Mental Health Nursing

1. R. RUPPAMERCY,
M.Sc NURSING II YEAR,
DR. M.G.R EDUCATIONAL & RESEARCH
INSTITUTE

2. Although we all know when to take our loved ones to the
hospital when we see signs of physical illness, the majority
of us are entirely unaware of psychiatric conditions. This
can be a grave problem in case it is a psychiatric
emergency. As compared to a medical emergency, major
psychiatric emergencies are different because they can
harm the patient and others around them. Situations with
significant and severe danger to the patient’s life, to a
minor, or to others around them.

3. An emergency is defined as an unforeseen combination of
circumstances which calls for an immediate action.
A medical emergency is defined as a medical condition
which endangers life and/or causes great suffering to the
individual.
Psychiatric emergency is a condition wherein the patient
has disturbances of thought, affect and psychomotor
activity leading to a threat to his existence(suicide), or
threat to the people in the environment(homicide). This
condition 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.

4. Psychiatric emergency might be defined as: A sudden,
serious, psychological or psycho-social disturbance which
renders the individual unable to cope effectively with his life
situation, his interpersonal relationships, and/ or his
intrapsychic conflicts.
• W.J. Cassidy(1967)

5. • The initial approach to the patient should be warm, direct and
concerned.
• A quick evaluation to identify the nature of the condition and to
institute care on the basis of seriousness is essential.
• The emergency staff should have basic knowledge of handling
psychiatric emergencies.
• Medico legal cases need to be registered separately and
informed to the concerned officer.
• Hospital security must be adequate to control violent and
dangerous patients.
• History and clinical findings should be recorded clearly in the
emergency file.
• Patient’s condition and plans of management should be
explained in simple language to the patient and family
members.

6. • To safeguard the life of patient
• To reduce the anxiety
• To provide the emotional security
• To educate the client and family members

7. 1. Triage
• includes assessing the immediate needs of individuals
presenting across a variety of priority concerns.
• two factors must be considered first when triaging the
psychiatric patient: medical stability and legal status.
• The acronym ASSAULTS can assist the nurse to
systematically address critical components of an all-
encompassing triage evaluation.
• A - assess for all the areas
• S – safety
• S – suicidality
• A - aggressive/assaultive behavior,
• U - underlying medical conditions,
• L - lethality,
• T - trauma, and
• S - substance use/abuse,

8. • TITLE - Care of Psychiatric Patients: The Challenge to
Emergency Physicians
• AUTHOR - Leslie Zun, MD, MBA
• JOURNAL NAME – Western Journal of Emergency Medicine
• CURRENT ISSUE: VOLUME 17 ISSUE 2
• PUBLISHED: MARCH 2, 2016
• The purpose of this article is to discuss disparity and challenges
in caring for psychiatric patients. EDs do a good job of
determining how to improve the care of the medical patient but
they have done little addressing the unique needs of the
psychiatric patients. Patient care surveys focus on evaluating
the patient care experience of non-psychiatric patients in the
ED. These customer service surveys have identified many
priorities for patient care and satisfaction in the ED, need for
improvement, hence The triage process in the ED is skewed to
patients with medical problems over those with psychiatric

10. RESULT - The author suggests that better treatments protocols are
needed for psychiatric patients in crisis in the ED. However, best
practices in evaluation and treatment of agitation (BETA) expert
guidance recommends that medication be determined by the most
probable etiology. Treatment of psychiatric illness should be similarly
tailored to the patient and situation.
CONCLUSION - It is time to advocate for the psychiatrically ill patient
in the ED. We need to push for more training, establishment of
standards of care, reduced wait times and find alternatives to
boarding.

