MANAGING THE PSYCHIATRIC CRISIS
MANAGING THE PSYCHIATRIC CRISISCourse # 202515 Contact HoursAuthors: Julie M. Mroczek, BSN. RN-BC, CLNCSilvia Prodan Lange, R.N., M.N.Expert reviewer: Meredith Patterson, RN, BSN, CRRNMaterial Valid Through June 2020G:INURATCopyright 2017J.L. KeeferAll rights reservedPublished by theNational Center of Continuing Education, Inc.,Lakeway, Texas.Printed in the United States of America.FEE L S No Exams,Just Learning!Enhanced Learning & SkillsTesting Mandatory For Electrologists, Florida & Ohio OnlyA NATIONAL EPIDEMICWE ALL KNOW . . . . . that U.S. Copyright Law grants to the copyright owner the exclusive right to duplicate copyrighted, printedand recorded materials. Piracy involves the illegal duplication of copyrighted materials.YOU MAY NOT KNOW . . . . . that every time you use or make an illegal copy of any printed material in any form or by any method youmay be liable for further litigation. . . that your institution’s duplication or processing equipment may also be confiscated and destroyed if involved in illegal duplication. . . that the penalty for criminal violation is up to five years in prison and/or a 250,000 fine under a toughnew law. (Title 17, U.S. Code, Section 506, and Title 18, U.S. Code Section 2319). . . that civil or criminal litigation may be costly and embarrassing to any organization or individual. We request you contact us immediately regarding illegal duplication of these copyrighted, printed materials. TheNational Center of Continuing Education will pay a substantial reward for information leading to the conviction of any individual or institution making any unauthorized duplication of material copyrighted by J.L.Keefer or The National Center of Continuing Education.
Table of ContentsAbout The Authors.3Purpose and Goals.3Instructional Objectives.3Self-awareness Explorations.3Introduction.3Impact on Health Professionals.5Reactions to Psychiatric Emergencies.5Stress.6Stressors.6APA Survey Reveals Deepening Concerns About ConnectionBetween Chronic Disease and Stress.6Stress Reduction.8Promoting the Relaxation Response.8The 5 R’s of Stress/Anxiety Reduction.8Understanding Crisis.8Crisis Theory and Intervention.8Caplan and Lindemann.8Danger And Opportunity.9Aguilera And Messick.9Crisis Intervention.10One Crisis After Another.11Life-Threatening Conditions.12Suicide.12Assessment Of Suicidal Behavior.13Direct verbal warnings.13Depression.13Changes in Social Behavior.13Making Final Plans.14Suicidal History.14Use of Drugs and Alcohol.15Intuition of a person close to the individual.15Problems and Goals.15Caring For Acutely Suicidal Patients.15Problem:.15Goal:.15Action:.15Suicide Precautions.16Violence.16Understanding Anger.17Assessment Of Violence.17Problems And Goals.19Dealing With Anger and pting Conditions.20Anxiety.20The Continuum Of Anxiety.20Helping Highly Anxious Patients.21Nonsuicidal Self-Injurious (NSSI) Behaviors.21Factors Associated With NSSI.22Risk Factors.22Motivations.22Risk-Rescue Rating.22Risk factors.22Rescue factors .23Total rescue points .23Impaired Functioning.23Actions.24Drug Abuse Related Problems.25Problems and Goals.26Cerebral Dysfunction From Other Causes.26Traumatic Brain Injury.26Assisting Survivors of Disaster.26Defusing.28Death Notification.28Medications.28Environmental Interventions.30Restraint Guidelines for Psychiatric Emergencies.30General Guidelines in Crisis Situations.31Resources.31References and Suggested Readings.31Appendix A.33Appendix B.34
About The AuthorsJulie M. Mroczek, BSN. RN-BC, CLNC, iscertified as a Psychiatric/ Mental Health Nurse,serving as the mental health professional onMental Health Boards in Nebraska for the past20 years, which legally determines if a patientis mentally ill and dangerous, and determinesthe least restrictive treatment alternativesavailable. She has also served as the RN-casemanager for Home Health and Hospice Careserving central Nebraska. Ms. Mroczek is alsoa Certified Legal Nurse Consultant.Silvia Prodan Lange, R.N., M.N., clinicalspecialist in psychiatric/mental health nursing. She completed her graduate work at theUniversity of Washington, Seattle. She hasworked in a variety of psychiatric settings -acute inpatient units, long-term state hospitals,VA units (acute and long-term), day treatmentcenters and outpatient work. The latter includesemergency room consultation and crisis intervention. She has taught psychiatric/mentalhealth nursing and has formerly directed theMental Health Program at the Seattle University School of Nursing. Her many professionalpublications include material on the violentpatient, suicide and hope. As a mental healthintegrator, she applies concepts from psychiatric nursing to other clinical nursing situations.Content review update provided by Meredith Patterson, RN, BSN, CRRN. She hasworked in numerous clinical settings including acute psychiatric care, head injury rehabilitation and acute neurology. Her business,Brainstorm Mind Fitness, specializes in theeducation and application of brain health lifestyle practices to promote optimum cognitivefunction. Certified in rehabilitation nursing,she is past president of