Musculoskeletal/​Neurological/​Psychosocial Study Guide for the CCRN

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Behavioral/Psychosocial

Patients will often present to or develop behavioral and psychosocial concerns while in critical care units. As mental health initiatives come to the forefront of research in medicine, nursing participation in management will become more involved to prevent complications or injury from these conditions. Review the following behavioral and psychosocial conditions, how they affect the patients, treatments for certain conditions, and nursing interventions.

Aggression and Violence

Antisocial behaviors, aggression, and violence may take a variety of forms. Some people retreat and some people fight when faced with adversity, fear, anger, etc. Aggression and violence tend to come from insufficient coping mechanisms and must be addressed. Patients may also be the victim of these behaviors. Review the common conditions involving these negative behaviors.

Domestic Violence

Specific patient injuries can make a nurse more suspicious of abuse than others. In the event that it is uncertain whether or not a patient has experienced abuse, the patient should be questioned in a private, safe space. Treating patient injuries while maintaining a patient’s safety is important throughout the critical care stay. Nurses may implement the help of social workers, psychologists, and community resources to manage these patient cases.

Key injuries that are characteristic of abuse include ruptured eardrums, rectal or genital injury, bites, burns (cigarette and rope included), trauma, numerous bruises in varying levels of healing, and object-shaped welts. When a patient’s story of how an injury occurred does not match the injury pattern, one should suspect foul play.

Observation of the pattern of injury is also important. Injuries that are on the central parts of the body, or a bathing suit pattern, are easy to hide. Head and neck injuries occur in approximately 50% of domestic violence presentations. Bilateral arm and leg injuries are also common if the victim has been bound or grabbed.

Defensive wounds may be present if the victim has resisted their attacker. Common defense wounds include injuries or wounds to the back,soles of the feet, and ulnar aspect of the hand and palm. These injuries can be acquired from turning away from the attacker, crouching on the floor to protect the front of the body/face, kicking and hitting the attacker, or blocking the attacker’s blows.

Violence and Aggression

While patients may be admitted to critical care units for acts of violence and aggression, sometimes the acts themselves are committed within the hospital setting. Early recognition of escalating situations in critical care should be identified to help promote both patient and staff safety.

The definition of violence includes any physical act against something else (an object, animal, or person) with the intent to do harm. Violence can develop in response to a fight or flight reaction, escalating situation, or emotional outburst. It is usually preceded by the offender feeling threatened or insecure. It can also evolve from feelings of fear, frustration, and anger.

Aggression, alternatively, is the verbal or non-verbal communicated threat of violence. It occurs before the act of violence. Aggression may escalate to violence. Nurses must recognize early signs of aggression, like shouting, violent gestures, invasion of personal space, and prolonged eye contact, and act to deescalate the situation before a violent act occurs. Sometimes redirecting and physically removing the patient or staff member from a specific situation is required to neutralize the situation.

Agitation

Critically ill patients can become quickly agitated. Loss of control, pain, drug or alcohol withdrawal, decreased sleep, anxiety, hypoxemia, adverse drug reactions, and electrolyte or metabolic imbalance all contribute to a patient’s behavior. Family members may become agitated as well in the emotionally dense acute care environment.

Delirium is common in critical care patients, as their acute care environments and medications are often disrupted and unfamiliar from their everyday environment. Delirium is defined as changes in cognition that can present as disorientation and/or confusion. Patients with delirium often have disorganized thinking and may experience a decreased or altered level of consciousness. Agitation rises with delirium as patients experience confusion, loss of control, and unfamiliarity with their environment and the people helping them.

Agitation and delirium can have a series of physical effects on patients. These symptoms include increased heart rate, respiratory rate, blood pressure, ICP, and oxygen use. Patients experiencing delirium have difficulty understanding their current situation and may try to leave. Patients may try to disrupt or discontinue IV lines, bed alarms, and other essential medical tubing and equipment. This behavior may cause serious harm to the patient.

Treatment

Close observation of agitated patients is important to promote patient safety. Treating any underlying cause(s) (such as hypotension, sleep deprivation, medication effects, infection, pain, etc.) is essential to regaining normalcy. Medications may be prescribed to manage pain, anxiety, agitation, and harmful behaviors.

