FaCilitator Manual Introduction to Agitation, Delirium ... · PDF fileIntroduction to Agitation, Delirium, and Psychosis Curriculum for Nurses ... Before a psychotic disorder can be

English-haiti

Introduction to Agitation,

Delirium, and Psychosis

Curriculum for nurses

FaCilitator Manual

IPartners In Health | FaCilitator Manual

Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses

Partners in health (Pih) is an independent, non-profit organization founded over twenty years ago in haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment, and to address the root causes of their illness. today, Pih works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and disease — through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.

Pih’s work begins with caring for and treating patients, but it extends far beyond to the transformation of communities, health systems, and global health policy. Pih has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in haiti. through collaboration with leading medical and academic institutions like harvard Medical school and the Brigham & Women’s hospital, Pih works to disseminate this model to others. through advocacy efforts aimed at global health funders and policymakers, Pih seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.

Pih works in haiti, russia, Peru, rwanda, sierra leone, liberia, lesotho, Malawi, Kazakhstan, Mexico and the united states. For more information about Pih, please visit www.pih.org.

Many Pih and Zanmi lasante staff members and external partners contributed to the development of this training. We would like to thank giuseppe raviola, MD, MPh; rupinder legha, MD ; Père Eddy Eustache, Ma; tatiana therosme; Wilder Dubuisson; shin Daimyo, MPh; leigh Forbush, MPh; Ketnie aristide, and Jenny lee utech.

this training draws on the following sources: World health organization, Mental Disorders Fact sheet 396, oct 2014; Michelle sherman, support and Family Education: Mental health Facts for Families, april 2008, http://www.ouhsc.edu/safeprogram/; World health organization, mhgaP intervention guide (geneva: World health organization), 2010; american Psychiatric association, Diagnostic and statistical Manual of Mental Disorders (5th ed.) (Washington, DC: american Psychiatric association), 2013; Journal of Clinical Psychiatry, Consensus development conference on antipsychotic drugs and obesity and diabetes, February 2004; Psychiatric times, aiMs abnormal involuntary Movement scale, april 11, 2013, http://www.psychiatrictimes.com/clinical-scales-movement-disorders/clinical-scales-movement-disorders/aims-abnormal-involuntary-movement-scale.

We would like to thank grand Challenges Canada for their financial and technical support of this curriculum and of our broad mental health systems-building in haiti.

© text: Partners in health, 2015 Photographs: Partners in health Design: Katrina noble and Partners in health

II Partners In Health | FaCilitator Manual


This manual is dedicated to the thousands of health workers whose tireless efforts make

our mission a reality and who are the backbone of our programs to save lives and improve

livelihoods in poor communities. Every day, they work in health centers, hospitals and visit

community members to offer services, education, and support, and they teach all of us that

pragmatic solidarity is the most potent remedy for pandemic disease, poverty, and despair.

IIIPartners In Health | FaCilitator Manual


Table of Contents

Introduction to Agitation, Delirium, and Psychosis

introduction ...........................................................................1

objectives .............................................................................2

time required ......................................................................4

Materials ..............................................................................5

Session 1: introductions, Pre-test and Confidentiality ............6

Session 2: Epidemiology, the treatment gap, and stigma ....10

Session 3: the Psychosis system of Care and the Four Pillars of Emergency Management of agitation, Delirium and Psychosis ........................................................17

Session 4: safety and Management of agitated Patients ... 25

Day 1 Review ......................................................................32

Session 5: Medical Evaluation and Management of agitation, Delirium, and Psychosis .......................................33

Session 6: Medication Management for agitation, Delirium, and Psychosis .......................................................38

Session 7: Follow up and Documentation ...........................45

Day 2 Review ......................................................................47

Session 8: review session, Post-test and training Evaluation ..............................................................49

IV Partners In Health | FaCilitator Manual


Annex

Pre-test and Post-test ........................................................58

Pre-test and Post-test answer Key .....................................63

Psychosis Care Pathway .......................................................68

agitation, Delirium and Psychosis Checklist .........................69

Medical Evaluation Protocol for agitation, Delirium, and Psychosis ......................................................................70

agitated Patient Protocol ....................................................72

agitation, Delirium and Psychosis Form ...............................73

Medication Card for agitation, Delirium, and Psychosis .......74

abnormal involuntary Movement scale (aiMs) ...................77

Jeopardy review Questions and answer Key .......................78

training Evaluation Form .....................................................81


Partners In Health | FaCilitator Manual 1

Introduction to Agitation, Delirium, and Psychosis

INTRODUCTION

Psychotic disorders refer to a category of severe mental illness that produces a loss of contact

with reality, including distortions of perception, delusions, and hallucinations. The most common

psychotic disorders are schizophrenia and bipolar disorder, which affect a combined 81 million

people. Despite the immense burden of illness from psychotic disorders, about 80% of people

living with a mental disorder in low-income countries do not receive treatment.1 Stigma and

discrimination against people living with severe mental illness often result in a lack of access

to health care and social support. Human rights violations such as being tied up, locked up, or

left in inhumane facilities for years are all common.

Before a psychotic disorder can be diagnosed, however, patients require comprehensive medical

evaluation to ensure that medical problems are not the root cause of the symptoms. The

term ‘agitated’ is often misused to describe patients who appear psychotic and are, therefore,

immediately referred to mental health. However, oftentimes these patients are actually

suffering from delirium, a state of mental confusion that can resemble a psychotic disorder but

is actually caused by a potentially severe medical illness. Patients who are delirious are often

injected with high doses of haloperidol to quell their ‘agitation,’ and they frequently do not

receive any medical evaluation or care. Unfortunately, this misdiagnosis and mismanagement

can lead to death.

Fortunately, nurses can learn how to safely manage agitated patients and work with other

providers to properly treat patients’ delirium. Zanmi Lasante nurses work side by side with

psychologists, social workers and community health workers to assist in the management

and diagnosis of agitation, delirium and psychosis. Psychotic disorders are treatable and for

some, completely curable. With the right training and system of coordinated care, people with

psychosis can receive effective treatment and lead rich, productive lives.

In this training, participants will learn how to manage agitated patients safely and effectively.

Participants will also learn how to distinguish between delirium and a psychotic disorder

1. World health organization. (oct 2014). Mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/

2 Partners In Health | FaCilitator Manual


caused by mental illness. Ultimately, participants will learn how to provide high-quality

humane medical and mental health care for agitated, delirious, and psychotic patients.

ObjeCTIveS

By the end of this training, participants will be able to:

Session 1:a. Describe the purpose of the training.

b. Establish ground rules that create a respectful and trusting environment.

c. Demonstrate prior knowledge of the training topic.

Session 2:d. Identify participants’ current and past attitudes surrounding severe mental illness.

e. Describe the epidemiology of psychotic disorders and the corresponding treatment gap.

f. Describe the various ways that psychosis may be viewed by the community and by health providers.

g. Describe the impact of stigma on patient care and outcomes.

Session 3:h. Describe the psychosis care pathway and its collaborative care approach.

i. Outline the main roles of physicians, psychologists, social workers, nurses and community health workers in the system of care.

j. Explain the four pillars of emergency management of agitation, delirium and psychosis.

k. Describe how a nurse should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis.

Session 4:l. Describe the identification, triage, referral, and non-pharmacological management of an

agitated patient through the use of the Agitated Patient Protocol and Agitation, Delirium and Psychosis Form.

Session 5:m. Define medical delirium.

n. Describe the importance of proper medical evaluation for an agitated, delirious or psychotic patient.

o. Explain how to conduct a medical evaluation for an agitated, delirious or psychotic patient.



Session 6:p. Describe the use and possible side effects of the primary medications for agitation,

delirium, and psychosis.

q. Provide comprehensive psychoeducation messages to a patient and their family around medication management.

Session 7:r. Explain how to provide follow-up for people living with psychotic disorders and severe

mental illness.

s. Describe the importance of documentation during patient follow-up.

Session 8:t. Review all unit objectives.

u. Demonstrate learning through a post-test.

v. Give feedback on the training.



TIme ReqUIReD 2 ½ days (13 hours and 45 minutes of training sessions)

DAy 1: 6 hours of training sessions

Session Content methods Time

1Introductions, Pre-Test and Confidentiality

• Facilitator presentation• icebreaker• assessment

1 hour 45 minutes

2epidemiology, the Treatment Gap, and Stigma

• reflection journey• Facilitator presentation• role play

1 hour 15 minutes

3

The System of Care and the Four Pillars of emergency management of Agitation, Delirium, and Psychosis

• Facilitator presentation• large group discussion• Case studies

1 hour 15 minutes

4Safety and management of Agitated Patients

• Facilitator presentation• role play

1 hour 45 minutes

DAy 2: 4 hours and 30 minutes of training sessions


Review Day 1 Review • group presentations 30 minutes

5medical evaluation and management of Agitation, Delirium and Psychosis

• Facilitator presentation• Case studies

1 hour 15 minutes

6medication management of Agitation, Delirium and Psychosis

• Facilitator presentation• Worksheet• role play

2 hours

7Follow-Up and Documentation • Facilitator presentation

• small group work45 minutes

DAy 3: 3 hours and 15 minutes of training sessions


Review Day 2 Review • Jeopardy 1 hour

9Review, Post-Test and Training evaluation

• Case studies• assessment• reflection

2 hours 15 minutes



mATeRIAlS NeeDeD

materials

� Facilitator Manual — 1 copy/facilitator

� Participant handbook — 1 copy/participant

� agitation, Delirium and Psychosis PowerPoint

� Jeopardy PowerPoint

� laminated Medication Card for agitation, Delirium and Psychosis — 1 copy/participant

� Computer and projector

� Flip chart

� Markers

� Pens

� Post-it notes (estimate 7/participant)

� tape



SeSSIon 1: Introduction, Pre-Test and Confidentiality

methods: Facilitator presentation, ice breaker and assessment

Time: 1 hour 45 minutes

materials: � PowerPoint presentation (agitation,

Delirium, and Psychosis slides 1– 8) � Pre-test (1 copy/participant) � Flip chart or chart paper

� Markers, pens � tape � Post-it notes

Preparation:• Post a blank sheet of paper on the flip chart and title it “goals & Expectations.”• Post a blank sheet of paper on the flip chart and title it “training rules.”• Photocopy the pre-test.

Objectives:a. Describe the purpose of the training.b. Establish ground rules that create a respectful and trusting environment.c. Demonstrate prior knowledge of the training topic

NOTe FOR FACIlITATOR PRePARATION:

General Tips for Presenting PowerPoint (PPT) Slides:

When presenting PowerPoint slides, it is not necessary to read everything on each slide. instead, summarize the main ideas on the slide and add any supplemental information that will help the audience to understand the most important ideas.

Encourage participant feedback during PowerPoint presentations. some slides have a conversation bubble that contains a question. use these conversation prompts to ask the audience questions and hear their feedback before clicking forward to reveal the answers.



StePS

20 minutes

1. Turn on the projector and begin the PowerPoint at Slide 1: Agitation, Delirium, and Psychosis. Welcome the participants, then introduce yourself and this training.

2. Show Slide 2: Session 1: Welcome and Learning Objectives.

Tell the participants that this training is about the management of agitation, delirium and psychosis.

3. Show Slide 3: Building a System of Care.

Explain how this training ties into past trainings on depression and epilepsy. Tell the participants that when taken together, these three trainings articulate the beginnings of a coherent community-based system of mental health care. Tell the participants that a community-based system of care facilitates:

• High-quality care (safe, effective, evidence-based and culturally attuned) that keeps patients in their local communities, resulting in less socioeconomic burden on families.

• Comprehensive medical evaluation.

• Multi-disciplinary and biopsychosocial approach to care involving physicians, nurses, community health workers, psychologists, and social workers.

• Humane care that does not involve institutionalizing patients for years or traumatizing them by tying them up, beating them or injecting them with high doses of medication.

4. Show Slide 4: Psychosis Care Pathway.

Tell the participants that they may remember seeing similar care pathways for both de-pression and epilepsy. These pathways guide how these mental health issues are handled in Zanmi Lasante’s community-based mental health system of physicians, psychologists, social workers, nurses and community health workers. Tell the participants that today we will be introducing a similar care pathway for psychosis. Allow the participants to look at the various responsibilities of the health providers in the psychosis system of care. Explain that the participants will be seeing this model throughout the training.

5. Show Slide 5: Zamni Lasante Mental Health.

Explain that since the development of the community-based system of mental health care, Zamni Lasante has been able to identify and treat many patients with various mental health issues.

6. Turn off the projector (or cover the lens).



40 minutes

7. Pass out one Post-it note to each participant. Ask the participants to take a minute and write down one goal or expectation that they have for this training. Then, ask all the participants to introduce themselves and share their goals. After each person speaks, place their Post-it note on the flip chart entitled ‘Goals and Expectations.’

8. Assure the participants that many of these goals and expectations will be met during the training. Others will be addressed through monthly meetings and ongoing communications.

9. Explain that in order to ensure an effective training, the group will follow some ground rules. Invite the participants to brainstorm ground rules. Write the ground rules on a sheet of chart paper and keep them in view during the training. Ground rules can include punctuality, confidentiality, participation in discussions and activities, respect for different opinions and cell phones being switched off.

ConFiDEntiality

Confidentiality is one of the most important parts of being a clinician. you must keep everything that family members tell you, and everything that you know about their condition, confidential. you should only share such information with other clinicians when needed.

some of you may reference confidential patient information during the training. you must share or ask in a way that maintains confidentiality. For example, do not use the person’s name, say where she or he lives, or give any other information that would reveal the person’s identity. also, you must not talk about confidential information outside of this training.

10. Designate someone as the ‘time keeper’. The role of the time keeper is to keep the training running smoothly by being aware of time, and to signal to the facilitator when there is five minutes left in a session. The time keeper should have a watch or cell phone.

11. Write ‘parking lot’ on a piece of flip chart paper and hang it on the wall. Tell the participants that when a question is raised that might not be answerable or relevant at that particular moment, it will go to the parking lot. When there is a lull in the training, or at the end of each day (whichever time interval works) the facilitator can take the time to address some of the questions in the parking lot. By the end of the training all questions in the parking lot will hopefully be answered, and if not, the facilitators should guide the participants to the resources to answer any remaining questions.

30 minutes

12. Distribute the pre-test and explain how it should be completed.

13. Collect the completed pre-tests.



14. Explain that the participants will take a post-test at the end of the training in order to measure what they have learned.

15 minutes

15. Explain to the participants that they have materials and resources that will be referred to throughout the training. The materials and resources will also be a resource to them once the training has finished. Tell them that they can refer to the training materials when they are seeing patients or need clarification on the topics covered in the training.

16. Ask the participants to turn to the agenda in their participant handbooks. Tell them that the training is divided into a series of sessions as they can see listed in the agenda.

17. Tell them that each session has learning objectives associated with it. Tell them that the learning objectives represent what they should learn during each session of the training. The participants should re-visit the learning objectives throughout the training to ensure that they are meeting the expectations for the training. Request that the participants ask for clarification or more information if ever they feel like they cannot meet a learning objective.

18. Tell the participants that the additional materials will be distributed and explained as the training progresses.

19. Remind the participants that they are responsible for their own learning in some ways. As such, encourage them to ask questions throughout the training, especially if they do not feel like they are able to fulfill the training objectives.

20. Turn on the projector (or uncover the lens).

21. Show Slide 6 – 8: Learning Objectives.

Animate and read each objective (ask a participant to read the objectives aloud or do so yourself). Tell the participants that these objectives will be covered by the training in the next two and a half days.



SeSSIon 2: epidemiology, the Treatment Gap, and Stigma

methods: reflection journey, facilitator presentation, role play


Participant Handbook page: 3

materials: � PowerPoint (agitation, Delirium,

and Psychosis), slides 9 –17 � Flip chart � 3 or more markers

Preparation:• Practice implementing the reflection Journey.• review the PowerPoint (agitation, Delirium, and Psychosis), slides 9 –17

Objectives:d. identify the participants’ current and past attitudes surrounding severe mental illness.e. Describe the epidemiology of psychotic disorders and the corresponding treatment gap. f. Describe the various ways that psychosis may be viewed by the community and by

health providers.g. Describe the impact of stigma on patient care and outcomes.

