Continuing Education Series No.

40

Nursing Management of Patients with Psychiatric Emergencies

Aruna Gnanapragasam1, Dani Paul2, Jeeva Sebastian1, Manoranjitham Sathiyaseelan3
1
Reader, Junior Lecturer, Professor and Head, Department of Psychiatric Nursing, College of Nursing, Christian Medical College, Vellore, Tamil Nadu, India
2 3
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Abstract
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Psychiatric emergencies are situations in which individuals’ thoughts and behaviours are acutely altered causing potential or actual risks to
the life of the person or others in the environment. Prompt identification and appropriate interventions will reduce the mortality and disability
caused due to psychiatric emergencies. This article reviews the major psychiatric emergencies such as suicide, violence, delirium tremens,
stupor and drug‑related emergencies and highlights the nursing care of patients with these psychiatric emergencies.

Keywords: Delirium, drug‑related emergency, emergency, nursing management, psychiatry, stupor, suicide, violence

Introduction Definitions
Suicide is the death caused by self‑directed injurious behaviour
The psychiatric emergencies are acute disturbances in thought,
with any intent to die as a result of the behaviour, whereas
behaviour, mood or social relationship that requires immediate
attempted suicide or suicide attempt is a nonfatal self‑directed
interventions; if untreated can cause harm to either the
potentially injurious behaviour with any intent to die as a result
individual or the others in the environment. Of all emergencies
of the behaviour. A suicide attempt may or may not result in
reported in India, psychiatric emergencies contribute around
injury.[5]
9%.[1] Major emergencies are those which pose danger to the
life of the patient or the others in the environment and minor Methods of suicide attempt
emergencies are those when there is no threat to life but leads • Physical attempts (jumping from heights, drowning,
to incapacitation.[1] In this article, the authors discuss the injuring self by cutting the throat and wrist and hanging)
major life‑threatening psychiatric emergencies and the nursing • Attempts with the help of noxious chemicals, poisons and
management. The following conditions are considered as sleeping tablets.
emergency in psychiatric settings:
• Suicide Psychiatric conditions where suicide is common
• Violence • Acutely depressed clients, clients with schizophrenics
• Delirium tremens who constantly ruminate over suicide
• Stupor • Hysterical states, alcohol and substance abuse, personality
• Drug‑related emergencies. and character disorders.[6]

Suicide/Attempted Suicide Address for correspondence: Mrs. Aruna Gnanapragasam,

Suicide is a major public health concern in many developing Department of Psychiatric Nursing, College of Nursing, Christian Medical
College, Vellore, Tamil Nadu, India.
countries. It contributes to premature mortality accounting E‑mail: [email protected]
for over 800,000 deaths worldwide ever year.[2] The suicide
rate in many western countries is between 8 and 30 per
100,000 population with a recent increase in suicide among Submitted: 05‑May‑2021 Revised: 20‑May‑2021
young men.[3] Several investigators have studied on suicide in Accepted: 28‑May‑2021 Published: 07-Jul-2021
different parts of India, using police records, and have reported
that suicide rates vary from 6.8 to 58.3 per 100,000 population.[4] This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
Access this article online remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
Quick Response Code: is given and the new creations are licensed under the identical terms.
Website: For reprints contact: [email protected]
www.ijcne.org

DOI: How to cite this article: Gnanapragasam A, Paul D, Sebastian J,

10.4103/ijcn.ijcn_40_21 Sathiyaseelan M. Nursing management of patients with psychiatric
emergencies. Indian J Cont Nsg Edn 2021;22:80-92.

80 © 2021 Indian Journal of Continuing Nursing Education | Published by Wolters Kluwer - Medknow
 Gnanapragasam, et al.: Psychiatric Emergencies

Risk factors for suicide Biological theory of suicide

The factors that increase the chance of attempting or Recent studies with suicide attempters have focused on the
considering suicide are as follows[6] genotypic variation in the gene for tryptophan hydroxylase, with
• Previous suicide attempt(s) and history of mental results indicating significant association to suicidality.[13] Some
disorders, particularly depression studies have revealed a deficiency of serotonin in depressed
• History of alcohol and substance abuse, family history of clients who attempted suicide.[14]
suicide and child maltreatment
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Assessment and management of suicide

• Impulsive and aggressive tendencies, barriers to accessing Suicide‑related death is considered more preventable than any
mental health treatment[7] other death. The patient who is self‑destructive needs close
• Financial loss, relationship loss, work loss and physical observation and active listening. It is acceptable to ask few
illness
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questions regarding suicide clues and motive for suicide which

