MAMATA COLLEGE OF NURSING

KHAMMAM
Date:
Time:
SUBJECT: CLINICAL SPECIALTY PSYCHIATRY- II
TOPIC : PSYCHIATRIC EMERGENCIES
GUIDE: MRS.ASHA KUMARI
ASST. PROFESSOR
PRESENTED BY: UDAYA SREE.G
M.Sc. (N) II YEAR

MASTER PLAN ON PSYCHIATRIC EMERGENCIES

INTRODUCTION
Psychiatric emergencies are the conditions wherein the patient needs immediate
intervention to safeguard the life of the patient, bring down the anxiety of the family
members and enhance emotional security to others in the environment. It may be resulting
from either psychiatric disorders or due to medical conditions related to environment. For
example, natural disasters or manmade disasters. It is the combination of circumstances
which needs immediate attention.

DEFINITION
A condition in which the client will have disturbance in thought, affect and psychomotor
activity that leads to threat either to himself or his existence. Example suicide-threat to
people in the environment, homicide- which need immediate attention and care.
-R.Sreevani

A sudden onset of an unusual, disordered inappropriate behavior caused by an

emotional and physiological situation
-Bimla Kapoor, 2002

It is a stress induced pathologic response, which physically endangers the affected

individual, disrupts the functional equilibrium of the individual and his environment.

COMMON PSYCHIATRIC EMERGENCIES

 Suicidal attempt and committing suicide
 Violent, aggressive behavior and excitement
 Panic attacks
 Catatonic stupor
 Hysterical attacks
 Transient situational disturbances
Organic psychiatric emergencies are
 Delirium tremens
 Epileptic furor
 Acute drug induced extra pyramidal syndrome
 Drug toxicity

OBJECTIVES OF PSYCHIATRIC EMERGENCY INTERVENTION

 To safeguard the life of patient
 To reduce the anxiety
 To promote emotional security of client and the family members
 To educate the client and his family members the way of dealing emergency situation
by utilizing adaptive coping strategies and appropriate problem solving technique
client

CHARACTERISTICS OF PSYCHIATRIC EMERGENCIES

Certain conditions or stressors predisposes the client and his family members to
seek immediate intervention, as they feel more discomfort
Disharmony between client and his environment
Sudden, unexpected, disorganization in person
Unable to cope up with the stressful situation or failure in handling the stressors.

ASSESSMENT
Immediate assessment
 The client behavior and how the client is brought to hospital
 The physical environment and its safety
 Availability of trained persons
 Mental status examination
 Search for availability of instruments and collect it
 Identify the stressors which predisposing the events
 Level of adjustments or coping abilities prior to the problem
 Main complaints of present illness
 H/O any psychiatric illness
 Thorough physical examination has to be conducted to exclude physical illness
 Assist for laboratory investigations

Management of psychiatric emergencies

Nurses have to assume overall in charge for interventions and seeks guidance from the
psychiatrist whenever necessary
 Handle the cases tactfully
 Provide calm and watchful environment
  Emergency cases has to be shifted as early as possible where he will be safeguarded
against injury either to himself or to the others
 Clients disturbed mood will disturb the other clients, hence immediately nurses has
to shift them to the calm areas with adequate safety and supervision
 Provision of care in meeting the client’s needs accordingly.

SUICIDAL THREAT
In psychiatry a suicidal attempt is considered to be one of the commonest emergencies.
Suicide is a type of deliberate self- harm and is defined as an intentional human act of killing
oneself.

Etiology
Psychiatry disorders
Major depression
Schizophrenia
Drug or alcohol abuse
Dementia
Delirium
Personality disorder

Physical disorders
Patient with incurable or painful physical disorders like, cancer and AIDS

Psychosocial factors
 Failure in examination
 Dowry difficulties
 Marital difficulties
 Loss of loved object
 Isolation and alienation from social groups
 Financial and occupational difficulties

Risk factors for suicide

Age
 Males above 40 years of age
 Female above 55 years of age

Sex
 Men greater risk of completed suicide
 Suicide is 3 times more common in men than in women
 Women have higher rate of attempted suicide
Being unmarried, divorced, windowed or separated
Having a definite suicidal plan
History of previous suicidal attempts
Recent losses

MANAGEMENT
Be aware of certain signs which may indicate that the individual may commit suicide, such
as
 Suicidal threat
 Writing farewell letters
 Giving away treasured articles
 Making a will
 Closing bank accounts
 Appearing peaceful and happy after a period of depression
 Refusing to eat or drink, maintain personal hygiene