StePS

20 minutes

1. Show Slide 9: Session 2: Epidemiology and Treatment Gap.

Read the objectives and explain to the participants that the group will begin to discuss psychotic disorders.

2. Ask the participants to begin by closing their eyes or putting their heads down. Explain that you will take them through a ‘Reflection Journey’— some quiet thinking before a large group discussion.



3. Once the participants are ready, lead them through the following ‘Reflection Journey’. Be sure to pause for 5 – 10 seconds after each question to allow them to reflect. Keep in mind that you do not need to ask every question (and you may add any questions that might be more relevant).

When you hear the word ‘psychosis’:

• What words come to mind?

• What images come to mind?

Think back to a time when you were very young:

• How did you learn about psychosis? What were your thoughts or feelings about it?

• What words did you hear and use related to psychosis?

• What did you think or feel about people with psychosis?

Think about your life since then:

• How have your thoughts about psychosis changed?

• What events or experiences changed the way that you think or feel about psychosis?

• In what ways have your ideas about psychosis remained the same?

4. Ask the participants to open their eyes. Invite a few volunteers to share their thoughts (maintaining patient and family confidentiality), and lead a brief discussion during which you discuss the participants’ past and current experiences with psychosis.

5. Ask the participants if they think that their understanding and views around psychosis and severe mental illness are different than their patients’. If so, ask them to elaborate on how patients and families might interpret psychosis. Write the participants’ ideas on a flip chart as they share their ideas.

6. Emphasize the importance of understanding that patients and families might have different understandings than physicians or other community members as to why someone has psychosis. Explain that each person and family, depending on their personal and cultural background, has an ‘explanatory model of illness’, which helps them to understand and make sense of their experience. Explain that participants are going to be introduced to some biomedical terms in this training, but it is important to note that using these terms with patients is less important than understanding patients’ and families’ experiences. It is important to help families to feel heard and understood, and physicians can do this by avoiding medical jargon and instead engaging with patients on their level.



40 minutes

7. Show Slide 10: Severe Mental Illness: Psychosis.

Animate the speech bubble. Ask the participants the following question:

• What is psychosis?

Wait for a few responses, and then respond by animating the answer. Tell the participants that there are some psychiatric disorders that mimic psychosis, which can include PTSD, acute stress, intellectual development disorder, and autism spectrum disorder.

8. Show Slide 11: Schizophrenia.


• How would you define schizophrenia?

Wait for a few responses, and then respond by animating the answer.

9. Show Slide 12: Bipolar Disorder.


• What is bipolar disorder?

Wait for a few responses, and then respond by animating the answer.

10. Show Slide 13: Schizophrenia and Bipolar Disorder: The Global Burden.


• How many millions of people are affected by schizophrenia and bipolar disorder?

Wait for a few responses, and then respond by animating the answer. Tell the participants that globally, approximately 1 in 100 people lives with a psychotic illness.

11. Ask the participants to reflect upon the following question:

• As we just learned, people with schizophrenia/bipolar disorder have a reduced life expectancy. Why do you think this is?

Have the participants share their answer with the person sitting next to them, and then have the pairs share their ideas with the group.

12. Explain that there are many reasons for reduced life expectancy, some of which are consequences of what we call the ‘treatment gap’.



13. Show slide 11: Treatment Gap.

Animate the speech bubble. Ask participants the following question:

• What does “treatment gap” mean?

Wait for a few responses, and then respond by animating the answer. Tell participants that the two most common severe mental illnesses are schizophrenia and bipolar disorder.

Explain that health systems have not yet adequately responded to the burden of mental disorders. As a consequence, there is a wide gap between the need for treatment and its provision all over the world. In low- and middle-income countries, between 76% and 85% of people with mental disorders receive no treatment for their disorder. In high-income countries, between 35% and 50% of people with mental disorders receive no treatment for their disorder.2

14. Show Slide 15: Reasons for the Treatment Gap.

Animate the title. Ask the participants to specifically share why there is a treatment gap. After all the ideas have been given, respond by animating the text on the slide.

15. Show Slide 16: Consequences of the Treatment Gap.

Animate the title. Ask the participants the following question:

• What are the consequences of this treatment gap in Haiti?

Allow the participants to respond. Animate the picture and text. Explain to the partici-pants that lack of awareness around mental health treatment often leads to abuse and mistreatment of those living with severe mental illnesses.

16. Show Slide 17: Consequences of the Treatment Gap.

Explain that lack of treatment can have direct effects on the physical health of those living with severe mental illness. This photo is of a girl with epilepsy who fell into a fire when she had a seizure.

2. World health organization. (oct 2014). Mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/



17. Explain that the treatment gap directly affects society’s concepts of severe mental illness and leads to stigma and discrimination of those with severe mental illnesses. Use the exercise below to demonstrate this concept further.

Ask the following questions sequentially to the participants:

Raise your hand if:

1. You have been to a doctor’s appointment during the last year.

– Wait for the participants to raise their hands.

2. You were admitted to a hospital for any reason during the past year.


3. You have taken any medication during the last year.


Ask the participants how it felt to answer these questions in this group setting. Allow the participants to respond.

Now say:

If we were to ask you to raise your hand (BUT no need to raise your hand) if…

1. You saw a mental health professional during the past year.

2. You were admitted to a psychiatric hospital, such as Mars and Kline, for any reason during the past year.

3. You have taken any psychiatric medication during the last year.

… how would you feel? Why?3

Have the participants share how they felt during this exercise.

18. Tell the participants:

Even though we are providers of mental health care, and understand the epidemiology behind severe mental illness, we can still feel stigma towards severe mental illness. This can lead to discrimination and unfair or low-quality treatment of patients.

3. sherman, M. (april 2008). support and Family Education: Mental health Facts for Families. retrieved from: http://www.ouhsc.edu/safeprogram/



stigMa

Stigma refers to negative or prejudicial thoughts about someone based on a particular characteristic or condition, in this case someone with a severe mental illness.

19. Highlight the fact that, as clinicians, it is not acceptable to have stigmatizing thoughts or behaviors toward people with severe mental illnesses. It the clinicians’ responsibility to overcome these feelings to be able to treat patients with dignity and respect.

15 minutes

20. Tell the participants that they are now going to role play how providers can perpetuate stigma in their work with people with severe mental disorders — sometimes without even realizing it.

21. Ask for three volunteers to participate in the role play. Give the three volunteers 2 – 3 minutes to read over the role play found in their participant handbook. Tell the volunteers that the ‘story’ section of the role play is intended to give the role play participants key background information, however, participants should just read the script aloud.

22. Invite the role play volunteers to the front of the room to complete the role play about stigma.



FACIlITATOR NOTeS

STIGmA ROle PlAy

STORy

a patient is brought by his family to the emergency room. he is very talkative and focuses mainly on vodou and religion. the emergency nurse fears that he is violent and does not wish to touch him because he may be contagious. the nurse does not check vital signs or provide any medical care. instead the nurse calls the psychologist and says “a mental health patient is here.” in the meantime, the patient is totally dehydrated, and has a high fever that goes undetected. his sister reports he has never behaved this way before and only became 'a crazy person' after a dog bit him. For more than two hours, the patient and his sister wait and no one comes to them for help.

SCRIPT

Family (Participant 2): Brings in the sick patient to the emergency room. “hello, please help us. My brother is sick.”

Patient (Participant 1): arrives at the emergency room with his sister. Begins to talk a lot about vodou and religion.

Nurse (Participant 3): acts scared because he might be violent. Calls the psychologist: “a mental health patient is here for you.”

Patient (Participant 1): is sitting down now. has a fever and is dehydrated. Does not look well. no longer very talkative.

Family (Participant 2): “Excuse me, nurse? i’m looking for help for my brother. he’s never been like this before. he only became like this after a dog bit him.” looks frustrated that no one helps them. “nurse, please help us.”

Nurse (Participant 3): “i have called the psychologist and i will let you know when he is available to see the patient.”



23. After the role play, ask the following question:

• Which of the nurses’ actions might have perpetuated the stigma around people with severe mental disorders?

• What should have been done?

• Has anyone ever encountered a similar situation in their work? What was done well or done poorly by the clinician in those situations?

24. Tell participants:

The Zanmi Lasante psychosis system of care aims to diminish Haiti’s treatment gap by safely and effectively treating people living with severe mental illness in a community-based system of care. Nurses have the opportunity to close the treatment gap and reduce stigma related to psychosis by building on the coherent system of care already developed for depression and epilepsy. Nurses have the opportunity to help some of the most vulnerable and marginalized people living in communities — those living with mental illness.



SeSSIon 3: The Psychosis System of Care and the Four Pillars of emergency management of Agitation, Delirium, and Psychosis

methods: Facilitator presentation, large group discussion, case studies




and Psychosis), slides 18 – 37 � Flip chart

� Markers � tape

Preparation:• review PowerPoint (agitation, Delirium, and Psychosis), slides 18 – 37.

Objectives:h. Describe the Psychosis Care Pathway and its collaborative care approach.i. outline the main roles of physicians, psychologists, social workers, nurses, and

community health workers in the system of care related to the identification, treatment, and management of agitation, delirium, and psychosis.

j. Explain the four pillars of emergency management of agitation, delirium, and psychosis. k. Describe how nurses should use the biopsychosocial model when managing a patient

with agitation, delirium or psychosis.

StePS

30 minutes

1. Show Slide 18: Session 3: The Psychosis System of Care and the Four Pillars of the Emergency Management of Agitation, Delirium, and Psychwosis.

Explain to the participants that you will discuss how Zanmi Lasante clinicians will facilitate care for complex patients, including psychotic patients.




Tell the participants that nurses’ main roles in the Zanmi Lasante system of care are:

a. to ensure safety for the patient and others;

b. to work with the physician and psychologist/social worker to rule out a treatable medical illness and to prevent further harm;

c. to provide follow-up by educating to patient and families and coordinating care with other providers;

d. to perform monitoring and evaluation of patients.

Explain that nurses are just one important element in the collaborative care approach; to provide quality care they need to work closely with other team members that include psychologists, social workers, physicians and community health workers.

3. Have the participants turn to the Agitation, Delirium, and Psychosis Checklist in their participant handbooks. Explain that all cadres will be receiving this checklist, which is an outline of key responsibilities. Give the participants several minutes to read the checklist.

4. Show Slide 20: The Psychosis System of Care Responsibilities.

Explain that this is a summary of the checklist responsibilities for each cadre.

5. Assess the participants’ understanding of the checklist by asking the questions below. Call randomly on participants. If a participant is unable to answer correctly, ask if another participant might be able to assist with the correct answer. Give them at least one to two minutes to look for an answer before calling on someone else.

1. According to the psychosis care pathway, which providers are responsible for deciding if a patient has a medical problem or a psychological disorder?

– Psychologists and physicians work together to determine whether patients have a medical problem or a psychotic disorder (a mental health problem).

Animate Slide 21: Question 1: Psychologists & Physicians

2. According to the psychosis care pathway, which providers are responsible for managing an agitated patient?

– Physicians, psychologists, and nurses work together to manage agitated patients. However, physicians are expected to take the lead, due to the need for prompt medical evaluation to rule out a treatable medical condition, and to possibly prescribe an initial medication for either a medical or mental health problem. Physicians should be careful, however, about jumping to the prescription of a psychiatric medication such as Haldol before a medical evaluation is done.

Animate Slide 22: Question 2: Physicians, Psychologists & Nurses.



3. According to the psychosis care pathway, which providers are responsible for giving psychoeducation?

– All providers! Physicians are responsible for psychoeducation about medication in particular.

Animate Slide 23: Question 3: All Providers.

4. According to the psychosis care pathway, how should physicians collaborate with psychologists/social workers during the initial evaluation of a calm patient and the follow-up visit for a calm patient?

– During an initial visit: to diagnose delirium/medical illness or mental disorder and to plan follow-up visits.

– During a follow-up visit: to determine whether a patient is improving and to plan follow-up visits.

Animate Slide 24: Question 4: Diagnose Delirium/Medical Illness, Plan Follow-Up Visits, Patient Improvement.

6. Show Slide 25: Psychosis Care Pathway Discussion.

Animate the slide. Tell the participants to turn to their neighbor and discuss the questions on the slides for five minutes. After five minutes, bring them together and ask them to share some of their ideas.

7. Show Slide 26: Tools Used by Psychologists with which Nurses Should be Familiar.

Animate the slide and mention that psychologists and nurses each have their responsibili-ties in the system of care that require tools. There are some diagnostic tools that are only used by psychologists, however, nurses should be familiar with these tools.

8. Show Slide 27: Tools Used by Physicians with which Nurses Should be Familiar.

Animate slide and mention that there are other tools only used by physicians.

9. Show Slide 28: Tools Used by Nurses.

Animate slide and emphasize that these tools will be used by nurses.



45 minutes

10. Show Slide 29: Psychotic Patients at the Hospital.

Ask participants the question on the speech bubble. Respond by telling participants that there are three types of patients that will come looking psychiatric, although not all of them will have a psychiatric illness:

• Patient is agitated

• Patient has a medical illness

• Patient has a psychiatric illness

11. Show Slide 30: Four Pillars of Emergency Management of Agitation, Delirium and Psychosis.

Explain that the nurses’ responsibilities in the care pathway align with the four pillars of managing a patient with psychotic symptoms. Emphasize that these pillars lay the frame-work for how clinicians manage patients with psychotic symptoms. Tell the participants that they will be coming back to these pillars throughout the training.

12. Show Slides 31: How do these pillars direct our thinking and action with psychotic patients?

Explain that there are several steps and processes within each pillar that the participants will learn to address when confronted with a psychotic patient. Read the slide and explain that these are some of the main steps that will guide clinicians to provide appropriate care for a patient with psychotic symptoms.

13. Show Slide 32: Biopsychosocial Model.

Explain that medical providers need to approach the treatment and management of psychotic disorders and severe mental illness from a biopsychosocial approach, because there are biological, psychological and social factors involved in the development of mental disorders.

Explain to the participants that a biopsychosocial approach to mental health treatment, will:

• Assist with understanding the condition

• Assist with structuring assessment and guiding intervention

• Inform multidisciplinary practices

14. Show Slide 33: Biopsychosocial Considerations.

Animate the title. Ask the participants what biological considerations nurses should have when working with patients with psychotic symptoms. Once they have responded, animate the ‘bio’ column.

Ask the participants what psychological considerations nurses should have when working with patients with psychotic symptoms. Once they have responded, animate the ‘psycho’ column.



Ask the participants what social considerations nurses should have when working with patients with psychotic symptoms. Once they have responded, animate the ‘social’ column.

Emphasize that the biopsychosocial approach to evaluation will lead to better identification of problems, communication between providers and care for patients.

15. Show Slide 34: Case 1.

Animate the case. Ask for a volunteer to read the case aloud. Ask the participants to think about the Four Pillars of Emergency Management and how they can apply the pillars to this case.

16. Show Slide 35: Case 1: How Should We Think About Mental Health?

Animate the title. Before animating the text for the ‘safety’ pillar, ask the participants what questions they would ask the patient and his family about patient safety. Then, animate the text. Repeat this process for each of the following pillars: medical health, mental health and follow-up.

17. Show Slide 36: Case 1: Biopsychosocial Considerations.

Animate the title. Ask the participants to take five minutes to fill in the Biopsychosocial considerations table in their participant handbook for Case 1. Specifically have the partici-pants write what information they know, and what further considerations or information they would want to find out. Then, ask the participants to share their answers for the ‘bio’ column, animating the column after all responses have been given. Ask the participants to share their answers for the ‘psycho’ column, animating the column after all responses have been given. Repeat the same process for the social column.