the San Antonio chapterof the Association of Rehabilitation Nurses andis a frequent guest speaker for conferences onmental and cognitive health topics.Purpose and GoalsThe goal of this course presents generalguidelines for addressing and treating the mostfrequently encountered psychiatric emergencies including suicide, violence, anxiety, andsubstance abuse and self-harm.InstructionalObjectivesUpon completion of this course the studentwill be able to:1. Define and describe the most commonpsychiatric emergencies.2. Summarize Crisis Intervention andoutline the model developed by Aquileraand Messick.3. Apply crisis theory and intervention toclinical situations.List common signs and symptomsof depression, anger, anxiety, andnonsuicidal self-injurious (NSSI)behavior.5. Assess suicide, violence potential andlethality.6. Outline psychological, pharmacological,and environmental treatment approachesfor the psychiatric patient.7. Recognize professional and personalreactions to psychiatric emergencies.8. Define and clarify the following terms:psychiatric emergency and crisis.9. Relate the mnemonic code device forpsychiatric emergencies.10. Identify categories of psychiatricemergencies.11. Expand and improve psychiatric nursingterminology.12. Utilize the Social Readjustment RatingScale.4.Self-awarenessExplorationsWrite down your initial response to thequestion. There are no right or wrong answers.Refer back to this section as you go throughthe unit.1. What’s the first thing that comes toyour mind when you hear the term“psychiatric emergency”?2. Remember one crisis event that turnedout to be tragic. How did you feel aboutit at the time? Now?3. Remember one crisis event that turnedout well. What was your part in it? Whatdid you learn?4. What makes you most anxious about apsychiatric emergency?5. W h a t ’s t h e m o s t m e m o r a b l edramatization of a psychiatric emergencythat you’ve seen on TV, in the movies,in a play or read about in a book ornewspaper? 6. What’s the differencein your reactions to a crisis situation atwork and in your personal life?6. “Homicidal maniac!” What does thisconjure up for you? Have you everbeen faced with a violent person? Whathappened?7. How do you feel about people who makemultiple suicide attempts and who getrepeatedly detoxed from alcohol or drugsand go back on them?8. In your opinion, should people havethe right to decide when and how theywill die? Does this conflict with yourprofessional ethics? 10.What do youthink your reactions would be if you hadto be part of restraining, medicating orhospitalizing patients against their wills? National Center of Continuing Education - NurseCE.com9.In your wildest imagination, whatpossible psychiatric emergencies couldhappen to you or a significant other?How would you want others to help you?10. List several areas where you feel thatyou may need some assistance as a nurseregarding the psychiatric aspects ofpatient care. (Helps identify weakness)11. Make a list of several interpersonalinteractions that you have experiencedbetween staff to staff, patient to staff,which you feel required an improvementin communication techniques and/ orrequired someone to intervene andfacilitate problem solving.IntroductionPsychiatric emergency? Suicide! Violence!Panic! Though they don’t occur too often,healthcare professionals must be prepared forthese disturbing situations. When a psychiatriccrisis hits, the health team must act quicklyto mitigate a dangerous or life-threateningsituation.Healthcare professionals can be involvedin these situations in the emergency room,general hospital, psychiatric unit and the community. Although nothing can take the place ofactual clinical experience for one to becomemore competent and con dent in handlingpsychiatric emergencies, prior preparationcan help. Health professionals need an understanding of attitudes and reactions, a body ofknowledge, and action approaches in order tomeet the challenge of a crisis situation.Consider these scenarios: An elderly man has recently been dischargedfrom an alcohol detoxification unit. He callsone of the staff on the floor to “thank” heragain and say good-bye. Sounding angryand intoxicated, he adds that he is in aphone booth at the Golden Gate Bridge andas soon as he hangs up, he is going to jump.If you were that nurse, how might you feel?What would you do? Following cardiac surgery, a woman beginsto whisper to her husband that she’s afraidof being cloned in the ICU. She begs himto take her home before the staff destroysher. The husband turns to the nurse, terrifiedthat his wife has lost her mind and will needto be “put away.” If you were that professional, what wouldyou say to him? What would you do forthe woman? The police surround a house where a man isholding his family hostage with an arsenalof guns. He rants, “God will punish thewicked!” The police recruit the man’s priestto encourage him to give up and come to thenearest emergency room for help. You arethe nurse working in the ER. How mightManaging the Psychiatric CrisisPage 3
