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RUFINA EWANE 

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Psychiatric emergencies are severe behavioral changes that may result from worsening mental illness. Psychiatric emergency is any disturbance in thoughts, feelings, or actions that require immediate therapeutic intervention (Stahl, S. M., 2014). The providers approach, attitudes and work environment may escalate the situation and interfere with the quality of care. Certain therapeutic measures can reduce the intensity of the situation and provide a more dignified way for patients to recover from the crisis. It is thus important that the PMHNP understand how to assess patient’s emergency status and address their unique needs while maintaining safety.

 Case selected.

Patient is a 25-year-old AA male who presents to the emergency department with psychotic behavior in believing he should kill his mother which led to his attempt to stab his mother. Patient is admitted for inpatient psychiatric stabilization. Patient has a history of schizoaffective disorder and major depression that was managed with use of clozapine 150mg twice a day and Zoloft 100mg daily. Family reported that patient has a history of medication non-compliant and had been on different psychiatric medications in the past but were not working for him. Additional reports by his parents shows that patient had missed several doses of his medication, decompensated and they had notices some changes  recently including increase agitation, delusional believes that he is the savior in the family and God had directed him to cast the demon in his mother. Reports also that he had drawn a picture of himself with knives cutting a woman he portrayed as a demon with blood flowing with a man standing to the side, laughing. Patient currently stated that he participates in a meeting with angels from which he gets directives on how to attack his mother which led to his attempt to stab his mother. Because of this, patient was considered dangerous to his mother per admitting physician. Patients symptoms include psychosis, extreme agitation, paranoia, verbal outburst, combative and very difficult to redirect. Patient has no known drug allergies per parents.  Verbal restraint was used including letting patient know what will happen if he does not comply, respecting his autonomy, empathetic listening, decrease environmental stimulation, reassure patient that they will be safe, and maintain a safe environment. The patient was given emergency medications including haloperidol lactate 5mg, lorazepam 2mg, and diphenhydramine 50mg all IM for severe agitation and danger to others. To prevent re-hospitalization within 12-24 hours of discharge, the physician ordered outpatient therapy and continued use of clozapine and Zoloft along with necessary lab work.

How I would treat the client differently if he or she were a child or adolescent

Children and adolescent are usually brought for treatment when their behavior or thoughts come to the attention of parents, teachers, social workers, or school.  For pediatric patients in a mental health crisis, the typical chaotic nature of the situation may easily further exacerbate an already traumatized state of the patient. Just like in adults, as a PMHNP I would perform an evaluation to determine the type of emergency and contributing factors in child and adolescent emergency by assessing not just the child but also the entire family. Additionally, safety and protection are essential mandate in psychiatric emergency evaluation especially when the patient pose imminent threat to self or others. What I will do different when interviewing children especially younger children is to assess the underlying cause of the violent behavior and delusional symptoms within a developmental context. Specifically, I would clarify that "bizarre thinking " or accounts of seeing or hearing things that others do not see or hear are different from developmentally appropriate fantasy or difficulty while distinguishing inner voices from distressing hallucinations. On like in adults where they can provide information during the interview, when it comes to younger children, I would need to obtain information from parents or guardian. For adolescents, I would obtain information from the patient first then talk to their parent or guardian if the adolescent is able to tell most of their own story. This may also help to give a sense of autonomy and control to the adolescent which promote cooperation with the interview process.  However, information from family is very crucial particularly for a child who is psychotic, frightened, unable, or unwilling to corporate with the provider to help understand how the situation occurred and the severity of the behavior.

Same interviewing strategies used in adult may be used including speaking in a soft voice respecting patients’ autonomy, assuring safety, validating feelings, offering distractions (like video games) especially with very young children, and clear limit-setting can be helpful. However, children should be evaluated in a carefully planned setting with doors closed for limiting access, and be sure appropriate backup is available (Margret, C. P., & Hilt, R., 2018). 

In violent situations children may require a different approach in deescalating the situation than adults. Safety is the essential mandate in an aggression evaluation, with the interviewer specifically looking for imminent threats, plans, targeted people, and access to means of harm (Margret, C. P., & Hilt, R., 2018). Because adults are much stronger, they may require physical restrain specially to administer medication to calm the patient. Verbal restrain such as providing verbal directions in a nonthreatening manner, setting limits, and assuring the child that treatment may help them calm may be used for children first. However, if the child is dangerously out of control and aggressive, they may need medication to keep them calm and safe.

Legal or ethical issues I would consider when working with a child or adolescent emergency case

The ethical issue I will consider when working with children and adolescent is respect for their autonomy, privacy, and confidentiality. For very young children parents must consent to treatment and the health care provider treating the child should make every reasonable effort to obtain and document informed consent. (American Academy of Pediatrics, 2015). Just like adults, maintaining a patient’s confidentiality is an important ethical consideration when providing care to children and adolescents. However, when a PMHNP is concerned that the patient may be at imminent risk for harm to self or others, confidentiality requirements no longer apply (Chun, T. H., Katz, E. R., & Duffy, S. J., 2013). This means that the PMHNP in this situation may disclose information collected  from patient to caregivers or others as needed and may obtain information from others such as friends, family members, school personnel, employers and other without obtaining consent from the patient or guardians (Chun, T. H., Katz, E. R., & Duffy, S. J., 2013. Patient autonomy is a major principle in making decisions about an individual’s health, and as a PMHNP we are obligated to respect this right and allow patients to practice their autonomy in the course of their treatment (Parsapoor, A., Parsapoor, M. B., Rezaei, N., & Asghari, F., 2014). However, a psychiatric emergency and age may limit a child’s ability to make such decisions. Regardless, it is always important to involve the child in informed decision making even if the consent is signed by the parents or guardian.

References

Chun, T. H., Katz, E. R., & Duffy, S. J. (2013). Pediatric mental health emergencies and special

health care needs. Pediatric clinics of North America, 60(5), 1185–1201. Retrieved from,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792398/

Da Silva, A. G., Baldaçara, L., Cavalcante, D. A., Fasanella, N. A., & Palha, A. P. (2020). The

Impact of Mental Illness Stigma on Psychiatric Emergencies. Frontiers in psychiatry, 11,

573. https://doi.org/10.3389/fpsyt.2020.00573

Margret, C. P., & Hilt, R. (2018). Evaluation and Management of Psychiatric Emergencies in

Children. Pediatric Annals, 47(8), e328–e333. https://doi-

org.ezp.waldenulibrary.org/10.3928/19382359-20180709-01

Parsapoor, A., Parsapoor, M. B., Rezaei, N., & Asghari, F. (2014). Autonomy of children and

adolescents in consent to treatment: ethical, jurisprudential and legal considerations.

Iranian journal of pediatrics, 24(3), 241–248. Retrieved from,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4276576/

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New

York, NY: Cambridge University Press.