Behavioral/Psychosocial - Suicide, Substance Use Disorders, PTSD, Restraints, Abuse/Neglect

Suicide - statistics

• over 500,000 patients/yr are admitted for suicide-related injuries

• there are over 47,000 suicides annually

• the 10TH LEADING CAUSE of death in US

• by gender:

  • four men succeed for every woman who succeeds

  • women attempt twice as often as men

  • men over 65 years of age are at a greater risk

• suicide behavior continuum

  • ideation: contemplation without action

  • gesture: nonlethal action

  • attempt: potentially lethal

  • suicide: 30% of people are successful on their first attempt

Suicide - Assessment for Suicide Intent

• evaluate patient’s intent, determine whether there is or was a PLAN, and assess the patient’s ABILITY to follow through with the plan

  • are you feeling depressed, sad, or discouraged?

  • how long have you felt like this?

  • do you feel that your life is no longer worth living?

  • are you thinking of acting on that feeling by hurting yourself or taking your own life?

  • do you have a suicide plan?

  • can you tell me about your plan?

Suicide - nursing interventions for patient with suicide intent/attempt? safety measures?

• establish a SAFE environment; provide ONE-on-ONE observation

• explain precautions to the patient

• document comprehensive assessments, interventions, and the patient’s response to those interventions

• SAFETY MEASURES:

  • remove hazards from room

    • sharp or hazardous objects (plastic bags, cords, metal coat hangers); personal items (shoelaces, belts, lighters)

  • conduct a contraband check on the patient’s personal belongings

  • provide only paper or plastic food utensils

  • do NOT allow visitors to leave anything with the patient unless the nurse approves it

  • make sure the patient swallows his or her mediations

  • move the patient near the nurse’s station

Substance Use Disorders - ALCOHOL WITHDRAWAL SYNDROME (signs/symptoms)

• AWS is evidenced by 2 or more symptoms of autonomic hyperactivity: insomnia, agitation, sweating, tremulousness, a heart rate >100 beats/min

• seizures may occur during first 48 hours

• “alcoholic hallucinosis” may occur after 12-48 hours without alcohol; visual, auditory, and/or tactile hallucinations may occur; patient orientation and VS are normal

• delirium tremens (DTs) may occur after 48-96 hours without alcohol; delirium, agitation, tachycardia, HTN, fever, and/or diaphoresis may be present

  • with early treatment, the mortality rate of DTs is about 5%; without early treatment, the mortality rate is ever higher

Substance Use Disorders - ALCOHOL WITHDRAWAL SYNDROME (TREATMENT)

• known heavy alc intake or previous history of DTs → PREVENTATIVE with oral benzos (ATIVAN)

  • benzos enhance effect of neurotransmitter gamma-aminobutyric acid (GABA) at the receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties

• provide symptom-triggered treatment with benzos, using a valid tool (CIWA (only if patient can talk), RASS)

• correct volume deficits that result from diaphoresis, lack of oral intake, or insensible loss

• **ADMINISTER GLUCOSE AND THIAMINE to prevent Wernicke encephalopathy (gait disturbances, nystagmus, eye muscle paralysis) and Korsakoff syndrome (decreased spontaneity, amnesia, denial of memory loss by making up facts)

• administer multivitamins with folate

• correct potassium, magnesium, and/or phosphate deficiencies

• provide quiet environment

• evaluate need for restraints for patient safety, especially until agitation is controlled

• remove restraints once sedation is achieved, since resistance against restraints may lead to temp increase or rhabdomyolysis and may cause a physical injury

• following acute treatment, follow-up treatment should be planned (encourage and support abstinence, involve patient’s family and social services)

Substance Use Disorders - BENZODIAZEPINE WITHDRAWAL (overview? management?)