18. Show Slide 37: Case 1: Resolution.

Ask a participant to read the slide. Ask the participants if they can appreciate how the four pillars of emergency management and the biopsychosocial approach were used to manage this case. Ask if there are any questions.

19. Ask the participants to take a moment to review the checklist again. Emphasize how the checklist draws upon these two approaches (four pillars of emergency management and biopsychosocial approach). Explain how physicians are responsible for medical management of patients, while nurses assist with agitated patients and do much of the monitoring of these agitated, delirious or psychotic patients at the health facility. Psychologists and social workers are responsible for completing the mental health evaluation.

20. Before finishing this session, show the participants the table in their participant handbook entitled, The Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis. Inform them that they can use this table as a guide.



thE Four Pillars oF EMErgEnCy ManagEMEnt oF agitation, DEliriuM, anD PsyChosis

1. SAFeTy

violence:

• is the patient agitated or violent currently? (use the agitated Patient Protocol)

• What is the history of violence? When did it happen, how severe was it?

• is the patient being exposed to violence/abuse?

Suicide:

• is the patient suicidal currently? actively or passively?

• What is the history of suicide? Past attempts with medical severity, past suicidal ideation? When did it happen?

management:

• how is safety being managed? is 1:1 present?

• how is risk being decreased?

2. meDICAl

medical evaluation of Psychosis:

• Must do a physical and neurological exam, vital signs, weight, laboratory tests (hemogram, hiV and rPr for all patients; renal and hepatic panels if available; CD 4 count for all hiV patients).

• Consider a Ct scan if the patient has a clear neurological deficit.

Consider Delirium:

• Disturbance of consciousness with reduced ability to focus, sustain or shift attention; change in cognition/development of perceptual disturbance not due to dementia; disturbance develops over a short period of time (hours to days) and fluctuates during the day; evidence from the history, physical exam or lab tests that the disturbance is caused by a medical problem.

• treatment is aimed at underlying medical problem and avoiding diazepam.

Consider epilepsy (Post-Ictal Psychosis):

• the family reports the development of psychosis/agitation after seizures.

• treatment is anti-epileptic.

medication management:

• use the medication card to dose and prescribe.

• Provide fluids and do an EKg for all hospitalized/emergency room patients receiving haloperidol.

• Check for medication side-effects; do aiMs.

• Check vital signs and weight for all patients



3. meNTAl HeAlTH

Diagnosis:

• Work with a psychologist/social worker, use the Differential Diagnosis information sheet.

• reconsider the diagnosis at each visit.

Psychoeducation and Support:

• Provide education to patients and families regarding psychosis and medication.

medication management:

• use Medication Card for agitation, Delirium and Psychosis; consider diagnosis.

4. FOllOw-UP

Date of next appointment/visit:

• Follow-up based on acuity; for hospitalized patients, daily or several times a day; for outpatients, can be every 1– 2 days or weekly for more acute patients and every 2 – 4 weeks for stable patients.

• involve community health workers in the care.



SeSSIon 4: Safety and management of Agitated Patients

methods: Facilitator presentation, role plays




and Psychosis), slides 38 – 50 � Flip chart � Markers

Preparation:

• review the PowerPoint (agitation, Delirium, and Psychosis), slides 38 – 50.• review the facilitator role play and assign facilitators to the activity.

Objectives:l. Describe the identification, triage, referral and non-pharmacological management of

an agitated patient through the use of the agitated Patient Protocol and the agitation, Delirium, and Psychosis Form.

StePS

1 hour

1. Show Slide 38: Session 4: Safety and Management of Agitated Patients.

Remind participants that they have just learned about the four pillars of emergency man-agement. Ask the participants what the first pillar is (safety!). Respond by telling them that safety is the first pillar when dealing with an agitated, delirious or psychotic patient so the participants will spend this session talking about safety and the management of agitated patients.

2. Ask the participants:

• Why it is important to be able to manage an agitated patient?

• What experiences do you have managing agitated patients?

Allow for a few participants to respond.



3. Have the participants turn to the Medical Evaluation Protocols for Agitation, Delirium, and Psychosis Form in their participant handbook. Explain that this protocol guides physicians from managing an agitated patient (Step 1a) to performing a medical assessment to rule out delirium (Step 2). This set of protocols is to be used as a reference and will be referred to throughout the training.

4. Show Slide 39: What is the first step in managing an agitated patient?

Animate the slide. Tell the participants that often nurses and other health providers are unsure what to do when there is an agitated patient. Ask the participants to show how they would answer the question by raising their hands:

• Who thinks the first step is A?

Pause for participants to raise their hands. Continue by asking who would do B, C, and D as a first step.

Explain that the answer is D, and animate the slide again. Tell the participants that by talking to the patient, the nurse can evaluate the risk of violence, begin the medical evaluation, and calm the patient.

5. Show Slide 40: Managing Agitated Patients Following the Psychosis Care Pathway.

Animate the slide. Emphasize to the participants that nurses manage agitated patients as a team with psychologists, social workers, and physicians. Clarify that these roles listed on the PowerPoint slide are found on the Agitation, Delirium and Psychosis Checklist under ‘Agitated Patient’ for each cadre.

6. Have the participants turn to the Agitated Patient Protocol and Agitation, Delirium and Psychosis Form in their participant handbooks. Explain that these forms are the main tools that physicians will use to evaluate and manage agitated patients. Specify that the Agitated Patient Protocol will assist the participants in properly managing different levels of agitation. The Agitation, Delirium and Psychosis Form assists physicians in recording vital information related to determining if an agitated patient is delirious or psychotic. Give the participants several minutes to review the forms independently.

7. Show Slide 41: Agitation Etiology.


• By a show of hands, who thinks agitation is a disease?

Wait for the participants to raise their hands.

• Who thinks agitation is not a disease?

Wait for the participants to raise their hands. Respond by animating the text on the slide.



8. Show Slide 42: Agitation/Violence Spectrum.

Explain that there is a spectrum of agitation and patients can fall anywhere on the spectrum. Choose participants to read aloud the various behaviors of those with mild, moderate and severe agitation. Ask the participants to take a moment to look at the Agitated Patient Protocol. Confirm by asking if they see how there are different degrees of agitation/aggression/violence and that this level determines their management of the patient. Explain that the purpose of this tool is to guide safe and effective care of patients, including reducing the use of physical restraints, and medication.

9. Explain to the participants that there are some key differences in agitation management, especially in the treatment between moderate and severe agitation. Ask the following questions to provoke critical thinking and discussion. Pause between questions to allow the participants to respond. Give additional information as needed, and suggest that the participants refer to their Agitated Patient Protocol.

• When should we give medication intramuscularly?

– From a human rights perspective, we always want the least restrictive approach and use the fewest interventions necessary. We only give medication intramuscularly to a severely agitated patient who is at risk for imminent self-harm or is harming those around him. We only administer medication intramuscularly when a severely agitated patient refuses oral medication or is unable to comprehend the request to take oral medication. We must remember that administering an intramuscular injection is invasive and can cause physical pain. It can also potentially lead to physical harm towards providers.

• Why is it important that we monitor the vital signs of the patients we give medication to?

– The process of taking medication or having medication administered against one’s will can be stressful. Stress, in combination with medical and psychiatric conditions, can lead to physiologic instability. The medications themselves can affect the heart, for example potentially causing heart arrhythmia. Vital signs are key measures to physiologic status and are therefore essential.

• In what situations should clinicians use physical restraint?

– From a human rights perspective, the goal is to use the least restrictive means necessary. The rights of a person must take priority, in balance with the safety of those around them. Physical restraint can be considered if:

• If calming measures have been tried AND

• The patient has been offered an oral medication and refused AND

• The patient reaches a state of severe agitation where there is a significant worry about harm to self and others AND

• It is felt that all alternatives have been tried.



10. Show Slide 43: When Managing an Agitated Patient, Safety and Talking First!

Read the slide. Tell the participants that this safety information is on the Agitated Patient Protocol. Explain how to ensure safety and remind them that it is the first of the four pillars of emergency management for a reason. Emphasize that a nurse should never inject a patient with haloperidol without speaking to the patient first, even if the patient is agitated.

11. Ask the participants: what is a “1:1” and when would you arrange one? Facilitate a short discussion around when it would be appropriate to have a clinician, auxiliary staff member, or family member stay with a patient to monitor them (typically it should take place in a less stimulating place than the waiting room).

12. Have the participants turn to the Agitation, Delirium and Psychosis Form. Point out the first box on the form is about safety. Explain the steps in completing the safety section of the form.

45 minutes

13. Show Slide 44: Agitated Patient 1.

Have a participant read the case study aloud.

14. Tell the participants that the facilitators will now put on a three-minute role play acting out the case on the slide.

ROle PlAy

CASe

a 55-year-old man is brought to the clinic by concerned neighbors. they report that he has been talking to himself, yelling at people for no reason and making threatening comments. they refer to him as 'crazy' and report that he has no friends or family. in the clinic he is disorganized and confused.

INSTRUCTIONS FOR THe FACIlITATOR

one facilitator will play the part of a nurse and the other facilitator will play the part of the patient. the facilitator playing the nurse will demonstrate inappropriate, commonly-used tactics for managing agitated patients. in particular, the facilitator playing the role of the nurse should raise his/her voice at the patient, threaten to inject the patient with medication and tie the patient up, demonstrate anger and frustration, and not provide any medical care (such as doing vital signs or a physical exam).



15. After the role play concludes, ask the participants: What went wrong? Allow participants to respond and add any of the following points they may have missed.

• Raising one’s voice at the patient.

• Threatening to tie up the patient/give an injection.

• Showing anger and frustration.

• Not providing care to the patient.

16. Ask the participants to use the Agitated Patient Protocol to discuss how they would approach the patient instead. Allow participants one minute to read over the Agitated Patient Protocol and then have participants share their answers with the person sitting next to them. Ask for a few pairs to share their answers. Responses should include: emphasizing safety first, talking before injecting, and managing the behavior and the environment.


Tell the participants that they will be redoing the role play, demonstrating how to properly manage and evaluate the patient using the Agitated Patient Protocol and the Agitation, Delirium, and Psychosis Form.

Recruit four volunteers and assign each to one of the following roles: physician, patient, neighbor, and nurse. Give role play volunteers three minutes to plan amongst themselves. Reiterate that the actors should use the Agitated Patient Protocol and should complete the safety section of the Agitation, Delirium, and Psychosis Form. Participants not participating in the role play should follow along using the Protocol and Form.

The role play should last no longer than five minutes.

ROle PlAy

CASe

a 55-year-old man is brought to the clinic by concerned neighbors. they report that he has been talking to himself, yelling at people for no reason and making threatening comments. they refer to him as 'crazy' and report that he has no friends or family. in the clinic he is disorganized and confused.

18. After the role play ends, ask the following questions to the audience:

• What was done well by the participants?

• How were the forms used to guide agitation management?

• What could be improved?



19. Show Slide 46: Take a Clinical History.

Explain to the participants that physicians and psychologists/social workers should try to obtain as much history about the patient as possible to better inform the management of the patient’s agitation. Nurses assist in this process. Show the participants the left hand column of the Agitation Patient Protocol that says “Throughout Visit: Assessment.” Reiterate the importance of assessing patients as thoroughly as possible even when they are agitated.

Then, ask the participants what questions they might ask the neighbors who brought the man to the health center in the case study (if not demonstrated during the previous role play). Ask for the participants to share their answers. Once all answers have been shared, animate text on the slide. Mention that although it would be ideal to obtain information about the agitated patient (whether from the patient or someone else), it is not always possible depending on the level of agitation.

20. Show Slide 47: Perform a Brief Assessment.

Remind the participants that throughout the process of interacting with the agitated patient, they should try to get information to inform their evaluation. It is helpful to obtain this information from the patient, if possible, but also from family members or anyone who has accompanied the patient.

21. Tell the participants that part of taking a clinical history and performing an assessment includes the identification and triage of patients who may have suicidal ideation. It is important that each agitated or psychotic-appearing patient with a concern of self-harm is screened for suicidality. Explain to the participants that psychologists/social workers have the responsibility within the system of care to evaluate and properly screen patients for suicidality. The physician, when managing an agitated patient will ask and then record on the Agitated Patient Form if that patient has a history of suicide attempts. If the patient does have a history of suicide attempts, the psychologist/social worker will immediately use the Suicidality Screening Instrument to determine the patient’s level of risk. If a nurse is assessing a patient, and has a concern about a patient’s safety, they should contact the psychologist/social worker immediately so the patient can be properly screened.

22. Show Slide 48: Perform a Physical Exam.

Explain that while physicians will perform the bulk of the exam, nurses are responsible for taking and recording vital signs.

23. Show Slide 49: Refer to Physician and Psychologist.

Animate the slide. Tell the participants that nurses would refer a patient’s case to a physician and/or psychologist if the patient’s crisis occurred in the in-patient unit, where the nurse was working.




Tell the participants that they will continue to practice their use of the Agitated Patient Protocol and the Agitation, Delirium, and Psychosis Form through another three-to-five minute role play. Ask for five volunteers and assign each of them one of the following roles: a patient, (2) family member, a physician, and a nurse. The doctor will be responsible for using the Agitated Patient Protocol and the Agitation, Delirium, and Psychosis Form to properly manage and medically evaluate the patient.

Give the participants three minutes to plan amongst themselves, and then begin the role play.

25. After the role play has concluded, debrief with the audience. Ask the audience the following questions:

• What level of agitation did this patient have?

• What did the nurse and physician do well?

• What could have been improved?

26. Conclude the session by reminding the participants that safety is the first pillar of emergency management. Talking to a patient effectively and helping the patient to feel safe and respected — not simply medicating a patient — is a key part of safety and evaluation.



DAY 1 RevIew

methods: group presentations

Time: 30 minutes

materials: � Flip chart � Markers

StePS

30 minutes

1. Explain to the participants that they will be reviewing yesterday’s sessions by participating in group presentations.

2. Tell the participants that they will be divided into small groups and will be assigned a session from yesterday. The groups will have 10 minutes to create a three-to-five minute presentation summarizing the most important information from their assigned session. Each group will be given a piece of flip chart paper and markers — participants are free to draw, create a map or write down an outline to present their information to the audience. Encourage the groups to draw information from their participant handbooks.

3. Divide the participants into three groups. Distribute the flip chart paper and markers. Assign one of the following sessions to each group (if there are more than five participants in each group, you can divide into further groups and assign the same session to more than one group):

• Session 2: Epidemiology, Stigma and the Treatment Gap

• Session 3: The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis

• Session 4: Safety and Management of Agitated Patients

4. Read the following questions aloud to the participants to guide their work:

• What were some of the key points raised during the session?

• What ideas and suggestions are you taking away from this training?

5. After 10 minutes, invite each group to the front of the room to present. Instruct the timer to time each group so that no group goes over the five-minute time limit. Thank each group after they have presented.



SeSSIon 5: medical evaluation and the management of Agitation, Delirium, and Psychosis

methods: Facilitator presentation, case studies




and Psychosis), slides 51 – 63 � Flip chart

� Markers � tape

Preparation:

• review PowerPoint (agitation, Delirium, and Psychosis), slides 51 – 63.

Objectives:m. Define medical delirium.n. Describe the importance of proper medical evaluation for an agitated, delirious or

psychotic patient.o. Explain how to conduct a medical evaluation for an agitated, delirious or psychotic patient.

StePS

45 minutes

1. Show Slide 51: Session 5: Medical Evaluation and Management.

Tell the participants that once they have calmed an agitated patient, the physician and the psychologist/social worker need to determine if the patient is psychotic or has a medical delirium.

2. Show Slides 52 – 53: Case – Part 1 and Case – Part 2.

Review the case. Allow the participants to indicate whether they agree or disagree with the management of the case at each stage and why.



3. Show Slide 54: Case – Part 3.

Ask the participants what went wrong. Give them time to respond. Highlight the points below:

• The patient did not receive a comprehensive medical evaluation.

