Psychosocial Emergencies Flashcards
1. Explain concepts related to the assessment of an emergency department patient experiencing a psychosocial emergency. 2. Describe various patient presentations related to psychosocial emergencies. 3. List interventions necessary for a patient presenting with a psychosocial emergency.
how many US adults have mental health diagnosis
1 out of 5
define anxiety
feeling of worry, nervousness, unease, typically about an imminent even or something with an uncertain outcome
synonyms for anxiety
discontent concern apprehension fearfulness tension
define situational crisis
series of life events rooted in anxiety that may cause pt to present to ED
managing situational crisis
typically with outpatient followup
pyschosocial crises that bring people to ED
job loss
divorce
sudden illness
sudden death
grieving variables
culture
personality
hx of loss
coping skills
sx situational crisis
shock, disbelief, denial emotional lability slow speech inability to concentrate hyperfocused helplessness anorexia appetite/weight change sleep alterations
types of anxiety disorders
panic attack specific phobia social phobia OCD PTSD acute stress disorder generalized anxiety disorder
define panic attack
discrete period of intense fear of discomfort in which 4 or more sx develop abruptly and reach peak w/in 10 min
sx of panic attack
palpitations, sweating trembling, shaking sob feeling of choking cp N, GI upset dizziness, LH derealization/ depersonalization fear of losing control fear of dying paresthesias chills, hot flashes
intervene for panic attack
therapeutic communication de-escalation trusting relationship reassure low stimulation assess risk of SI/HI psych substance use dc for support services
pharm for panic attack
clonazepam
lorazepam
diazepam
pharm for anxiety disorder
benzo
anxiolytic
antidepressant
define OCD
rituals or actions performed to reduce anxiety
define compulsion
repetitive behaviors
define obsessions
recurrent and persistent thoughts, impulses, images that are regarded as unwanted and inappropriate
sx OCD
repeated handwashing, checking
recurring/persistent thoughts
thoughts that are not simply excessive worries
attempts to ignore thoughts
intervene OCD
anxiolytics, antidepressants
supportive therapy
define PTSD
provoked by traumatic incident that person relives or constantly fears will recur
acute vs chronic PTSD
acute < 3 mo
chronic > 3 mo
sx PTSD
re-experiencing (flashbacks, dreams)
avoidance (loss of interest, isolation)
hyperarousal (startle reflex, tense, irritable)
intervene PTSD
trusting relationship supportive dc plan referral to counseling support groups low stimulation
define depression
common but serious illness, particularly if untreated or unmanaged
define major depression
severe sx that interfere with pt’s ability to work, sleep, study, actively participate in life
how often does depression occur?
may occur only once, but often pt has several episodes
types of depressive episodes
psychotic depression
postpartum depression
seasonal affective disorder
psychotic depression
associated w/ psychotic hallucinations or delusions
postpartum depression
10-15% of postpartum women
season affective disorder
characterized by seasonal onset of depression during winter months
effectively treated w/ light therapy and Vit. D
sx depression
worthlessness, helplessness loneliness, sadness physical fatigue lack of energy sleep disturbance irritability weight change decreased interest feelings of guilt SI, death preoccupation psychomotor retardation/agitation decreased libido
define bipolar disorder
chronic, recurring condition characterized by cycles of depression and elation or mania
meds that precipitate manic event in bipolar disorder
antidepressants steroids bronchodilators alcohol cocaine decongestants
sx bipolar disorder
major depression sx
mania: inappropriate elation, irritability severe insomnia increased talking rapid, pressured speech grandiose notions poor judgment disconnected, racing thoughts increased sexual desire inappropriate social behavior increased energy impulsivity risk-taking behavior
intervene bipolar disorder
safety, security minimize external stimuli do not isolate assess SI allow decision making support systems safe dc
pharm interventions for bipolar disorder
lithium
carbamazepine
divalproex
precipitants of lithium toxicity
hyponatremia dehydration tetracycline phenytoin cyclosporine diuretics ACE inhibitors NSAIDs
sx lithium toxicity
N/V/D weakness, fatigue lethargy tremulousness dystonia hyperreflexia, ataxia cardiac dysrhythmias
intervene lithium poisoning
