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Behavioral health patients with comorbidities present special challenges

Monday June 4, 2012
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Kate Enright, RN, BSN, ED manager at Lenox Hill Hospital in Manhattan, N.Y., said her staff often see patients with both mental health and medical issues. But knowing which treatment takes precedence and effectively caring for and stabilizing these patients in a busy ED can be challenging.

"We tend to see a lot of patients that could be nondomicile, [with] underlying schizophrenia or substance abuse, who come in quite sick, medically," Enright said. "And sometimes the underlying psychiatric issue can overcome the medical situation."

Carleigh Gustafson, RN, BSN, director of emergency nursing at Lenox Hill, recalls a recent ED patient who had a strong psychiatric history. It appeared that she might be going through an acute episode of schizophrenia, as she came in scattered and disorganized.

"However, there was much more going on with her," Gustafson said. "The mental confusion that we were seeing really wasnít the flight of ideas or anything related to schizophrenia. It was more due to the underlying condition: she was septic, which also can alter mental status."

These patients are particularly challenging if the ED does not have a psychiatric bay or beds dedicated to psychiatry, said Benjamin Evans, RN, DNP, APN, PMHCNS-BC, associate vice president of behavioral health services at Bergen Regional Medical Center in Paramus, N.J.

"Psychiatric patients may be in any phase of their illness, from being mildly depressed to floridly psychotic acting out, which then is disruptive to the whole ED area and other patients who might not be there for psychiatric reasons," Evans said.

Like the general population, patients with psychiatric problems are aging and experiencing cardiovascular disease, obesity, diabetic conditions and more, Evans said.

However, how nurses and other staff manage these diseases often is affected by the underlying chronic mental illness, said Patricia Schepis, RN, MS, BC, director of staff education at Carrier Clinic in Belle Mead, N.J.

"Compliance with their regular medications — even blood pressure medications — might be the last thing on their minds if theyíre depressed or suicidal," Schepis said.

Steps toward better care

Good medical histories are paramount in the care of these patients, Evans said.

"If the patient has been seen at the facility before, there needs to be a quick review of [the] past medical history so that something is not missed," Evans said. "I get it that in a busy ED today, thatís not always possible, and patients can be poor historians, but we need to get as much information about underlying medical conditions as possible."

Nurses who cannot get adequate information from patients should turn to secondary sources, such as medical records, paramedics or others who may have brought them to the ED — even community caseworkers.

To better manage these patients and anticipate care challenges, Lenox Hill ED triage nurses are trained to screen all patients to identify acute psychiatric components early on.

"That is done, as well as screening them for any acute medical issues that are going on at the time," Enright said.

ED nurses follow up by performing psychiatric and medical screenings simultaneously to better pinpoint the true cause for the ED visit, Enright said.

Care transitions

ED nurses deal with the emergency components of caring for these patients before moving the patients to the next care level, Enright said.

"Patients are stabilized, and a full medical clearance is completed to make sure we put them in the best location to be able to continue that care," Gustafson said. "For example, if a patient was found to have a primary medical diagnosis with psychiatric manifestations of their primary condition, they would be treated on a medical unit [and] the psychiatric care would be brought to that patient. If a patient was medically cleared, physiologically, we would bed that patient for inpatient therapy on the psychiatric unit so we could just really focus on that primary diagnosis."

Good medical clearance is required before sending patients who have had acute medical issues to behavioral health units, Evans said. Without a good medical clearance, these patients might be sent to a behavioral health unit with underlying medical issues, requiring a quick turnaround to a med/surg or ICU unit.

"If staff hasnít done a good screening, then they may miss things, like elevated blood sugars," Evans said. "In some instances, a hypertensive crisis has been attributed to [a patientís nervousness from] being in the ED, and a dose of antihypertensive is given and the patient is shipped to a behavioral health unit. Of course the medicine is out of their system in a few hours, and theyíre back in a hypertensive crisis."

Medical stability is important because patients in the behavioral health unit need to be able to participate in treatment, Schepis said.

"Obviously, we treat the whole person. If theyíre diabetic or have hypertension, whatever illnesses they come to us with, we deal with their illnesses, but they need to be stable in order to benefit from the psychiatric treatment," Schepis said.

Ensuring staff safety

When dealing with psychiatric patients, nurses should keep in mind that they can be unpredictable, Schepis said.

"They can have outbursts. There sometimes can be unpredictable bouts with aggression, acting out violence, impulse control — all those kinds of things," Schepis said. "Our whole mission is to treat the whole patient [by] getting to know the condition, getting background from their family, understanding precipitating circumstances."

Nurses need to be aware of changes in behavior or status among psychiatric patients in the ED, Gustafson said.

"We make sure that all psychiatric patients are observed for safety ... so the nurse knows if the patient is becoming a little more agitated or if ... thereís a change in the condition," Gustafson said.

Picking up on early warning signs is key not only for staff safety, but also for optimal patient care, Enright said. Earlier interventions, such as creating diversions or reassuring patients, are better than having to take more extreme measures, such as medicating the patient.

Evans recommends nurses caring for these patients remain firmly grounded, calm, directive and nonconfrontational.

"They donít have to believe everything that the patient says, but you donít negate what the patient is saying. You donít argue with the patient," he said.

Keen assessment

The nurseís best approach with behavioral health patients who have comorbidities is to make a keen assessment, Gustafson said.

"You really have to think differential diagnosis ... and not anchor into that psychiatric diagnosis," Gustafson said.

That, Enright said, requires the nurse to listen to the patient, as well as to perform a thorough physical assessment.

Another requirement for nursing: be nonjudgmental, said Deveka Montalvo, RN, MSN, Lenox Hill Hospitalís nurse educator.

"Look at your own biases and donít impose those on your patientsí conditions," Montalvo said.


Lisette Hilton is a freelance writer. Send letters to editorNY@nurse.com or post a comment below.