ongoing care, it is essential that family members and other caregivers receive accurate information and a resource for ongoing help.

Evaluation

As discussed earlier, clinicians evaluate the care they give clients, especially the care they give vulnerable clients. In a way, the arrival of a client in an ED constitutes a "precipitating event" of a potential crisis for the staff. The clinicians use their coping skills (experience, knowledge, and reasoning) and support system (professional colleagues) to meet the needs of clients. As a result, the potential crisis is resolved and staff go on about their work successfully.

Posted April 9, 2007

Expires April 1, 2010

Copyright © 2007 Wild Iris Medical Education. All rights reserved.

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