stabilize, reverse life-threatening conditions
IV fluids with isotonic NS
monitor cardiac fxn
HD if severe
define psychosis
severe mental disorder in which thoughts and emotions are impaired or distorted to the point that contact with reality is lose
psychosis overview
state of bizarre and profoundly altered thinking with associated deterioration of thought processes
often w/ sensory hallucinations/delusions
r/o alternatives (medical, drug-induced)
causes of psychosis
organic vs psychiatric delirium dementia depression schizophrenia
sx psychosis
delusion: personal belief
hallucination: sensory
disorganized speech
grossly disordered behavior
define delirium
acute disturbance in attention and cognition
sx delirium
rapid onset fluctuating course hallucinations disorientation memory impairment change in temperament blunted affect confabulation difficulty thinking clearly lack of insight into problems
define dementia
degenerative disturbance in cognition
sx dementia
gradual onset repetitive speech recent memory loss disorientation lack of awareness of problem impaired cognition personality changes sundowning
define schizophrenia
disease state characterized by bizarre behavior including self or other reports of inability to care for self or manage other activities of daily living
schizophrenia overview
r/o organic causes
manageable but not cureable
usual onset in 20s
typically no family hx
sx schizophrenia
delusions hallucinations disorganized thinking, speech disorganized motor behavior negative sx -flat affect/speech -impaired cognition
intervene schizophrenia
orient but don't deny reality short, concrete sentences avoid figures of speech antipsychotic meds maybe restraints observe
dystonic reactions
aka severe extrapyramidal sx
occur w/in hours-week of new antipsychotic meds
disordered muscle tonicity
oculogyric risis
torticollis
oculogyric crisis
deviation of eyes in all directions
torticollis
spasm of neck muscles with twisting to side
intervene dystonic rxn
diphenhydramine
benztropine
trihexyphenidyl
define neuroleptic malignant syndrome
life-threatening condition caused by antipsychotic agents
sx neuroleptic malignant syndrome
hyperthermia AMS severe muscle rigidity autonomic instability diaphoresis leukocytosis elevated CK renal failure
intervene neuroleptic malignant syndrome
O2, intubate stabilize BP reduce temperature reduce muscular rigidity ICU
mandated reporting requirements
child abuse
elder abuse if in gov’t home
in domestic abuse, pt must make complaint
types of abuse
neglect physical sexual emotional abandonment financial
types of neglect
failure to provide basic needs:
medical physical emotional educational mental
types of physical abuse
intentional trauma excessive discipline punishment torture unreasonable force
define sexual abuse
inappropriate sexual contact (physical, verbal, other)
behavioral signs in an abuser that indicates high index of suspicion for maltreatment
delay care, bypassing EDs child fearful of caregiver events confusing vague answers focuses on child behavior denies knowledge recent caregiver change emphasizes unrelated details focuses on own concerns tension btwn caregivers uncooperative, demanding hx multiple ED visits describes pt as clumsy refuses to leave communicative pt alone
fractures in high index of suspicion for maltreatment
humerus ribs scapulae distal clavicle fingers/femur in immobile child various stages of healing any fracture < 3 yo
head injuries in high index of suspicion for maltreatment
traumatic alopecia uneven growth head injuries subdural hematomas skull fracture unexplained LOC sx increased ICP
EENT injuries in high index of suspicion for maltreatment
displaced nasal cartilage bleeding from septum retinal hemorrhages detached retina hyphema periorbital ecchymosis ruptured tympanic membrane battle sign fractured mandible lacerated frenulum loose, missing teeth petechiae around head/neck
genitalia and perineum in high index of suspicion for maltreatment
trauma discharge bleeding pain UTI sx STIs
poisoning in high index of suspicion for maltreatment
ingestion of alcohol or drugs
burns in high index of suspicion for maltreatment
lips and tongue rectum and perineum cigarette chemical electrical lines of demarcation uniform burn depth burns in shape of object splash burns of non-uniform depth
bruising in high index of suspicion for maltreatment
various stages of healing
shape of identifiable object
human bite marks
behavioral in high index of suspicion for maltreatment
PTSD ADHD secondary enuresis or fecal soiling in toilet-trained child nightmares inappropriate sexual behavior