• Easy access to lethal methods, local epidemics of suicide will give information regarding the specificity of the plan and
• Isolation, a feeling of being cutoff from other people.
its degree of lethality. The assessment tool SAD PERSONS
Access to the method of suicide is an important risk factor Scale is often used to determine the suicide intent.[15]
for and determinant of suicide. The method used depends on
Nursing management of suicidal individuals
the availability of the means and the individual motivation
The aim of the management is to prevent individuals from
to kill oneself. Pesticides are the most common method in
hurting themselves and promoting coping and a sense of
India, so attention should be focused on reducing the access
inclusiveness.
to pesticide.[8]
Objective: To promote safety and prevent injury/death
Warning signs
An individual in a severely disturbed status, with acute thoughts
There are some definite warning signs of suicide which
of suicide, needs to be hospitalised for further management.
indicate the intention of suicide in a person. They may include,
Therefore, the individual and the family should be explained
appearing depressed or sad most of the time, feeling hopeless,
about the need for hospitalisation. In the inpatient facility, the
expressing hopelessness, withdrawing from families and
person should be provided with a safe environment to avoid
friends, sleeping too much or too little, feeling tired most of
any triggers for suicide and also a suicidal attempt.
the time, making overt and covert statements, writing poems or
1. Establish a safe environment:
notes about suicide or death, losing interest in most activities
• Constant/close observation (round the clock
and giving away prized possessions.[9]
vigilance)
Theories of suicide • Take all suicidal threats or attempts seriously and
Sociological theory of suicide notify the psychiatrist/physician immediately
Durkheim[10,11] categories the types of suicide based on an • Do not leave the drug tray within the reach of the
individual’s integration into society, the types are as follows patient
1. Egoistic – It is the result of too little social integration, • Make sure that the drugs administered are swallowed
for example, suicide of a retired elderly widower • Remove objects or items that could be used to inflict
2. Altruistic – The consequence of excessive integration, for self‑injury (e.g., knives, medications and razors)
example, the death of a child which is viewed as more • Remove the bolts of the room/toilet/bathroom.
stressful/leading to suicide in parents following severe 2. Recognise changes in mood or behaviour that could
depression indicate a plan for self‑injury including assessment for
3. Anomic – It results from too little regulation or the warning signs of suicide
shattering of one’s ties with the society, for example, 3. Assist in meeting the basic needs of the patient so there
divorce or unemployment is constant but subtle supervision
4. Fatalistic – This form is the result of excessive regulations 4. Obtain ‘NO SUICIDE’ contract with the patient.
coupled with high personal needs to control one’s A written contract stating that when suicidal thoughts
environment, for example, when a highly motivated occur, the patient will approach the healthcare members
college student takes his own life upon failing in an instead of acting upon it
internal examination. 5. Assist in specific psychiatric treatment that includes
psychotropic drugs, electroconvulsive therapy and
Psychological theory of suicide psychotherapy
Sigmund Freud believed that suicide was a response to the
6. Encourage individual to involve in an activity which is
intense self‑hatred that an individual possessed.[12] Freud
an outlet for tension and anger.
believed that suicide occurred as a result of an earlier repressed
desire to kill someone else. He interpreted suicide to be an Objective: To improve social interaction and support
aggressive act towards the self that often was really directed 1. Assess the non‑verbal and verbal communications of the
towards others. patient

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 Gnanapragasam, et al.: Psychiatric Emergencies

2. Make frequent, brief visits and develop rapport situational and structural factors contributing to the occurrence
3. Stay with the patient even when the patient is not of violence. Increased levels of dopamine and decreased levels
communicating of norepinephrine and serotonin are associated with irritability
4. Use short sentences and open‑ended questions to and associated behaviours.[14]
communicate
5. Initially talk about topics of the patient’s interest
Risk factors
There can be diverse ways of communicating an individual’s
6. Introduce other staff and patients in the ward to the patient
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anger or aggression, some characteristics that can help identify

7. Encourage the patient to participate in milieu activities.
violence or otherwise called as the cues of violence are
Objective: To improve coping of individual and family • Pacing, restlessness
1. Assess and identify coping mechanisms used in the past • Tense facial expression and body language
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by the patient and the family • Verbal or physical threats

