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Behavioral outcomes and expressions of feelings based on an individual's perception of self (mind, body) as it interfaces with change in health status are evaluated in the emotional health system. The nursing assessment includes the capacity of the individual to draw on adaptive behaviors needed to maintain or regain homeostasis in response to life stressors.
Suicide attempts and aggressive behavior management are two highly intensive patient situations that are equally as stressful to the nurse and ED care providers as any emergent trauma presentation. The emotional drain on staff in these situations can be significant. The following two case studies provide strategies for nursing care that help to minimize poor outcomes for the patient while lending emotional support (control) to the staff.
| BEHAVIOR | FEELINGS |
| adjustment | anxiety |
| coping | fear |
| diversional activities | grieving |
| posttrauma response | hopelessness |
| self-control | powerlessness |
| thought process | self-concept |
| violence | sexual self-concept |
| gender identity | |
|
spiritual distress |
body image disturbance
self-esteem disturbance
chronic low self-esteem
situational low self-esteem
personal identity disturbance
hopelessness
powerlessness
dysfunctional grieving
anticipatory grieving
potential for violence: self-directed or directed at others
post trauma response
rape—trauma syndrome
rape—trauma syndrome: compound reaction
rape—trauma syndrome: silent reaction
anxiety
fear
spiritual distress (distress of human spirit)
diversional activity deficit
ineffective denial
ineffective individual coping
impaired adjustment
| Emotional Health System | |||
| Level I | Level II | Level III | Level IV |
| Patient expresses
sadness, dejection, unworthiness; feelings may be appropriate to reality; mild and/or transitory depression; no suicidal or homicidal ideation |
Patient depressed with
change in ADL, eating, or sleeping habits; somatic complaints; no suicidal
or homicidal ideation; patient waiting with a responsible significant other |
Same as I or II but has suicidal or homicidal ideation without a plan; patient will be waiting with a responsible significant other and can contract to safely wait in waiting room | Expresses suicidal or homicidal ideation with plan; thoughts may contain gross misrepresentation of reality; body and motor activity may be slowed and decreased or rapid and agitated |
| Suicidal or homicidal gesture | |||
| Experiencing mild anxiety; not dysfunctional | Displays anxious behavior | Perceptual field is greatly reduced; attention may focus on a structions with much direction | Loss of control; unable to do things even with direction; perceptions may be distorted; unable to communicate or function effectively |
| Mild, transient anger | Frustrated but able to control behavior; some contact with reality; will be waiting with a responsible significant other | Unable to control anger; perception of reality temporarily impaired by emotions; real or potential for injury to self or others | |
| All patients at risk for elopement | |||
| All emergency petition patients | |||
Debra Lanouette, RN, MSN, CS
Ruth is a 25-year-old white female who was brought to the ED by her boyfriend after she cut her left wrist several times with a razor blade. She is disheveled in appearance, tearful, and obviously quite distressed. She admits to having cut her wrist in a suicide attempt after her boyfriend (of 6 months) came home intoxicated, began to argue with her, and told her he wanted to terminate the relationship. She went into the bathroom and cut herself several times before being discovered by her boyfriend.
She denies any premeditation of the suicide act or recent change in mood or behavior. although she has been worried about her boyfriend's heavy alcohol use. Ruth was born and raised in a large metropolitan area. graduated from high A school in 1982. and currently works as a hairdresser. Her family history includes alcoholism in her father and an attempted suicide by a sister while "depressed. " Three years ago, during a dispute with a boyfriend, Ruth took an overdose of 15 to 20 Tylenol tablets, was seen in the ED. and released. She has had no psychiatric ho5piiaii:u-tions or outpatient treatment. She admits to occasional use of marijuana and alcohol, usually on the weekends and often to the point of intoxication, but denies a history of blackouts or withdrawal. Her boyfriend was recently released from jail for burglary and has a history of alcoholism and spouse abuse.
Ruth is difficult to engage in conversation and avoids eye contact. She is tearful and describes feeling "very depressed." Her affect is sad and irritable. Her speech is normal in volume, rate. and rhythm and is logical and goal-directed: there is no evidence of a formal thought disorder. Cognitively she is alert and oriented x3, with a clear sensorium and no evidence of alcohol or drug use. She denies hallucinations. delusions, obsessions, compulsions, and phobias. She states cutting her wrist was "stupid": she had not intended to die. rather she was in "a panic" at the thought of her boyfriend leaving her and "just wanted him to slop drinking. "She denies current suicidal ideation and intent.