• Haloperidol was used inappropriately and dangerously to sedate the patient.

• The patient was not properly diagnosed with delirium (psychosis and agitation are medical problems until proven otherwise).

4. Show Slide 55: Consequences of Mismanagement of Agitation, Psychosis and Delirium.

Walk the participants through the case timeline on the PowerPoint slide, highlighting the consequences of sedating a patient rather than doing a medical evaluation that would have uncovered a medical delirium (not psychosis).

5. Show Slide 56: Definition of Agitation, Delirium and Psychosis.

Read through the definitions. Emphasize how all of these phenomena are considered medical problems unless proven otherwise; these patients are not automatically ‘mental health patients’, rather they are medical patients who need care from physicians.

6. Show Slide 57: Definition of Delirium.

Tell the participants that delirium is not well understood biologically, but that it can be characterized as a physiologic imbalance in the body and brain that can be potentially fatal. Delirium is often misdiagnosed as psychosis or other psychiatric illnesses. Remind participants of the case of the 28-year-old woman who was seven months pregnant and died.

7. Show Slide 53: Physical Illness Causes Delirium.

Ask the participants:

• Which physical illnesses cause delirium?

Read the list of medical problems and indicate which ones are common in Haiti.

8. Show Slide 59: Other Medical Causes of Psychosis/Agitation.

Read the slide.

9. Show Slide 60: Standard Medical Evaluation for Delirium/Psychosis/Agitation.

Explain that physicians will medically evaluate a patient to determine whether a medical problem is the cause of their agitated or psychotic behavior.



10. Ask participants to turn to the Medical Evaluation Protocols for Agitation, Delirium and Psychosis in their participant handbooks. Remind the participants that they saw this protocol last session, and were focused on the managing agitation portion (step 1a and 1b). Now, they can use this protocol (step 2) to manage the medical assessment portion alongside the physician. Give the participants a minute to silently read over the steps of the medical assessment as described by the protocol.

11. Show Slide 61: How do you distinguish between mental illness and medical illness?

Allow the participants to look at the Medical Evaluation Protocols and then respond with their ideas.

12. Show Slide 62 – 63: Medical Illness or Mental Illness?

Ask for a participant to read the case study aloud. Once the case has been read, ask the questions on the slides and allow participants to respond. Emphasize that participants should be using the Medical Evaluation Protocols and Agitated Patient Form when trying to decide if a patient has a medical illness or mental illness.

30 minutes

13. Tell the participants that they will now individually practice using the Medical Evaluation Protocol to determine if a patient has a medical illness or a mental illness. Instruct participants to take 15 minutes to read the case studies in their participant handbook and answer the accompanying questions.



FACIlITATOR NOTeS

CASe STUDy 1

a 45-year-old woman is brought by her family to your health center. she is clearly psychotic, making nonsensical comments about god and other spirits and also yelling. you recognize her as she has been a patient seen in the hiV/aiDs program.

1. after managing her agitation, how would you evaluate her? What psychosis forms would you use?

• look to step 2 of the Medical Evaluation Protocols, à see Box 1 – standard Medical Evaluation for agitation/Delirium/Psychosis.

• Even though the patient has hiV/aiDs and has been treated in that program, she still needs a comprehensive medical evaluation that includes a brief history (current medical problems, alcohol/substance abuse, current medications, and history of mental illness), vital signs, physical exam, neurological exam, mental status exam (orientation, alertness, confusion), and laboratory tests (CBC, rPr, Vih, CD4).

• if they are available, a renal panel and hepatic panel should also be done. additional tests (Ct scan, EEg, lumbar Puncture, CXr) can be considered after the initial work-up.

you performed a brief assessment and conducted a blood test. you discovered that the patient is hiV positive and the patient’s CD4 count has come back at less than 200.

2. What do you do next?

• Ensure a thorough medical approach. Consider a lumbar puncture and starting empiric treatment with the appropriate antibiotic medication. Consider treatment for toxoplasmosis or cryptococcus. Check if the patient has an rPr.

3. is this person suffering from medical delirium or a psychotic disorder?

• Probably medical delirium. to be sure, continue seeing the patient over the next few weeks to see if delirium symptoms resolve.



CASe STUDy 2

a middle-aged man arrives at the health center. his daughter brought him there. he is sweating, disoriented and is anxious. he is mildly agitated and wants to leave the health center. after performing an initial assessment, you find out from his daughter that he drinks alcohol every day (‘a lot’ she reports). the daughter took away all his alcohol and money yesterday because she wants him to stop. you have taken his vital signs, and he has a pulse of 130.

1. What are the signs of alcohol withdrawal you would look for?

• Within a few hours: withdrawal tremors, nausea, vomiting, sweating, anxiety, and increasing heart rate.

• Within a few days: hallucinations, seizures, fever, disorientation, hypertension.

2. how would you treat the alcohol withdrawal?

• treat alcohol withdrawal with 10 mg iV/iM diazepam, repeat after 15 minutes as needed until response, then repeat in 6 hours.

• Monitor the respiratory rate to avoid overdose.

3. is this person suffering from medical delirium or a psychotic disorder?

• Medical delirium.

4. After 15 minutes, bring the participants back together. Call on different groups to share their answers. Ask if there are any outstanding questions on the Medical Evaluation Protocol for Agitation, Delirium and Psychosis.



SeSSIon 6: medication management for Agitation, Delirium, and Psychosis

methods: Facilitator presentation, worksheet, role plays

Time: 2 hours



and Psychosis), slides 64 – 78 � Medication Card for agitation,

Delirium and Psychosis

� Flip chart � Markers

Preparation:


Objectives:p. Describe the use and possible side effects of the primary medications for agitation,

delirium, and psychosis.q. Provide comprehensive psychoeducation messages to a patient and his/her family

around medication management.

StePS

1 hour

1. Show Slide 64: Session 6: Medication Management for Agitation, Delirium and Psychosis.

Tell the participants that once a medical evaluation has been performed, a physician must decide if pharmacologic treatment is necessary. Frequently, the nurse will be assisting the physician administer IM and oral medication. Distribute the laminated Medication Card for Agitation, Delirium and Psychosis.

2. Show Slide 65: Zanmi Lasante Tools for Prescribing Psychotropic and Anti-Epileptic Medications.

Briefly review the primary tools that can be used to guide prescribing practices. After you illuminate the bullet point ‘Medication Card for Agitation, Delirium, and Psychosis’ on the Power Point, give the participants five minutes to review the card independently.



3. Show Slide 66: Review of Zanmi Lasante Formulary.

Animate the title and speech bubble. Ask the participants what medication for mental disorders they can name. Animate the table.

4. Show Slide 67: Risperidone.

Read the important points outlined on the slide. Mention to the participants that this medication should be the first-choice drug for most patients.

5. Show Slide 68: Haloperidol.

Read the important points outlined on the slide. Emphasize that risperidone has fewer side effects and should be tried before haloperidol, unless the patient is violent or aggres-sive and could benefit from the sedation of haloperidol.

6. Show Slide 69: Carbamazepine.

Read the important points outlined on the slide. Emphasize that carbamazepine should typically be prescribed before valproate as a long-term mood stabilizer.

7. Show Slide 70: Valproate.

Read the important points outlined on the slide. Emphasize that valproate is particularly for patients with longstanding aggression or violence, and should never be prescribed to a pregnant woman (and avoided for women of child-bearing age).

8. Show Slide 71: Diazepam.

Read the important points outlined on the slide. Emphasize that diazepam is only used in agitated patients and those experiencing alcohol withdrawal.

9. Show Slide 72: Anti-Psychotics – Side Effects.

Explain to the participants that physicians will need to evaluate and manage antipsychotic medication side effects. Nurses will be helping physicians manage the side effects of antipsychotic medication given to patients in the in-patient ward. Read the text on the slide, emphasizing that acute dystonia and neuroleptic malignant syndrome are two side effects that constitute an emergency. Tell the participants that tardive dyskinesia is a possible side effect of antipsychotic medications, particularly ‘typical’ antipsychotics such as haloperidol. Patients and their families need to know about these side effects.



10. Tell the participants that it is important they can identify side effects of anti-psychotic medication, as it can mean the difference between life and death. Divide the participants into pairs and tell the participants they will spend five minutes brainstorming how the following side effects present clinically (what are the symptoms that a nurse might observe?):

• Akathisia (psychomotor restlessness)

• Tardive Dyskinesia (involuntary orofacial movements)

• Neuroleptic Malignant Syndrome

11. After five minutes, ask the participants to share their answers. Write down participants’ answers on a flipchart. Allow participants to share personal experiences identifying anti-psychotic side effects, if relevant. Add any answers that participants did not mention from below.

• Akathisia (psychomotor restlessness)

– Tapping of knees

– Difficulty sitting; pacing to alleviate discomfort in knees

– Worsening anxiety or panic

– Difficulty sleeping

• Tardive Dyskinesia (involuntary orofacial movements)

– Unusual facial expressions, such as: lip smacking, puckering or pursing, grimacing, excessive eye blinking

– Rapid, involuntary movements of the libs, torso and fingers

– Cogwheel rigidity of limbs as in Parkinson’s Disease: rigidity in which muscles respond with cogwheel-like jerks when the clinician tries to move the limb

– Rigidity of neck, shoulders and other body parts

• Neuroleptic Malignant Syndrome

– Muscle cramps and rigid muscles (not cogwheel rigidity, but stiffness)

– Tremors

– Fever (hyperpyrexia) to >38 °C (>100.4 °F)

– Autonomic nervous system instability: unstable blood pressure, pulse

– Mental status changes and delirium

– Diaphoresis

12. Explain that when a patient with agitation or psychosis has been given anti-psychotic medication for an acute episode at the clinic, it will be the nurses’ responsibility to monitor the patient. The nurse will check in with the patient every 15 minutes, if not more frequently.



13. Show Slide 73: Antipsychotic Side Effects and Toxicities.

Emphasize that there are some side effects that are non-life threatening, but there are other side effects that are life-threatening (which nurses just identified in the previous activity).

14. Show Slide 74: Prescribing Principles for Agitation, Delirium, and Psychosis.

Note that physicians should only prescribe risperidone and haloperidol. Mood stabilizers should not be routinely prescribed for bipolar disorder.

45 minutes

15. Tell the participants they will now take time to review information about medication for agitation, delirium and psychosis. Participants will have 30 minutes to complete the medication review questions in their participant handbook. Explain that participants may use the Medication Card and Agitated Patient Protocol (refer to Facilitator Notes).

16. After 30 minutes, bring the participants together and go over answers on the medication review sheet, asking for participants to share their answers.

15 minutes

17. Show Slide 75: Psychoeducation about Medication.

Animate the title. Ask the participants:

• If you or a family member were being prescribed an antipsychotic, what information would you like to know about the medication? Once participants have responded, animate the text.

Tell the participants that it is incredibly important to speak to patients and their family members in language that they understand, depending on their education level and knowl-edge. Do not speak to patients and family members in jargon or complex medical language.

Mention additional information about prescribing principles:

• It is important to take the medication regularly and not miss a dose.

• Do not double up on a dose if a dose is missed.

• It is important to continue to take medication even if symptoms improve.

• Symptoms may worsen if medication is discontinued.

• If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist or physician) by phone, or return to the hospital for evaluation.



18. Show Slide 76: Psychoeducation – Case 1.

Ask a participant to read the case on the slide aloud. Give participants one minute to consult the Medication Card, and ask for responses.

• What the medication is for: risperidone is used for psychosis.

• How to take the medication properly: take it at night before bed because it can make you sleepy.

• Common side effects: sedation, weight gain.

• Toxic side effects and when to seek immediate medical care: difficulty breathing, muscle tightness in body, difficulty seeing or controlling eyes (dystonia, tardive dyskinesia, akathisia), rash, hot feeling or fever, abnormal blood sugars (diabetes).

• How long it takes for medication to work: it can work within one day. But it usually takes 4 – 6 weeks for full effect.

19. Show Slide 77: Psychoeducation – Case 2.

• What the medication is for: used for psychosis, especially in violent patients.

• Common side effects: sedation, stiffness, a heavy tongue.

• Toxic side effects and when to seek immediate medical care: difficulty breathing, muscle tightness in body, difficulty seeing or controlling eyes (dystonia, tardive dyskinesia, akathisia), rash, hot feeling or fever, abnormal blood sugars (diabetes).

• How long it takes for medication to work: immediately. Once it has been given, the physician will wait 30 minutes and if patient remains agitated the physician may consider giving haloperidol again (but only half the original dose).

20. Show Slide 78: Side Effects – AIMS.

Read the slide and tell the participants that physicians will be utilizing the AIMS (Abnormal Involuntary Movement Scale) every six months with patients that are on an anti-psychotic medication. Explain to participants:

• Tardive dyskinesia can develop over the course of months and years, and should be monitored using AIMS. AIMS is useful for detection and follow up of tardive dyskinesia. If one can catch tardive dyskinesia early, one can intervene.

• The AIMS will be performed by physicians at the beginning of treatment, and then every six months. It can be done in less than 10 minutes.



meDICATION RevIew wORkSHeeT

Use the Medication Card for Agitation, Delirium, and Psychosis and the Agitated Patient Protocol.

1. Which three medications on the medication card can Zanmi lasante physicians prescribe without consulting the mental health team?

• haloperidol

• risperidone

• Diazepam

2. Which two medications on the medication card should not be routinely prescribed by Zanmi lasante physicians for bipolar disorder or other forms of mental illness?

• Carbamazepine

• Valproic acid

3. a 63-year-old man arrives in the emergency room. he is violent and out of control, pushing people and running around. he has been brought in by his wife and son, who report he has never behaved this way before. according to the agitated Patient Protocol Form, which medication should the physician instruct you to give the patient? give the medication name, dose, and form.

• haldol 5 –10 mg iM + diphenhydramine 25 mg iM or diazepam 10 mg iM

• Because the patient is older, it would be better to give haldol 5 mg iM (or even 2.5 mg if possible). avoid diazepam because the patient likely has delirium (he has no history of mental illness). since anti-cholinergic medication can cause delirium, especially in older people, it would be better to not give diphenhydramine. instead, administer the haloperidol alone and wait and see if there are any side effects warranting treatment with diphenhydramine.

4. a 25-year-old woman who is six months pregnant is hospitalized for a clot in her leg. she has been psychotic for many years and is currently mildly agitated (she is irritable and does not cooperate with hospital staff, but is not threatening). she refuses to take the anti-coagulant because of her psychosis. Which anti-psychotic should the physician prescribe for her?

• Prescribing an anti-psychotic to a pregnant woman is a high-risk intervention that warrants careful consideration, informed consent with the patient and her husband (or guardian), and collaboration with the psychologist or social worker to ensure proper diagnosis. For these reasons, Zanmi lasante physicians are not to prescribe an anti-psychotic to a pregnant patient without consulting the mental health team first.

FACIlITATOR NOTeS



5. a doctor is working in the emergency room of a local clinic when a father brings his 19-year-old daughter in. she is totally rigid, unable to walk, unable to turn her head, and unable to open her mouth. her father has to carry her. he reports that she was taken to a psychiatric facility after becoming violent following a breakup with her boyfriend. at the facility, she was given multiple injections. how should you and the physician treat this case? What medication should she be given?

• the patient has severe dystonia, and, therefore, should be given diphenhydramine 50 – 75 mg iM daily. she should also receive liters of fluids to flush out the haloperidol and also because she is receiving a strong dose of an anti-cholinergic medication. she should also be monitored closely for signs of neuroleptic malignant syndrome.



SeSSIon 7: Follow-Up and Documentation

methods: Facilitator presentation, group discussion

Time: 45 minutes



and Psychosis), slides 79 – 83 � Flip chart � Markers

Preparation:


Objectives:r. Explain how to provide follow-up for people living with psychotic disorders and severe

mental illness, including general psychoeducation messaging.s. Describe the importance of documentation during patient follow-up.

