•

o Career Tips
o Career Opportunities/Classifieds
o Travel Company Profiles
o Travel Opportunities
•

o Accreditation Information
o CE Library
o Questions
•

o Clinical Highlights
o Clinical Tips
o Continuing Education
o Drug Update
o Hands-on Help
o Innovations in Practice
o Patient Handouts
o Related Links
o Urology
•

o Advice of Counsel
o Career Compass
o Career Options
o Conference Planner
o Ethics in Action
o Features
o Image Makers
o Legal Q&A
o Management Help Line
o Nurse Biz
o Nurses in the News
o Professional Update
o Related Links
o Travel Nursing Today
•

o Break Room
o Community Watch
o Destinations
o Escapes
o Financial Facts
o Fitness
 o Foodstuffs
o Real Deals
o RN MySpace
•

o From the Editors

o Mail Box
o Nursing Lite
o Question of the Month
o Reflections on Caring
•

o Article Indices
o Current Issue
o Previous Issues
o Travel Nursing Today
•

o Advertise With Us
o Author Guidelines
o Customer Service
o Editorial Staff
o Lists & Reprints
o Mission and Vision
o Publishing Staff

Question "But I'm not a psych nurse!"

of the Publish date: Dec 1, 2006
Month By: Melinda Stanley Hermanns, RN, MSN, Carol Ann
Russell-Broaddus, RN, MSN • Mod

Free E- Source: RN ernMedicine

What
Newsletter • Reco
difficulti
mmended Sites
es do
you
foresee Email|Print|
in Share
impleme
nting • Del.icio.us RSS feeds for
electron this site
• Digg
ic health
• Reddit
records
? • Facebook
Customized
|Save|License Patient
Education
RN/AHC Media Home Study
Handouts
RN's Program
 free CE CENTER
monthly
newslett
CE credit is no longer available for this article. (Expired Clinical
er Resources
Subscrib December 2008) powered by
Mediwire
e Now!

Check
out past Originally posted December 2006
issues
Web By MELINDA STANLEY HERMANNS, RN, MSN, and
Poll CAROL ANN RUSSELL-BROADDUS, RN,
MSN
SEARCH:
MELINDA STANLEY HERMANNS and CAROL ANN RUSSELL-
BROADDUS are members of the mental health faculty of
the College of Nursing and Health Sciences as the
GO
University of Texas at Tyler. The authors have no
Has the financial relationships to disclose.
View All
econom
You didn't choose psych nursing as your specialty, but Topics
ic
slowdo you still need to know some basics when caring for
wn had patients with mental disorders.
any
direct Accompanied by his wife, a patient we'll call Francis Carlin,
effect 43, is admitted to your unit with an exacerbation of chronic
on your obstructive pulmonary disease (COPD). While you're
salary? obtaining the patient's admission history, Mrs. Carlin
mentions that her husband is supposed to take risperidone
Yes (Risperdal) for schizophrenia but hasn't been taking it
consistently.
No
During the assessment, you observe that the patient's
breathing is labored and he's coughing up copious amounts of
Ye 61 yellowish-green sputum. His pulse oximeter reading is
s % dipping below 87%; the cardiac monitor shows a heart rate of
N 39 118 beats per minute.
o %
Thank You report your findings to the hospitalist, who orders
you for oxygen by nasal cannula at 1.5 L/min, an arterial blood gas
participa test, sputum culture, and a host of other laboratory tests.
ting in While you're applying the cannula, Mr. Carlin begins flailing
our poll. his arms. "The bats are attacking me," he yells. "Hey, look
out. They're after you, too!"

Though you're trying to remain calm, an uneasy feeling takes

 Subscribe
to our sister
hold. You need to figure out how to best care for this patient;
nursinginstead, you're shaking your head and thinking, "But I'm not a
publications
psych nurse!"

No matter. Regardless of where you practice, the chances are

Get a great that you'll encounter patients who are mentally as well
FREE as physically ill. Recent studies have shown that more than
subscrip ever, mentally ill patients are seeking treatment in acute care
tion to: hospitals, where many clinicians have minimal training in
psychiatric care.1 The latest national statistics indicate that
EDs in 2002 saw more than 2 million people whose principal
complaints were attributable to psychological disorders. 2, 3

No longer solely the domain of psychiatric institutions,

patients with disorders such as depression, suicidal ideation,
uncontrolled anger, and delusions are now cared for on
med/surg units, in ICUs, and in extended-care facilities,
clinics, and other outpatient settings. Acknowledging this
Healthc trend is the first step toward providing the additional care
are these patients require.
Travele
r Is the illness physical or mental?