Triage Assessment, Acuity Level III: Suicidal 'behavior: no current ideation or immediate intent: patient will be waiting with a responsible family member and can contract to notify staff immediately should she experience a recurrence of suicidal thoughts or wish to leave the department before being seen by a physician.
ED nurses are frequently called upon to provide care to patients presenting with suicidal behaviors. Suicidal behaviors include the expression of suicidal ideation, suicide attempts, and completed suicides (1). Approximately 29,000 persons commit suicide each year in the United States, making it the eighth leading cause of death (2). It is estimated, however, that the rate of suicide attempts is at least 10 times the rate of completed suicides (3). It is well documented that while females attempt suicide 3:1 over males, males succeed 3 times as often as females (4). This success rate is related to more serious intent and more lethal means (firearms, hanging, etc.) used by males. White males 60 years and older represent the highest percentage of completed suicides, particularly when other risk factors are present such as failing health, loss of a spouse or significant other, isolation or weak social supports, and alcoholism (5).
Although the presence of depressive illness and/or alcoholism correlate highly with suicide, the most sensitive predictor of a serious attempt is the presence of hopelessness (6,7). The hopeless and helpless patient views his or her present anguish and despair as unending and is unable to see a way out of what is experienced as an unbearable existence. Patients at high risk for a lethal attempt generally have contemplated and planned their suicides over a period of time. may have gotten their affairs in order or prepared a suicide note, and execute their attempts under circumstances designed to minimize the chance of discovery or rescue.
In contrast to patients at risk for completed suicides are "suicide-attempters." who, like Ruth, tend to be female (2:1 over males). 20 to 30 years of age. with histories of unstable interpersonal relationships and employment patterns (2,8). The methods most frequently utilized in suicide attempts by these patients are pill overdose (70 to 90%) and wrist cutting (11 %) (8). The suicide attempt is often precipitated by the perceived loss of a significant other and occurs impulsively. with low intent and low fatality risk. These attempts may be termed "parasuicides" or "object-related" attempts, as the intent is usually not so much to end one's life as to prevent abandonment or elicit a caring response from the significant other. In some individuals this can become a chronic behavioral response when similarly stressed. It must be emphasized, however, that all suicidal behaviors should be taken seriously, as it is entirely possible that an impulsive. low-intent attempt could result in a fatal outcome if the patient ingests a highly toxic agent (e.g.. tricyclic antidepressants) or attempts hanging, shooting, or drowning.
In assessing suicide risk. the nurse must consider the broad clinical picture, the demographic profile, and the circumstances of the attempt. In particular, it must be elicited whether the patient intended to die, what the patient expected to happen, and whether the patient regrets having survived the attempt and will continue to have suicidal ideation or intent. A useful tool for analyzing the circumstances of a suicide attempt is Weisman's "Risk-Rescue Rating Scale" (9) which considers the agent used, its effect on the patient (level of consciousness, reversibility), and the chances of the patient being discovered and rescued. The evaluation of suicide risk is optimally made in collaboration with a psychiatrist or other well-trained psychiatric professional.
Although there is no clearly defined "suicidal personality." there are historical and characterological features that may contribute to a pattern of suicide attempts. These patients have often been reared in unstable or chaotic families where parental figures were insensitive or unresponsive to the patient's emotional needs and thus made the development of healthy attachment behaviors impossible. Alcoholism in one or both parents is a common finding (10). In addition. these patients may have suffered neglect, physical abuse, or sexual abuse. As adults these individuals tend to be needy and dependent in their relationships and are extremely sensitive to the retreat or potential abandonment by their partners. They view themselves as bad, unlovable, and unloved, often choosing partners who are themselves unstable, abusive, and unable to make healthy and mature emotional attachments. The patient may exhibit characterological traits suggestive of a personality disorder or may meet the diagnostic criteria necessary to formally make the diagnosis. Patients with borderline personality disorder are frequently seen in EDs with suicidal ideation or following a self-destructive act. Gunderson (11) has identified the essential features of this disorder, which include intense, unstable interpersonal relationships: unstable sense of self: negative affects; impulsivity; and low achievement. He points out that self-destructive behavior is extremely prevalent in the disorder. generally manifested in self-mutilation or "manipulative" suicide attempts, sexual promiscuity, reckless behavior, and alcohol or drug abuse. Suicide attempts are usually in response to anticipated loss which arouses intensely dysphoric affects including panic, rage. and helplessness. These patients may be extremely fearful of being alone, having tenuous sense of self, and perceive rejection and abandonment by a partner as not only loss of the relationship, but a loss of the self.
Nursing diagnoses for the patient who has attempted suicide should consider the patient's physical and psychological needs.