StePS

45 minutes

1. Show Slide 79: Session 7: Follow-Up and Documentation.

Tell the participants that once a patient is treated for their agitation or psychosis, the nurse is responsible for educating the patient and family about mental illness and the patient’s next steps in the psychosis care pathway. Because psychoeducation is so important, all Zamni Lasante health providers have a role in delivering psychoeducation. Psychologists and social workers will give the most detailed psychoeducation through their psychotherapy work.

2. Tell the participants they are now going to brainstorm important psychoeducation messages to share with patients and their families. Ask participants:

• What are key messages to share with patients and families when counseling them about mental illness?

Have the participants respond while you write the answers on the flip chart. Add any ideas from below that are not mentioned by the group.



GeNeRAl meSSAGeS TO SHARe wITH PATIeNTS AND FAmIlIeS

• a patient’s symptoms can improve with treatment and they can even recover.

• it is important to continue with work, social, and school activities as much as possible.

• the patient has a right to be involved in making decisions about their treatment.

• it is important to exercise, eat healthy, and maintain good personal hygiene.

• Families should not tie up or lock up patients. instead, bring them to the clinic/hospital or ask the ChW for help/support.

3. Have the participants turn to their Agitation, Delirium and Psychosis Checklist to identify the two different times when they are supposed to provide psychoeducation: 1) for all agitated patients and 2) if psychosis is diagnosed.


Remind the participants that this pathway only works with functional follow up and documentation. Emphasize the importance of using consistent protocols and procedures in continued evaluation and treatment. Tell the participants that they will be recording all their work in nursing forms. If the patient they are seeing is at a follow-up appointment, the nurse will be recording information like vital signs, weight and labs in the Mental Health Follow-Up Form.

5. On a piece of flipchart paper, draw two columns. Label the left column “challenges documenting information” and the right column “strategies to ensure documentation.” Ask the participants what challenges they face in properly documenting information. Take a few responses from the audience and write their answers in the left column. Then, divide up the participants into groups of two to three and tell them they have five minutes to brainstorm strategies to the overcome the barriers listed on the flipchart.

6. After five minutes, have a representative from each small group take a minute to share their strategies in front of everyone. Record participants’ strategies in the right column on the flipchart.

7. Show Slide 81 – 83: Documentation Question 1 – Documentation Question 3.

Read the question presented on the slide. After asking the question, give participants time to look at the documents and determine where to document. Allow several participants to give responses before animating the answer.



DAY 2 RevIew: jeopardy Review Game

methods: game

Time: 1 hour

materials: � PowerPoint (Jeopardy) � PowerPoint (agitation, Delirium,

and Psychosis), slides 84 – 85

� Flip chart � Markers

Preparation:• review PowerPoint (Jeopardy)


StePS

30 minutes

1. Explain that the participants will now review day two’s training content using a game called Jeopardy. Jeopardy is a question-and-answer type of game where participants can earn points by answering questions correctly.

2. Show Slide 84: Day 2 Review: Jeopardy Rules.

Explain that the first row on the slide shows the categories. Each question under that category column is related to that category.

3. Explain that each category will have a series of values listed under the category title. Each value corresponds to a different question. The questions with a greater value are more difficult questions. For example, a question with a value of 100 is easier than a question with 300 points. The value also corresponds to the points that are awarded for a correct answer.

4. Divide the participants into two or three groups according to the total number of participants (ideally, about five to seven participants per group). Tell the teams that they should decide on a team name and a team leader. The team leader will speak for the team.

5. To begin the game, the facilitator will ask the first team to choose a category and a value. The facilitator will read the question that corresponds to the category and value aloud. For this activity, one of the facilitators will keep score on a flip chart. Another facilitator should lead the game. A third facilitator (or volunteer participant) can be the ‘time-keeper’ to monitor the elapsed time.



6. Show Slide 85: Jeopardy Rules.

Explain that the team leaders are responsible for raising their hand once their team thinks that they know the correct answer. The organizer will watch carefully and will decide which team leader raised his or her hand first. The team whose team leader raised his or her hand first is given the first opportunity to try to respond to the question.

7. Each team has 15 seconds in which to answer the question that they are asked. If they answer incorrectly, the next team has an opportunity to answer correctly and so on. The team that answers correctly is awarded the points. When the question has been answered, the next team chooses the category and value. Ultimately, the game ends when all questions have been answered. The team with the most points wins.

8. During this game, questions about the training content often arise. Use the game to clarify information and answer questions that the participants may have.

9. Load the Jeopardy PowerPoint, start the game, have fun, alter the rules as necessary, and reward the team who wins in the end!



SeSSIon 8: Review, Post-Test and Training evaluation

methods: Case studies, assessment, evaluation

Time: 2 hours 15 minutes



and Psychosis), slides 86 – 87 � Flip chart � Markers � Post-it notes

� Post-test answer Key (on a computer to be projected)

� training Evaluation Forms (1 copy/participant)

� Post-test (1 copy/participant) � tape

Preparation:

• review PowerPoint (agitation, Delirium, and Psychosis), slides 86 – 87.• review the case studies ahead of time.• Photocopy the post-tests and training evaluation forms.• Create three flip chart pages, each individually titled:

1. how will you share what you’ve learned?

2. What strategies will you use to ensure collaboration with other team members?

3. When i’m unsure or struggling i will…

Objectives:t. review all unit objectives.u. Demonstrate learning through a post-test.v. give feedback on the training.

StePS

1 hour

1. Show Slide 86: Session 8: Review and Feedback.

Explain to the participants that they will discuss case studies as a way to review the management of patients with agitation, delirium and psychosis and to become more familiar with the forms and tools that are available to help with patient management.

2. Divide the participants into small groups of three or four people.



3. Have the participants turn to the case studies in their participant handbook. Tell them that the case studies are formatted like stories. The participants should read the first part of the case, respond accordingly, and then continue on to the next part of the case.

4. Assign each group one case study to complete. Tell them they will have 30 minutes to complete the case study questions in their groups.

5. Remind the participants to reference the tools and forms they have been provided. Encourage them to think about the system of care more broadly and their roles within the system. Ask them to consider how they should best work with community health workers, physicians, social workers and psychologists, and other members of the care team.

6. After 30 minutes, ask everyone to join the larger group again. Review the case studies by asking each group to present their case and their answers (refer to Facilitator Notes). Use the questions included in the case studies to guide the conversation.

7. Answer any questions that arise.

Post-test:

40 minutes

8. After the case studies discussion has finished, administer the post-test to the participants. Allow the participants 30 minutes to complete the post-test. The participants cannot use their notes nor participant handbooks during the test.

9. Once the post-test has finished, and all tests have been collected, project the post-test answer key. Go over each question and the correct answer. Answer any questions that arise from the participants.

Reflection exercise:

20 minutes

10. Hang up the three pre-written flip chart pages on three separate walls in the training space.

11. Show slide 87: Reflection.

Tell the participants they will spend a few minutes reflecting on this training. Pass out three Post-it notes to each participant. Instruct participants to reflect and write down an answer for each of the three questions (listed on the slide) on a different Post-it note. There is no need for participants to put their name on the Post-it notes, as this is an anonymous activity.



12. Once participants have finished writing their three Post-it notes, they should go and stick their Post-it notes on the corresponding flipchart page. Participants should take three to five minutes to circulate between the three flipchart pages to view what others have written.

13. After all participants have had a few minutes to circulate and read others’ reflections, ask for the participants to sit down.

14. Conclude by taking down the pages and reading all answers aloud to the group. Highlight similar answers and unique ideas.

evaluation:

15 minutes

15. Explain that you would like to gather participants’ comments and feedback on this training, in order to revise and improve future trainings if needed.

16. Give each participant an evaluation form. As the participants fill in the evaluation, circulate and help as needed.

17. Once all the participants have finished their evaluations, collect the written evaluation forms.

18. Congratulate the participants on having completed this training. Thank them for their participation. Distribute certificates as appropriate.



FACIlITATOR NOTeS

CASe STUDy 1

a 65-year-old woman is brought into the health facility by her two sons. she is barely able to walk and is clearly confused. she is not able to speak easily and she cannot follow simple commands. her sons said that she has been fatigued and feverish for the past few days. the patient is mildly agitated, clearly frustrated with her sons. you are the first to attend to the patient.

1. seeing that the patient is agitated, who would you notify immediately?

• the psychologist/social worker.

2. What would you do to manage the patient’s agitation? What form would you use to guide you?

to manage the patient’s agitation:

• accompany to emergency room.

• Manage behavior and environment. use calm voice, “how can i help?”, asking about hunger/thirst, arrange 1:1 if necessary, allow patient to show frustration.

• Collect information from patient’s family.

• remain at bedside if necessary, give phone number to family.

Form to use:

• agitated Patient Protocol

• agitation, Delirium and Psychosis Checklist

3. how would you support the physician in evaluating the agitated patient? What forms would you help the physician manage during the medical evaluation?

support the physician:

• assist in obtaining vital signs, lab tests, EKg, fluids

• Prepare oral and intramuscular medications if needed

• Monitor antipsychotic medication side-effects (if administered)

Forms to help manage:

• use agitation, Delirium and Psychosis Checklist



CASe STUDy 1 (continued)

you have concluded that the patient probably needs further neurologic testing to determine if the patient has a neurological problem. the patient also has a confirmed fever above 38 °C. the two sons said that they are sad that she is now ‘crazy’ and want to know how you can cure her.

4. What would you say to the two sons?

• Emphasize that most likely, their mother does not have a mental disorder and should not be considered ‘crazy’.

• Explain that through further testing, the physician might be able to identify the medical issue and then identify possible solutions.



CASe STUDy 2

a 27-year-old man is brought into the health center by two community health workers. he is yelling that the community health workers are trying to kill him. he lunges at anyone who tries to get close to him, screaming that he will kill everyone.

1. is this patient agitated? What level of agitation does the patient have?

• the patient is severely agitated.

2. the physician tells you to inject the patient immediately with intramuscular medication. What should you do first before automatically sedating a severely agitated patient?

• talk with the patient first.

3. What are some ways you would manage the patient’s behavior and environment? Who would you collaborate with?

What you do:

• Manage behavior and environment:

– use calming interventions, such as talking with the patient or arranging a 1:1

– show sympathy and empathy, make eye contact

– allow the patient to show anger

– Decrease stimulation

– Keep yourself and the staff safe by using safety considerations including removing objects that can be used to harm

Collaborate with:

• Psychologist/social Worker

• Physician

after you speak with the patient, the patient agrees to take some medication and is admitted as an in-patient.

4. how often would you check in on the patient, and what would you specifically be monitoring?

how often:

• at least every 15 minutes

specifically monitoring:

• Vital signs

• Potential antipsychotic side-effects



CASe STUDy 2 (continued)

5. once the patient has stabilized, the physician declares the patient able to go home. the patient has been diagnosed by the psychologist/social worker with schizophrenia and has been given medication. the patient will be coming back to the health facility next week to meet with the physician again. Who else should the patient meet with when he comes for his next appointment?

• the psychologist/social worker.



CASe STUDy 3

During the past year the physician has been seeing a young, 18-year-old woman with who had experienced episodes of psychosis. she was prescribed risperidone. today during her monthly follow up visit, as she waits for her appointment with the psychologist and physician, you notice that she appears restless, frequently wringing her hands.

1. What do you do?

• you would notify the physician and psychologist that the patient may be agitated.

• you would manage the patient’s behavior and environment through use calming interventions, such as talking with the patient or arranging a 1:1.

– show sympathy and empathy, make eye contact

– Decrease stimulation

after asking the patient how she is doing and how you can help her, she begins to cry and tells you that things are not going well. she recently broke up with her boyfriend and cannot find a job to support herself.

2. What are some key messages you would give her during this time of stress related to medication and social support?

Key messages:

• it is important to continue taking her medication.

• she should continue seeing the psychologist and can visit the psychologist with more frequency, if needed.

• she should look to her social supports for assistance during this time.

57Partners In Health | FaCilitator Manual | Annex

Annex

58 Partners In Health | FaCilitator Manual | Annex

� PRe-teSt � PoSt-teSt (check one)

Name: Date:

Site: Supervisor:

1. Combined, psychotic and mood disorders such as schizophrenia and ( / 1 point) bipolar disorder affect how many people worldwide? (Choose one)

a. 5 million people

b. 81 million people

c. 500 million people

d. 25 million people

2. What are the responsibilities of nurses in the psychosis care pathway? ( / 1 point) (Choose one)

a. help manage agitated patients

b. assist the physician with the medical evaluations

c. Perform therapy such as iPt with patients and their families

d. Diagnose psychotic patients with mental illness

e. Provide psychoeducation to patients and their families

f. a, B and E

g. all of the above

3. What are the four pillars of emergency management of agitation, delirium, ( / 1 point) and psychosis? (Choose one)

a. Vital signs, history of illness, mental health evaluation, treatment

b. agitation reduction, physician visit, psychologist visit, ChW visit

c. Physicians, psychologists, social workers, and nurses

d. safety, medical health, mental health, follow-up


4. Which of the following are biopsychosocial considerations that providers ( / 1 point) should have when approaching the treatment and management of psychotic disorders? (Choose one)

a. religious and spiritual beliefs

b. Personality

c. Medications

d. Exposure to stigmatization

e. socioeconomic stressors

f. all of the above

5. you observe a patient in the waiting room who is pacing, frustrated, and ( / 1 point) yelling at staff. What level of agitation does this patient have? (Choose one)

a. no agitation

b. Mild agitation

c. Moderate agitation

d. severe agitation

6. When you encounter an agitated patient, what is the first step to managing ( / 1 point) his agitation? (Choose one)

a. give the patient medication to sedate them

b. ask the patient to leave the health facility

c. use calming interventions and talk to try to get as much information from the patient as possible

d. refer the patient to Mars and Klein

7. intramuscular medication of an antipsychotic, such as haloperidol, should ( / 1 point) only be used when… (Choose one)

a. a patient is physically aggressive and has refused oral medication

b. a patient is verbally threatening and cursing at staff

c. a patient is running around the emergency room and nurses are scared

d. intramuscular medication should be used on all agitated patients

8. true or false: Delirium is a psychiatric illness. (Choose one) ( / 1 point)

a. true

b. False


9. What piece of clinical information should a nurse immediately collect ( / 1 point) from an agitated patient? (Choose one)

a. results of a renal panel

b. Vital signs

c. height and weight

d. aiMs score

10. What would a physician do to assess a patient with psychotic symptoms? ( / 1 point) (Choose one)

a. Do a physical exam and take vital symptoms

b. Conduct a mental status exam

c. Do a neurologic exam

d. use the Mental health form to get a history of the illness

e. Conduct tests such as rPr, hiV, CBC, BMP

f. all of the above

11. Which of the following could cause a medical delirium? (Choose one) ( / 1 point)

a. Dementia

b. hiV encephalopathy

c. Emotional trauma

d. alcohol withdrawal

e. a, B, and D

f. none of the above

12. true or false: only after a complete medical evaluation can a mental ( / 1 point) health evaluation be considered. (Choose one)

a. true

b. False

13. Which of the following should physicians not do when prescribing medication? ( / 1 point) (Choose one)

a. adjust the medication dose for the elderly

b. For suicidal patients, give a small number of tablets to avoid overdose

c. inform patients about side-effects

d. Prescribe a medication that may be best for the patient, but is not always in adequate supply


