Chapter 7: Other Medical / Surgical Emergencies

Introduction

As you saw in the previous chapter of this module, respiratory, cardiovascular and neurologic conditions are the most common types of medical emergencies encountered in emergency care settings in the United Kingdom (UK). However, patients may present to emergency care settings with a variety of other medical and surgical emergencies - including those related to the gastrointestinal, renal / genitourinary and endocrine systems, those due to intoxication and mental health emergencies. It is essential that nurses working in emergency settings are able to assess and manage these diverse medical and surgical emergencies. This chapter introduces the knowledge and skills required to accurately and rapidly assess, and effectively manage, a variety of general, acute medical and surgical problems in the emergency care setting. You will also study the most common emergency presentations of these problems. This chapter will continue building your capacity to provide quality emergency care to patients with acute medical and surgical problems.

Important note

This chapter assumes a basic knowledge of human anatomy and physiology. If you feel you need to revise these concepts, you are encouraged to consult a quality nursing textbook.

Gastrointestinal emergencies

Complaints related to the gastrointestinal system - including generalised abdominal pain, heartburn, nausea, vomiting, constipation, diarrhoea, bloating and blood in the stool / vomitus, etc. - are common reasons people present to emergency care setting in the UK. Usually, these are signs and symptoms of a mild and self-limiting (though undoubtedly unpleasant!) gastrointestinal condition, such as indigestion, gastroenteritis or another minor gastric upset. However, these signs and symptoms may also indicate the presence of one of a number of other serious conditions related to the gastrointestinal system with which nurses working in emergency care settings must be familiar. If these conditions are poorly assessed and managed, as with any of the other emergency conditions you have studied in this module, disability and death may result. This section of the chapter will introduce you to emergency conditions related to the gastrointestinal system, and their assessment and management.

Nurses working in emergency care settings must be familiar with their organisation's policies and procedures for gastrointestinal assessment, and work within these. As always, the assessment of the patient with gastrointestinal illness must begin with an assessment of airway, breathing and circulation (ABC). A more focused assessment of the gastrointestinal system can then be undertaken; this will involve:

• A detailed assessment of the gastrointestinal system. This begins with inspecting the abdomen for any obvious abnormal movement, masses, symmetry and / or surgical scars. The bowel sounds should be auscultated in all four abdominal quadrants to determine their frequency, quality and pitch, and to identify absent bowel sounds (which are an indication of a number of serious gastrointestinal problems). The large abdominal organs may be percussed; dull sounds may be heard over distended organs (e.g. a colon filled with stool). Finally, all four quadrants should be palpated; in particular, the nurse should assess for abnormal masses and tenderness, and note the patient's response (e.g. such as automatically guarding painful regions, etc.).
• A detailed assessment of the patient's history. As you saw in an earlier chapter of this module, a health history is a fundamental aspect of patient assessment - however, it is particularly important during gastrointestinal assessment. Most importantly, nurses must ask a patient about their recent food and fluid intake, any changes in their bowel pattern (e.g. using a chart such as the Bristol Stool Chart to determine faecal consistency), and other symptoms they are experiencing.
• An assessment of the patient's gastrointestinal pain, if present, using the 'OPQRST' mnemonic introduced in an earlier chapter of this module. It is important to consider the anatomical location of the pain; for example, right lower quadrant pain is characteristic of appendicitis. However, in conducting a pain assessment, nurses should be aware that pain in the gastrointestinal region may radiate from the renal, genitourinary and / or gynaecologic regions, so differential diagnosis is important.