Monitoring the patient’s safety needs

Take all suicidal threats or attempts seriously and notify psychiatrist
Search for toxic agents such as drugs/ alcohol
Do not leave the drug tray within reach of the patient, make sure that the daily
medication is swallowed
Remove sharp instruments such as razor blades, knives, glass bottles from his
environment
Remove straps and clothing such as belts, neckties
Do not allow the patient to bolt his door on the inside, make sure that somebody
accompanies him to the bathroom
Patient should be kept in constant observation and should never be left alone
Have good vigilance especially during morning hours
Spend time with him, talk to him, and allow him to ventilate his feelings
Encourage him to talk about his suicidal plans/ methods
If suicidal tendencies are very severe, sedation should be given as prescribed

Encourage verbal communication of suicidal ideas as well as his/ her fear and depressive
thoughts. A no suicidal pact may be signed, which is a written agreement between the
client and the nurse, that client will not act on suicidal impulses, but will approach the nurse
to talk about them.

Enhance self –esteem of the person by focusing on his strengths rather than weakness. His
positive qualities should be empathized with realistic praise and appreciation. This fosters a
sense of self-worth and enables him to take control of his life situation
VIOLENT OR AGGRESSIVE BEHAVIOR OR EXCITEMENT
This is severe form of aggressiveness. During t his stage, patient will be irrational,
uncooperative, delusional and assaultive.

Etiology
 Organic psychiatric disorders like, delirium, dementia, wernicke-Korsakoff’s psychosis
 Other psychiatric disorders like schizophrenia, mania, agitate depression, withdrawal
from alcohol and drugs, epilepsy, acute stress reaction, panic disorder and
personality disorders.

Management
 An excited patient is usually brought tied up with a rope or in chains. The first step
should be to remove the chains. A large proportion of aggression and violence is due
to the patient feeling humiliated at being tied up in this manner.
 Talk to the patient and see if he responds. Firm and kind approach by the nurse is
essential.
 Usually sedation is given. Common drugs used are: diazepam 10- 20 mg, IV;
haloperidol 10-20 mg; chlorpromazine 50-100mg IM.
 Once the patient is sedated, take careful history from relatives; rule out the
possibility of organic pathology. In particular check for history of convulsions, fever,
recent intake of alcohol, fluctuations of consciousness.
 Carry out complete physical examination
 Send blood specimens for hemoglobin, total cell count ect.
 Look for evidence of dehydration and malnutrition. If there is severe dehydration,
glucose saline drip may be started.
 Have less furniture in the room and remove sharp instruments, ropes, glass items,
ties, strings, match boxes, ect. From patient’s vicinity.
 Keep environmental stimuli, such as lighting and noise levels to a minimum; assign a
single room; limit interaction with others possibility of an accident.
 Stay with the patient as hyperactivity increases to reduce anxiety level and foster a
feeling of security.
 Redirect violent behavior with physical outlets such as exercise, outdoor activities
 Encourage the patient to talk out his aggressive feelings, rather than acting them out.
 If the patient is not calmed by talking down and refuses medication, restrains may
become necessary
 Following application of restraints, observe patient every 15 minutes to ensure that
nutritional and elimination needs are met. Also observe for any numbness, tingling or
cyanosis in the extremities. It is important to choose the least restrictive alternative
as far as possible for these patients.
 Guidelines for self-protection when handling an aggressive patient
 Never see a potentially violent person alone
  Keep a comfortable distance away from the patient ( arm length)
 Be prepared to move, a violent patient can strike out suddenly
 Maintain a clear exit route for both the staff and patient.
 Be sure that the patient has no weapons in his possession before approaching him.
 If patient is having a weapon asks him to keep it on a table or floor rather than
fighting with him to take it away.
 Keep something like a pillow, mattress or blanket wrapped around arm between you
and the weapon
 Distract the patient momentarily to remove the weapon ( throwing water in the
patient’s face, yelling ect.)
 Give prescribed antipsychotic medications

PANIC ATTACKS
Episodes of acute anxiety and panic can occur as a part of psychotic or neurotic
illness.
The patient will experience palpations, sweating, tremors, feeling of choking, chest pain,
nausea, abdominal distress and fear of dying, paresthesias, chills or hot flushes.

Management
 Give assurance first
 Search for causes
 Diazepam 10 mg or lorazepam 2 mg may be administered.

CATATONIC STUPOR
Stupor is a clinical syndrome of akinesis and mutism but with relative preservation of
conscious awareness. Stupor is often associated with catatonic signs and symptoms
(catatonic withdrawal or catatonic stupor). The various catatonic signs include mutism,
negativism, stupor, ambitendency, echolalia, echopraxia, automatic obedience, posturing,
mannerisms, stereotypes, ect.