RIGHTS OF THE MENTAL HEALTH PATIENT The right to be treated as a human being, with decency and respect The right to integrity of mind and body The right to receive treatment and medication only whenadministered with informed consent The right to have access to one’s own legal and medical counsel The right to refuse to work in a mental hospital and to receive theminimum wage for any work done there The right to decent and prompt medical attention The right to uncensored communication by phone or letter and withvisitors The right to refuse to be locked up involuntarily, and to refuse togive fingerprints and photographs The right to decent living conditions The right to keep one’s own personal possessions The right to counsel and a court hearing about any mistreatment The right to refuse to be a part of research for experimental drugsor treatments and the right to refuse to be used as a learningexperience for students The right to protection from defamation of character The right to an alternative to commitment in a mental hospitalyou feel? What would you do? On a psychiatric unit, a woman rips downthe holiday decoration of Santa Claus andis heading right toward the Christmas tree.You are coming in the door at that moment.What will you do now? An elderly man hears that his best friendhas just died. Immediately, his heartbegins to pound and he starts to breatherapidly. Sweat pours off as he feels asense of impending doom. When theambulance brings him to the hospital, he isyelling, “I’m dying! Help!” As the healthprofessional, what would you do to helphim now and after a myocardial infarctionhas been ruled out? A young girl sits in the corner of thewaiting room, eyes wide and frightened.Her friends mention that she’s taken somesort of hallucinogen as they head towardthe exit. What would you do? How couldthey help her? On a surgical floor, a woman is making avery slow recovery from a mastectomy. Theaide tells you that she has refused breakfastagain, saying, “What’s the use?” As theteam leader, what would you do now? Whatdo you need to know?All of the above have the potential to bepsychiatric emergencies. Each emergency generally involves a sudden serious psychologicaldisturbance that affects behavior, with one ormore of the following characteristics: sense of urgency: something must be donePage 4now or very soon, or else . . . and a feeling ofintolerable anxiety if relief is not immediate sense of being overwhelmed lack of adequate coping abilities recognition of a need for assistancefrom others to manage and alleviate thepsychological distressPsychiatric emergency and crisis are oftenused interchangeably. A psychiatric emergencycan be viewed as a sudden, specific behavioralstate that, if not responded to, will result inlife-threatening or psychologically damagingconsequences. A crisis is less immediate inthat it has been developing over time within apsychological stress situation. If not alleviated,a crisis situation may develop into a psychiatricemergency specifically if it leads to acts ofsuicide, violence or severe agitation.Managing the Psychiatric CrisisA mnemonic or code device for remembering the usual patterns of psychiatric emergencyis the phrase, “I’ve had it!” This stands for theelements of:I ImpasseV Victim or ViolenceE EmergencyH Helplessness or HopelessnessA Agitation or ApathyD Despair and DisorganizationI IncapacitationT TerrorAcute subjective distress and/or disturbedbehavior can be alarming to the affected personand others, by any of the following routes:1. The emergency arises while the personis already a hospitalized patient, in eithera general hospital or psychiatric unit.2. The individual comes to an emergencyroom or crisis center or is brought in byfamily, friends or the police.3. The person is referred by a physician,another health professional, or an agencyfor additional evaluation and treatment.4. There is a crisis phone call seeking help,direction and resources.In addition to helping the identified patient,it is important to consider the needs andproblems of the other people involved in thesituation. Family and friends are valuable alliesin assessing the crisis, especially if the patientis unable or unwilling to give information.They are also vital to treatment decisions. Thedecision to hospitalize an acutely disturbed individual, for example, may depend on whetheror not there is a support system network forthe person. Significant others may also becontributing to the emergency situation, andinterventions may need to target them as well.Psychiatric emergencies can be grouped intothe following categories: Life threatening behavior, includingthreatened or attempted suicide, assault,homicide, or other violent acts. Life disrupting behavior, resulting fromsevere anxiety, loss of contact with reality,mood disorders such as depression or mania,self-injurious behavior or conversionreactions. Life impaired behavior, resulting fromintoxication or withdrawal from alcoholor drugs, toxic or idiosyncratic reactions tomedication, or cerebral dysfunction.These groupings cut across many categoriesof psychiatric and medical diagnoses. The National Center of Continuing Education - NurseCE.com
