Know conditions that threaten psych patients
A man walks into your ED screaming and thrashing around, and he says that he hears voices. Would you assume the patient is mentally ill?
Your answer could potentially save this patient’s life, says Carol A. Ziolo, RN, LCPC, a mental health liaison specialist for the ED at Northwest Community Hospital in Arlington Heights, IL. "The patient may be in alcohol or benzodiazapine withdrawal, which can be fatal and requires close monitoring," she explains.
Since many psychiatric patients come back repeatedly with the same complaint, there is a risk of becoming complacent, adds Heather Freiheit, RN, BSN, EMT-P, clinical manager for emergency services at Rogue Valley Medical Center in Medford, OR. "This population often has nowhere else to go for care," she says. "It is not uncommon for staff to refer to these patients as frequent fliers’ due to their regularity of visits to the ED."
If you perform a cursory triage or incomplete assessment on these patients, you may miss a legitimate, underlying medical complaint, she warns. To improve assessment of psychiatric patients, you can do the following:
- Have psychiatric nurses assess patients.
After ED psychiatric patients are medically cleared, an inpatient nurse from Rogue Valley’s behavioral health unit comes down to perform a thorough assessment. "We know that ED nurses did not go into emergency nursing to perform long, complex psychosocial assessments, and realized the inpatient psychiatric nurses were not comfortable in looking for acute medical complaints," says Freiheit. The following steps occur when a psychiatric patient comes to the ED:
- The patient initially is triaged by an ED nurse and then evaluated by the ED charge nurse. "This way, another experienced ED nurse is evaluating for any underlying medical issues," says Freiheit. "Also, this second evaluation made our physicians feel more comfortable with an inpatient psychiatric nurse caring for these patients."
- The ED physician performs the medical exam and orders tests as needed, with repeat vitals done on any patient with abnormal vital signs.
- The triage nurse and the charge nurse ask the patient if they have intentionally overdosed on any medications. If the answer is yes, that patient is evaluated by an ED nurse.
- If the patient is medically cleared by the ED nurse and physician, the psychiatric nurse comes to the ED and performs an assessment. "If at any time the psychiatric nurse feels uncomfortable, they have the charge nurse as their buddy to answer questions or help re-evaluate the patient," says Freiheit. For example, the psychiatric nurse may ask for help with drawing bloods or want to know about medication interactions or abnormal lab results, she adds.
- Assess for underlying conditions.
Any patient with new onset of abnormal behavior must have a thorough assessment to rule out medical problems before they are assumed to be psychiatric-related, Freiheit emphasizes.
When police brought a prisoner and known methamphetamine user to Rogue Valley’s ED because he was incoherent and delusional, instead of just drug testing the patient and sending him to detox, nurses made sure he received a full work-up because of increased heart rate and fever — and it might have saved his life.
"He was in the early stages of rhabdomyolysis, with grossly elevated [creatine kinase levels] and early renal failure," says Freiheit. "We could have chalked up his strange behavior to the drugs and sent him back to jail, and he very well could have died if we had not been astute to his abnormal vital signs."
Always perform a full substance abuse assessment to rule out withdrawal and associated delirium, says Ziolo. "Patients become delusional and many times have visual and tactile hallucinations, and ED staff may think they need to go to a mental health unit instead of a medical unit where they can receive intravenous fluids and can be assessed for alcohol withdrawal."
- Get a thorough history.
The medications a patient is taking can give you important cues as to whether the patient has a psychiatric diagnosis, says Denise Casaubon, RN, BSS, trauma coordinator at Maricopa Medical Center in Phoenix. "Sometimes a patient is taking a psychotropic medication or antidepressant, but they fail to mention they have a psychiatric diagnosis during the history," she says. "Asking what medications the patient is on gives a more accurate picture."
Severely depressed individuals may lack the energy to give a complete history, notes Casaubon. "They may appear with a flat effect at triage and may not be willing to divulge much information," she says. "The triage nurse must be diligent about obtaining necessary information to make an accurate triage." Ask directly if the patient has any thoughts of hurting themselves or another person, and document the response, Casaubon advises. "Also document any unusual tics or speech patterns, and describe how the patient is acting and interacting with staff," she says.
Sources
For more information on assessment of psychiatric patients in the ED, contact:
- Denise Casaubon, RN, BSS, Trauma Coordinator, Maricopa Medical Center, 2601 E. Roosevelt St., Phoenix, AZ 85008. Telephone: (602) 344-5670. E-mail: [email protected].
- Heather Freiheit, RN, BSN, EMT-P, Clinical Manager, Emergency Services, Rogue Valley Medical Center, 2825 E. Barnett Road, Medford, OR 97504. Telephone: (541) 608-4768.E-mail: [email protected].
- Carol A. Ziolo, RN, MA, LCPC, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-4145. Fax: (847) 618-3996. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content