Diagnosis: Impaired skin integrity related to self-inflicted lacerations of the wrist
Desired patient outcome: The patient will have cessation of bleeding from the wound: the patient will verbalize an understanding of wound care; the patient will not experience a wound infection.
Diagnosis: Self-directed violence related to feelings of powerlessness and fear of abandonment
Desired patient outcome: The patient will express no suicidal ideation or intent; the patient identifies and agrees to a well-defined plan for managing suicidal ideation in the future.
Diagnosis: Ineffective individual coping related to feelings of helplessness and inadequacy
Desired patient outcome: The patient identifies alternative. more adaptive coping strategies; the patient identifies mental health resources and voices a willingness to participate in treatment.
All laceration wounds should be cleaned with a mild antiseptic soap or hydrogen peroxide and then irrigated with normal saline. Ruth's lacerations were sutured by the surgeon with 4.0 dermalon x4. An antibiotic ointment may be applied, followed by the application of a sterile dressing. The nurse should administer tetanus-diphtheria toxoid if the patient has not received one within the past 5 years. Oral antibiotics are not generally prescribed, although a local antibiotic ointment may be. The nurse should review wound and dressing care and the date to return for suture removal with the patient.
Depending on the setting and care delivery system, the nurse may play an integral role in collaborating with a psychiatrist or mental health professional in evaluating suicide risk. All psychiatric patients should be questioned directly about suicidal ideation or intent, including how seriously suicide has been contemplated, whether a plan has been formulated, and whether the patient has the means to execute the plan. The patient and family should be questioned about changes in behavior that indicate an impending suicide attempt, i.e., withdrawal from usual activities and significant others, putting affairs in order or making out a will, or giving away valued possessions. A past history of suicide attempts or family history of psychiatric illness or suicide should be elicited. It is also critical that the nurse assess the patient for the risk of an immediate self-destructive act or suicide attempt in the ED. The question should be asked, "Do I need to be concerned that you will try to harm yourself here in the ED?" Patients exhibiting (or with histories of) impulsivity, self-destructiveness, low frustration tolerance, and anger toward care providers should be considered at risk. This is particularly true if the patient is intoxicated (alcohol is a disinhibitor). In the patient who has made a suicide attempt the intent and seriousness of the attempt should be elicited. The patient should be asked if there is any regret that the attempt was unsuccessful and whether there is continued suicidal ideation or intent.
Patients who express suicidal ideation or intent, and those who have attempted suicide, especially if assessed as representing an immediate risk for a self-destructive act in the ED. should be searched and any potentially dangerous items removed from that person. Although every effort should be made to not unduly violate a patient's right to privacy and autonomy, the nurse has an overriding duty to protect from harm those patients believed to be at risk for injury to self or others (12). The nurse should approach the patient in a calm. respectful, and nonthreatening manner, perhaps saying, "I need to check your pockets and purse to make sure you are safe." The patient may then be less resistant to being searched. The patient must also be placed on suicide precautions, which generally means placing the patient in a highly visible and well-lighted location where he or she may be observed on a one-to-one basis. Patients should be accompanied to the bathroom. Family members cannot be permitted to assume responsibility for this observation.
The nurse must be aware of his or her own emotional responses to suicide attempters, especially anger, indifference, hate. or helplessness. It is essential that the nurse maintain an objective and professional response and control emotional reactivity, as these patients are often acutely sensitive to perceived disinterest or rejection on the pan of the care provider. A therapeutic alliance should be established between the patient and a small, stable number of care providers, so as to minimize the patient's attempts to manipulate or "split" staff. When managing patients with borderline personality disorder. Cousins (13) also emphasizes giving clear directions and expectations. providing structure, and focusing on the task at hand. A consistent approach by all providers is essential.
The nurse may provide brief crisis-oriented intervention, focusing on the precipitating event or stressors, the feelings aroused or emotional response, and the patient's usual coping strategies. The mal-adaptive strategy of suicide attempting must be identified as such and alternatives explored. It should be pointed out that this behavior may in fact anger or repulse the significant other, diminishing even further the chance that they will remain in the relationship. The nurse should verbalize hope that the patient can develop more healthy and adaptive means of getting emotional needs met. Efforts should be made to identify and mobilize social support systems.
The psychiatrist or mental health professional will conduct a formal psychiatric interview, including a social, psychiatric, and medical history, and mental status exam. Based on this evaluation they will determine whether or not a psychiatric illness is present and a DSMIII-R (Diagnostic and Statistical Manual Ill-Revised) diagnosis will be made. They will decide if the patient can receive psychiatric care on an outpatient basis or if psychiatric hospitalization is necessary. For patients believed to be at risk for a suicide attempt and who refuse voluntary psychiatric hospitalization, the psychiatrist or mental health professional will determine whether the patient meets the criteria for involuntary hospitalization (certification) and will initiate the process.