interviewing in c/f abuse
set tone, augment information interview caregivers separately listen, watch evaluate appearance nonjugemental nonaccusatory
memorializing events and history in c/f abuse
quotes photos objective descriptions draw injuries on body map medical terms record dates/times accurately don't assume, make conclusions mandated reporting
risk factors for dependent adult abuse
shared living psychopathology of abuser caregiver stress extensive care needs generational abuse caregiver inexperience lack of caregiver support unpredictable needs of pt poor physical living conditions financial distress
cultural, ethnic practices that produce physical marks that may be mistaken for abuse
cupping
coining
physiologic manifestations that may be mistaken for abuse
coag disorders
failure to thrive
mongolian spots
define Munchausen by proxy
adult caregiver fabricates child’s illness or actually creates symptoms
commonly reported sx in Munchausen by proxy
apneic spells cardiac/resp arrest SZs allergic rxns dehydration suffocation
commonly manufactured sx in Munchausen by proxy
rashes sepsis hemorrhage vomiting diarrhea
common characteristics of Munchausen by proxy
illness unexplained, prolonged, recurrent, rare unresponsive
Sx only in perpetrator’s presence
perp overly knowledgeable, interested in interacting with healthcare team
not concerned about painful procedures
believes ill child will improve relationship with partner
hx emotionally deprived childhood
uses illness to escape responsibilities
gains gratification in presence of providers
define anorexia
weight loss > 25% below baseline
failure to gain weight after diagnosis
define builimia
bingeing and purging behavior
characteristics of bulimia
vomiting laxatives diuretics diet pills fasting excessive exercise
risk factors for eating disorders
female (95%) model children academic success asexual behavior excessively dependent developmentally immature preference for isolation OCD personal crises
sx anorexia nervosa
amenorrhea hypercarotenemia muscle weakening constipation cool skin peripheral edema thinning hair nail fragility dehydration hypocalcemia
sx laxative abuse
hypokalemia
hypocalcemia
dehydration
hypoglycemia
sx diuretic abuse
hyponatremia
hypokalemia
increased uric acid
hypercalcemia
sx excessive diet pill use
hypertension renal failure dysrhythmias intracerebral bleeding MI HF
sx induced vomiting
Mallory-Weiss tears pancreatitis tooth enamel erosion callus on index finger hypokalemia hypomagnesemia metabolic acidosis fractured ribs
assessing eating disorders
changes in appetite, weight, exercise
N/V
history in eating disorders
psychological disorders
anorexia or bulimia
substance use
laxative or diet pill use
intervene for eating disorders
medical clearance IV, monitor psych, diet consult electrolytes protective environment antidepressants admission
aggression continuum
thought plan means access action
risk factors for aggression
SI/HI ideas, plans, attempts, intent
cognitive assessment in aggression
loss of executive fxn tunnel vision polarized thinking closed-mindedness self-report tools
gender in SI risk assessment
females attempt males succeed (4x)
age in SI risk assessment
highest rate 45-64 yo
second highest 85+
younger groups have lower rates
race in SI risk assessment
white males 70%
second highest American Indians and Native Alaskans
risk factors for SI
family hx hx behavioral health hx substance abuse hx other abuse spring season access to weapon prior attempts chronic physical illness
sx SI
worthless, hopeless, helpless confusion, impaired insight restlessness, agitation irritability indifference, fatigue insomnia decreased physical activity withdrawal social isolation
intervene for SI
undress remove belongings manage illness meds as appropriate involve social support as appropriate psych suicide hotline number
psychological risk factors for HI
anxiety/fear for personal safety
overwhelming feelings
hx abuse
organic risk factors for HI
alcohol, drugs
side effects of meds
pain
delirium
psychiatric risk factors for HI
delusions of persecution "command" hallucinations acute depression suicide attempt mania
intervene for HI
calm pt collaborative relationship appear calm, unthreatening personal safety threats taken seriously confiscate objects clear furniture remove bystanders don't hurry patient engage in conversation simple, direct sentences allow verbalization of complaints speak calmly reassure help regain self control be clear, honest avoid confrontation stand sideways hands visible clear exit get assistance