14. Circle two medications below that are anti-psychotic medications. ( / 1 point) (Choose one)

a. Carbamazepine and haloperidol

b. haloperidol and diazepam

c. risperidone and diphenhydramine

d. haloperidol and risperidone

e. Valproate and carbamazepine

15. What medication is the first-choice for psychotic symptoms and mood ( / 1 point) disorders? (Choose one)

a. Carbamazepine

b. haloperidol

c. Valproate

d. risperidone

16. When an agitated patient has been given medication by a clinician and has ( / 1 point) been admitted to in-patient, how frequently should you check-in with the patient? (Choose one)

a. Every hour

b. at least every 15 minutes

c. once a day

d. never; it is the physician’s role to check the patient

17. the abnormal involuntary Movement scale (aiMs) helps physicians to… ( / 1 point) (Choose one)

a. recognize when a patient has psychotic symptoms

b. Determine how quickly a patient metabolizes medication

c. identify if a patient is experiencing involuntary movements as part of antipsychotic medication side-effects

d. Monitor an agitated patient’s movement after sedation

18. if a patient is found to have tardive dyskinesia, what could the clinician do? ( / 1 point) (Choose one)

a. stop the medication if the clinical condition allows it

b. lower the dose of medication

c. switch the patient to another antipsychotic medication

d. Continue with the current treatment

e. a, B, and C

f. all of the above


19. how often should the abnormal involuntary Movement scale (aiMs) be ( / 1 point) administered to a patient? (Choose one)

a. Every visit

b. Every 6 months

c. once a year

d. only if the clinician observes abnormal involuntary movements

20. Before discharging an agitated patient from the health facility, what should ( / 1 point) nurses confirm? (Choose one)

a. the patient has been calmed and given a medical evaluation by the physician

b. the patient has a follow up appointment with the psychologist/social worker if needed

c. the patient and their family has received psychoeducation/support for the patient’s illness

d. all of the above


PRe-teSt AnD PoSt-teSt AnSweR KeY

Name: Date:

Site: Supervisor:

1. Combined, psychotic and mood disorders such as schizophrenia and ( / 1 point) bipolar disorder affect how many people worldwide? (Choose one)

a. 5 million people

b. 81 million people

c. 500 million people

d. 25 million people

2. What are the responsibilities of nurses in the psychosis care pathway? ( / 1 point) (Choose one)

a. help manage agitated patients

b. assist the physician with the medical evaluations

c. Perform therapy such as iPt with patients and their families

d. Diagnose psychotic patients with mental illness

e. Provide psychoeducation to patients and their families

f. A, b and e

g. all of the above

3. What are the four pillars of emergency management of agitation, delirium, ( / 1 point) and psychosis? (Choose one)

a. Vital signs, history of illness, mental health evaluation, treatment

b. agitation reduction, physician visit, psychologist visit, ChW visit

c. Physicians, psychologists, social workers, and nurses

d. Safety, medical health, mental health, follow-up


4. Which of the following are biopsychosocial considerations that providers ( / 1 point) should have when approaching the treatment and management of psychotic disorders? (Choose one)

a. religious and spiritual beliefs

b. Personality

c. Medications

d. Exposure to stigmatization

e. socioeconomic stressors

f. All of the above

5. you observe a patient in the waiting room who is pacing, frustrated, and ( / 1 point) yelling at staff. What level of agitation does this patient have? (Choose one)

a. no agitation

b. Mild agitation

c. moderate agitation

d. severe agitation

6. When you encounter an agitated patient, what is the first step to managing ( / 1 point) his agitation? (Choose one)

a. give the patient medication to sedate them

b. ask the patient to leave the health facility

c. Use calming interventions and talk to try to get as much information from the patient as possible

d. refer the patient to Mars and Klein

7. intramuscular medication of an antipsychotic, such as haloperidol, should ( / 1 point) only be used when… (Choose one)

a. A patient is physically aggressive and has refused oral medication

b. a patient is verbally threatening and cursing at staff

c. a patient is running around the emergency room and nurses are scared

d. intramuscular medication should be used on all agitated patients

8. true or false: Delirium is a psychiatric illness. (Choose one) ( / 1 point)

a. true

b. False


9. What piece of clinical information should a nurse immediately collect ( / 1 point) from an agitated patient? (Choose one)

a. results of a renal panel

b. vital signs

c. height and weight

d. aiMs score

10. What would a physician do to assess a patient with psychotic symptoms? ( / 1 point) (Choose one)

a. Do a physical exam and take vital symptoms

b. Conduct a mental status exam

c. Do a neurologic exam

d. use the Mental health form to get a history of the illness

e. Conduct tests such as rPr, hiV, CBC, BMP

f. All of the above

11. Which of the following could cause a medical delirium? (Choose one) ( / 1 point)

a. Dementia

b. hiV encephalopathy

c. Emotional trauma

d. alcohol withdrawal

e. A, b, and D

f. none of the above

12. true or false: only after a complete medical evaluation can a mental ( / 1 point) health evaluation be considered. (Choose one)

a. True

b. False

13. Which of the following should physicians not do when prescribing medication? ( / 1 point) (Choose one)

a. adjust the medication dose for the elderly

b. For suicidal patients, give a small number of tablets to avoid overdose

c. inform patients about side-effects

d. Prescribe a medication that may be best for the patient, but is not always in adequate supply


14. Circle two medications below that are anti-psychotic medications. ( / 1 point) (Choose one)

a. Carbamazepine and haloperidol

b. haloperidol and diazepam

c. risperidone and diphenhydramine

d. Haloperidol and risperidone

e. Valproate and carbamazepine

15. What medication is the first-choice for psychotic symptoms and mood ( / 1 point) disorders? (Choose one)

a. Carbamazepine

b. haloperidol

c. Valproate

d. Risperidone

16. When an agitated patient has been given medication by a clinician and has ( / 1 point) been admitted to in-patient, how frequently should you check-in with the patient? (Choose one)

a. Every hour

b. At least every 15 minutes

c. once a day

d. never; it is the physician’s role to check the patient

17. the abnormal involuntary Movement scale (aiMs) helps physicians to… ( / 1 point) (Choose one)

a. recognize when a patient has psychotic symptoms

b. Determine how quickly a patient metabolizes medication

c. Identify if a patient is experiencing involuntary movements as part of antipsychotic medication side-effects

d. Monitor an agitated patient’s movement after sedation

18. if a patient is found to have tardive dyskinesia, what could the clinician do? ( / 1 point) (Choose one)

a. stop the medication if the clinical condition allows it

b. lower the dose of medication

c. switch the patient to another antipsychotic medication

d. Continue with the current treatment

e. A, b, and C

f. all of the above


19. how often should the abnormal involuntary Movement scale (aiMs) be ( / 1 point) administered to a patient? (Choose one)

a. Every visit

b. every 6 months

c. once a year

d. only if the clinician observes abnormal involuntary movements

20. Before discharging an agitated patient from the health facility, what should ( / 1 point) nurses confirm? (Choose one)

a. the patient has been calmed and given a medical evaluation by the physician

b. the patient has a follow up appointment with the psychologist/social worker if needed

c. the patient and their family has received psychoeducation/support for the patient’s illness

d. All of the above


PS

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ocol

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chot

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vide

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ycho

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n an

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ppor

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ure

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ycho

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-UP

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exam

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l sig

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�

use

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icat

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mon

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antip

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m

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lm)

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rev

iew

initi

al M

enta

l hea

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valu

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Form

with

psy

chol

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t/sW

to

diag

nose

de

liriu

m/m

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al il

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tal d

isor

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plet

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al e

valu

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ysic

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Med

ical

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alua

tion

Prot

ocol

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tatio

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eliri

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s

�

if p

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base

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alua

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icat

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st u

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t

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-UP

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rev

iew

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low

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with

ps

ycho

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e if

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�

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phys

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xam

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mon

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�

use

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icat

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or s

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P


1

me

DIC

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ev

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CO

lS

FO

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AT

ION

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el

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PS

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mm

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Pr

ot

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iN

A C

liN

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Al

se

tt

iNg

STeP

1a:

Is P

erso

n A

gita

ted?

Pati

ent

is c

onsi

dere

d ag

itat

ed if

the

y ar

e an

y of

the

follo

win

g:

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iole

nt, a

ggre

ssiv

e

•ye

lling

, thr

eate

ning

•M

anic

, del

usio

nal (

has

untr

ue, fi

xed

belie

fs)

•h

allu

cina

ting

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cute

ly p

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oid

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ringi

ng o

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nds,

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ing,

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han

d

•r

apid

spe

ech,

rai

sing

voi

ce

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eque

nt r

eque

sts,

low

fru

stra

tion

tole

ranc

e

STeP

1b:

Det

erm

ine

leve

l of

Agi

tati

on a

nd m

anag

e•

Ref

er t

o A

gita

ted

Pati

ent

Prot

ocol

to

guid

e ag

itat

ion

man

agem

ent

depe

ndin

g on

sym

ptom

s an

d se

veri

ty

•u

se c

alm

voi

ce

•g

ive

verb

al s

uppo

rt

•D

ecre

ase

stim

uli

•a

sk, “

how

can

i he

lp?”

•a

lert

sta

ff

•K

eep

your

self

safe

•u

se W

ho

mhg

aP

(p.7

4) f

or s

elf-

har

m/s

uici

de a

sses

smen

t

if ne

cess

ary

box

1: S

tand

ard

med

ical

eva

luat

ion

for

Agi

tati

on/D

elir

ium

/Psy

chos

is

•Br

ief

his

tory

–M

edic

al h

isto

ry

–a

lcoh

ol/s

ubst

ance

abu

se

–C

urre

nt m

edic

atio

ns

–h

isto

ry o

f m

enta

l illn

ess

•V

ital s

igns

, phy

sica

l exa

m

•n

euro

logi

cal E

xam

•M

enta

l sta

tus

Exam

–o

rient

atio

n

–a

lert

ness

–C

onfu

sion

box

2: D

elir

ium

1. D

istu

rban

ce o

f co

nsci

ousn

ess;

red

uced

abili

ty t

o fo

cus,

sus

tain

or

shift

att

entio

n.

2. a

cha

nge

in c

ogni

tion

or t

he d

evel

opm

ent

of a

per

cept

ual d

istu

rban

ce (

hallu

cina

tions

)

that

is n

ot d

ue t

o a

pree

xist

ing,

est

ablis

hed

or e

volv

ing

dem

entia

.

3. t

he d

istu

rban

ce d

evel

ops

over

a s

hort

perio

d of

tim

e (u

sual

ly h

ours

to

days

) an

d

fluct

uate

s du

ring

the

day

4. t

here

is e

vide

nce

from

the

his

tory

, phy

sica

l

exam

inat

ion

or la

bora

tory

find

ings

tha

t

the

dist

urba

nce

is c

ause

d by

the

dire

ct

phys

iolo

gica

l con

sequ

ence

s of

a g

ener

al

med

ical

con

diti

on.

NO

THeN

yeS

STeP

2: P

erfo

rm m

edic

al A

sses

smen

t (S

ee b

ox 1

, ReF

eR t

o an

d R

eCO

RD

info

rmat

ion

on A

gita

ted

Pati

ent

Form

, inc

ludi

ng):

•Sa

fety

: tal

k fir

st, d

o no

t m

edic

ate

first

•m

edic

al H

ealt

h: t

ake

vita

l sig

ns, p

hysi

cal e

xam

, men

tal s

tatu

s ex

am t

o as

sess

for

del

irium

•m

enta

l Hea

lth:

tak

e hi

stor

y

•Fo

llow

-Up:

con

tact

psy

chol

ogis

t

•C

ontin

ue e

valu

atio

n an

d tr

eatm

ent

of u

nder

lyin

g

med

ical

con

ditio

n.

•C

onsi

der

low

-dos

e an

tipsy

chot

ic f

or d

eliri

um

(see

med

icat

ion

card

)

•C

onsu

lt m

enta

l hea

lth t

eam

/psy

chol

ogis

t

abn

orm

al m

enta

l sta

tus

exam

or

mee

ts c

riter

ia f

or

delir

ium

(Se

e b

ox 2

)

See

Page

2 f

or c

onti

nuat

ion

of m

edic

al A

sses

smen

t

yeS

NO


2

med

ical

eva

luat

ion

Prot

ocol

s fo

r A

gita

tion

, Del

iriu

m a

nd P

sych

osis

Sum

mar

y (c

onti

nued

)

•tr

eat

alco

hol w

ithdr

awal

with

10

mg

iV/i

M

diaz

epam

, rep

eat

afte

r 15

min

s as

nee

ded

until

res

pons

e, t

hen

repe

at in

6 h

ours

.

•M

onito

r re

spira

tory

rat

e to

avo

id o

verd

ose

•M

alar

ia s

mea

r an

d co

nsid

er e

mpi

ric

trea

tmen

t fo

r m

alar

ia

•lu

mba

r pu

nctu

re a

nd c

onsi

der

empi

ric r

x

with

app

ropr

iate

ant

ibio

tic m

edic

atio

n

Con

side

r C

t be

fore

lP

if a

sym

met

ric

pupi

ls o

r

abno

rmal

ext

ra-o

cula

r m

ovem

ent

or g

ait.

•lP

, as

abov

e

•C

onsi

der

empi

ric r

x w

ith a

ppro

pria

te

antib

iotic

med

icat

ion

Con

side

r tr

eatm

ent

for

toxo

plam

osis

or c

ryto

cocc

us.

•C

onsi

der

addi

tiona

l tes

ts: r

enal

pan

el, l

iver

pane

l, ch

est

x-ra

y

•tr

eat

acco

rdin

gly

trea

t fo

r ne

uros

yphi

lis w

ith p

enic

illin

•Fu

rthe

r ne

urol

ogic

al t

estin

g (S

ee b

ox 3

)

•C

onsi

der

Ct,

EEg

, or

lP

•C

onsu

lt w

ith s

peci

alis

ta

bnor

mal

neu

rolo

gic

exam

rec

ent

onse

t an

d

tem

pera

ture

> 3

8 C

hiV

+ w

ith C

D4

coun

t <

200

Posi

tive

rPr

abn

l glu

cose

, ele

ctro

lyte

s,

or o

ther

evi

denc

e of

med

ical

illn

ess

(See

box

4)

ris

k fa

ctor

s fo

r dr

ug o

r

alco

hol w

ithdr

awal

or

into

xica

tion?

(Se

e b

ox 5

)

Con

side

r a

prim

ary

psyc

hotic

dis

orde

r

Perf

orm

men

tal H

ealt

h A

sses

smen

t

and

Con

sult

men

tal H

ealt

h Te

am

on

med

icat

ion

caus

ing

psyc

hosi

s? (

See

box

6)

Det

erm

ine

whe

ther

his

tory

of

psyc

hosi

s an

d m

edic

atio

n us

e co

inci

de.

Con

side

r di

scon

tinui

ng m

edic

atio

n.

yeS yeS

yeS

yeS

yeS

yeS

yeS

yeS

THeN

THeN

box

4: C

omm

on S

yste

mic

Con

diti

ons

that

can

Cau

se/C

ontr

ibut

e to

Psy

chos

is

•M

alar

ia

•El

ectr

olyt

e ab

norm

aliti

es (

sodi

um, c

alci

um)

•M

alnu

triti

on, t

hiam

ine

defic

ienc

y

•th

yroi

d di

seas

e

•a

lcoh

ol w

ithdr

awal

•h

ypox

ia

box

6: m

edic

atio

ns t

hat

can

Cau

se/C

ontr

ibut

e

to P

sych

osis

•C

ortic

oste

riods

•C

yclo

serin

e

•is

onia

zid,

Efa

vire

nz

•C

ortic

oste

roid

s

•Ph

enob

arbi

tal

•h

igh

dose

s of

ant

i-ch

olin

ergi

c m

edic

atio

n

box

3: N

euro

logi

cal C

ondi

tion

s th

at C

ause

or

Con

trib

ute

to P

sych

osis

•te

rtia

ry s

yphi

lis

•En

ceph

ilitis

•D

emen

tia (

hiV

, alz

heim

ers)

•Pa

rkin

sons

•Br

ain

tum

ors

or o

ther

mas

s le

sion

s (t

B,

lym

phom

a, t

oxop

lasm

osis

)

box

5: A

lcoh

ol w

ithd

raw

al

•h

isto

ry o

f he

avy

alco

hol u

se (

last

drin

k

24 –

28

hour

s pr

ior

to s

ympt

oms)

•se

vere

alc

ohol

with

draw

al:

–W

ithin

a f

ew h

ours

: with

draw

al

trem

ors,

nau

sea,

vom

iting

, sw

eatin

g,

anxi

ety

–W

ithin

a f

ew d

ays:

hal

luci

natio

ns,

seiz

ures

, fev

er, d

isor

ient

atio

n,

hype

rten

sion

Con

tinu

atio

n of

med

ical

Ass

essm

ent

NO

NO

NO

NO

NO

NO

NO


AG

ITA

Te

D P

AT

IeN

T P

RO

TO

CO

l

THR

OU

GH

OU

T v

ISIT

: Ass

essm

ent

•R

eFeR

to

Med

ical

eva

luat

ion

Prot

ocol

s

for

Agi

tati

on, D

elir

ium

and

Psy

chos

is

•R

eCO

RD

on

Agi

tati

on, D

elir

ium

and

Psyc

hosi

s Fo

rm

SAFe

Ty F

IRST

!