Nurses should be proficient in non-pharmacologic measures to de-escalate the situation, including active listening, comfort measures, and limit setting. Patients with concerns for agitation and delirium should have their wake/sleep cycles, timing and effects of their medications, and risk for infection evaluated. Early identification of symptoms promotes earlier interventions/treatments to return patients to a less or non-agitated state.

Suicidal Ideation and/or Behaviors

Suicide and suicidal attempts happen for a variety of reasons. Patients with severe depression, social isolation, bereavement, psychotic disorder, and those experiencing situational crises are at high risk for suicide ideation and behaviors. Patients who become increasingly hostile, have difficulties with peer relationships, and have extreme stress should also be monitored.

In many facilities, a suicide and depression assessment tool may be given to patients to determine their risk for suicide ideation and attempt. Tools such as the PHQ, SAFE-T, C-SSRS, and ASQ are commonly used. Patients with histories of suicide ideation and attempt are more likely to have repeat occurrences.

Nurses should take all suicide talk seriously. In an acute care facility, individual 1:1 surveillance of the patient should be implemented. Any harmful or potentially weaponized objects, such as sharps, cords, breakaway walls, rails, and shower heads, should be removed from the patient’s room. Patients should be only allowed to have plastic silverware and disposable plates during their stay. Upon discharge, family and community resources should be used to help promote patient safety through the post-acute phases. Sometimes, admission to a long-term psychiatric health facility may be required.

Mood Disorders, Depression, and Anxiety

Mood disorders can affect numerous patients. Complications from these conditions may cause or complicate acute care. The most common mood disorders include:

  • Major depressive disorder— Characterized by abnormally, overwhelmingly sad feelings that occur almost daily for at least two weeks. Symptoms include hopelessness, worthlessness, dejection, emptiness, and melancholy that often exceed the causing factors. A combination of both cognitive behavioral therapy and pharmacologic therapy may be used to treat depression. The most common pharmacologic antidepressants fall within the categories of: SSRI, SNRI, tricyclic antidepressants, and MAOI.

  • Bipolar disorder— Classified by periods of mania and depression that cycle and symptoms persist most every day. Common symptoms include insomnia, irritability, energy disturbances, decreased focusing ability, erratic speech, racing thoughts, impulsive and risky decisions, and difficulty maintaining relationships. Hospitalization may be required for both severe manic and depressive episodes. Mood stabilizers should be used to maintain patient equilibrium.

  • Generalized anxiety disorder— Defined as constant worry or anxiety over daily activities and events. Symptoms include restlessness, fatigue, muscle tension, decreased concentration, irritability, and sleep disturbance. Anxious feelings in this condition often exceed the situation that warrants the patient’s feelings. Patients with GAD may also have depression and substance abuse. Cognitive behavioral therapy and relaxation techniques may be implemented to reduce symptoms. When nonpharmacologic medications do not resolve this condition, medications such as anxiolytics, sedatives, and antidepressants (SSRIs and SNRIs) may be used.

  • Dysthymic disorder— Type of chronic depression with symptoms of lowered, darkened, and sad mood almost daily for over two years. Treatment is similar to those with major depression and focuses on the use of antidepressants and counseling/psychotherapy involvement.

Patients with these conditions are more likely to be admitted to health facilities and have a higher risk of substance or alcohol misuse. Nurses should monitor patients for acute changes in mental stability and any risk for suicidal thoughts or actions. Ensure the medications that these patients take are continued throughout their hospital stay, as many have severe adverse reactions if stopped suddenly. Patients should be evaluated for effectiveness of therapy and any concerns with medication or cognitive behavioral therapy changes that occur throughout the hospitalization.

Medical Non-Adherence

Medical non-adherence can present numerous issues for patients. It can be defined as a person’s willingness or unwillingness to participate in recommendations given to them by a healthcare provider based on their health conditions. This can revolve around behaviors of diet, activity, and medication regimens. Failure to comply with health recommendations can result in higher readmission rates and failure of therapies.