2. Encourage open expressions of feelings and listen • Loud voice, shouting, use of obscenities and argumentative
attentively • Threats of homicide or suicide
3. Teach adaptive coping skills such as diversional techniques • Increase in agitation, with overreaction to environmental
and problem‑solving skills stimuli
4. Spend time with the patient and family members and • Panic anxiety, leading to misinterpretation of the
enhance the family and social support system. environment
• Disturbed thought processes, suspiciousness
Objective: Injury actual related to attempted • Angry mood, often disproportionate to the situation.[6]
suicide (inpatient setting)
1. Assess for vital signs While assessing the risk factors of violence, one must consider
2. Check airway, if necessary clear airway the following three factors:
3. Start IV fluids, if pulse is week 1. Past history of violence, which is considered as the major
4. Emergency measures in case of self‑inflicted injuries risk factor. Peter also describes violence was repetitive
5. Shift the patient to medical emergency service if further in his study[22]
interventions are needed. 2. Client diagnosis, patients who get violent are usually
those who are diagnosed with a psychiatric illness such as
schizophrenia, those who are deluded and hallucinated[22]
Violence 3. Current behaviour.[6]
Introduction
In general, male gender, patient’s with psychiatric illness,
The term violence came from the Latin word called ‘Violentia’.
especially schizophrenia, substance use and when there is
Violence is something that has been for ages, and has been
past evidence of violent behaviour might be some factors
a part of expression of an individual’s emotional outburst.
that precipitate violence.[18] Aggression is more connected
Anger is expressed in varied ways which if not controlled
with younger age, male gender, admission under involuntary
can be expressed as violence. Violence is a severe form of
consent, being single, having diagnosed with schizophrenia,
aggressive behaviour.[6] Nurses are one of the common victims
multiple previous admissions, past history of violence, history
of violence in healthcare settings, especially psychiatric units.
of self‑injurious behaviour and the use of substance.[23]
A study done in Saudi Arabia reports that 81.3% of nurses were
exposed to violent behaviours by the psychiatric patient[16] and Diagnosis
many a time, patient’s relative become victims too.[17] It is Violence being an acute phenomenon cannot be diagnosed
understood that 20% of patients admitted in emergency service by fixed criteria. The cues of violence can be part of the
of psychiatric units might show a behaviour of violence.[18] assessment. Diagnosis can be possible depending on the history
and physical examination.
Definition
Oxford dictionary defines violence as ‘Behavior involving History in aspects of physical abuse would disclose
physical force intended to hurt, damage, or kill someone or non‑accidental physical injury as a result of punching,
something’ or as ‘Strength of emotion or of a destructive beating, kicking, biting, shaking, throwing, stabbing, choking,
natural force’ [19] In psychiatry, violence is an extreme hitting and burning. Emotional abuse would be demeaning
form of aggression as defined by American Psychological or rejecting the victim, ignoring or blaming the victim,
Association[20] which is exhibited in the form of assault, rape isolation from normal routines, use of harsh and inconsistent
or murder. Reiss and Roth[21] defines violence as ‘behaviors discipline.[6]
by individuals that intentionally threaten, attempt or inflict
physical harm on others’.
Management
The first step to manage violence is de‑escalation,[24] if not
Pathophysiology responding to de‑escalation, then some common ways to
Violence may not always have a specific cause, it might be manage physical violence are seclusion, use of restraint both
an interface of several types of influences such as individual, physical and chemical and forced medication.[25]

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 Gnanapragasam, et al.: Psychiatric Emergencies

When an individual is restrained, ensure their hydration and Mechanism of action

nutritional status is kept to optimal status. Keep environment Lithium is a powerful anti‑manic (mood stabilising) drug used
safe from hazardous equipment.[24] in the management of manic episodes of bipolar disorder,
Other common interventions could be schizoaffective disorder, cyclothymia, adjuvant in refractory
1. Providing a safe house or shelter depression and prophylaxis of bipolar mood disorder. The
2. Rendering psychosocial therapies such as individual action of lithium is not known and not clearly understood. The
