Skill List > Effective Strategies for Caring for Medical-Surgical Patients with Mental Health Issues (Mental Health)
Clinical Alert
It is sometimes difficult to identify whether a person is suffering from a medical condition or a mental health condition because the symptoms can appear very similar. Identifying the source – medical or mental ill-health – which is causing the patient’s symptoms is critical to their care and a vital nursing skill. The nurse must perform a thorough investigation to determine and treat these problematic mental ill-health symptoms properly.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:

Based on Mosby Nursing Skills
Adapted by: Naomi Sharples BSc MBA PGCE ProfDoc RMNH RMN; Neil Murphy BSc(Hons) MSc RMN; Tommy Healy BA MA GradCertEd CertCBT RPN RGN RNT
Updated by: Catherine Johnson RGN RMN
Last updated: August 2017

Learning Objective
After reading the skill overview, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of caring effectively for medical-surgical patients with mental health issues.

Introduction

People with severe mental illness have a significantly reduced life expectancy and experience serious health inequalities. To address this, it is vital that physical health monitoring and screening is improved and an in-patient admission presents a window of opportunity to address this and promote improved management of physical health conditions (Haddad et al. 2016). One of the top three priorities set out by the Independent Mental Health Taskforce (2016) for the next 5 years is to develop integrated approaches towards mental and physical health. One example of this is the investment in secondary care, focusing on perinatal mental health and liaison psychiatry in acute general hospitals (Das et al. 2016). 
People with severe mental illness who are hospitalised for medical or surgical reasons have twice the chance of adverse events, associated with poorer clinical and economic outcomes (Elder et al. 2014).
 Furthermore, unhealthy lifestyles such as higher incidence of smoking, poor exercise and poor nutrition are compounded by social deprivation, social exclusion, poverty, poor housing, and unemployment, which have all been implicated as contributory factors causing ill health (Stuart 2013, Das et al. 2016). Medical 
and surgical patients who are responding to treatment may begin, without provocation, to display behaviours of aggression, depression, anxiety, anger, withdrawal, or suspicion. These behaviours may make it difficult to maintain the patient’s treatment regimen and can impact on the safety of the patient, family, and staff. 
These behaviours in a surgical care setting can evoke a sense of caution in health professionals, with a perceived or real threat interpreted and a sense that the management of such behaviours is potentially outside of their scope of practice, knowledge or expertise (Giandinoto & Edward 2014).
 Careful assessment, including patient history, medication use, disease status, and laboratory values, along with effective communication among staff and with the patient, can mean improved outcomes and safety. Many pathophysiological problems can present as an emotional or behavioural problem or impaired thinking. These include an elevated body temperature (e.g., associated with a urinary tract infection), and imbalances in fluid and electrolytes, blood glucose, and thyroid hormones.

Cultural considerations

  • Carefully assess the patient’s cultural background, language, and socio-cultural expectations of care.
  • Behaviours that are seen as challenging in Western culture may be acceptable in other cultures.
  • Assess within the patient’s culture for what are considered normal behavioural changes or responses to illness and care (Holland 2017).

Patient and family education

  • Inform the patient and family of their rights and responsibilities while recipients of health care.
  • Encourage the family to collaborate in the patient’s care.
  • Set treatment goals with the patient and family.
  • Consistently inform the patient and family of the care plan using language that promotes inclusion, and support them in decision making.
  • Discuss safety concerns with the family and patient, and ask for information about previous or present mental health conditions.
  • Where relevant, reassure the family that the patient’s behaviour is a result of a pathophysiological change within the patient.
  • Assure the family that action will be taken immediately to maintain the patient’s safety when a behavioural change is noted.
  • Provide respectful and compassionate care, and maintain the patient’s dignity.
  • Offer time, compassion, and encouragement to the patient and family.
  • Provide information to support the patient and their family in understanding this distressing and potentially frightening event.

Young people (adolescents) – considerations

  • Young people may experience physiological and psychological challenges which may result in them behaving in a rebellious or challenging way.
  • Patients in this age group may exhibit challenging behaviour without any pathophysiological cause as a result of the complex ways they are learning to deal with stressors in their lives.
  • However, young people who present with conduct disorders and associated antisocial behaviours commonly have at least one coexisting mental health problem (National Institute for Healthcare Excellence CG158 2017).
  • Young people who have good mental health and well-being may still ‘bend the rules’ such as the use of illicit drugs, alcohol, or food in an attempt to control their lives and define their identity.
  • If the young person is using illicit drugs or alcohol, family members may not be aware. In situations such as these, family members may not be able to provide complete and accurate information about the adolescent’s behaviour.
  • Part of adolescence is about defining your own identity and taking control over your life, and as such young people may not consider the full implications of being non-compliant with treatment or acting inappropriately.
  • Some mental health disorders begin to show symptoms during this age group. For example, the early phases of schizophrenia can be taken for negative adolescent behaviour (e.g. social withdrawal, unresponsive, changes in sleep pattern).