11. 2. Safe environment for emergency evaluation
• Weapon screening
• Rooms in which the examiner cannot be easily trapped
• Method to call for help
• Adequate personnel to respond if help is needed
including trained security personnel

12. 2.
VIOLENT/AGGRESSIO
N
1. SUICIDAL ATTEMPT

13. 3. EXCITEMENT 4. PANICK ATTACK

14. 5. CATATONIA 6. WITHDRAWAL
SYNDROME

15. 7. HYSTERICAL
ATTACKS
8. DELIRIUM
TREMENS

16. 9. DYSTONIC
REACTION
10. TRANSIENT
SITUATIONAL
DISTURBANCES

17. 11. ABNORMAL
REACTION TO
STRESSFUL
SITUATION
12. DISASTERS

18. • DEFINITION
Suicidal behaviour includes suicidal ideation (frequent thoughts
of ending one's life), suicide attempts (the actual event of trying
to kill one's self), and completed suicide (death occurs). Suicidal
behavior is most often accompanied by intense feelings of
hopelessness, depression, or self‐destructive behaviors
(parasuicidal behaviors).
RISK FACTORS
• Age- adolescent and middle age
• Gender - women
• Marital status - unmarried
• Socio-economic status
• Occupations – lawyers, dentist, musicians, physicians with F/H

19. PSYCHIATRIC DISORDERS
Major depression
Schizophrenia
Drug/ alcohol abuse
Dementia
Delirium
Personality disorder
PHYSICAL DISORDERS
Cancer
Arthritis
AIDS
PSYCHOSOCIAL FACTORS
Failure in examination
Dowry harassment
Marital problem, Loss of loved
Isolation
Alienation from social groups
Financial and occupational
difficulties

20. • Assessing suicidal risk
• MSE
• Psychopharmacological Treatment
NURSING MANAGEMENT
 Assessing the suicidal risk/potential.
 Mental status examination.
 Monitor the patient’s safety needs-
 Search for toxic agents such as drugs or alcohol.
 Do not leave the drug tray within the reach of the patient. Make
sure that daily medication is swallowed.
 remove sharp instruments, straps, belts etc.
 Do not allow the patient to bolt the door on inside, make sure
that somebody accompanies him to the bathroom.

21.  Patient should be kept in constant observation and
should be never left alone.
 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 tendency are very severe, sedate the patient.
 A ‘no suicidal’ pact may besigned.
 Enhance self esteem of the patient by focusing on his
• strengths rather than weaknesses.

22. • One to one relationship
• Assess suicidal risk daily
• Remove hazardous objects
• Window locked
• Monitor patient
• Be alert of verbal and non-verbal clues
• Verbal and written contracts
• Problem solving techniques
• Place near nurses station
• Do not allow to bolt the door

23. • Do not panic/ raise an alarm
• Act with speed and coordination
• Emergency medical measures-check pulse, respiration
and airway
• -if overdose of medicine- gastric lavage
• -Turn head to one side
• -pulse- inj. Decadron 4mg IV
• Plan intervention to control future attempts.

24. DEFINITION
• Social psychologists define aggression as behavior that
is intended to harm another individual who does not wish
to be harmed. (Baron & Richardson, 1994)
• Violence is defined as “a physical act of force intended to
cause harm to a person or an object and to convey the
message that the perpetrator’s point of view is correct
and not the victim’s.” (Harper-Jaques and Reimer, 1992)

25. • Personality disorder
• Organic psychiatric disorder
• Drug intoxication
• Panic disorder
• Acute stress reaction
• Psychotic disorder

26. • IN TRIGGERING
PHASE-
• Restlessness
• Anxiety
• Irritability
• Muscle tension
• Rapid breathing
• Perspiration
• Loud voice.
• IN ESCALATION
PHASE-
• Pale or flushed face
• Yelling
• Agitated
• Threatening
• Demanding
• Clenched fists
• Hostility, loss of ability
to solve problems.
IN CRISIS PHASE-
Loss of emotional and
physical control
Throwing objects
Kicking, Hitting
Spitting
Biting, scratching
Screaming
Inability to
communicate clearly.
IN RECOVERY
PHASE-
Lowering of voice
Decreased muscle
tension
Clearer
More rational
communication and
IN POST
CRISIS
PHASE-
Remorse
Apologies
Crying
Quiet
Withdrawn
behavior.