focus in any psychiatric emergency is the immediate problem behavior, and how the personcan regain equilibrium without destructiveoutcome for self or others.Impact on HealthProfessionalsAs health care patterns in the U.S. continueto change, more people are using emergencyrooms and crisis units for help with pressingemotional problems. Part of this is due to theshift in psychiatric care from large state hospitals to community based treatment programs.Fewer patients are kept in psychiatric hospitalsfor any length of time. These people are treatedrapidly and discharged to community facilities for follow-up care. Periods of increasedstress leads to more patients seeking help atthe emergency room for medication, rehospitalization, or other resources, including foodand shelter. It is especially important to addressthese issues with patients and families dealingwith dramatic mental healthcare changes inuncertain times.The emergency room is where the initialpsychiatric evaluation often occurs. Humanbeings have highly complex psychosocialand biological interactions. What seems tobe a primary physical disorder may maskunderlying anxiety or depression. And thesesyndromes may in turn mask or accompanyother conditions that are organic in etiology.It takes skilled assessment and evaluationtechniques to make the differential diagnosis.Physical examination, including appropriatetests and lab work, is often essential.Suicide attempts and threatened suicide areamong the most common psychiatric emergencies seen in nursing situations. Stressorsconnected with illness that may lead to depression and suicide include the threat of surgerywith an unknown outcome, death of a lovedone, agony of chronic pain with little relief,the prospect of chronic illness and incapacitation, and disfigurement from a radical burn oroperation.Suicide ranks among the leading causes ofdeath in the United States, as one of the toppublic health concerns of today. The statisticsgenerally quoted are misleading. Many suicides are not reported or recorded, and othersare listed as alcohol-related accidents. Suicideis considered the tenth leading cause of deathoverall; according to National Center forHealth Statistics, (April 2016), it ranks thirdamong young adults (aged 15 to 24).In addition to treating acutely suicidal patients, professionals also treat patients whoshow chronic patterns of self-destructive behavior. Any behavior that significantly shortensor threatens a person’s lifespan can be con-sidered self-destructive. Included are chronicalcohol and substance abuse, non-suicidalself-injurious behavior, anorexia and bulimia.Patient examples include the daredevil whohas broken almost every bone in his body,the person with emphysema who refuses toquit smoking, and the person with an MI whoinsists on going right back to work.A suicide attempt may result in a series ofdifficult and painful long-term disabilities,such as the person who swallows pills andneeds extensive medical/surgical treatmentor the person who sets herself on re and lives,despite third-degree burns. Psychiatric emergency states may occur in the family membersof a person who dies, especially if the deathis sudden, particularly horrible or by suicide.The family and significant others need the opportunity to talk and express their grief, anger,bewilderment and sometimes relief. They mayneed temporary medication for sedation.Other health professionals may be involvedwith psychiatric emergencies that occurwithin families. Stillbirth or delivery of aninfant with a congenital defect may bring onoverwhelming anxiety and depression, but theextreme reaction called postpartum psychosiscan sometimes be precipitated even by normalchildbirth. Acute or chronic illness in a childmay develop into a crisis for the family as wellas for the young patient.Health education and recognition and treatment of depression and drug/alcohol abuseare important parts of school nursing jobs.Death, illness, or separation and divorce ofparents can have a very significant impact ongrowing children. They may turn to the nursein times of crisis.Large numbers of previously hospitalizedpsychiatric patients are discharged to the community after the treatment of the psychiatricemergency. Follow-up care is usually needed,and the public health nurse or communitymental health nurse then becomes responsiblefor providing care to this group of individuals.The number and severity of the psychosocialstressors in the individual’s environmentinfluence change in acuity level. These former patients are a population at high risk forcatastrophic reactions to increased stress. Theymay develop acute psychosis, depression and/or suicidal and violent behavior. Crisis intervention and the patients’ successful return tothe community are the goals of communityhealth care workers.Another group at risk for psychiatric emergencies is the elderly. Faced with loneliness,death of loved ones, increasing disabilityand /or financial pressures, they begin to feeldepressed and overwhelmed. Deteriorationof emotional and social support systems iscommon. Declining memory and cognitive National Center of Continuing Education - NurseCE.comabilities due to dementia may lead to