psychotherapy, family therapy, cognitive therapy and probable action can be by increasing the pre‑synaptic re‑uptake
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milieu therapy.[6] of catecholamine and blocking the release of catecholamine at

synapse. It also reduces the post‑synaptic serotonin receptor
Nursing management sensitivity.[24]
Nursing diagnosis: risk for violence directed towards self or
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others related to command hallucinations, manic excitement Dosage and therapeutic levels
and delusional thinking. The dosage is usually 900–2100 mg/day. Lithium has a very
narrow therapeutic index. Therapeutic level in the treatment
Objective: Patient will not harm self or others in the of acute mania is 0.6–1.2 mEq/L. The prophylactic level is
environment 0.6–1.0 and >2 mEq/L is considered to be toxic.[26]
1. Maintain low level of stimuli in patient’s environment (low
lighting, few people, simple decor and low noise level) Aetiology of lithium toxicity
2. Observe client’s behaviour frequently even while carrying 1. Excessive intake: When patients take increased number of
out routine activities tablets accidentally or with an intention to attempt suicide
3. Remove all dangerous objects from patient’s environment and while patients are on long‑term lithium treatment and
4. Intervene at the first sign of increased anxiety, agitation the dosage is adjusted as part of treatment.[28]
or verbal or behavioural aggression Impaired excretion: The factors that reduce the sodium
5. Offer empathetic response to the patient’s feelings level and the cause fluid deficit such as vomiting, diarrhoea,
6. Offer some alternatives: to participate in a physical febrile illness, renal insufficiency, excessive exercise, water
activity (e.g. punching bag and physical exercise), talking restriction, excessive sweating, low sodium diet and congestive
about the situation heart failure impair the excretion of lithium. A reduction in
7. Administer medications such as injection haloperidol GFR due to aging and drugs can also impair the excretion of
25–50 mg IM or injection lorazepam 1–2 mg IM as lithium from blood causing a raised serum lithium levels. Drugs
prescribed such as nonsteroidal anti‑inflammatory drugs, angiotensin‑I
8. Use physical restraints if needed and observe at least every converting enzyme inhibitors and thiazides that affect the renal
15 min to ensure that circulation to extremities is not function also impair the excretion of lithium.[30]
compromised (check temperature, colour and pulses); to
assist the client with needs related to nutrition, hydration Types of lithium toxicity
and elimination and to position the client so that comfort • Acute toxicity – It occurs when a person takes excessive
is facilitated and aspiration is prevented amount of lithium drug accidently or purposefully
9. Remove one restraint at a time while assessing the client’s • Chronic toxicity – It occurs when a person takes a little
response.[6] extra dose daily for a long time
• Acute‑on‑chronic toxicity – It occurs when a person is
Drug‑related Emergencies on lithium for a long time and takes one drug extra either
accidentally or purposefully.[31]
The common and severe drug‑related emergencies are
discussed below. Symptoms of lithium toxicity
Symptoms of toxicity varies with serum lithium levels[12]
Lithium toxicity 1. 1.5–2.0 mEq/L: Individuals may present with blurred
Lithium is a smallest alkali ion discovered by Arfueson in
vision, ataxia, tinnitus, persistent nausea, vomiting and
1817, used in the management of Gout.[26] The use of lithium
severe diarrhoea which may indicate rising lithium levels
in the management of patients with mania was approved by the
2. 2.0–3.5 mEq/L: A serum lithium level of above 2 is
US Food and Drug Administration (FDA) in the year 1970.[27]
serious and causes many adverse effects. Individuals
Pharmacokinetics may complain of excessive urine output, dilute urine,
The drug is available only as an oral preparation. It is absorbed increasing tremors, muscular irritability, hyper‑reflexia,
rapidly from the gastrointestinal tract and the peak serum levels psychomotor retardation and mental confusion
achieved within 30 min to 3 h.[26] The half‑life of lithium single 3. >3.5 mEq/L: This level can be lethal and may cause death
dose ranges from 12 to 27 h. As it is not protein bound, the if not identified early. Impaired consciousness, nystagmus,
95% is excreted through the kidneys,[28] and it is filtered at the seizures, coma, oliguria/anuria, arrhythmias, myocardial
rate of glomerular filtration rate (GFR).[29] It crosses placenta infarction and cardiovascular collapse are manifestations
and is secreted in breast milk. seen when lithium levels are dangerously high.