27. • Talk
• Food
• Medications
• Physical restraints
• Support
• NURSING INTERVENTION
• Decreased environmental stimuli
• Limit interaction with others
• Stay with patient
• Gentle approach
• Create safe environment
• Maintain clear exit
• Do not keep provocative members
• Redirect violent behaviour
• Talk out rather acting out

28. DEFINITION
Panic attack:
Is a brief period of extreme distress, anxiety, or fear that begins
suddenly and is accompanied by physical and/or emotional
symptoms. •
Panic disorder:
Is involves spontaneous panic attacks that occur repeatedly,
worry about future attacks, and changes in behavior to avoid
situations that are associated with an attack.
Episodes of acute anxiety and panic can occur as a part of
psychotic or neurotic illness. The patient will experience
palpitations, sweating tremors, feelings of choking, chest pain,
nausea. abdominal distress, fear of dying, parasthesia, chills or
hot flushes

29. • Neurochemical dysfunction
• Genetic hypothesis
• Cognitive dysfunction

30. • Signs and symptoms
• Palpitation
• sweating
• Tremors
• Feeling of choking
• Chest pain
• Nausea
• Abdominal pain
• Chills
• Fear of dying

31. • Give reassurance
• Search for causes
• Diazepam 10mg/ lorazepam 2mg
NURSING MANAGEMENT
• Develop trust relationship through communicating core
communication values(caring, acceptance, empathy)
• Stay with the client and offer reassurance of safety and
security
• Maintain a calm non threatening environment
• Help client recognize early signs

32. DEFINITION
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 .
 The various catatonic signs include mutism, negativism,
stupor, ambitendency, echolalia, echopraxia, automatic
obedience, posturing, mannerisms, stenotypes, etc.,

33. • Akinesia and mutism ( conscious awareness)
• Signs:
• Mutism
• Negativism
• Stupor
• Ambitendency
• Echolalia
• Echopraxia
• Automatic obedience
• Posturing
• Mannerism

34. • Maintain hydration
• Check vitals
• Keep airway patent
• Ventilator support
• Personal hygiene
• Identify specific cause and threat
• NURSING MANAGEMENT
 Collect history and perform physical examination.
 Ensure patent airway.
 Administer iv fluids.
 Draw blood for investigations before starting any
treatment.
 Care of skin, nutrition and personal hygiene.

35. Excitement is a general psychomotor over activity i.e.
excessive motor and psychic activity leading to behavior
disorder, where the behavior disorder, where the patient
may hurt himself and/or others.
• Etiology
• 1. Psychosocial disorder
• 2. organic disorder – Delirium, Dementia
• 3. Substance abuse – intake of stimulant eg. Cocain,
alcohol or during the withdrawal period

36. • Remove chains and restrains
• Talk
• Sedate
• Take history
• Physical examination
• Send blood for Hb ,WBC,ESR,RBC etc
• Treat hydration
• Retain limited furniture
• Provide safe environment

37. Collect history and perform physical examination
Administer IV fluids
Ensure patent airway
Draw blood for investigations before starting my
treatment
Other care is same as that for an unconscious patient.

38. DEFINITION
An uncontrollable outburst of emotions or fear, often
characterized by irrationality, laughter, weeping etc.
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
Marked by dramatic
Quality & sadness of mood

39. • It is a attention seeking behavior, repressed anxiety,
tranformation of an unconscious conflict in to physical
symptoms, such as paralysis, blindness, loss of
sensation etc.
• MANAGEMENT
• Hysterical fits are distinguish from true / genuine fits •
Explain the psychological nature of disease to the
relatives of the patient • Reassure the family members
that no harm would come to pt. • Help the pt to recognize
the meaning of symptoms & identify suitable alternative
coping mechanism • Observe the patient continuously •
Suggestion therapy with IV pentothal, helpful in some
cases.

40.  Identify primary and secondary gains.
 Do not focus on the disability; encourage the patient to perform self
care activities as independently as possible. Intervene only when
patient requires assistance.
 Do not allow the patient to use the disability as a manipulative
tool to avoid participation in therapeutic activities.
 Withdraw attention if patient continues to focus on physical
limitations.
 Encourage patient to verbalize fears and anxieties.
 Identify specific conflicts that remain unresolved and assist patient
to identify possible solutions.
 Assist the patient to set realistic goals for the future.
 Help the patient to identify the areas of life situation that are not
within his ability to control.

41. • An idiopathic reaction to major transquilizers and related
drugs such as phenothiazanes( compazine,
prochlorperazine), Haloperidol, metaclopramide etc.
consisting of abnormal muscle contractions.
• Can occur after single, first time dose or in patients who
have had the same medicine before without problem.