• identify a history of chronic benzodiazepine use by a patient or family report

• onset of signs/symptoms may occur 2-21 days after the last dose of benzodiazpines, depending upon the half-life of and amount of benzodiazepine that was taken chronically

• signs/symptoms - TREMORS, ANXIETY, PERCEPTUAL DISTURBANCES, PSYCHOSIS, SEIZURES

• MANAGMENT

  • GOAL: prevent/eliminate symptoms without causing respiratory depression or moderate to deep sedation

  • administer a benzodiazepine (the same agent that the patient was taking chronically) or a long-acting agent, such as chlordiazepoxide (Librium), as the patient’s condition warrants

Substance Use Disorders - OPIOID WITHDRAWAL (overview, management)

• first 24 hours? → patient may experience a fear of withdrawal, anxiety, and/or drug craving

• insomnia, restlessness, yawning, lacrimation, rhinorrhea, and/or diaphoresis may follow after first 24 hours

• SEVERE SIGNS/SYMPTOMS - vomiting, diarrhea, fever, chills, muscle spasms, tremors, tachycardia, HTN

• MANAGEMENT

  • controlling s/s may be done with one or more of the following agents:

    • opioid agonists (morphine, methadone)

      • often used initially, then gradually tapered

    • partial opioid agonists (buprenorphine)

    • alpha-2 agonists (clonidine)

    • anti-nausea agents (ondansetron (Zofran))

    • Dicyclomine (Bentyl) for abdominal cramping

    • Ibuprofen for pain

PTSD - what is it? symptoms? management?

• PTSD - a mental condition that is triggered by a traumatic event; symptoms last longer than 1 month

• symptoms:

  • flashbacks; nightmares; anxiety; difficulty coping; uncontrollable thoughts of the event

• Management of PTSD IN THE ICU

  • consider psych consult; provide emotional support/allow time for emotional expression

  • MEDICATIONS (antidepressants (paroxetine, sertraline, venlafaxine) or alpha blockers (prazosin); AVOID BENZODIAZEPINES!!!

PTSD - risks of developing post-ICU stay? prevention post-ICU stay?

• RISKS OF DEVELOPING:

  • history of anxiety/depression prior to critical illness

  • deep level of sedation during critical illness

  • frigtening memories of ICU stay post-discharge

  • increased severity of critical illness during ICU stay

  • use of benzos for sedation while in critical care

• PREVENTION POST-ICU STAY:

  • initiate strategies to prevent delirium

  • involve patient’s family/significant others in plan of care

  • encourage patient to express his or her emotions

  • utilize ICU notebook or diary; clinicians and family write daily messages about what is happening to the patient, which assists the patient in filling in memory gaps

USE OF RESTRAINTS

• has been associated with increased incidences of delirium and with the endangerment of patient safety

• reduction of use of restraints is a team effort and is dependent upon many factors, including unit leadership and unit culture

• physical restraints should only be used to prevent a patient from harming himself/herself/others after alternatives have been attempted

• rule out physiological causes for the patient’s behavior (such as hypoxemia, hypotension, pain, withdrawal), and address them

• frequently assess patient, and remove restraints as soon as the behavior that had necessitated the use of restraints has been resolved

  • restraints that are applied as a result of violent behavior require a face-to-face evaluation by a provider or a specially trained practitioner within 1 hour of application, more frequent monitoring, and more frequent orders than restraints that are used for nonviolent behavior

• explain the plan of care for restraint use to the patient and patient’s family

• restraint use is closely monitored by regulatory agencies

Abuse/Neglect - DOMESTIC ABUSE

• 85% of victims are female

• individuals who are at risk include children younger than 12, those who are 16-25, those who are recently separated, those who are homeless, and those who are pregnant

• SIGNS:

  • evasiveness, hesitancy; inconsistent explanations; frequent visits to the ED; injuries to the trunk and/or extremities

Abuse/Neglect - ELDER ABUSE

• includes physical, emotional, sexual, and financial abuse, abandonment, and/or a violation of personal rights

• SIGNS:

  • soft-tissue injuries

  • untreated medical problems

  • withdrawal

  • lack of personal hygiene

Abuse/Neglect - NURSING INTERVENTIONS

• interview patient privately

• utilize therapeutic communication

  • this involves exploring how person actually feels while interpreting spoken words, gestures, and facial expressions; DO THEY MATCH?

  • in a case where patient’s words do NOT match his or her gestures or facial expressions, further explore how the person actually feels

  • for therapeutic communication to be effective, the nurse needs to be aware of how he or she appears to the patient and be able to assess the overall message that is communicated by the patient, such as fear, pain , sadness, anxiety, or apathy

• provide support

• do NOT judge

• document assessment and any referrals

• refer patient to social services

• it is the LAW to report elder abuse to Adult Protective Services