Determining whether your patient's psychotic symptoms are

caused by a mental or physical problem—or both—can be
tricky. That makes a thorough assessment all the more
important, because many physiological diseases can mimic
psychiatric disorders. In Mr. Carlin's case, of course, your
immediate thought is that his behavior is a result of not taking
his risperidone consistently. But other factors could also be at
play. For example, hypoxia could be responsible for his
delusional mental state, or he may have developed a new
problem, such as a brain tumor, which could be causing his
aggression and psychosis.

Consider, too, that the patient might be having an adverse

reaction to a medication he's taking. So, as you perform an
assessment, find out about any prescription medications he's
on. A wide range of prescription drugs are associated with
acute brain syndrome, or delirium. This condition is
characterized by a fluctuating clouding of consciousness,
restlessness, and emotional changes such as fear and
perplexity. Paranoid delusions or visual hallucinations may
occur in severe cases. 4
The list of drugs that can produce delirium or other
behavioral or emotional problems is long and includes:
psychotropics, anticholinergics, steroids, antihistamines, anti-
arrhythmics, beta-adrenergic blockers, and more. Anxiolytics
and hypnotics can also produce confusion, particularly in the
elderly.5

Don't forget to inquire about over-the-counter drugs, herbs,

and vitamins, some of which can cause adverse reactions.
Herbals like St. John's wort, ephedra, ginseng, kava kava, and
yohimbine can interact with psychotropics and other
medications or cause agitation, anxiety, or drowsiness.6
Remember to ask about sleep disturbances, which may
indicate or exacerbate a mental disorder. And, of course,
inquire about alcohol and illicit drug use.7

You've got questions, but will the patient open up?

Obtaining information from patients with mental illness can

be especially difficult, because they may be reluctant or
unable to report or describe their symptoms.5 Some patients
somaticize their mental symptoms, insisting they have a
physical illness even though tests can detect none.5,8 Others
may be apathetic, withdrawn, mistrustful, or simply confused.

To get patients to open up to you about what they're

experiencing, it helps to build trust right away. Remain calm
and unhurried, and demonstrate genuine acceptance of the
patient. Adopt an informal interviewing approach, even if
you're using a standardized assessment tool, like the Mini-
Mental Status Exam.7,9 Ask questions in a way that will allow
the patient to express his thoughts and feelings, rather than
simply responding Yes or No. For example, begin with, "Tell
me why you are here." Promote further discussion with, "Tell
me more."6

Ask the patient—or a family member if the patient is unable

to respond coherently—about his current problem, or what
brought him to the hospital.

This nonjudgmental approach is essential, particularly with

patients who are substance abusers, as they may be evasive.
You might ask, for example: "With all the stress in your life, I
wonder if you've been drinking more lately?"
Eye contact may help establish rapport, but you'll have to
break it if you see the patient becoming uncomfortable.

Bear in mind that a chronic physical illness—like COPD—

may be a risk factor for suicide attempts. A patient may not
readily admit that he has thought about killing himself. Still,
encourage patients to begin talking about such feelings by
asking, "How would you describe your mood lately?"5 Then
ask them directly, "Do you feel like hurting yourself?" (For
more on how to determine if a patient is suicidal, see "Could
your patient be at risk for suicide?" below.)

If a patient becomes agitated, don't turn your back on him.

Talk softly and ask about any needs he might have. Although
you want the patient to express his feelings, you'll need to cut
him short if his agitation increases, posing a clear danger to
you or to others.10 Call in security, according to your facility's
protocol.

Safety issues beyond the ED

Safety remains a concern when a patient with the potential to

become dangerous is admitted to your floor. Be sure to create
a quiet environment with as little stimulation as possible. It
may be best to place the patient in a private room close to the
nurses' station so you can keep an eye on him. Remove any
items that could be used as weapons, such as belts, ties,
shoelaces, razors, or plastic bags. 7

Request that the patient have only one nurse per shift. This
will help him develop a sense of trust, and his nurse can take
note of what helps the patient and what disturbs him.

Maintaining structure and familiarity in the patient's

environment is critical, as is frequent reality orientation. For
example, you would tell Mr. Carlin, "I understand that you
see bats. I know this is real to you, but I don't see any bats."