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 Gnanapragasam, et al.: Psychiatric Emergencies

Treatment pelvic musculature. Opisthotonus occurs when the whole

There is no specific antidote for lithium toxicity, if untreated, body is involved and the patient arches on the bed. Laryngeal
it may be life‑threatening. The following treatment would dystonia/laryngospasm is a rare but serious side effect
reduce the adverse effects and may help in preserving characterised by dysphonia and stridor. In pseudomacroglossia,
life.[28] The objective of the intervention is to hasten maximum tongue swells and protrudes.[30,31,34]
elimination of the drug from the body as early as possible and
Treatment
stop worsening of patients’ condition
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Specific drugs help in controlling and relieving the

• Withhold the drug until there is clinical improvement in
symptoms.[33,35] Patients generally respond within 15–30 min
a patient and the serum concentration of lithium is within
after the administration of drugs. Anticholinergic drug, Injection
the therapeutic range[32]
benztropine 1–2 mg IM/slow IV is given initially and can be
• The first step is to assess and stabilise circulation, airway
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continued as a oral dose of 1–2 mg twice a day for 2 days to

and breathing, if a patient presents with altered mental
prevent recurrence. Antihistamine, Injection diphenhydramine
state
1–2 mg/kg IM/slow IV needs to be administered in the acute
• Hydrate with isotonic saline to ensure maximum
phase and can be continued as oral dose every 6 h for 1–2
elimination of lithium
days to prevent recurrence of symptoms. Also, injection
• Gastric lavage in case of acute intoxication
promethazine 25–50 mg IV/IM can be administered. If patients
• Bowel irrigation using polyethylene glycol for sustained
do not respond to anticholinergic drugs, benzodiazepines can be
release drugs
used. IV or IM lorazepam at 0.05–0.10 mg/kg or IV diazepam
• Monitor serum lithium level every 2–4 h initially, later
at 0.1 mg/kg may be considered. Oxygen therapy should be be
when symptoms reduce monitor every 6–12 h
initiated for patients with laryngospasm. Patients need to be
• Haemodialysis if lithium levels are >4 mEq/L
monitored for recurrence of acute dystonia and if needed can
or >2.5 mEq/L in a patient with severe intoxication and
be continued with anticholinergic drug.
renal insufficiency.[29]
Neuroleptic malignant syndrome
Patient education
It is a rare but life‑threatening complication associated with
Psycho‑educate the patients to take only the prescribed dose
the use of neuroleptics/antipsychotic drugs and occurs in
and not to double dose a missed dose. Take adequate salt in
1–2/10,000 population.[36] Most cases occur within 2 weeks
the diet. Monitor the intake and output regularly and report to
after the initiation to 30 days of treatment.[37]
the prescriber if vomiting and diarrhoea persist. Monitor the
therapeutic level of lithium on regular basis. Avoid excessive Aetiology
use of beverages that contain caffeine such as coffee, tea and It is believed to be due to the decreased central
cola drinks.[6] dopaminergic activity in the nigrostriatal, hypothalamic and
mesolimbic/mesocortical pathways due to the D2 dopamine
Acute dystonia
receptor blockade.[38] The risk factors are treatment with
Acute dystonia is characterised by slow sustained muscular
high potent typical antipsychotic drugs, use of long‑acting
spasms causing involuntary movements or postures.[24]
antipsychotic drugs, parenteral route of administration, higher
Acute dystonia generally occurs within first few days after rates of titration, abrupt stoppage/reduction in dopaminergic
the initiation or increase in the dose of antipsychotics and drugs, use of multiple antipsychotic drugs, agitated and
antiemetics. 50% occurs within 48 h and 90% within 5 days catatonic patient and previous history of neuroleptic malignant
after the initiation of treatment.[33] syndrome (NMS). Men are affected more than women.[36,38,39]
Aetiology Clinical features
It is believed to be due to the imbalance of dopaminergic‑ The clinical features last up to 7–10 days.[40] The patients can
cholinergic pathway in basal ganglia.[34] The risk factors present with severe muscle rigidity and elevated temperature
include, male gender, younger age, history of acute dystonia 102°F–104°F, diaphoresis, dysphagia, tremor, incontinence,
in the past, family history of dystonia and history of cocaine changes in level of consciousness ranging from confusion to
and alcohol use.[33,34] stupor and coma, mutism, sialorrhoea, diaphoresis, flushing,
skin pallor, tachycardia and elevated or labile blood pressure.
Clinical features Patients may develop rhabdomyolysis that causes leucocytosis,
The clinical features vary depending on the group of the
elevated creatine phosphokinase and haemoglobinuria that can
muscle that is involved. The Buccolingual presents as trismus,
lead to renal failure.[38]
risus sardonicus, dysarthria, dysphagia, grimacing and tongue
protrusion. Oculogyric Crisis occurs due to the spasm of the Treatment
extra ocular muscles and presents as upward lateral movement Treatment of NMS involves a combination of management
of the eyes. Torticollis involves the neck muscles leading to interventions.[38,41] Discontinue the treatment with neuroleptic
abnormal asymmetric head or neck position. Tortipelvic crisis medication immediately. If NMS is precipitated by stopping
causes abnormal contractions of the abdominal wall, hip and dopaminergic drugs, restart the drug. Administer intravenous

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 Gnanapragasam, et al.: Psychiatric Emergencies

fluids to hydrate the patient. Institute fever management to also if not treated effectively on time. The term delirium tremens
control the hyperthermia. Administer benzodiazepines to was first used by the English physician Thomas Sutton in his
control agitation. Tracts.[43] It is seen in <1% among general population and nearly
2% of the patients who are diagnosed with alcohol dependence.[44]
Pharmacological treatment
Injection dantrolene 1–2.5 mg/kg IV is administered initially Definition
followed by 1 mg/kg to a maximum 10 mg/kg/day. Tablet Delirium tremens is a condition where an individual has a group
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bromocriptine 2.5.mg can be administered through nasogastric of symptoms of variable clustering and severity occurring on
tube every six hours. Other dopaminergic agents such as absolute or relative withdrawal of a psychoactive substance
amantadine hydrochloride 200–400 mg per day in divided after persistent use of that substance. The withdrawal state is
doses,[42] levodopa and apomorphine can also be administered. complicated by delirium and convulsions may also occur.[45]
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Injection Lorazepam 1–2 mg IM/IV every 4‑6 hrs or diazepam