•D

o no

t se

e th

e pa

tient

alo

ne

(ask

for

sec

urity

). r

emai

n

calm

. rem

embe

r th

at p

atie

nts

do n

ot s

udde

nly

beco

me

viol

ent;

the

ir be

havi

or o

ccur

s

alon

g a

spec

trum

.

•M

aint

ain

safe

phy

sica

l dis

tanc

e

from

pat

ient

. Do

not

allo

w

exit

to b

e bl

ocke

d. K

eep

larg

e

furn

iture

bet

wee

n yo

u an

d

patie

nt.

•r

emov

e al

l obj

ects

tha

t ca

n

be u

sed

to h

arm

(ne

edle

s,

shar

p ob

ject

s, o

ther

sm

all

obje

cts)

. Che

ck w

heth

er

patie

nt h

as a

his

tory

of

viol

ence

or

subs

tanc

e ab

use.

•ta

lkin

g to

pat

ient

is s

afe

and

effe

ctiv

e. D

o no

t ye

ll. K

eep

your

voi

ce c

alm

, qui

et, a

nd

frie

ndly

.

•M

ake

eye

cont

act

to s

how

you

care

abo

ut t

he p

atie

nt.

show

sym

path

y an

d em

path

y

(“i u

nder

stan

d yo

u ar

e sc

ared

,

but

i am

her

e to

hel

p. i

will

not

hurt

you

.”)

STeP

1:

Det

erm

ine

leve

l of

agi

tati

on b

y ob

serv

ing

pati

ent

beha

vior

STeP

2:

man

age

agit

atio

n

Rem

embe

r:

•Sa

fety

: tal

k fir

st, d

o no

t m

edic

ate

first

•m

edic

al H

ealt

h: v

ital s

igns

, phy

sica

l exa

m,

men

tal s

tatu

s, e

xam

to

asse

ss f

or d

eliri

um, l

abs

and

stud

ies

•m

enta

l Hea

lth:

tak

e hi

stor

y

•Fo

llow

-Up:

con

tact

psy

chol

ogis

t/so

cial

wor

ker

mIl

D A

gita

tion

�

wrin

ging

/tap

ping

of

hand

s

�

paci

ng, m

ovin

g re

stle

ssly

�

freq

uent

req

uest

s/de

man

ds

�

loud

or

rapi

d sp

eech

�

low

fru

stra

tion

tole

ranc

e

1. m

anag

e b

ehav

ior/

envi

ronm

ent

�

use

cal

m v

oice

, sim

ple

lang

uage

,

soft

voi

ce, s

low

mov

emen

ts

�

ask

“h

ow c

an i

help

?” a

nd

prob

lem

sol

ve w

ith p

atie

nt;

be e

mpa

thic

�

rem

ove

pote

ntia

lly h

arm

ful

obje

cts

from

are

a

�

ask

abo

ut h

unge

r/th

irst

�

Dec

reas

e st

imul

atio

n/ar

rang

e 1:

1

�

off

er v

erba

l sup

port

and

unde

rsta

ndin

g

�

allo

w t

he p

atie

nt t

o sh

ow

ange

r/fr

ustr

atio

n

�

Cal

m s

taff

�

if a

gita

tion

due

to d

eliri

um,

cons

ider

hal

dol 1

– 2

mg

Po;

not

in e

lder

ly

1. m

anag

e b

ehav

ior/

envi

ronm

ent

2. C

onsi

der

OR

Al

med

icat

ions

�

off

er P

o m

edic

atio

ns fi

rst

if

(hal

dol 5

mg

+ d

iphe

nhyd

ram

ine

50 m

g o

r D

iaze

pam

10

mg)

�

if p

atie

nt r

efus

es P

o, g

ive

iM

med

icat

ions

(h

aldo

l 5 m

g +

diph

enhy

dram

ine

25 m

g o

r

Dia

zepa

m 1

0 m

g)

�

Wai

t 30

min

utes

; if

patie

nt

rem

ains

agi

tate

d, c

an g

ive

½ t

he

orig

inal

dos

e

�

use

Med

icat

ion

Car

d to

mon

itor

side

eff

ects

1. m

anag

e b

ehav

ior/

envi

ronm

ent

2. C

onsi

der

OR

Al

med

icat

ions

3. C

onsi

der

INTR

Am

USC

UlA

R

med

icat

ions

�

hal

dol 5

–10

mg

iM +

diph

enhy

dram

ine

25 m

g iM

or

dia

zepa

m 1

0 m

g iM

�

Wai

t 30

min

utes

; if

patie

nt

rem

ains

agi

tate

d, c

an r

e-do

se

with

½ t

he o

rigin

al d

ose

�

use

Med

icat

ion

Car

d to

mon

itor

side

eff

ects

�

Deb

rief

with

sta

ff

�

Con

sult

men

tal h

ealth

tea

m if

etio

logy

is p

sych

iatr

ic

mO

DeR

ATe

Agi

tati

on �

verb

al t

hrea

ts

�

yelli

ng/c

ursi

ng

�

does

not

res

pond

to

verb

al

redi

rect

ion

�

does

not

res

pond

to

incr

ease

d

staf

f pr

esen

ce

Sev

eRe

Agi

tati

on �

dest

royi

ng p

rope

rty

�

phys

ical

agg

ress

ion

(e.g

.,

hitt

ing,

kic

king

, biti

ng)

�

self-

inju

rious

beh

avio

r (e

.g.,

bitin

g ha

nd, h

ead

bang

ing)


AGITATION, Del IR IUm AND PSyCHOSIS FORm

1. SAFeTy (USe AGITATeD PATIeNT PROTOCOl)

Patient is: � not agitated (But appears psychotic) � agitated (Mild) � aggressive (Moderate) � Violent (severe)

History of violence: � no � yes: Describe violent behavior ________________________________________________________________ When did it take place:__________________________________________________________________

� Manage Behavior/Environment Completed Does patient need a 1:1? � no � yes:___________

2. meDICAl HeAlTH (USe meDICAl evAlUATION PROTOCOl)

Vital signs: temp:______ Pulse:______ BP:______ rr:______ o2:______ Weight:______

Physical exam Neurological exam

hEEnt: � normal � abnormal:___________ Cranial nerves: � normal � abnormal:___________

Cardiac: � normal � abnormal:___________ Motor strength: � normal � abnormal:___________

Pulmonary: � normal � abnormal:___________ sensory: � normal � abnormal:___________

abdominal: � normal � abnormal:___________ reflexes: � normal � abnormal:___________

skin/Extremities: � normal � abnormal:___________ gait/Coordination: � normal � abnormal:___________

mental Status exam laboratory Tests Ordered

� alert � sleepy � unable to arouse � hemogram � CD4 � hepatic Panel

thought Process: � normal � Confused:___________ � rPr � tB � renal Panel

Can Follow simple Commands: � no � yes � hiV � urinalysis � Malaria

hallucinations: � no � yes:__________ Family History of mental Illness: � no � yes

orientation: Person � no � yes medical History: � hiV/aiDs (CD4:_____) � tB

Place � no � yes � htn � head injury (with loss of consciousness)

time/Date � no � yes � Epilepsy � Dementia � other:___________

Friend/Family Member � no � yes Alcohol Use: � no � yes: � Daily?

Current medications (names and doses):___________________________ Drug Use: � no � yes:___________

Delirium

� Disturbance of consciousness with reduced ability to focus, sustain or shift attention.

� a change in cognition or the development of a perceptual disturbance (hallucinations) that is not better accounted for by a preexisting, established or evolving dementia.

� the disturbance develops over a short period of time (usually hours to days) and fluctuates during the day

� there is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.

� no � yes (Patient must meet all four criteria above to make diagnosis)

3. meNTAl HeAlTH

History of mental illness: � no � yes:___________________________________________________________________________________

Has the patient gone to m&k/beudet/other psych facility? � no � yes:_____________________________

Is this the first episode of agitation? � no � yes:_______________ History of suicide attempt: � no � yes:__________________

Post-Ictal Psychosis: � no � yes (episodes of agitation/psychosis only take place after epileptic seizure)Antipsychotic medication (Use Agitated Patient Protocol; give dose and indicate whether PO/Im):

� risperidone:_______________ � haloperidol:_______________ � other: Diphenhydramine:_______________

4. FOllOwUP

� Psychologist contacted about patient

Presumed Etiology of agitation/Psychosis: � Medical Problem/Delirium: _______________ � Mental health Problem:_______________

has haloperidol been given?: � no � yes � Fluids ordered/given � EKg ordered/done

notes: _________________________________________________________________________________________________________________

Patient Name:________________________ Sex:____ Phone:_____________ Provider:_________________ Date: dd/mm/yy


1

me

DIC

AT

ION

CA

RD

FO

R A

GIT

AT

ION

, D

el

IRIU

m,

AN

D P

Sy

CH

OS

IS

RIS

PeR

IDO

Ne

HA

lOPe

RID

Ol

DIA

ZePA

mC

AR

bA

mA

ZePI

Ne

vA

lPR

OA

Te

1st

Cho

ice:

“A

typi

cal”

Ant

ipsy

chot

ic/M

ood

stab

ilize

r

Use

for

: Psy

chos

is (

wit

h or

wit

hout

man

ia)

2nd

Cho

ice:

“ty

pica

l”

Ant

ipsy

chot

ic/M

ood

stab

ilize

r

Use

for

: Agg

ress

ive

or v

iole

nt

psyc

hosi

s (w

ith

or w

itho

ut m

ania

)

Ben

zodi

azep

ine

Use

for

: Alc

ohol

wit

hdra

wal

,

acut

e ag

itat

ion

wit

h or

wit

hout

ant

i-ps

ycho

tic

3rd

Cho

ice:

Moo

d st

abili

zer

Do

not

pres

crib

e w

itho

ut

cons

ulti

ng m

enta

l hea

lth

team

Use

for

: man

ia w

itho

ut

psyc

hosi

s

4th

choi

ce: M

ood

stab

ilize

r

Do

not

pres

crib

e w

itho

ut

cons

ulti

ng m

enta

l hea

lth

team

Use

for

: man

ia w

itho

ut

psyc

hosi

s (l

ongs

tand

ing

aggr

essi

on o

r vi

olen

ce in

mal

es)

DO

NO

T U

Se IF

•C

autio

n if

child

/ado

lesc

ent

•Pr

ior

hist

ory

of d

ysto

nia

on

antip

sych

otic

med

icat

ion

•C

hild

ren

(18

or y

oung

er)

•Pa

tient

is d

eliri

ous

•Pr

egna

nt/b

reas

tfee

ding

wom

en

•C

hild

ren

(18

or y

oung

er)

•El

derly

(65

or

olde

r)

•Bl

ood

diso

rder

•Ep

ileps

y: a

bsen

ce s

eizu

res

•C

autio

n if

child

•w

omen

of

child

-bea

ring

age/

preg

nant

wom

en

•li

ver

dise

ase

•C

autio

n if

child

mU

ST C

ON

SUlT

m

eNTA

l H

eAlT

H

TeA

m

•Fo

r ps

ycho

sis

due

to d

emen

tia

(incr

ease

d ris

k of

dea

th)

•C

hild

ren

18 o

r yo

unge

r

•Pr

egna

nt w

omen

•Fo

r ps

ycho

sis

due

to d

emen

tia

(incr

ease

d ris

k of

dea

th)

•Pr

egna

nt w

omen

•Fo

r tr

eatm

ent

of a

ll m

enta

l

illne

ss (

excl

udin

g ep

ileps

y)

•Pr

egna

nt o

r br

east

feed

ing

wom

en

•Fo

r tr

eatm

ent

of a

ll m

enta

l

illne

ss (

excl

udin

g ep

ileps

y)

Star

ting

Dos

e (A

dult

)Ta

ke a

t ni

ght

due

to s

edat

ive

effe

cts

•Bi

pola

r/Ps

ycho

sis

– 0.

5 – 1

mg

•D

eliri

um –

0.2

5 –

0.5

mg

Take

at

nigh

t du

e to

sed

ativ

e ef

fect

s

•Bi

pola

r/Ps

ycho

sis

Mod

erat

e sx

s: 0

.5 –

2.5

mg

seve

re s

xs: 2

.5 –

5 m

g

•a

lway

s pr

escr

ibe

diph

enhy

dram

ine

25 –

50

mg

daily

with

hal

oper

idol

•D

eliri

um: 0

.5 –

2.5

mg

at n

ight

(Con

side

r lo

w-d

ose

of

rispe

ridon

e fir

st)

•A

ggre

ssiv

e/v

iole

nt P

atie

nts:

See

Agi

tate

d Pa

tien

t Pr

otoc

ol

see

agi

tate

d Pa

tient

Pro

toco

l

for

guid

elin

es r

egar

ding

use

.

200

mg

twic

e da

ily20

0 –

250

mg

twic

e da

ily

*Pat

ient

s re

ceiv

ing

valp

roic

acid

may

req

uire

a z

idov

udin

e

dosa

ge r

educ

tion

to m

aint

ain

unch

ange

d se

rum

zid

ovud

ine

conc

entr

atio

ns

“Ste

p” o

f up

titr

atio

na

ntip

sych

otic

s re

quire

4 –

6 w

eeks

to

reac

h fu

ll ef

fect

. if

ther

e ar

e sa

fety

conc

erns

, phy

sici

ans

can

incr

ease

dose

s m

ore

quic

kly

(eve

ry 3

– 7

day

s)

by 0

.5 m

g in

crem

ents

. Del

irium

:

incr

ease

by

0.25

mg

incr

emen

ts.

ant

ipsy

chot

ics

requ

ire 4

– 6

wee

ks t

o

reac

h fu

ll ef

fect

. if

ther

e ar

e sa

fety

conc

erns

, phy

sici

ans

can

incr

ease

dose

s m

ore

quic

kly

(eve

ry 3

– 7

day

s)

by 2

.5 m

g in

crem

ents

.

see

agi

tate

d Pa

tient

Pro

toco

l

for

guid

elin

es r

egar

ding

use

.

200

mg

tota

l dai

ly25

0 –

500

mg

tota

l dai

ly

max

imum

Dos

e2

mg

Dos

es a

bove

2 m

g da

ily m

ust

be

revi

ewed

with

the

men

tal h

ealth

tea

m.

10 m

g

Dos

es a

bove

10

mg

daily

mus

t be

revi

ewed

with

the

men

tal h

ealth

team

.

10 m

g

Dos

es a

bove

10

mg

daily

mus

t be

rev

iew

ed w

ith t

he

men

tal h

ealth

tea

m.

800

mg

(for

men

tal i

llnes

s)

Dos

es a

bove

800

mg

mus

t

be r

evie

wed

with

the

men

tal

heal

th t

eam

.

1000

mg

(for

men

tal i

llnes

s)

Dos

es a

bove

100

0 m

g m

ust

be r

evie

wed

with

the

men

tal

heal

th t

eam

.