Causes

Reasons for medical non-adherence include difficult therapy instructions, perceived ineffectiveness of therapy, adverse reactions or side effects to medication, and cost of therapy. Patients, especially elderly patients, may have difficulty remembering which medications to take when. Barriers to lifestyle modifications may include financial and accessibility constraints.

Reducing the Incidence

Nurses should provide patient instructions both verbally and in writing. When possible, discussing discharge and medication instructions should occur with the patient and another caregiver or family member. Family and friend support greatly increases a patient’s adherence to prescribed therapies. Instructions should be written simply, in a way that even a child could understand. Follow-up appointments should be scheduled prior to the patient leaving the facility, and phone calls to check in on regimen adherence may help patients stay on track.

Restraints

Some patients may experience acute disturbances that can be dangerous to themselves or others. This may fall within the realm of medical non-adherence or defiance. At times, patients may need to be restrained to stop patients from self-harm or harm to others. Two types of restraints exist: behavioral restraints and clinical restraints.

Typical Use

Patients in psychiatric units or those who present with aggressive behaviors due to drug use or alcohol intoxication may need to have behavioral restraints placed. Patients who experience delirium, have a developmental delay, or are agitated and a danger to their medically necessary equipment (IV lines, endotracheal tubes, chest tubes, surgical sites, etc.) may need to have clinical restraints implemented.

Procedures for Use

Each acute care facility should have protocols in place regarding restraint use, charting requirements, and discontinuation measures for restraints. At minimum, assessment of patients in restraints must occur every 1-2 hours. Patients in behavioral restraints should have the restraints removed, patient assessed, and restraints reapplied as necessary every hour. Patients should be restrained with the least amount of equipment possible and have them removed as soon as patient and staff safety has been secured. Restraints must also be a last-case resort for patient safety. Other therapies such as medications, psychotherapy, and de-escalation techniques must be tried first.

Chemical Forms

Patients may also need chemical restraint. Chemical restraint comes in the form of pharmacologic sedatives to manage a patient’s behavior. It is only indicated in the event of severe violence or agitation where risk of injury is elevated. These medications stop or reduce physical movement. Benzodiazepines and antipsychotic medications are the most commonly used medications in this situation. Medications may be given orally (preferred), intramuscularly, or intravenously. The use of these medications should be reserved for events not otherwise able to be managed with more conservative measures.

Post-Traumatic Stress Disorder (PTSD)

PTSD is defined as an event that occurs when patients re-experience trauma that has occurred in the past. These events can be extremely distressing to the patient. Patients will often resist situations in which their PTSD may be triggered. Nurses must also understand common triggers and de-escalation techniques to maintain patient safety.

Symptoms and Diagnosis

Symptoms of PTSD include difficulty sleeping, mood swings, emotional lability, difficulty concentrating, and difficult memory recollection. Untreated PTSD can significantly impact a patient’s life. Nightmares, flashbacks, hyperarousal, avoidance, and negative view of self and others may occur. Diagnosis of PTSD can be given after psychological assessment. Criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) must be followed for the formal diagnosis.

Treatment

Treatment of PTSD is patient specific. However, general therapies include pharmacologic management such as anti-anxiety and anti-depression medications, as well as psychotherapy. Non-pharmacologic measures of treatment include group or individual therapy, cognitive behavioral therapy, anxiety and deep breathing exercises, and hypnosis.

Risk-Taking Behaviors

Patients with mental health disorders and teenagers can struggle with making appropriate choices with regard to risk. Risk-taking behaviors are also exemplified in patients with depression, anxiety, bipolar, personality disturbances, drug dependence, alcohol abuse, and traumatic brain injury. Nurses should help to identify patients at high risk for disordered thinking patterns. Questionnaires, patient interviews, personal testaments, and psychological evaluation can help with this evaluation.

Common risk-taking behaviors include drug use, alcohol abuse, high-risk sexual behaviors, high speed driving, impaired driving, and violence. Patients with higher inclination of risk-taking behaviors may show signs of impulsivity and attention or sensory seeking. Safety measures should be implemented in acute care facilities to prevent patients from self-harm and injury.