Clinical manifestations
10 mg every 8 hrs can be given.
The psychological manifestations include confusion, motoric
Nursing management activation, sensory hyperarousal (auditory, visual and tactile
Objective: To alleviate anxiety promote a sense of hallucinations and illusions are common) and autonomic
calmness in mind hyperactivity in individuals.[43] Delirium tremens being a
1. Assess the level of anxiety withdrawal complication which might occur within 4–12 h of
2. Stay with the patient and maintain a calm, nonthreatening cessation of or reduction in heavy and prolonged alcohol intake,
approach can cause physical manifestations such as (1) coarse tremors of
hands, tongue or eyelids, (2) nausea or vomiting, (3) malaise
3. Provide reassurance in subtle and acceptable manner
or weakness, (4) tachycardia, (5) sweating, (6) elevated blood
4. Explain the situation and the procedures in simple
pressure, (7) anxiety, (8) depressed mood or irritability,
words
(9) transient hallucinations or illusions, (10) headache,
5. Provide a low stimuli environment
(11) insomnia, (12) disturbances in cognition, (13) disorientation
6. Teach the patient various methods to relax like deep
and (14) clouding of consciousness.[6]
breathing exercises and guided imagery
7. Administer anti‑anxiety drugs such as benzodiazepines. Diagnosis
Diagnosis of delirium tremens is usually made by the presenting
Objective: To restore and maintain fluid and electrolyte
symptoms and proper history collection. Certain assessments
balance that are made include severity of alcohol withdrawal,
1. Monitor the vital signs evaluation of delirium and screening for underlying medical
2. Check the weight regularly co‑morbidities among which liver disease is common.[44]
3. Monitor the electrolytes, if required correct the imbalances
4. Increase the intake of oral fluids and administer Management
intravenous fluids to ensure adequate hydration The treatment of delirium tremens can be classified into
5. Maintain a strict the intake and output two approaches, (1) using pharmacological agents that are
6. Assist in haemodialysis to maintain a fluid and electrolyte cross‑tolerant and cross‑dependent with alcohol and slowly
balance. eliminated from the body which is called substitution and (2) use
of agents that reduce neuronal hyper excitability and autonomic
Objective: To maintain normal body temperature hyperarousal. Substitution is a more straight forward approach
1. Monitor vital signs regularly and is commonly in practice.[43] Benzodiazepines are commonly
2. Provide a well‑ventilated, cool environment used in the management of delirium tremens where diazepam and
3. Remove excessive clothing, blankets and linen and lorazepam are mostly preferred.[44] Chlordiazepoxide (Librium)
provide light clothing and oxazepam (Serax) are also used amongst benzodiazepines.
4. Increase the fluid intake and administer intravenous fluids The use of benzodiazepines is to start with relatively high doses
if needed and reduce the dose by 20%–25% until withdrawal is complete.[6]
5. Maintain an accurate record of intake and output In case benzodiazepines do not work effectively, medications
6. Institute the nursing measures such as cold compress, ice such as phenobarbital, propofol and dexmedetomidine are
cap and tepid and cold sponging. used.[44] These anticonvulsants are used to manage withdrawal
7. Administer antipyretic drugs. seizures. Replacement therapy with Vitamin B1, thiamine, is
replaced in the body to prevent side effects of the above drugs
Delirium Tremens such as neuropathy, confusion and encephalopathy.[6]
Introduction Nursing management
Psychoactive substances can be addictive when abused, and can The major role of nurse in rendering care to a patient who has
lead to dependence and further to withdrawal.[6] Delirium tremens delirium tremens would be to provide optimal safety and meet
is a complication of alcohol withdrawal, which can lead to death the basic needs of the patient.

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 Gnanapragasam, et al.: Psychiatric Emergencies

Objective: To maintain normal sensory perception, and Types

reorient to reality Stupor is usually presented clinically as (1) manic stupor,
1. Decrease the amount of stimuli in client’s environment (2) depressive stupor, (3) catatonic stupor, (4) withdrawal
2. Do not reinforce the hallucinations, let the patient know stupor, (5) delirious stupor and (6) organic stupor.
that you do not share the perception
Clinical manifestation
3. Maintain reality through reorientation and focus on real
Extreme psychomotor retardation – It is a decrease in
situations and people
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spontaneous movements and activity, mutism, negativism,

4. Provide reassurance of safety if patient responds with fear
waxy flexibility and posturing.[6] Individuals presenting
to inaccurate sensory perception as patient’s safety and
with stupor respond poorly or not at all to stimuli and after
security are nursing priorities[46]
5. Have watchfulness attitude throughout the care, as the recovery no recollection of events during the episode. Patients
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physical symptoms might wade away as withdrawal with depressive stupor appear depressed and especially
symptoms cease and might not need much of interventions when emotional topics are discussed. Catalepsy, obstruction,
6. Have the side rails up all the time, to ensure physical safety stereotypies, changes in muscle tone and incontinence of urine
of the patient and faeces do not occur. In manic stupor, the manifestation
7. Monitor strict intake and output chart, to balance fluid and is slowing of thinking. Catatonic stupor manifests as pure
electrolyte imbalance if any exist akinesia and all muscles are flaccid, snout spasm is sometimes
8. Administer benzodiazepines as per advise as it might seen.
help in the detoxification of the patient and help sedate Outstanding features of stupor are deadpan facial expression,
the patient to improve insomnia. change in muscle tone, catalepsy, stereotypies and incontinence
or urine. Psychological pillow is also a manifestation in
Stupor which patient lies down with the head raised few inches off
the bed,[48] occurs when sternomastoid muscles are usually
Introduction
contracted. Psychogenic stupor may present as if the patient
Stupor is a psychiatric emergency which is associated with
disorders like drug overdose, stroke, and lack of oxygen, was paralysed with fear.[47] Stupor is often associated with
meningitis, or cerebral oedema. The individual with stupor catatonic signs and symptoms (catatonic withdrawal or
becomes dependent on all their needs, as they become catatonic stupor). The various other catatonic signs include
immobile, and tend to remain in a kind of vegetative state yet stupor, ambitendency, echolalia (repeating the words
their consciousness remains intact. The term stupor comes of the examiner), echopraxia (repeating the movements
from Latin word meaning “numbness or insensible’, it is of the examiner), automatic obedience, mannerisms
also referred to as ‘obtunded’. Psychomotor inhibition and (involuntary, repetitive goal‑directed movements), purposeless
obstruction may produce a general slowing down of activity excitement, impulsiveness, combativeness or nudism.[26]
in patients with stupor.[47] Risk factors
Definition The following are some of the risk factors for developing
Stupor as defined by ICD‑10 by the code R401 states that stupor
those in a stuporous state are rigid, mute and only appear to 1. NMS
be conscious, as the eyes are open and follow surrounding 2. The diagnosis of catatonic schizophrenia
objects.[45] Stupor is a state of more or less complete loss of 3. Affective disorders which might present as stupor
activity where there is no reaction to external stimuli.[47] Stupor 4. Substance withdrawal with complications such as
is a clinical syndrome of akinesis and mutism but with relative Wernicke’s encephalopathy
preservation of conscious awareness.[26] 5. Advanced stages of organic brain syndromes.