In this case, the psychiatrist made the following DSMIII-R diagnoses: Adjustment disorder with disturbance in mood and conduct and R/0 (rule out) borderline personality disorder. The psychiatrist and nurse collaborated in providing brief crisis-oriented intervention, following which the patient expressed an improved mood and no further suicidal ideation. The patient expressed a willingness to participate in outpatient treatment and a referral was made to her local Community Mental Health Center. She was able to identify several alternative strategies for coping with anger and dysphoric and agreed to call or return to the ED should she experience serious suicidal ideation or intent.
Debra Lanouette, RN, MSN, CS
Mrs. T. is a 31-year-old white female who is escorted by the police to the ED with an emergency petition. According to her sister, Ms. K., the patient has not slept in 3 days, is talking constantly, and is argumentative and threatening. Mrs. T. has been leaving the house during the night and walking around the neighborhood for 2 to 4 hr at a time. She has not eaten in 2 days claiming "I don't need food; food is for mortals."
Mrs. T. is large and disheveled, appears to be her stated age. and looks well nourished. She is following direct ions and, in fact, is quite gregarious, smiling and extending her hand to all persons nearby, introducing herself as "Medea, a prophet of God." Mrs. T. describes her mood as "great, terrific. " Her affect is labile, and at times markedly irritable. Her speech is loud, rapid, and pressured, with loosening of associations She will give her proper name with encouragement and is oriented to place and time She is alert, appears cognitively intact, and there are no fluctuations in her level o' consciousness. She openly and vividly reports hearing ' 'the voice of God'' who tells her she is a messenger who has the power "to save our culture from certain doom." She is seductive and hypersexual with the male security personnel. Her vital signs arc temperature 98.8° F. pulse 90, respirations 20. and BP 130/76. Her past psychiatric records establish a prior diagnosis of bipolar disorder, manic phase.
Triage Assessment, Acuity Level IV: Emergency Petition.
All too frequently nurses in the ED are called upon to manage patients who are verbally abusive, threatening, or physically aggressive. These behaviors can arouse strong feelings in care providers including fear, vulnerability, anger, and inadequacy. Prompt recognition of escalating patient behavior and early, appropriate intervention can. however, minimize the risk of injury to the patient, staff, and others,
Aggressive behavior occurs when stimuli, either internal or external, overwhelm the individual, producing intense fear and a sense of threat and powerlessness. There is frequently a weakening of the patient's internal controls. Risk factors for aggressive behavior include a history of violence, particularly violence that has occurred immediately prior to arrival in the ED, and violent family or social systems. Drug and alcohol abuse can significantly contribute to agitated. threatening behavior. Alcohol particularly acts as a disinhibitor.
Psychiatric (functional) disorders associated with aggression include schizophrenia (paranoid type), bipolar disorder (mania), and personality disorder (borderline, antisocial type). Aggressive behavior in the acutely psychotic patient is often in response to frightening hallucinations, delusions, and impaired reality-testing. These produce terrifying feelings of threat and vulnerability. The patient's aggressive response tends to be diffuse and nonfocused and is intended to protect the individual from what is perceived as immediate danger. In contrast, patients with a personality disorder manifest life-long characterological traits that predispose them to volatile behavior. These include poor frustration tolerance, impulsivity. self-destructiveness. and anger towards care providers. Threatening or aggressive behavior in these individuals is most likely to occur if the care provider is perceived as aloof. rejecting, or disinterested, or when the "agenda" of the patient is not met, i.e.. the physician refuses to give a prescription drug of abuse. The volatile outbursts of personality disorder patients tend to be more focused and at times willful and malicious.
Patients with medical illnesses, including conditions that may be life-threatening. may present with "psychiatric symptoms." including agitated or violent behavior. The most common conditions in the emergency setting include acute alcohol and/or drug intoxication or withdrawal, head trauma, seizure disorders, cerebral tumors, and organic brain syndromes including delirium, and dementia (1). An organic etiology should be suspected in any patient who is age 40 or older with no history of psychiatric illness, who has experienced a rapid change in mental state and presents with disorientation, clouded sensorium. alteration in level of consciousness, and abnormal vital signs.
Not necessarily. However, an acutely manic patient is more likely to "fool" care providers, who are seduced by his or her gregarious and entertaining demeanor and may relax their clinical guard against the threat of physical harm.