Substance Dependence or Abuse

Substance dependence and abuse plague many people. Patients that present to acute care facilities may be doing so due to their drug or alcohol dependence. These dependencies may also complicate their hospitalizations due to alternate conditions. Serious effects of acute withdrawal may occur and nurses must be aware of the signs and symptoms of these.

Withdrawal

Withdrawal from substances, especially alcohol, can become extremely dangerous in patients. Symptoms of alcohol withdrawal include anxiety, tachycardia, headache, sweating, agitation, hallucinations, behavior disturbances, and psychotic behavior. It usually occurs in patients with chronic alcohol abuse where a physical dependency on alcohol has formed. Patients with untreated withdrawal symptoms have increased mortality reaching up to 35%. Even with treatment, approximately 5-15% of patients with alcohol withdrawal will succumb to symptoms.

Pharmacologic treatment of alcohol withdrawal include use of IV benzodiazepines and electrolyte and nutritional replacement. Patients must have their behavior controlled and symptoms reduced to prevent escalation and self-harm. Magnesium and thiamine are often low in patients with chronic alcohol abuse and will need to be replaced. The CIWA scale may be used in acute care facilities to determine the extent of a patient’s withdrawal and will have treatment guidelines directed based on their results. Limiting external stimulus can help to prevent agitation and escalation. Finally, patient safety measures such as padded railings and floors, removal of harmful objects, and reduction of obstacles in the patient’s room should be implemented.

Prevention of withdrawal is important to reduce symptoms and mortality of withdrawal. All patients admitted to acute care facilities should have their alcohol use assessed via a questionnaire, such as the CAGE assessment. Providing patients with comfort and support during this time may improve symptoms and reduce escalation. After patients have had resolve of withdrawal symptoms, alcohol and drug use education should be provided.

Drug-Seeking Behavior

Nurses should monitor patients for drug-seeking behavior. Drug-seeking behavior is a sign of drug dependence or abuse. The most common medications sought include opioids and benzodiazepines. Some antipsychotic medications such as quetiapine and olanzapine may also be sought. Prescription stimulants such as dexamphetamine and methylphenidate are also included in this group.

Common symptoms of drug-seeking behavior include aggressively asking for specific medications or complaining about the need for a medication, asking for brand name medications, requesting dosage increases, anger or irritability when questioned about medication use, claiming allergies to alternate drugs, hoarding medications, using medications for “off-label” uses, visiting multiple healthcare facilities and prescribing providers for the same prescription, calling for early refills of medication, unwillingness to stray from requested therapy, and patterns of lost or misplaced prescriptions.

To help curb drug-seeking behavior, nurses must work with the prescribing provider to have both pharmacologic and nonpharmacologic measures in which to manage the patient’s symptoms and medical conditions. Establishing limits on medications, preventing excessive pain, and encouraging open communication with all healthcare teams and prescribing providers for each patient can help to avoid misuse of medication.

Chronic Drug Dependence

Chronic drug dependence and substance abuse are medical conditions often hidden by patients when giving their medical history. Patients may present to an acute care facility due to symptoms related to their substance abuse or with conditions unrelated to their use. Common medical conditions may be exacerbated due to the interaction with substances used, and nurses should be aware of symptoms of both drug-seeking and withdrawal as described previously.

Signs of patients with concern for substance abuse may include both physical and behavior indicators. Common physical indications include numerous burns on fingers or lips, skin breakdown (e.g., needle tracks) on forearms or legs, pupil abnormality, abnormal speech patterns, decreased coordination, repeated sniffing or snorting, nose bleeds, weight loss, pallor, and dysrhythmias. Behavioral signs of substance abuse include smell of alcohol or marijuana on clothing or breath, emotional lability, agitation, anger, inappropriate acting, impulsiveness, lying, difficulty concentrating, memory loss, insomnia or excessive sleeping patterns, confusion, decreased personal hygiene, and missing scheduled appointments.

Patients with chronic drug dependencies should be educated on and provided resources to stop drug abuse. Involvement of social work, external rehabilitation facilities, and community support groups may be beneficial to patients.

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