42. • Promethazine 25-50 mg
• Diphenhydramine 25-50 IM/IV
• Biperdone 2-3 mg/IM
• Diazepam 5-10 mg IM/IV slowly
• No response after 3 doses-suspect other diseases.
NURSING MANAGEMENT
• Administer medication and assess for effectiveness.

43. These are characterized by disturbed feelings and
behaviour occurring due to overwhelming external
stimuli.
The symptoms include depression, fatigue, sadness, cruing
spills, anxiety, poor concentration, social withdrawal etc.

44. Management:
Reassurance
Mild sedation if necessary
Allowing the patient to ventilate his/her feelings
Counseling by an understanding professional
NURSING MANAGEMENT
Presence, support, reassurance as well as the bond with
the family are cornerstones of the nursing care.

45. Delirium tremens is a potential form of ethanol(alcohol)
withdrawal.
Symptoms:
• may begin a few hours after the cessation of ethanol, but
may not peak until 48 – 72 hours.
• Altered mental status – confusion, hallucinations, service
agitation or generalized seizures – 6 – 48 hours after last
drink.
• Tremors
• Irritability
• Insomnia
• Nausea/vomiting
• Hallucinations, delusions

46. • Safe environment
• Sedation
• Diazepam 10mg/ Lorazepam 4mg IV
• Fluid and electrolyte balance
• Reassurance
NURSING MANAGEMENT
 Monitor vital signs, observe the patient carefully.
 Decrease stimulation, provide a quiet and safe
environment.
 Evaluate the patients hydration and serum electrolytes.
 Maintain I/O chart. Administer IV fluids.
 Carefully evaluate the patient for presence of other concomitant
medical or surgical problems like trauma, GI bleed etc.

47.  Observe for the development of possible focal
neurological sign.
 Institute high calorie and high carbohydrate diet.
 Add thiamine 100 mg IM, then orally, folic acid 1 mg orally
daily for 7 – 10 days.
 Infections, that is, aspiration pneumonia should be suspected
and treated.
 Reassure patient and family.

48. Following epileptic attack patient may behave in a strange
manner and become excited and violent.
• After attack
• Patients becomes excited and violent
Management:
• Inj. Diazepam 10mg
• Haloperidol 10mg IV
• Inj. Luminal 10mg followed by oral
anticonvulsant

49. • Withdrawal from drugs and alcohol is a common psychiatric
emergencies and the substances such as
• Alcohol
• Opioids
• Barbiturates and Benzodiazepine
• Stimulants - Cocaine and amphetamines
• SIGNS AND SYMPTOMS
• More severe symptoms such as hallucinations, seizures,
delirium may also occur in some instances.
• Changes in appetite, Changes in mood, Congestion,
Fatigue, Irritability, Muscle pain, Nausea, Restlessness,
Runny nose, Shakiness, Sleeping difficulties, Sweating,
Tremors, Vomiting etc.

50. • Patients should be monitored regularly (3-4 times daily) for
symptoms and complications.
• Patients should drink at least 2-3 litres of water per day during
withdrawal to replace fluids lost through perspiration and
diarrhoea. Also provide vitamin B and vitamin C supplements.
• The dose must be reviewed on daily basis and adjusted based
upon how well the symptoms are controlled and the presence
of side effects
• Symptomatic medications should be offered as required for
aches, anxiety and other symptoms.
• psychological therapy that focuses on providing patients with
skills to reduce the risk of relapse.
• Patients in withdrawal should not be forced to do physical
exercis

51. • The response to stressful events has three components:
• 1. an emotional response, with somatic accompaniments
• 2. a coping strategy
• 3. a defence mechanism.

52. • This is a prolonged and abnormal response to exceptionally intense
stressful circumstances such as a natural disaster or a sexual or other
physical assault.
• MANAGEMENT
• Comfort and consolation
• • Protection from further threat and distress
• • Immediate physical care
• • Helping reunion with loved ones
• • Sharing the experience (but not forced)
• • Linking survivors with sources of support
• • Facilitating a sense of being in control
• • Identifying those who need further help (triage)
• • facts—the victim relates what happened
• • thoughts—they describe their thoughts immediately after the incident
• • feelings—they recall the emotions associated with the incident
• • assessment—they take stock of their responses
• • education—the counsellor offers information about stress responses and
how to manage them.

