Management of the psychiatric patient Flashcards
key areas of management
- context and disposition
- acute risk management
- diagnostic clarification
- management of the acute symptoms using B/P/S
- psychosocial and contributory factors
- long term rehabilitation
patient disposal
does the patient need admission?
no = GP, mental health clinic, psychiatrist
yes = voluntary vs involuntary
how to tell the patient they need involuntary treatment
inform patient of your concerns for their health, safety, the safety of others
state it is your duty of care to ensure they receive the treatment that they require whilst they are not well enough to make an informed decision
pierce scale of suicide intent
to be completed after a suicide attempt
circumstances: isolation, timing, precautions against rescue, acting to gain help, final acts in anticipation, suicide note
self-report: lethality, stated intent, premeditation, reaction to act
risk: predictable outcome, death without medical treatment
what is the potential suicide risk
deliberate self harm
suicidal ideation
intent of attempts
homicidal ideation / Hx violence or aggression
what is stopping you from carrying it out
contribution to risk by illnesss or psychosocial factors
immediate risk management measures
safety (check for presence of syringes on their body, safety of environment etc)
separate from others
listen to the patient
consider using medication eg. short term benzodiazepines or physical restriants
medium term risk management measures
antidepressants
one-on-one special observations
decrease boredom through the OT
clinical psychologist
deal with social crises eg. relationship breakdown, unemployment
diagnostic clarification
further history
past medical history
collateral history
ongoing history in ED and on the ward
old patient notes
PSOLIS
MSE
physcial
investigations
physical examination
should be done within 24 hours of admission, check if examination performed in ED
bloods
FBC - anaemia can mimic depression, some drugs cause decreased WCC, infection may cause delirium
UEC - drugs metabolised by kidneys
LFTs - drugs metabolised by liver, alcohol, cirrhosis
TFTs - high or low levels can mimic depression/anxiety/mania/irritability
Drug levels (Li, Valproate for indication of compliance, toxicity, therapeutic range)
bHCG - pregnancy
fasting BSL - metabolic syndrome can be caused by drugs
fasting lipids - “
B12, folate - deficiency mimics psychiatric syndromes eg. depression, dementia, delirium
Ca, Mg - parathyroid problems can mimic psychiatric syndromes
HSV, syphilis, hepatitis, HIV, chlamydia/gonorhhoea PCR for IVDU groups
urine
urine MCS - for UTI in oder people
urine toxicology - opiates, speed
imaging for patients with 1st episode physosis and delirium
CT head to exclude space occupying lesion, subdural hematoma, atrophy
other tests for diagnostic clarification
ECG - for possible drug side effects
EEG - temporal lobe encephalopathy (wernicke’s), CJD, seizures (temporal lobe epilepsy)
starting new medication s
i would discuss with the team but i would anticipate we would start on _
obtain informed consent for new medications
side effects
risks
expectations/onset
ECT
Whilst under general anaesthesia (e.g. propofol) and a muscle relaxant (e.g. suxamethonium), electrodes placed on patient’s head and an electrical impulse is passed through the brain continuously and this induces a generalised convulsive seizure. Therapeutic response is correlated with total seizure time.
Most troublesome S/E is short-term memory loss (hours to days)
Other S/E: anaesthetics risk, headaches, myalgia
Contraindications: increased ICP
indications for ECT
acute management of cases where the patient is not eating or drinking, or imminently suicidal
severe depression (especially melancholic)
catatonic schizophrenia
severe depression during pregnancy
biopsychosocial
medication
psychologicla therapies eg. clin psych, individual/group programs
social work/welfare officer: finances, relationships, family meetings, community supports
substance use
considerations for patients capacity
- memory
- can they believe the info told to them is true
- do they have the ability to reason
- can they communicate their needs
- can they persevere with their actions and see them through
psychosocial and other contributory factors
psychoeducation
implimentation of services and psychotherapy
compliance/adherance
psychoeducation
education of family members, social supports, carers about condition, treatment prognosis, prognosis
SAD PERSONS
used to evaluate for risk of suicide
Sex - male>female
Age - risk increases with age
Depression
Previous attempt
ETOH
Rational thinking loss (impulsive)
Social supports lacking
Organised plan
No spouse
S sickness
safety
- can you interview the patient alone
- do they need supervision/observation
- most appropriate place to interview the patient
- are they likley to leave before being assessed
- intoxication
SACCIT
assessment and management goals in an ED setting
safety
assessment
confirmation of provisional diagnosis
consultation
immidiate treatment
transfer of care
Assessment
reliable history, MSE, risk, physical and vitals
consultation
consultant for initial advice/referral
PSOLIS
CMHC
GPs
other services in ED eg. drug and alcohol, social work
immidiate treaatment
bio: pharmacological, sedation
psycho: therapeutic engagement, supprotive counselling, using de-esclation
social: mobilising social supports, family and others to provide care post discharge, finding emergency accomodation
Transfer of care
safe and effective transfer of care
voluntary or involuntary
may reuire police transfer
disposition planning