Aetiology Management
Some common causes of stupor are The management of stupor would be based on the cause of
1. Neurological disorders such as post‑encephalitic the stupor. The following steps of intervention must be taken
Parkinsonism and limbic encephalitis, etc. to manage the unconscious patient. The cardiac functioning,
2. Systemic and metabolic disorders such as diabetic airway patency and fluid electrolyte imbalance become priority
ketoacidosis, acute intermittent porphyria and to ensure there are no threats to life of the patient.
hyperparathyroidism which causes hypercalcaemia, etc. • Monitor cardiac functioning and stabilise the patient
3. Drugs and poisoning due to organic alkaloids, if cardiac functioning is altered, as stupor could be a
antipsychotics and disulfiram, etc. presentation of cardiac malfunction also
4. Psychiatric disorders such as catatonic schizophrenia, • Ensure the airway is patent, if needed provide ventilation
depressive stupor, manic stupor, periodic catatonia, with oxygenation
conversion and dissociative disorder, reactive psychosis • Correct and maintain if any fluid and electrolyte imbalance
and during hypnosis.[26] occurs

86 Indian Journal of Continuing Nursing Education ¦ Volume 22 ¦ Issue 1 ¦ January-June 2021

 Gnanapragasam, et al.: Psychiatric Emergencies

• Correct hypoglycaemia, as decrease in blood glucose 4. Encourage independence

level can be misinterpreted as stupor. If not recognised 5. Show the patient how to perform activities as concrete
hypoglycaemia can lead to coma. thinking of the patient prevails, explanations must be
• If the cause is poisoning, provide antidotes as per policy[26] provided at the client’s concrete level of comprehension.[46]
• Administer tablet lorazepam as per advice, as
benzodiazepines can help reverting stupor[49] Conclusion
• Draw blood for necessary investigations and ensure
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Psychiatric emergencies need prompt attention and immediate

laboratory investigations are done, to investigate whether
intervention. However, this area of concern is often not
the cause of stupor is psychological or organic.
highlighted in healthcare settings other than psychiatric
In case it is caused due to NMS, discontinue the medication. facilities. Nurses working in any setup need to be aware of
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In other cases, the management of the illness will relieve the the common psychiatric emergencies and the management
symptoms of stupor. Tablet quetiapine is found to be effective strategies to make appropriate and informed decisions related
in treating catatonic stupor.[50] Among patients who were to interventions and referral as needed.
resistant to pharmacological therapy, ECT was found to be
more effective.[51] Benzodiazepines are widely used to treat Financial support and sponsorship
stupor, especially tablet lorazepam is commonly administered Nil.
to relieve acute stuporous symptoms. Amongst other types of Conflicts of interest
schizophrenia, catatonic schizophrenia has good prognosis There are no conflicts of interest.
too.[49]
Nursing management References
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 Gnanapragasam, et al.: Psychiatric Emergencies

CE Test No. 40 Questions

Nursing Management of Patients with Psychiatric Emergencies

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1. Stupor can be explained as a state where the individual 8. Death caused by self-directed injurious behavior with any
a. Has severe muscle rigidity intent to die as a result of the behavior is
b. Doesn’t respond to stimuli yet being conscious a. Suicide
b. Stupor
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c. Doesn’t respond to stimuli and being unconscious

d. Cannot control involuntary movements of extremities c. Violence
d. Delirium Tremens
2. Stupor becomes an indication for
a. Insulin therapy 9. Which among the following example denotes the
b. Group therapy psychological theories of suicide
c. Electroconvulsive therapy a. Deficiency of serotonin in depressed patients
d. Marital therapy b. Suicide of retired widowed wife
c. Suicide of highly motivated student when she failed in
3. The group of medication which is given acutely to treat one subject
stupor is
d. Husband committing suicide to punish his wife’s wrong
a. Anti-manic doing
b. Anti-psychotic
10. A risk factor for suicide is
c. Benzodiazepine
a. Impulsive & aggressive tendency
d. Antabuse
b. No history of suicide in the past
4. Withdrawal is best explained as the range of symptoms that c. Being married
a. Arise after the treatment of substance abuse d. Occupation in an highly secure environment
b. Arise after cessation of heavy substance use
c. Denote that patient is going into complications 11. The common method of suicide in India is
d. Mark the severity of complications a. Use of lethal weapons
b. Drowning
5. Types of hallucinations present in Delirium Tremens are
c. Use of pesticides
a. Auditory, olfactory and visual
d. Hanging
b. Visual, auditory and gustatory
c. Auditory, visual and tactile 12. A farmer commits suicide to highlight the difficulties of
farmers in his region is an example of
d. Tactile, gustatory and olfactory
a. Egoistic suicide
6. The common type of medication administered to treat b. Altruistic suicide
Delirium Tremens are
c. Anomic suicide
a. Tab.Chlorpromazine
d. Fatalistic suicide
b. Tab. Clonazepam
c. Tab. Carbamazepina 13. The therapeutic level of Lithium is
d. Tab.Chlordiazepoxide a. 0.5 to 1.1 mEq/L
b. 0.6 to 1.2 mEq/L
7. The vitamin that is replaced in the body during replacement
therapy is c. 0.7 to 1.3 mEq/L
a. Vitamin B1 d. 0.8 to 1.4mEq/L
b. Vitamin B2 14. A
 n individual takes excessive amount of Lithium
c. Vitamin B5 accidently, this is indicates which type of lithium toxicity
d. Vitamin B6 a. Acute

