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S: A 28-year-old male with a history of schizophrenia is presenting to the Emergency Room in acute psychosis. He has been hearing voices and exhibiting physical aggression at home, prompting his mother to bring him to the ER.

B: - History of schizophrenia with a pattern of nonadherence to antipsychotic medication; last took medication as prescribed 2 months ago.

- Recent behavior includes paranoid delusions about radio waves entering his head, urging him to "protect himself."

- Incident of physical aggression towards apartment door with a baseball bat, threatening similar actions towards his brother.

A: - Mental status exam reveals flight of ideas, tangential thoughts, and grandiose delusions (believing he works for the President’s counter-intelligence team).

- Patient is disoriented and unable to follow instructions; actively attempting to leave the ER.

- Physical examination is unremarkable for injuries.

HR: 88 bpm

BP: 138/89 mmHg

RR: 20

Temperature: 37.5°C

SpO2: 95% on room air

R: - Monitor the patient to prevent elopement and ensure safety.

- Immediate psychiatric consultation for assessment and treatment adjustment.

- Consideration for admission to a psychiatric facility for stabilization and medication re-initiation.

- Continuous monitoring of vital signs and mental status.

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Patient became progressively more agitated upon seeing his brother speak with the nurse, and stated “I received signals alerting me to watch out from my brother and the nurse, because they are planning against me.”

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Intervention: De-escalation and Therapeutic Communication

Rationale: The patient's increasing agitation and paranoid ideation indicate a heightened risk of escalation to potentially dangerous behavior. Use de-escalation techniques by using a calm approach and validating the patient's feelings, reducing anxiety and maintain safe environment. Establish a therapeutic relationship that supports ongoing care and treatment and enhance trust, cooperation and empathy with the patient.

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Dr. Shanahan

1. Implement Safety Measures and Behavior Management:

Staff to be assigned to provide 1:1 observation or maintain visual contact at all times.

Indication: Risk for Self-Harm and Suicidal Ideation. Safety measure can manage aggressive behaviors and ensure the patient's safety, as well as the safety of others.

2. Initiate PRN Medication for Agitation and Aggression: Haloperidol 3mg IM Q 4 H PRN. DO NOT exceed 20MG in 24 Hours.

Indication: Acute symptoms of psychosis.

Long-term Anti-psychotic Medication Plan:

Risperidone 25 mg IM every 2 weeks.

Indication: Long-acting injectable anti-psychotics help ensure medication adherence, manage symptoms, and reduce risk of relapse.

3. Initiate & Prepare for Individual Therapy Sessions: Initiate Cognitive Behavioral Therapy (CBT) 2-3 times per week, during the acute phase.

Indication: Therapy aids the patient in learning how to manage symptoms, develop coping strategies, and prepare for long-term treatment.

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Nursing Action 2: Initiate Anti-Psychotic Medication Therapy 

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Nursing Action 2: Initiate Anti-Psychotic Medication Therapy 

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Administer ordered medication while continuing to monitor vital signs, side effects, symptom assessment, and patient's mental status.

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Complication 2: Escalation of Aggressive Behavior

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Complication 2: Escalation of Aggressive Behavior

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Patient became physically violent with Nurse because “signal changed and told me to take her out, before she takes me out.”

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Complication 3: Potential for Self-Harm or Suicidal Ideation 

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Complication 3: Potential for Self-Harm or Suicidal Ideation 

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Patient was seen pacing his room and appeared to be extremely agitated. Using therapeutic communication, the nurse and the patient had a conversation. During the interaction patient stated “I'm a fried fish, a change in signal occurred and I'm being told I will not make it past tonight.”

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Intervention: Establish a Therapeutic Relationship and Assess for Suicidal Ideation

Rationale: The patient's statement, "I'm being told I will not make it past tonight," indicates potential for self-harm and/or suicidal ideation. It is crucial to assess the severity and content of the patient's thoughts, and provide immediate support plus intervention to ensure their safety.

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Nursing Action 1: Re-assess Suicide Risk and Safety

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Nursing Action 1: Re-assess Suicide Risk and Safety

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Document continuous observation of any changes in behavior or mood that might indicate an increased risk for harm to self or to others.

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Nursing Action 3: Initiate and Monitor Individual Therapy

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Nursing Action 3: Initiate and Monitor Individual Therapy

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ex. Use music therapy 🎶 to help focus on what is around the patient, have pt focus on what they can:

- See👀

- Touch 🧸

- Smell 👃

- Hear 🙉

- Taste 🍰

This action helps ground the patient and shift their focus away from the distressing content of internal auditory hallucinations.

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Intervention: Secure the environment by removing potential hazards and ensuring the patient is in a safe, non-threatening space with reduced stimuli.

Rationale: Prevents access to dangerous objects and ensures a safe environment to help mitigate the risk of physical aggression towards fellow patients and nurses. Increased stimuli may lead to an increase in hallucination severity. Reduce stimuli by decreasing noise level and lowering the lights, with continued supervision from a member on the psychiatric care team.💡

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1. Padlet Operator

1. Rainel Castillo Rondon

2. Leader

1. Trinity McCourt

3. Presenters

1. Mario Garcia

2. Darby Shanahan

4. Designer

1. Trinity McCourt

2. Rainel Castillo Rondon

5. Researchers

1. Rainel Castillo Rondon

2. Mario (Dennis) Garcia

3. Darby Shanahan

4. Piper Shelton

5. Chelsea Paule

6. Jessica Gonzalez

7. Clarissa Valades

8. Kendall Williams

9. Trinity McCourt