confusion, reduced problem solving ability, and lesseffective use of previously acquired copingskills. Professionals in long-term care facilitiesand home health settings are often uniquelypositioned to recognize and address crises inthese patients.Nurses are considered by many peopleas authorities on health issues; families andfriends often seek their advice and support.However, nurses often face crisis situations intheir personal and professional lives.When this occurs, it is important to seek appropriate help, even if it is difficult to do so.A sizable number of healthcare professionalsabuse drugs and alcohol. Some even resortto suicide. The suicide potential of a personshould never be underestimated because ofeducation or profession.It is the skilled and properly educated professional who will be asked to provide psychiatricemergency care to those individuals in need.The present and future of healthcare practicerequire that all be prepared to administersafe and competent psychiatric care to thosewho need it. Skills in assessment, diagnosis,intervention, treatment, and evaluation ofpsychiatric emergencies are demanded in allareas of professional practice. An astute personrealizes that a psychiatric emergency may occur anywhere and at any time.Reactions toPsychiatricEmergenciesAnxiety is a common denominator in psychiatric emergencies. Anxiety is often referredto as the fear of the unknown. This fear iscertainly a very natural response to a psychiatric emergency and affects everyone involved- the patient, family and staff. Anxiety itself iscontagious. Persons who are in tenuous controlover impulses to hurt themselves or others canbe very frightening. This is especially true inan emergency room where the patient is oftena stranger and the staff has little informationimmediately available on which to base atreatment plan.If the disturbed behavior occurs on a generalhospital unit, the staff may feel inadequateand overwhelmed by uncertainty. They mayfeel angry toward the person or family forcausing “a scene” and taking them away fromother patients who are acutely physically ill.Generally, if the behavior of such people isidentified as coming from an organic disease,it is easier understood and tolerated. If it seemsthat the patient should have more control overthe confused, belligerent, peculiar or depressedbehavior, the staff may be more critical, evenjudgmental.Managing the Psychiatric CrisisPage 5
On a psychiatric inpatient unit or in a crisiscenter, the staff may be better able to take episodes of disturbed behavior in stride. However,the usual emphasis in that setting is on assessment, intervention and provision of adequatetreatment so that psychiatric emergenciesdon’t arise. When they do, the staff may feelguilty or angry with each other. They mayfeel they have failed. This is particularly truewith suicidal behavior, especially if a patientin treatment attempts suicide. Patients whopresent recurrent emergencies may cause thestaff to become frustrated, angry and rejectingof them. This generally stems from the staff’sfeelings of helplessness and inadequacy. Theyhave done all they know to do and it has notworked or has not been effective.Recurrent episodes of physical and psychiatric emergencies are often due to alcohol anddrug use, and the patients sometimes encountera negative attitude in treatment settings. Thereis the feeling that these patients “did it to themselves” and “deserve to suffer” to “teach thema lesson.” Because health personnel put a highpremium on health and recovery, they can findit difficult at times to cope with people leadinghighly self-destructive lives. They may feela sense of social injustice, pity, fear or angertoward these patients.These are all very human reactions and weneed to recognize and deal with them whenthey occur. Increased understanding of thepatient may help, along with awareness ofwhat can and can’t be done in the on-goingsituation. The important thing to keep in mindis that the patient and family come for somesort of help and the staff must be physicallyand emotionally able to provide it.If a given agency or staff is not equippedto offer appropriate services, the professionalobligation is to work out the best possiblealternative plan. There are usually severalresources available. A characteristic of a crisissituation is that those involved see few optionsor alternatives. Anxiety places “emotionalblinders” on an individual and interferes withproblem solving. The crisis worker, whether anurse or other staff member, helps by providingobjectivity and support, and by developing andreinforcing good coping strategies.A professional who is responsible for thecare of a patient in a psychiatric emergencyattempts to understand how the patient feelsat the time of the crisis. Professionals must beaware tha
psychiatric emergency? 5. What’s the most memorable dramatization of a psychiatric emergency that you’ve seen on TV, in the movies, in a play or read about in a book or newspaper? 6. What’s the difference in your reactions to a crisis situation at work and in your personal life?
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