Indian Journal of Continuing Nursing Education ¦ Volume 22 ¦ Issue 1 ¦ January-June 2021 89

 Gnanapragasam, et al.: Psychiatric Emergencies

b. Chronic c. 2.5 mEq/L with renal insufficiency

c. Acute on chronic d. 3.5 mEq/L without renal insufficiency
d. Induced
18. The drug used to treat violence
15. Slow sustained intense involuntary muscular spasms is a. Inj. Haloperidol
caused due to b. Inj. Risperidone
a. Attempted suicide
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c. Inj. Olanzapine
b. Lithium toxicity
d. Inj. Midazolam
c. Acute dystonia
d. Neuroleptic Malignant syndrome 19. The first step to manage violence is
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a. Physical Restraints
16. M
 r. X is started on Tab. Haloperidol 10 mg BID, his
temperature is 104 F. The possible reason is b. Chemical Restraints
a. Acute dystonia c. Seclusion
b. Lithium toxicity d. De-Escalation
c. Neuroleptic Malignant Syndrome 20. Nursing management of a patient with violence includes
d. Delirium Tremens the following EXCEPT:
17. Indication for hemodialysis for a patient with lithium a. Maintain low level of stimuli
toxicity is lithium level more than b. Observe client’s behavior frequently
a. 3 mEq/L with renal insufficiency c. Remove all dangerous objects
b. 1.5 mEq/L without renal insufficiency d. Using Judgmental attitude

90 Indian Journal of Continuing Nursing Education ¦ Volume 22 ¦ Issue 1 ¦ January-June 2021

 Gnanapragasam, et al.: Psychiatric Emergencies

ANSWERS FOR CE TEST NO. 39: TEAM BASED LEARNING

1. C 11. A
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2. D 12. A
3. A 13. B
4. B 14. C
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5. A 15. C
6. B 16. B
7. B 17. D
8. D 18. D
9. C 19. D
10. D 20. C

Indian Journal of Continuing Nursing Education ¦ Volume 22 ¦ Issue 1 ¦ January-June 2021 91

 Gnanapragasam, et al.: Psychiatric Emergencies

CE Test No: 40
Nursing Management of Patients with Psychiatric Emergencies
Select the best answer and shade the circle against the suitable alphabet in the answer form provided.

ANSWER FORM

A A A A A
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1. ο 2. ο 3. ο 4. ο 5. ο
ο B ο B ο B ο B ο B
ο C ο C ο C ο C ο C
ο D ο D ο D ο D ο D
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 08/11/2024

6. ο A 7. ο A 8. ο A 9. ο A 10. ο A
ο B ο B ο B ο B ο B
ο C ο C ο C ο C ο C
ο D ο D ο D ο D ο D

11. ο A 12. ο A 13. ο A 14. ο A 15. ο A

ο B ο B ο B ο B ο B
ο C ο C ο C ο C ο C
ο D ο D ο D ο D ο D

16. ο A 17. ο A 18. ο A 19. ο A 20. ο A

ο B ο B ο B ο B ο B
ο C ο C ο C ο C ο C
ο D ο D ο D ο D ο D

Evaluation: Listed below are statements about the CNE on ‘Nursing Management of Patients with Psychiatric Emergencies’.
Please circle the number that best indicates your response.

Strongly Disagree Disagree Agree Strongly Agree

Stated Objectives were met 1 2 3 4
Content was clearly presented 1 2 3 4
Content was related to the objective 1 2 3 4
Test questions were clearly stated 1 2 3 4

NAME: ______________________________________________
PRESENT MAILING ADDRESS: ________________________________________
_______________________________________
_______________________________________
Cut out or photocopy this form, fill and mail before December 31, 2021 to The Editor-in- Chief, IJCNE, College of Nursing, CMC,
Vellore- 632004, along with a demand draft of Rs. 100/- (One hundred only), drawn in favour of CMC, Vellore Association. A
Certificate will be awarded to all the participants and a merit certificate to those who secure marks 80% and above. Participants
who secure 100% will be awarded one issue free subscription of IJCNE.

92 Indian Journal of Continuing Nursing Education ¦ Volume 22 ¦ Issue 1 ¦ January-June 2021