2

med

icat

ion

Car

d fo

r A

gita

tion

, Del

iriu

m, a

nd P

sych

osis

(co

ntin

ued)

RIS

PeR

IDO

Ne

HA

lOPe

RID

Ol

DIA

ZePA

mC

AR

bA

mA

ZePI

Ne

vA

lPR

OA

Te

Toxi

citi

es*i

f ra

sh, s

top

med

icat

ion

and

retu

rn t

o ho

spita

l

Seri

ous

Dys

toni

a (e

spec

ially

of

phar

ynx,

eye

s, n

eck—

tem

pora

ry b

ut p

oten

tially

fat

al),

Tard

ive

Dys

kine

sia

(per

man

ent)

, Aka

this

ia (

rest

less

ness

), D

iabe

tes,

Car

diac

arrh

ythm

ia le

adin

g to

tor

sade

s de

s po

inte

s

Ris

k of

Sei

zure

if d

iaze

pam

with

draw

n w

ithou

t ta

per

afte

r re

gula

r us

e at

hig

her

dose

Ras

h, li

ver

failu

re, d

ecre

ased

whi

te b

lood

cou

nt

(Car

bam

azep

ine

can

caus

e hy

pona

trem

ia)

(Val

proa

te c

an c

ause

ser

ious

bir

th d

efec

ts in

pre

gnan

cy)

Com

mon

•se

datio

n

•W

eigh

t g

ain

•la

ctat

ion

•a

men

orrh

ea

•En

ures

is (

for

boys

)

•se

datio

n

•h

eavy

ton

gue

•st

iffne

ss

•a

rrhy

thm

ia (

for

patie

nts

rece

ivin

g

mor

e th

an 1

0 m

g da

ily)

•se

datio

n

•D

epen

denc

e (s

houl

d no

t

be g

iven

for

long

per

iods

of t

ime)

Fatig

ue, d

izzi

ness

, nau

sea/

vom

iting

, inc

oord

inat

ion,

dou

ble

visi

on

(Car

bam

azep

ine

decr

ease

s ef

ficac

y of

ora

l con

trac

eptiv

es;

Valp

roat

e ca

uses

tre

mor

)

mon

itor

ing

•Ba

selin

e: a

iMs,

wei

ght,

fas

ting

gluc

ose,

hem

ogra

m, h

epat

ic p

anel

(if a

vaila

ble)

•Ev

ery

visi

t: w

eigh

t, v

ital s

igns

•Ev

ery

6 m

onth

s: a

iMs,

fas

ting

gluc

ose,

hep

atic

pan

el, h

emog

ram

•Ba

selin

e: a

iMs,

wei

ght,

fas

ting

gluc

ose,

hem

ogra

m, h

epat

ic

pane

l (if

avai

labl

e)

•Ev

ery

visi

t: w

eigh

t, v

ital s

igns

•Ev

ery

6 m

onth

s: a

iMs,

fast

ing

gluc

ose,

hep

atic

pan

el,

hem

ogra

m

•M

onito

r fo

r si

gns

of

seda

tion

•M

onito

r fo

r de

pend

ence

(nee

d fo

r in

crea

sed

dose

to a

chie

ve s

ame

effe

ct)

lFts

, CBC

, sod

ium

Wei

ght

gain

, lFt

s, C

BC

hiV

pat

ient

s re

ceiv

ing

valp

roic

acid

may

req

uire

a z

idov

udin

e

dosa

ge r

educ

tin t

o m

aint

ain

unch

ange

d se

rum

zid

ovud

ine

conc

entr

atio

ns.

Tape

ring

/D

isco

ntin

uing

if t

here

is a

life

-

thre

aten

ing/

toxi

c si

de

effe

ct, s

top

imm

edia

tely

.

•C

onsu

lt w

ith

the

men

tal h

ealt

h

team

bef

ore

tape

ring

med

icat

ion.

Som

e pa

tien

ts m

ay n

eed

to

cont

inue

ris

peri

done

inde

fini

tely

.

•if

the

pat

ient

has

oth

er s

igni

fican

t

side

eff

ects

, con

side

r de

crea

sing

the

dose

slo

wly

(by

0.2

5 –

0.5

mg

incr

emen

ts)

and

mon

itorin

g cl

osel

y.

Can

als

o co

nsid

er c

hang

ing

to

halo

perid

ol.

•C

onsu

lt w

ith

the

men

tal h

ealt

h

team

bef

ore

tape

ring

med

icat

ion.

Som

e pa

tien

ts m

ay n

eed

to

cont

inue

hal

oper

idol

inde

fini

tely

.

•if

the

pat

ient

has

oth

er s

igni

fican

t

side

eff

ects

, con

side

r de

crea

sing

the

dose

slo

wly

(by

2.5

mg

incr

emen

ts)

and

mon

itorin

g

clos

ely.

Can

als

o co

nsid

er

chan

ging

to

rispe

ridon

e.

•o

nly

used

for

the

man

agem

ent

of

agita

ted/

viol

ent

patie

nts

and

alco

hol w

ithdr

awal

.

•it

sho

uld

not

be

cont

inue

d fo

r m

ore

than

seve

ral d

ays.

red

uce

by s

teps

abo

ve e

very

2 –

4 w

eeks

.

red

uce

by s

teps

abo

ve e

very

2 –

4 w

eeks

.

•Fo

r de

liriu

m, s

top

the

med

icat

ion

afte

r m

edic

al il

lnes

s is

tre

ated

.

•Fo

r ch

roni

c ps

ycho

sis

due

to m

enta

l illn

ess:

if t

he p

atie

nt is

sho

win

g

impr

ovem

ent

in s

ympt

oms

and

has

no m

ajor

sid

e ef

fect

s, d

o no

t st

op t

he

med

icat

ion.

•Fo

r ac

ute

psyc

hosi

s du

e to

men

tal i

llnes

s: c

onsi

der

slow

ly t

aper

ing

the

med

icat

ion

afte

r pa

tient

is s

ympt

om-f

ree

for

3 –

6 m

onth

s.

bre

astf

eedi

ngD

o no

t pr

escr

ibe

to p

regn

ant

or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g w

ith t

he m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Do

not

pres

crib

e to

pre

gnan

t or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g w

ith t

he m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Con

trai

ndic

ated

Do

not

pres

crib

e (f

or m

enta

l

illne

ss)

to p

regn

ant

or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g th

e m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Do

not

initi

ate.

if a

lread

y on

,

mak

e su

re t

akin

g 4

mg

folic

acid

QD

.


3

TR

eA

Tm

eN

T F

OR

AN

TIP

Sy

CH

OT

IC m

eD

ICA

TIO

N S

IDe

eF

Fe

CT

S

eSP

(ex

TRA

PyR

Am

IDA

l Sy

mTO

mS)

TAR

DIv

e D

ySk

INeS

IAN

eUR

Ole

PTIC

mA

lIG

NA

NT

SyN

DR

Om

e (N

mS)

AC

UTe

Dy

STO

NIA

Ak

ATH

ISIA

man

ifes

tati

onM

uscl

e rig

idity

(po

tent

ially

incl

udin

g:

eye

mus

cles

, thr

oat,

neck

, ton

gue,

bac

k)

eM

eR

Gen

CY

Psyc

hom

otor

res

tless

ness

invo

lunt

ary

orof

acia

l mov

emen

ts (

may

be p

erm

anen

t)

Con

fusi

on, d

eliri

um, s

tiffn

ess

(like

a

lead

pip

e), s

wea

ting,

hyp

erpy

rexi

a,

auto

nom

ic in

stab

ility

, dro

olin

g,

elev

ated

WBC

, ele

vate

d C

PK, d

eath

eM

eR

Gen

CY

Trea

tmen

tD

iphe

nhyd

ram

ine

50 –

75

mg

iM o

r

Po d

aily

seve

ral l

iters

of

iV o

r Po

flui

ds d

aily

Prop

rano

lol 1

0 –

20 m

g ti

D

Can

als

o de

crea

se t

he d

ose

of

med

icat

ion

Dis

cont

inue

neu

role

ptic

or

low

er d

ose

Con

side

r V

itam

in C

(50

0 –

1000

mg/

d)

+ V

itam

in E

(12

00 –

160

0 iu

/d)

1. D

isco

ntin

ue o

ffen

ding

med

icat

ion.

2. M

edic

al e

valu

atio

n an

d su

ppor

t

(con

side

r iV

flui

ds)

3. h

ospi

taliz

e

4. C

onsi

der

dopa

min

e ag

onis

ts o

r

dant

role

ne t

o im

prov

e ou

tcom

e.

Toxi

citi

esSe

riou

sa

naph

ylax

is, a

nem

ia, a

rrhy

thm

iaa

rrhy

thm

ia, b

ronc

hosp

asm

, ste

vens

-

John

son

synd

rom

e

Com

mon

Dro

wsi

ness

, diz

zine

ss, h

eada

che,

dry

mou

th, t

achy

card

ia, c

onst

ipat

ion,

blur

red

visi

on

Fatig

ue, d

izzi

ness

, nau

sea,

dep

ress

ion,

inso

mni

a


AbNORmAl INvOlUNTARy mOvemeNT SCAle (A ImS)

Facial and Oral movements

1. Muscles of Facial Expression e.g., movements of forehead, eyebrows, periorbital area, cheeks; include frowning, blinking, smiling, grimacing

2. lips and Perioral area e.g., puckering, pouting, smacking

3. Jaw e.g., biting, clenching, chewing, mouth opening, lateral movement

4. tongue rate only increases in movement both in and out of mouth, not inability to sustain movement

extremity movements

5. upper (arms, wrists, hands, fingers) include choreic movements (i.e., rapid, objectively purposeless, irregular, spontaneous); athetoid movements (i.e., slow, irregular, complex, serpentine). Do not include tremor (i.e., repetitive, regular, rhythmic)

6. lower (legs, knees, ankles, toes) e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot

Trunk movements

7. neck, shoulders, hips e.g., rocking, twisting, squirming, pelvic gyrations

Overall Severity

8. severity of abnormal movements

9. incapacitation due to abnormal movements

10. Patient's awareness of abnormal movements (rate only patient's report)

Dental Status

11. Current problems with teeth and/or dentures?

12. Does patient usually wear dentures?

� 0 � 1 � 2 � 3 � 4

� 0 � 1 � 2 � 3 � 4

� 0 � 1 � 2 � 3 � 4

� 0 � 1 � 2 � 3 � 4

� 0 � 1 � 2 � 3 � 4

� 0 � 1 � 2 � 3 � 4

� 0 � 1 � 2 � 3 � 4

� 0 � 1 � 2 � 3 � 4� 0 � 1 � 2 � 3 � 4

� 0 � 1 � 2 � 3 � 4

� yes �no

� yes �no

non

e, n

orm

al

Min

imal

(m

ay

be e

xtre

me

norm

al)

Mild

Mod

erat

e

seve

re

no

aw

aren

ess

aw

are,

no

Dis

tres

s

aw

are,

Mild

D

istr

ess

aw

are,

M

oder

ate

Dis

tres

s

aw

are,

sev

ere

Dis

tres

s

Patient’s Name: _________________________________________________________ Date: _____________________________________

Provider’s Name: ________________________________________________________ Phone Number: ____________________________

CURReNT meDICATIONS AND TOTAl mG/DAy

medication #1: ____________________ Total mg/Day: _________ medication #2: Total mg/Day:

INSTRUCTIONS: COmPleTe THe exAmINATION PROCeDURe beFORe eNTeRING THeSe RATINGS.

SCORING:

• score the highest amplitude or frequency in a movement on the 0 – 4 scale, not the average;

• a PositiVE aiMs EXaMination is a sCorE oF 2 in tWo or MorE MoVEMEnts or a sCorE oF 3 or 4 in a singlE MoVEMEnt

• Do not sum the scores: e.g. a patient who has scores 1 in four movements DoEs not have a positive aiMs score of 4.

Comments: ________________________________________________________________________________________________________

examiner's Signature ___________________________________________________________ Next exam Date_______________________

guy W: ECDEu assessment Manual for Psychopharmacology - revised (DhEW Publ no aDM 76-338), us Department of health, Education, and Welfare; 1976

dd/mm/yy


PSyCHOSIS jeOPARDy qUeSTIONS ANSweR key

AGITATION

1. name three possible causes for medical delirium: (100 points)

• brain diseases (dementia, stroke)

• metabolic disorders (electrolyte disorders)

• infections

• drugs

• pain

• immobility

• malignancy

2. Which form should a physician use for documenting a medical evaluation of an agitated patient? (200 points)

• the agitation, Delirium, and Psychosis Form

3. true or False: someone who is physically violent and refuses medication would be considered a moderately agitated patient. (300 points)

• False, they would be a severely agitated patient.

4. once you give medication to an agitated patient, what do you need to monitor? (400 points)

• Vital signs or

• side effects

5. name three calming interventions for agitated patients. (500 points)

• ask: “how can i help?”

• reassure the patient that you are there to keep the patient safe

• use a soft voice and slow movements

• Decrease stimuli

• allow venting

meDICATIONS

1. Why do we suggest that risperidone be prescribed first over haloperidol? (100 points)

• Because risperidone has fewer long-term side-effects than haloperidol.

2. What anticholinergic medication should always be given in conjunction with haloperidol to someone who is moderately or severely agitated? (200 points)

• Diphenhydramine


3. What supplement should a physician give to a pregnant woman on risperidone, haloperidol or carbamazepine? (300 points)

• 4 mg folic acid

4. With what type of medication should alcohol withdrawal be treated? (400 points)

• Diazepam

5. should a moderately agitated patient be offered oral medication or given an intramuscular injection? (500 points)

• offered oral medication

SIDe-eFFeCTS

1. What side-effect of antipsychotic medications is the aiMs intended to monitor? (100 points)

• tardive Dyskinesia

2. When do physicians administer the abnormal involuntary Movement scale (aiMs)? (200 points)

• When they first prescribe medication, then every six months after.

3. What side effect of medication could be deadly and require that the patient stop taking the medication and return to the hospital? (name one.) (300 points)

• a rash that develops after the patient begins a new medication.

• an acute dystonic reaction that could close the patient’s throat, or cause blindness.

• any kind of muscle tightness or physical discomfort that could be neuroleptic Malignant syndrome

4. What are possible serious side effects of antipsychotic medications, aside from death? name two possible side effects. (400 points)

• Weight gain leading to heart disease

• Diabetes

• tardive dyskinesia/permanent abnormal muscle movements

• Cardiac arrhythmia

5. if a patient develops acute dystonia, what medication should be given to resolve the dystonia immediately? (500 points)

• Diphenhydramine


FOllOw-UP AND DOCUmeNTATION

1. What cadre of health worker is responsible for monitoring potential side-effects from antipsychotics for agitated patients? (100 points)

• nurses!

2. true or False: Physicians will administer the WhoDas and Clinical global impressions scale to determine a patient’s improvement. (200 points)

• False, the psychologist/social worker will do this

3. What cadre of clinicians will physicians work most closely with to determine if a psychotic patient is improving over time? (300 points)

• Psychologists/social Workers

4. What form does the physician fill out each time they see a patient for a follow up appointment? (400 points)

• the Mental health Follow-up Form

5. the physician is deciding to medicate a severely agitated patient who is violent and refuses oral medication. Which two forms will assist the physician with deciding how to medicate the patient? (500 points)

• agitated Patient Protocol

• Medication Card


evAlUATION FORm

What training activity did you like the most? Why?

What training activity did you like the least? Why?

What did you learn that was valuable and that you will use in your work?

Was there anything you did not understand? give specific examples.

What are your recommendations to improve this training? What would you change? (For example, what activities, illustrations, etc. would you change?)


Do you have any recommendations for the facilitators of this training?

What questions do you still have for the facilitators of this training?

Were there any questions during the training which the facilitators did not answer?

What additional comments do you have?

Thank you for completing this evaluation.

Partners In Health888 Commonwealth Avenue, 3rd Floor, boston, mA 02215 www.pih.org

Documents

FaCilitator Manual Introduction to Agitation, Delirium ... · PDF fileIntroduction to Agitation, Delirium, and Psychosis Curriculum for Nurses ... Before a psychotic disorder can be