During assessment, a nurse may identify one or more of a variety of medical conditions related to the gastrointestinal system. The most common conditions, and their management in the emergency care setting, are described following:

• Gastrointestinal bleeding - bleeding may occur at any part of the gastrointestinal tract, and for a variety of reasons (e.g. in the upper gastrointestinal tract - ruptured oesophageal varices, ruptured peptic ulcers, etc.; in the lower gastrointestinal tract - haemorrhoids, diverticulum, colitis, cancer, etc.). A patient with gastrointestinal bleeding typically presents with bright red material (indicating fresh bleeding) and / or black material (indicating older bleeding) in the vomitus and / or stool, as well as changes in their vital signs (e.g. increased heart rate) if the bleeding is significant. In the emergency care setting, the focus is on resuscitation and stabilising the patient whilst further investigations and / or interventions are planned and undertaken.
• Appendicitis - this is the acute inflammation of the appendix, caused most often by the obstruction of blood flow to, and bacterial invasion of, the appendix, a very small abdominal organ. Patients with appendicitis typically present with a range of non-specific symptoms - including pain (which may initially be diffuse, but which eventually localises to the right lower quadrant), nausea, vomiting, malaise, anorexia and fever. If the appendix ruptures, acute pain and symptoms of acute infection will be seen. In most cases, appendicitis is treated by laparoscopic appendectomy; in preparation for this, nurses in emergency care settings may administer broad-spectrum intravenous antibiotics, and give fluid therapy to prevent dehydration.
• Cholecystitis - this is the acute inflammation of the gallbladder, caused most often by calculi (i.e. 'stones') obstructing the cystic duct within the gallbladder, resulting in an accumulation of bacteria. Patients with cholecystitis typically present with a range of non-specific symptoms - including severe pain (usually in the epigastrum and / or right upper quadrants, and often soon after the ingestion of fatty foods), nausea, vomiting, anorexia, fever and flatulence. In most cases, cholecystitis is treated by laparoscopic surgery to remove the gallstones and / or the entire gallbladder; in preparation for this, nurses in emergency care settings may administer analgesics, anti-emetics, fluid therapy and broad-spectrum antibiotics (if indicated).
• Acute pancreatitis - this is the acute inflammation of the pancreas. The exact pathophysiological mechanisms underpinning pancreatitis are unclear, however this condition is often associated with cholecystitis (described earlier in this section), alcohol abuse, infections, some drugs (including anti-metabolites), and malignant structures obstructing the pancreatic duct. Pancreatitis is usually managed using supportive therapies, including withholding oral intake, intravenous fluid therapy, anti-emetics and analgesics, and broad-spectrum antibiotics (if indicated).
• Bowel obstruction - the bowel may become obstructed for one of two reasons: (1) mechanical causes (i.e. where a disorder outside the intestines causes a blockage [e.g. adhesions from previous abdominal surgery, intussusception (i.e. inversion of one section of the intestine inside another), strictures, etc.]), or (2) non-mechanical reasons (i.e. where a disorder inside the intestines causes a blockage [e.g. foreign bodies, tumours and faecal impaction, etc.]). Bowel obstruction may be partial or complete. In either case, the bowel contents accumulate above the obstruction, resulting in a rapid overgrowth of bacteria and abdominal distention. Patients may present with a variety of non-specific symptoms - including abdominal distention, wave-like colicky pain (which may be severe), nausea and vomiting, and constipation. In emergency care settings, the focus is on resuscitation and stabilising the patient whilst further investigations and / or interventions are planned and undertaken. A nasogastric tube may be inserted to decompress the stomach and reduce vomiting. Fluid and antibiotic therapy are also often used. Rapid intervention to correct bowel obstruction is crucial, as ischaemia may result in deaths of lengths of the intestine, leading to acute shock (a condition you will study in a later chapter of this module).
• Gastroenteritis - this is the inflammation of the stomach and / or intestinal lining, caused most often by viral or bacterial pathogen/s. Patients with gastroenteritis present with nausea, vomiting, diarrhoea and abdominal cramps, and occasionally fever. Although it is unpleasant, gastroenteritis is usually self-limiting; supportive therapy - particularly intravenous fluid replacement and, in some cases, broad-spectrum antibiotics - may be offered in emergency care settings.

Renal and genitourinary emergencies

Renal and genitourinary problems - including urinary tract infections (UTIs), pyelonephritis (i.e. an acute infection of the kidney/s) and acute kidney failure - are commonly seen in emergency care settings in the UK. If poorly managed, renal conditions can result in severe fluid and electrolyte imbalances (which can be life-threatening) and / or chronic kidney disease. It is important that nurses working in emergency care settings can assess and manage acute medical conditions related to the renal and genitourinary systems.