Bipolar disorder is characterized by cyclical disturbances in mood and behavior. Usually there are depressive and manic cycles, although in 10 to 20% of all cases there are only manic episodes (2). Mean age of onset is 30 years, although it can occur anytime between childhood and age 50. There is strong evidence for a genetic or biologic basis for bipolar disorder, although psychosocial factors may also play a role in its etiology. Bipolar disorder is a life-long problem, requiring ongoing psychiatric care and treatment. Lithium is the drug of choice for this disorder, although neuroleptics may be needed during manic episodes. Medication noncompliance is a significant factor in relapse and ED visits.
The acutely manic patient experiences an elevated mood. enormous energy, heightened self-esteem and sense of power, and may have auditory or visual hallucinations and grandiose delusions. The patient is generally restless, loud, and hyperverbal with rapid, pressured speech, and disorganization of thought.
There is often pronounced mood liability with an underlying irritability that can emerge quickly. The patient can become threatening. verbally abusive, or violent, particularly when limits are set or when psychiatric hospitalization is discussed. A degree of clinical reserve is always necessary when caring for acutely manic patients.
Diagnosis: Potential for violence, directed at self and others, related to psychomotor hyperactivity, mood lability, overwhelming affects. and misinterpretation of reality
Desired patient outcome: The patient will maintain or regain internal controls and not injure self or others: the patient will demonstrate a decrease in psychomotor hyperactivity: the patient will verbalize more adaptive strategies for managing overwhelming feelings of rage, frustration, fear, and powerlessness; the patient will distinguish between hallucinations and external events and demonstrate improved reality testing.
Diagnosis: Noncompliance with medication regime related to knowledge deficit
Desired patient outcome: The patient, family, and/or significant others will verbalize an understanding of bipolar disorder and the need for long-term psychiatric treatment and medication.
Early recognition, intervention, and prevention are the keys to managing aggressive patients. Although these can be difficult to achieve in a busy emergency setting where patients sometimes arrive wildly out of control, there are ways to manage an escalating or violent patient that minimize the risk of assault or injury to both the patient and the staff. The goals for managing aggressive patients include assisting the patient to maintain or regain internal controls and preventing injury to the patient, staff, and others.
Smith (3) describes an assault cycle which, if recognized, can be interrupted by appropriate and timely intervention. This cycle begins with a trigger (internal or external). If unchecked, this trigger progresses to escalation. This escalation phase is characterized by increasing tension and volatility; a weakening of impulse control: and progression, if uninterrupted, toward aggression or assault. This phase may last minutes to several hours. The shortest but most intense period is the assault (crisis) phase, where the patient loses control and becomes acutely violent. Following an assault, the patient will usually de-escalate and eventually stabilize.
Interventions for the manic patient are outlined in accordance with Smith's model of the assault cycle (3). Appropriate clinical responses should be based on where the patient is in the assault cycle. At all times, however, the nurse should manage patients in a humane and concerned manner, using the least restrictive intervention that is consistent with patient and staff safety.
Activation
The nurse must be acutely sensitive to changes in patient behavior or signs of escalation. These cues include increased muscle tension. restlessness or pacing, clenched teeth or fists, an angry facial expression, and/or loud strident speech (4). Nursing interventions are as follows:
Escalation
A patient who is becoming increasingly more agitated and threatening and is in tenuous control must be managed using a firm and highly directive approach. Nursing interventions during this phase are intended to halt the progression toward loss of control and assault.
Assault
The patient at this point has lost control and is combative and violent. This patient requires rapid intervention with an organized team approach. Physical restraint may be necessary.
Recovery and Stabilization
Recovery is the time period when the patient is de-escalating and regaining internal controls. Stabilization is achieved when the patient is in control, is calm and cooperative, and is amenable to treatment. The nurse should continue to assess the patient frequently, giving positive feedback for appropriate behavior, and gradually wean her from seclusion or restraints. Every effort should be made to stabilize a patient prior to transport to an outside facility.
Mrs. T. is having an acute exacerbation of her bipolar disorder. manic phase. She is safely managed in the ED using oral neuroleptics (Haldol) and open-door seclusion. Her lithium level of 0.2 mEq/liter (therapeutic range is 0.8 to 1.5 m Eq/liter) suggests medication non-compliance. Psychiatric hospitalization is indicated to provide a safe. structured environment and restabilization of the patient with medications.
Mrs. T. agreed to come into the hospital voluntarily. If she had not. the psychiatrist would need to determine if the patient meets the criteria for involuntary hospitalization. The nurse and psychiatrist discussed with both the patient and her sister the nature of her disorder. and emphasized the need for long-term psychiatric outpatient care and compliance with medication.