Management
o Ensure patent airway
o Administer IV fluids
o Collect history and perform physical examination
o Draw blood for investigations before starting any treatment.
o Other care is same as that for an unconscious patient.
HYSTERICAL ATTACKS
A hysteric may mimic abnormality of any function, which is under voluntary control. The
common modes of presentation may be
Hysterical fits
Hysterical ataxia
Hysterical paraplegia
All presentations are marked by a dramatic quality and sadness of mood

Management
 Hysterical fit must be distinguished from genuine fits
 As hysterical symptoms can cause panic among relatives, explain to the relatives the
psychological nature of symptoms. Reassure that no harm would come to the patient
 Help the patient to realize the meaning of symptoms, and help him find alternative
ways of coping with stress
 Suggestion therapy with IV Pentothal may be helpful in some cases

TRANSIENT SITUATIONAL DISTURBANCES

These are characterized by disturbed feelings and behavior occurring due to overwhelming
external stimuli

Management
 Reassurance
 Mild sedation if necessary
 Allowing the patient to ventilate his/ her feelings
 Counseling by an understanding professionals

ORGANIC PSYCHIATRIC EMERGENCIES

DELIRIUM TREMENS
Delirium tremens is an acute condition resulting from withdrawal of alcohol

Management
Keep the patient in a quiet and safe environment
Sedation is usually given with diazepam 10mg or lorazepam 4mg IV, followed by oral
administration
Maintain fluid and electrolyte balance
Reassure patient and family
EPILEPTIC FUROR
Following epileptic attack patient may behave in a strange manner and becomes excited
and violent.

Management
 Sedation : diazepam 10mg IV or inj. Luminal 10mg IV followed by oral
anticonvulsants
 Haloperidol 10mg IV help to reduce psychotic behavior

ACUTE DRUG INDUCED EXTRA PYRAMIDAL SYNDROME

Antipsychotics can cause a variety of movement related side effects, collectively known as
extra pyramidal syndrome (EPS). Neuroleptic malignant syndrome is rare but most serious
of these symptoms and occurs in a small minority of patients taking Neuroleptic, especially
high potency compounds.

Management
The drug should be stopped immediately. Treatment is symptomatic and includes cooling
the patient, maintaining fluid and electrolyte balance and treating inter current infections.
Diazepam can be used for muscle stiffness. Dantrolene, a drug used to treat malignant
hyperthermia, bromocriptine, amantadine and L- dopa have been used

DRUG TOXICITY
Drug over- dosage may be accidental or suicidal. In either case all attempts must be
made to find out the drug consumed. A detailed history should be collected and
symptomatic treatment instituted.
A common case of drug poisoning is lithium toxicity. The symptoms include drowsiness,
vomiting, abdominal pain, confusion, blurred vision, acute circulatory failure, stupor and
coma, generalized convulsions, oliguria and death.
Management
 Administer Oxygen
 Start IV line
 Assess for cardiac arrhythmias
 Refer for heamodialysis
 Administer anticonvulsants.
SUMMARY
Psychiatric emergencies are the conditions wherein the patient needs immediate
intervention to safeguard the life of the patient, bring down the anxiety of the family
members and enhance emotional security to others in the environment. It may be resulting
from either psychiatric disorders or due to medical conditions related to environment. For
example, natural disasters or manmade disasters.

BIBLIOGRAPHY
KP. Neeraja. Essentials of mental health and psychiatric nursing, Volume-1 ; Jayapee
brothers publication, 2008

Bimla Kapoor. Psychiatric nursing, Volume-2, Pearsons publications, 2005

Sreevani. Psychiatric nursing, Volume-1, Suresh Kumar publications 2004

Mary C. Townson. Psychiatric and mental health nursing, Jayapee brothers

publications, 2009

Madhavi K. Essentials of mental health and psychiatric nursing for nurses, Vijams
series publications, 2009
 MAMATA COLLEGE OF NURSING
KHAMMAM

Date:
Time:
SUBJECT: CLINICAL SPECIALTY PSYCHIATRY- II
TOPIC : PSYCHIATRIC EMERGENCIES
GUIDE: MRS.ASHA KUMARI
ASST. PROFESSOR
PRESENTED BY: UDAYA SREE.G
M.Sc. (N) II YEAR

MASTER PLAN ON PSYCHIATRIC EMERGENCIES

I. Introduction
II. Definition
III. Common types of emergencies
IV. Objectives of interventions
V. Characteristics of interventions
VI. Assessment
VII. Management
 Suicidal attempt and committing suicide
 Violent, aggressive behavior and excitement
 Panic attacks
 Catatonic stupor
 Hysterical attacks
 Transient situational disturbances

VIII. Organic psychiatric emergencies are

 Delirium tremens
 Epileptic furor
 Acute drug induced extra pyramidal syndrome
 Drug toxicity

IX. Summary
X. Bibliography