53. Victims of disaster are people, who have survived a sudden,
unexpected, overwhelming stress.
This is beyond normally what is expected in life, like in and
earthquake, flood, riots and terrorism, Anger, frustration,
guilt,
numbness and confusion are common features in these
people.
Management:
• Treatment for life threatening physical problems
• Critical Incident Debriefing (CID) is a special technique,
which is used to lessen the discomfort of the disaster
victims.

55. Critical incident debriefing includes five phases:
Fact, thought, reaction, reaching and Re-entry
• In the fact phase, each participant is involved to share his or
her perception of the incident.The group members describe
the incident, new information and pieces of information are
integrated into a more understandable whole.
• The thought phase, builds on this information by asking
participants to reflect the incident and to share what they
were feeling personally during different times of the crisis.

56. • In the reaction phase, participants are asked to evaluate the
impact of the emotional aspects of the incident (for example,
what was the worst part of the incident for you). Knowing that
other people are experiencing the same feelings makes them
realize that these feelings are normal behavioural responses
to abnormal circumstances, and this brings a lot of relief to
people who are under intense stress. Participants discuss
stress related symptoms they had during the incident or are
experiencing currently.
• The teaching phase, focuses on specific cognitive, emotional
and spiritual strategies to reduce stress and ways to enhance
group support.
• In the final re-entry phase, the facilitator encourages
questions and summarizes the process, Finally individuals
are referred to further counseling if needed.

57. Rape is a perpetuation of an act of sexual inter- course with a
female against her will and consent.
SIGNS & SYMPTOMS:
 Acute disorganization characterized by self blame, fear of
being killed, feeling of degradation and loss of self esteem,
feelings of depersonalization and derealisation
 recurrent intrusive thoughts, anxiety and depression are
commonly seen.
 Long term psychological effects like post traumatic stress
disorders (PTSD) can occur in some cases.

58.  Be Supportive, reassuring and non – judgmental.
 Physical examination for any injuries.
 Give morning after pill to prevent possible pregnancy.
Send samples for STD & HIV infection.
Explain to the patient the possibility of PTSD, sexual
problems like vaginismus and anorgasmia which may
appear later

59. • TITLE - Psychiatric Illness in the Emergency Department
• AUTHOR – Ali Madeeh, kim – lan, qammar, samia
• JOURNAL NAME – Psychiatric annals
• Psychiatric Illness in the Emergency Department
• PUBLISHED – January 2018
• VOLUME – 48(1):21-27 ISSUE NO - 1

60. • A substantial number of patients with mental illness present
to emergency departments (EDs) for treatment, and their
numbers are continuing to rise. Patients with substance use
disorders are the most common, but there are also patients
with suicidal ideation or those who have al-ready attempted
suicide, as well as patients with psychosis, altered mental
status, and acute anxiety disorders. Among patients with
substance use disorders, “traditional” drugs of abuse (ie,
alcohol, marijuana, cocaine) continue to predominate, but
there is an increasing number of patients who present with
intoxication caused by “designer” drugs, which are much
harder to detect. Suicide attempts remain a leading cause of
ED presentation and require ED personnel to not just do
triage and in-depth assessment, but also to make
recommendations for adequate follow-up.

61. Substance use disorders including newer “designer” drugs
that are hard to detect continue to pose a challenge to ED
physicians. ED physicians, including psychiatrists and mental
health workers who work in EDs, need to be vigilant for
patients who may present to EDs with these disorders.
Appropriate triage, rapid but comprehensive evaluation,
appropriate management, and timely referrals for after care
ensure the best possible outcomes.

62. A psychiatric emergency is any unusual behavior, mood, or
thought, which if not rapidly attended to may result in harm to a
patient or others. The incidence of alcohol and substance
abuse in our country as well as the rise in levels of unipolar
depression, have led to an increased number of patients
reporting to the emergency care unit. It is necessary to be
familiar with common psychiatric emergencies especially
suicide attempts and violent behaviour and other psychiatric
emergencies so as to improve the level of care offered to the
patients