Clear messages and complete honesty are essential.7 If the

patient responds to you but you don't understand what he's
saying, let him know. If he starts hallucinating, get him to talk
about the visions by asking, "What are you experiencing?"

Medication is a must for psych patients

For his own safety, you may need to give your patient a
quick-acting antipsychotic such as ziprasidone (Geodon),
administered IM to control agitated behavior and psychotic
symptoms in patients with acute schizophrenia
exacerbations.11

Once he's stabilized, you'll need to help him get back on his
medication regimen. Medication compliance is frequently an
issue in mental illness, as it was for Mr. Carlin. A psych
consult should be ordered.

Once his medication regimen is re-established, observe for

therapeutic effects of his drugs and monitor for adverse
effects. Some antipsychotic drugs may produce side effects
like akathisia, a restlessness and inability to sit still; akinesia,
difficulty or absence of movement; and pseudoparkinsonism,
with tremors, drooling, shuffling gait, muscle rigidity, and
loss of facial expression. (For more information on
psychotropic drug therapy, see "Drug Watch 2006:
Psychotropics" in the July issue of RN.)

Share your knowledge and observations with the patient and

his family. Explain the purpose and benefits of the drug, and
the side effects that the patient might experience once he's
back home. Emphasize with patients like Mr. Carlin that their
mental status will improve when they take their antipsychotic
medication consistently. Teach them that a drug like
risperidone can't be stopped abruptly. And don't forget to
allow time for the patient and family to ask questions.

Because of Mr. Carlin's history of noncompliance, the

physician changed the patient's antipsychotic to Risperdal
Consta, a long- acting form of risperidone that's given
intramuscularly once every two weeks. Before going home,
he's given a dose.

Discharge planning for patients like Mr. Carlin should

include not only drug compliance, but also follow-up care
with a psychiatrist or psychiatric nurse practitioner and social
worker, and follow-up with a medical doctor.

In Mr. Carlin's case, you recognize that he's at risk for another
exacerbation of his COPD. So you teach him and his wife to
prevent it where possible by keeping up with pneumonia and
flu vaccines. Teach them that if he does become short of
breath or spikes a temperature, they will need to call the
physician right away. You also explain that his medical
workup showed no reason, other than the schizophrenia, for
his hallucinations.

As you would for any patient, provide a written copy of what

you discussed during discharge planning, as well as his
physicians' phone numbers. You could refer Mr. Carlin to
Assertive Community Treatment (ACT). Through this
program, available across the United States, a team of
professionals trained in social work, rehabilitation,
counseling, nursing, and psychiatry makes visits to administer
and monitor psychiatric meds. The Carlins may choose go to
an ACT office, instead.12 For more information on ACT, go to
www.actassociation.org, or phone ACT at (810) 227-1859.

It's understandable that you'll experience some anxiety when

caring for psychiatric patients if you're not a psychiatric
nurse. But even though you may not have chosen psychiatric
nursing as your specialty, every patient deserves a nurse who
knows how to address his psychosocial needs.

Could your patient be at risk for suicide?

Beginning in January, healthcare facilities accredited by

JCAHO will be required to identify patients at risk for suicide
as part of the organization's 2007 National Patient Safety
Goals. The regulation applies not only to psychiatric
hospitals, but also to general hospitals that treat patients for
emotional or behavioral disorders. So if you encounter a
patient who's at risk for suicide, you'll need to assess for
suicidal ideation.

Actively listen to your patient, paying close attention to both

his verbal and nonverbal cues. Pay particular attention to
overt statements like, "I don't want to take my medication; it's
not going to help me. It doesn't matter anyway because I'm
not going to be around too much longer." A covert clue might
be, "I'm OK, and everything will be fine."

Take your patient's statements seriously. Directly ask him,

"Are you having any thoughts of suicide?" and "Do you have
a plan for committing suicide?" Remember, the suicidal
patient is often crying for help, so don't be afraid to pose
these questions. If the patient is suicidal, provide the
necessary nursing interventions. For example, request that a
staff member be designated to provide one-on-one
supervision.

Be particularly alert for suicidal tendencies if you care for

patients with the following risk factors for suicidal behavior:
unemployment, being unmarried, previous suicide attempts,
substance abuse, and affective disorders.

