Transcript Managing Psychiatric Symptoms in the Acute Med Surg Setting

Managing Psychiatric Symptoms in
the Acute Med/Surg Setting
Where?
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ED
ICU
Med/Surg floors
OB/Gyn floor
Waiting areas, etc.
In short, EVERYWHERE!
Why?
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Sepsis
Substance Intoxication/Withdrawal
Electrolyte imbalance
Hepatic Dysfunction
CVA
Drug toxicity
Hyper or hypothyroidism
• Renal Dysfunction
• Hypoxia
• Head injury
How Do They Present?
IN EDOverdose
AMS
Psychotic symptoms (not taking psychotropic
meds)
Substance intoxication
Suicidal thoughts/ Suicide attempt
Self harming behaviors
Other floors- ANY Diagnosis and
Psychosis
Agitation/ Combativeness
Confusion
Delirium tremens/Drug withdrawal
Anxiety/Panic attacks
Depression
Pre-existing psychiatric illness
Diagnostic Tests
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CBC
Electrolytes
BUN, Creatinine
LFTs, Ammonia
Drug screen, therapeutic drug levels
Thyroid panel
CT Head
Case Studies
Betty is a 65 y/o white female who presents to
ED with AMS- brought in from home by
EMS. Betty denies any drug use and says she
only drinks occasionally. She is a poor
historian. CBC, Lytes, BUN, Creat are all
WNL. CT of the head is normal. Betty is
talking nonsense and having conversations
with imaginary people in the room.
Case Studies
Joe is a 19 y/o white male who presents to ED
with AMS- brought in by police because he
was running naked down FM 1960 at 9AM.
He is delusional- thinks aliens are after him.
He sees the alien creatures out in the hall and
hears them taunting him, saying they will kill
him. Joe is afraid, he is screaming, and he
wants to run away.
Case studies
Mary is a 58 y/o black female. She was
admitted for DKA 4 days ago. She was in ICU
for a few days on an insulin drip, but is now
on the floor in more stable condition. You
notice Mary is crying on and off throughout
the day, and ask her what is wrong. She tells
you that she lost her husband about a year
ago.
Mary says she stays at home alone and cries
all the time. She does not care about her
diabetic diet and eats whatever is on hand.
Friends and family bring her food so she
doesn’t have to go to the store. Her blood
sugar is always high (when she remembers to
check it). She says she forgets to take her
medications fairly often, and her B/P has been
running high, too.
Case Studies
David is a 28 y/o Hispanic male who was
admitted through ED for an infected wound
on his left 5th toe. He is a type I diabetic (since
age 8) and is now on an insulin pump. David
seems like a nice fellow-pleasant and
talkative. He tells you his medical history in
detail. You notice his speech is rapid. He says
he is disabled, but that he does many things.
When you ask him what kinds of things he
has done, he replies, “What have I done?
What haven’t I done?!” David proceeds to
inform you that he is the number one, top
record producer of Hip Hop artists in
Houston, and in the nation, and that he has
won numerous awards. He also owns a
recording studio, a private jet, a yacht, and he
is friends with Kanye West and the
Kardashians.
David denies any history of mental illness or
substance abuse. His toe has osteomyelitis,
and is starting to look gangrenous. He refuses
amputation of his toe, even though the
consequences have been explained to him. A
psychiatric consult is ordered. David says he
knows better than the doctors.
His mother and aunt appear to be afraid of
him, and will not contradict anything he says.
The mother will shake her head “No” when he
is saying things that are not true if she is sure
he cannot see her. They do his bidding, as
they have done all of his life.
Being One Step Ahead
Accurate Patient History is Critical
• Current meds
• Alcohol/Substance use
• Previous psychiatric treatment
• Suicide attempt/ Suicidal thoughts
• Sleep pattern
• Appetite issues
Problems Associated with
Depression
• Chronic illness
• Grief
• Feelings of failure- fear of losing job,
relationship
• Newly diagnosed illness
• Terminal illness diagnosis
• Feeling hopeless, overwhelmed
Depression Statistics
• 6.7% of American adults experience MDD
each year.
• Women are 70% more likely to experience
MDD than men in their lifetime.
• Average age of onset is 32 years.
• 3.3% of 13-18 year olds have experied a
debilitating depressive disorder.
• Non-Hispanic blacks are 40% less likely
than Non-Hispanic whites to experience
depression in their lifetime
DALYs- Disability Adjusted Life Years
The sum of years of potential life lost due to
premature mortality and the years of
productive life lost due to disability.
Ten leading causes of burden of disease,
world, 2004 and 2030
People who have depression along with
another medical illness• Tend to have more severe symptoms of both
illnesses
• Have more difficulty adjusting to their
medical condition
• Have more medical costs
(When compared to people without
depression)
Treating the depression can improve the
outcome of treating the co-occurring illness.
Problems Associated with
Anxiety
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Worry about self, home, job, relationships
Confinement to hospital
Fear of illness effects, need for treatment
Money worries
OCD
Panic disorders
PTSD
Anxiety Statistics
• Anxiety disorders affect 40 million
American adults (18%) each year.
• Women are 60% more likely than men to
experience an anxiety disorder in the
lifetime.
• Non-Hispanic blacks are 20% less likely
than Non-Hispanic whites to experience an
anxiety disorder in their lifetime.
• About 8% of 13-18 year olds have an
anxiety disorder.
• Only 18% of those 13-18 year olds receive
mental health care.
• Symptoms commonly emerge around the
age of 6.
Schizophrenia Statitics
• About 1% of Americans have this illness.
• Men and women are affected equally.
• Rates are similar in all ethnic groups around
the world.
• Usual onset is at ages 16-30.
• Men usually show symptoms earlier than
women.
• People usually don’t develop schizophrenia
after age 45.
• Rarely seen in children, but childhood onset
is increasing.
Psychotic Symptoms
Hallucinations, Delusional Thoughts, Bizarre
Behaviors
• Substance intoxication
• Psychosis in Psychiatric illness
• Dementia
• Delirium
• Substance withdrawal
Agitation
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Patient is yelling, cursing
Patient is combative
Patient is trying to leave the hospital
Patient is violent toward others
Management
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Keep patient and others safe
Treat associated cause
Keep environment calm and quiet
Provide reassurance
Monitor closely
Re-orient patient
Maintain a safe distance from patient when
they are agitated
Tools
• MedicationsBenzodiazepines
Antipsychotics
• Sitters
• Restraints
• Use of protocols
MAT
• MAT assesses patients for transfer to
inpatient psychiatric hospitals.
• MAT is made up of Social Workers
• MAT cannot prescribe medication
• MAT can tell you if a patient meets criteria
for transfer to an inpatient psychiatric
hospital and assist with the paperwork.
• MAT can assist with the EDO process.
DSRIP
(Delivery System Reform
Incentive Payment)
• SW visits patients who are at high risk of
being readmitted in 30 days.
• SW offers the patients to participate in our
program after discharge from the hospital.
• Follow up phone calls for 30 days
• Visit in the home by Nurse Aide with
Facetime visit from Psychiatric APRN.
• SW offers resources to patient in hospital
prior to D/C whether or not they choose to
participate in DSRIP program.
• SW and Psych APRN will see patients not
on DSRIP list if asked to do so.
• All adult patients on MedSurg floors, in
ICU, ED, Obs should have D2S2 screen
done on admission and every 8 days.
Moving Forward
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Communicate
Educate
Disseminate
Represent
ANY QUESTIONS???
THANK YOU!!!