Older people – considerations

  • Because of slowed metabolic processes in older people, medications may rise to toxic levels at lower doses.
  • This possibility requires vigilance on the part of the nurse, family, and patient; behavioural changes can be prevented by decreasing medication doses.
  • Some behavioural changes may be caused by neuro-degenerative conditions such as Alzheimer’s and Parkinson’s disease, but this possibility should not be the first consideration. Older people may exhibit behavioural changes as a result of small alterations in vital signs, fluid, and electrolytes, or glucose levels.
  • Older people may also use illicit drugs and alcohol as a lifestyle choice or to manage their own physical or mental illness symptoms, or social situation, for example, pain, anxiety, and loneliness. The nurse needs to ask the patient if they have continued to do so while in the healthcare setting.

Special considerations

  • Patients with a diagnosis of a severe mental illness must be carefully supported while receiving care for a physical health problem. For example, a patient’s antipsychotic medication regimen must be followed as prescribed; otherwise the patient’s mental health may relapse or deteriorate and they may not be able to continue physical treatment.
  • Mental health and medical-surgical medications can interfere with each other; the prescriber and the clinical team have a duty to inform the patient and carers of any potential or real complications and to support the patient’s management of these issues. Nurses should monitor the patient for medication side effects, inform the prescriber, and document any side effects.

Preparation and safety

  • Inform the doctor as soon as you notice any unexpected changes in the patient’s behaviour.
  • Note the time and circumstances of the behavioural change.
  • Look for patterns using an ABC chart. What is the Antecedent to the behaviour? Describe the Behaviour then identify the Consequence of the behaviour. Record the time of day, the people present, and whether there is there anything else significant happening on the ward. Establish if there is a possibility that the patient has used illicit drugs or alcohol.
  • Talk with family members to determine if the patient’s behaviour has occurred before and, if so, under what circumstances it occurred.
  • Assess staff safety. If the patient’s behaviour escalates, assess if there are enough staff present to calm the patient safely.
  • Measure and document vital signs. A fever or hypertensive crisis can cause abrupt behavioural changes.
  • If the patient has used illicit drugs or alcohol, the level of alcohol and drugs in the patient’s system may need to be determined. Legal or illegal substances can cause behavioural changes at both elevated and decreased levels.
  • The patient’s electrolytes, thyroid hormone, and glucose levels all need to be assessed. Both elevated and decreased levels can affect thinking and behaviour.
  • Assess pain firstly by asking the patient if they are in pain, pain location, and what the pain is like (e.g., hot, ache, sharp, radiating). The patient may be too distressed to respond to questioning, therefore the nurse must use subjective measures to determine if behavioural changes are a result of pain. This may be determined if the patient is restless, sweating, lying very still, avoiding resting on a particular part of their body, has shallow breathing, flinching, is crying, or grimacing.
  • Evaluate the patient’s history for current or previous mental health problems. If the current behaviour is evidence of an exacerbation of a mental illness or relapse in the patient’s mental state, the nurse should involve the mental health team and support in the initiation of mental health care and treatment.

Procedure

  1. Recognise that physical and mental health are inextricably intertwined, not separate entities (Nash 2014). 
    Rationale – Assessment of physical problems is an essential nursing function. The inclusion of assessment of mental status and behavioural changes ensures patient safety and effective treatment. Outcomes improve when mental health is taken into consideration during the assessment phase. Perform appropriate mental health screenings using tools such as the:

    1. Mini-Mental State Examination (MMSE)
    2. Beck Depression Inventory (BDI)
    3. Ask the patient directly if he/she has or is considering suicide or self-harm. The use of the S.L.A.P. (Specific plan, Lethality of plan, Access to means, and Proximity to help) suicidality assessment, may assist the nurse in this regard.
    4. Establish if the patient has used or is using illicit substances
    5. CRMT: Clinical Risk Management Tool.

    Negligence in the use of these measures compromises the patient’s safety. Continue to observe for behavioural changes while the patient is being treated for medical problems.

  2. Screen for patient history of mental illness or poor coping skills.
    Rationale – This critical information needs to be obtained during the initial assessment. If the patient has a mental health history, including prior use of psychotropic medications, this fact must not be overlooked or considered irrelevant. Abrupt withdrawal of psychotropic medications may exacerbate the physical condition, as well as jeopardise the patient’s mental health.  Key concerns raised by psychiatric liaison psychiatry professionals include delays or gaps in treatment, delays in investigations being carried out and diagnostic overshadowing (Noblett et al. 2017). Assessing the patient for previous psychotropic medication use is particularly important. Knowing the effects these medications have had in the past, or are currently having, may affect the well-being of the patient. Coping with a physical crisis increases the level of difficulty if the mental health of the patient is challenged. Careful management of the mental status of the patient is critical for this reason.