Since this is the holiday season, the following is worthy of

mention: Despite a commonly held myth that the Christmas
season has the highest suicide rate, studies have shown that
across North America, suicide rates are actually lower at this
time of year.

Sources: 1. Joint Commission on Accreditation of Healthcare

Organizations. "2007 National Patient Safety Goals." 2006.
www.jointcommission.org/PatientSafety/NationalPatientSafet
yGoals/07_hap_cah_npsgs.htm (22 Sept. 2006). 2. Dhossche,
D. M. "Suicidal behavior in psychiatric emergency room
patients." 2000. www.medscape.com/viewarticle/410512 (30
Sept. 2006). 3. Canadian Mental Health Association. "Suicide
statistics." 2006. www.ontario.cmha.ca/fact_sheets.asp?
cID=3965 (21 Sept. 2006).

REFERENCES
1. Hodges, B., Inch, C., & Silver, I. (2001). Improving the psychiatric knowledge, skills, and
attitudes of primary care physicians, 1950 — 2000: A review. Am J Psychiatry, 158(10), 1579.

2. Stefan, S. "Emergency department assessment of psychiatric patients: Reducing inappropriate

inpatient admissions." 2006. www.medscape.com/viewprogram/5768 (20 Sept. 2006).

3. McCaig, L. F., & Burt, C. W. "National hospital ambulatory medical care survey: 2002
emergency department summary." 2004. www.cdc.gov/nchs/data/ad/ad340.pdf (22 Sep. 2006).

4. Adverse Psychiatric Reactions Information Link. "Adverse psychiatric reactions to prescribed

drugs." 2006. www.april.org.uk/pages/iatrogenic_disease.html (20 Sept. 2006.)

5. Davis, B. "Assessing adults with mental disorders in primary care." 2004.

http://findarticles.com/p/articles/mi_qa3958/is_200405/ai_n9443447 (18 Sept. 2006).

6. Pedersen, D. D. (2005). Psych notes. Philadelphia: F. A. Davis Co.

7. Varcarolis, E. M. (2006). Foundations of psychiatric mental health nursing (5th ed.).

Philadelphia: W. B. Saunders Co.

8. Rost, K., & Barsky, A. J. "Recognizing and managing somatizing patients in primary care."
2006. www.medscape.com/viewprogram/5932 (18 Sept. 2006).
9. eMedicineHealth. "Mini-mental status exam." www.emedicinehealth.com/etools/mini-mental-
status-exam.asp (16 Oct. 2006).

10. Citrome, L. "Current treatments of agitation and aggression." 2002.

www.medscape.com/viewprogram/1866 (18 Sept. 2006).

11. Karch, A. M. (2006). Lippincott's nursing drug guide. Philadelphia: Lippincott Williams &
Wilkins.

12. Assertive Community Treatment Association. "ACT model." 2006.

www.actassociation.org/actModel (26 Sept. 2006).

About the Author

Melinda Stanley Hermanns, RN, MSN

MELISSA STANLEY HERMANNS is a member of the

mental health faculty of the College of Nursing and Health
Sciences at the University of Texas at Tyler. The author has
no financial relationship to disclose. Articles by Melinda
Stanley Hermanns, RN, MSN
Carol Ann Russell-Broaddus, RN, MSN

CAROL ANN RUSSELL-BROADDUS is a member of the

mental health faculty of the College of Nursing and Healtha
Scienes at the University of TExas at Tyler. The author has
no financial relationships to disclose. Articles by Carol Ann
Russell-Broaddus, RN, MSN

Rate this article

Low 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 High
Other Articles from RN

CE: House calls

CE: Battle plan for brain attacks

CE: Treating morbid obesity

CE: Circumcision care

CE: Nerve pain

post a comment
Please complete the form below to post your comment.
Bold = Required Your email
Email
address will NOT
Address
be published.
Display appears with your
Name comment
City
State
Country

Remember me: Yes No

Comment read our privacy policy

Note: does not support HTML

All comments submitted are subject to review, and may be
delayed before posting. We reserve the right not to post
comments.

Home | About RN | Contact RN | Associated Publications | Advertise

With Us | Site Index | RN Content | Modern Medicine Nursing | Travel
Nursing Tips | Privacy Policy | Terms of Use | Linking and RSS Policy
© 2009 Advanstar Communications, Inc. All rights reserved.
Reproduction in whole or in part is prohibited.
Please send any technical comments or questions to our webmaster.