Mental Health: Agitation and Risk of Violence in the Emergency Department
A 28-year-old man is brought to the emergency department by police after he was found wandering in the street, yelling at strangers, and appearing disoriented. He has a known history of schizophrenia but has not taken his medication for 2 weeks. On arrival, he is agitated, pacing, and refusing to answer questions. He appears to be responding to internal stimuli (talking to himself, looking around as if hearing voices). His vital signs are: temperature 37.2°C, heart rate 110 bpm, blood pressure 140/90 mmHg, respiratory rate 22 breaths/min. He is sweating profusely. The triage nurse notes that he has a strong body odor and is wearing dirty clothes. He suddenly raises his voice and clenches his fists when asked to sit down.
1. What is the priority nursing assessment and intervention at this moment?
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The priority is safety for the patient and staff. The nurse should:
- Ensure a safe environment: Remove potential weapons, keep a clear exit path, and call for security if needed.
- Use de-escalation techniques: Speak calmly, maintain a non-threatening posture, give personal space, and avoid arguing with delusions or hallucinations.
- Assess for medical causes: Agitation can be due to medical conditions (e.g., hypoglycemia, hypoxia, infection, substance withdrawal). Check vital signs, glucose, and consider urine toxicology.
- Administer medications as ordered: If the patient is a danger to self or others, antipsychotics (e.g., haloperidol, ziprasidone) or benzodiazepines may be needed.
- Document: Record all observations and interventions. The nurse should not turn their back or make sudden movements. If the patient becomes violent, follow the facility's code response.
2. What factors suggest a medical cause for his agitation rather than purely psychiatric?
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Factors suggesting a medical cause include:
- Sudden onset of agitation in a patient with known schizophrenia but who is off medication could be psychiatric, but medical causes must be ruled out.
- Vital signs: Tachycardia (110), hypertension (140/90), and sweating could indicate stimulant intoxication, alcohol withdrawal, or infection.
- Disorientation: He is disoriented, which is not typical of schizophrenia alone (unless severe).
- Poor hygiene: May indicate neglect or inability to care for self, but also could be due to homelessness.
- Sweating and body odor: Could be due to withdrawal or poor hygiene. The nurse should obtain a full set of vitals, point-of-care glucose, and consider infection (e.g., UTI, pneumonia) or substance use. Delirium is a medical emergency.
3. The provider orders haloperidol 5 mg IM and lorazepam 2 mg IM. What are the nursing considerations before administering these medications?
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Before administering:
- Verify orders: Check dose, route, and patient allergies.
- Assess for contraindications: Haloperidol is contraindicated in Parkinson's disease, QT prolongation, and CNS depression. Lorazepam is contraindicated in severe respiratory insufficiency and acute narrow-angle glaucoma.
- Obtain baseline vitals: Especially BP, HR, and respiratory rate. Both can cause hypotension and respiratory depression.
- Check ECG if possible: Haloperidol can prolong QT interval.
- Consent: In an emergency, if the patient lacks capacity and is a danger, medication can be given without consent per facility policy and local laws.
- Prepare for adverse effects: Dystonia, akathisia, neuroleptic malignant syndrome (NMS) with haloperidol; respiratory depression with lorazepam.
- Document: Reason for use, dose, time, and patient response.