  3. Monitor the patient for behavioural and physical changes.
    Rationale – Whether the patient has a history of mental illness, or whether behavioural changes are occurring as a result of medical stressors, these behavioural changes indicate the need for nursing care. Paying attention to and supporting the patient when they express small signs of difficulty can prevent major behavioural outbursts or reactions that are challenging in a healthcare situation. For patients experiencing severe mental illness, the routines of acute secondary care environments are not conducive with optimal care (Giandinoto & Edward 2014).
    When a patient appears rational and able to comprehend but within a short time becomes aggressive or irrational, the nurse must carefully consider physical changes, such as a pulmonary embolism, electrolyte imbalance, glucose level change, increased temperature, pain, and an inability to cope with stressful situations. Corrective action is required before a crisis develops.
  4. Address pathophysiological problems immediately and before these problems affect the patient’s behaviour.
    Rationale – Correcting physical problems can frequently eliminate potential behavioural issues. Balancing fluid and electrolytes, glucose, oxygen, or other imbalances, or decreasing fever or pain, can frequently correct the behavioural reactions. The sooner the pathophysiological problems are eliminated as the source of any psychological reaction, the better the treatment will be for the patient.

  5. Communicate with, and listen carefully to, the patient in a calm, respectful, and compassionate manner to elicit as much understanding and cooperation as possible through working in partnership.
    Rationale – Allowing the patient to express emotion will demonstrate that they are being listened to and provides them with the security of knowing that the nurse has control. No matter how exacerbated the patient’s behaviour or actions become, the nurse must demonstrate professionalism, respect, compassion, and clear thinking (Sharples 2013). In any crisis, the patient needs to feel that the staff are in control and will deliver assistance. If the nurse or any staff member reacts emotionally or allows emotions to interfere with the care being provided, the patient cannot trust that the nurse or staff member is capable of delivering effective care.

  6. Educate the support staff to observe for patient behavioural changes and to report any changes immediately.
    Rationale – Everyone on the care team affects the outcome of the patient’s treatment. Any information about the patient’s mental status is valuable and should be reported. All staff members should be provided with information about the ways in which patients may react negatively to their illnesses. When valuable information about a person’s deterioration in mental well-being is reported to the nursing staff, timely action may be initiated.

  7. Alert the security team if family members or friends are suspected of supplying substances that may cause behavioural changes, such as alcohol or illicit drugs.
    Rationale – Behavioural changes may occur abruptly when the patient uses illicit substances. Family and friends who bring drugs or alcohol to the patient can cause a variety of dangerous situations.
      Patients who use illicit substances may undermine the physical and mental health care and treatment they are undergoing. Patients and their families or friends who use illicit substances may not understand these dangers. To safeguard patients, the use of these substances must not be allowed.

  8. Notify the doctor for possible referral to a mental health professional.
    Rationale – If the patient’s behaviours do not resolve, or if the patient, family, or staff are in danger as a result of these behaviours, a mental health professional needs to assess the patient. Further mental health treatment or adjustment to the current treatment may be needed, psychiatric liaison services are being enhanced to provide increased cover for acute hospitals (Das et al.  2016).
  9. Document the strategy in the patient’s record.
    Rationale – Continuity of care is essential to prevent possible violence, challenging behaviour, and danger to the patient and others.  Careful documentation of the physical and mental status of the patient, behavioural and physical changes that have occurred, their causes, and the nursing actions taken may provide critical information to others who care for the patient. Clear and accurate documentation provides a legally accountable rationale for the delivery of the patient’s plan of care.

Ongoing care, monitoring and support

  • After providing care and treatment for the patient’s physical problem, signs, or symptoms (e.g., medication for fever, fluid and electrolyte replacement, antiemetic), the nurse must continue to observe the patient for signs of changes in behaviour.
  • Continue to communicate frequently with the patient.
  • Assess the patient’s return to behaviour that is within normal limits and provide reality orientation to support this improvement.
  • Maintain patient and staff safety during a challenging episode.
  • Monitor blood test (e.g., blood glucose) values, microbiological examination of urine and other body fluids, and vital signs (e.g., oxygen saturation, temperature) until they are within the normal range if this is a feasible goal given the physiological needs of the patient.
  • Monitor medication therapy carefully, especially those administered as required, or mental health medications that have been added to the patient’s medication prescription.
  • Monitor carefully medication adherence/compliance by the patient and educate them regarding the importance of this compliance, of recognising any side effects and of making contact with medical or nursing personnel if in doubt or if problems re-occur.

Documentation and reporting

Document the following in the patient’s records:

  • Assessment of behaviours, thoughts, and emotions.
  • Timing and circumstances of behavioural changes; include ABC charts.
  • Monitoring of patient’s physical and mental status and behavioural changes and the indicated interventions implemented.
  • Teaching provided to patient and family and collaborative work engaged.
  • Blood test results and interventions implemented based on results.
  • Changes in medication regimens and management of contraindicated drug therapies.
  • Patient reactions to interventions, medication regimen changes, electrolyte replacement, or other treatments for possible behavioural reactions.
  • Incident report for any events or extreme behaviours as indicated by local policy and protocols.
  • Mental health referral, if indicated and if implemented.
Your email :


Recipient: (email address)
To multiple recipients, separate email addresses with commas.


Note : (optional)