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. 

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.

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.

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.

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.

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.💡