Nurses working in emergency care settings must be familiar with their organisation's policies and procedures for renal and genitourinary assessment, and work within these. As always, the assessment of the patient with renal or genitourinary illness must begin with an assessment of airway, breathing and circulation (ABC). A more focused assessment of the renal and genitourinary systems can then be undertaken; this will involve:

• A detailed assessment of the patient's history. Again, a health history is a fundamental aspect of patient assessment - however, it is particularly important during renal and genitourinary assessment. Nurses should ask a patient about common comorbid conditions (e.g. diabetes) affecting the renal / genitourinary systems, history of previous renal / genitourinary problems, any changes in urinary patterns (e.g. frequency, urgency, dribbling, incontinence, dysuria, etc.), and any other symptoms experienced.
• An assessment of the patient's pain, if present, using the 'OPQRST' mnemonic introduced in an earlier chapter of this module.
• Additional assessments to assist with diagnosis - including urinalysis, X-rays or CT scans of the kidneys, blood assays (i.e. to determine renal function, and assess the concentration of waste products and electrolytes in the blood, etc.), and post-void bladder ultrasonography to assess residual volume, etc. In the UK, all female patients of childbearing age presenting to emergency care settings with renal and / or genitourinary symptoms are given a routine pregnancy test (via a urine dipstick); this is done even if the patient assures nurses that she is not / cannot be pregnant.

During assessment, a nurse may identify one or more of a variety of medical conditions related to the renal and genitourinary systems. The most common conditions, and their management in the emergency care setting, are described following:

• Acute kidney injury (AKI) - AKI is an acute problem which results in impairment in the function of the kidneys. AKI may be due to one of a number of causes: (1) pre-renal, which decrease blood flow to the kidneys (e.g. hypovolaemia, reduced cardiac output, etc.), (2) intra-renal, which damage the fragile structures within the kidneys (e.g. acute tubular necrosis, nephrotoxic agents, uncontrolled hypertension or diabetes, renal infection, etc.), or (3) post-renal, which obstruct the urinary tract (e.g. calculi, prostatic hypertrophy, tumours, structures, etc.). A patient with AKI may present to an emergency care setting with a range of non-specific symptoms - including nausea, vomiting, changes in urinary patterns (e.g. decreased OR increased urine output), and changes in neurological status (e.g. confusion, disorientation, loss of consciousness, etc. - these symptoms are primarily due to the accumulation of nitrogenous waste products in the blood). In the emergency care setting, the focus is on resuscitation and stabilising the patient whilst further investigations and / or interventions are planned and undertaken. The nurse will usually administer fluid therapy (e.g. to normalise the concentration of blood electrolytes), and in some cases emergency dialysis to remove nitrogenous waste products from the blood will also be used.

In addition to patients with AKI, it is important to note that nurses working in emergency care settings will also care for patients with acute complications of chronic renal failure. These include, most commonly, dialysis access complications (e.g. clotted vascular access, infection, etc.). Dialysis access complications are considered an emergency because (without renal transplantation) patients with chronic renal failure rely on regular dialysis for their survival.

• Rhabdomyolysis - this occurs due to the destruction of the skeletal muscles, and the release of the waste product myoglobin into the blood (often leading to AKI, discussed previously in this chapter). Rhabdomyolysis may result from a number of causes - including crush injuries, the ingestion of some toxins, major infections or burns, and general metabolic disturbances. Patients with rhabdomyolysis will present with myoglobinuria (i.e. urine containing high levels of myoglobin and, subsequently, with a brown tinge), generalised muscle pain, malaise and fever. Treatment focuses on the use of fluid therapy to maintain the patient's electrolyte balance, flush the myoglobin through the kidneys, and correct volume depletion.
• Urinary tract infection (UTI), including interstitial cystitis and pyelonephritis - the urinary tract may be infected by a variety of different bacteria, however most common are those originating in the gastrointestinal system (e.g. Escherichia coli). Patients with a UTI will present with symptoms of bladder irritability (e.g. frequency, urgency, dysuria, etc.), discomfort (e.g. cramping, stinging when passing urine, etc.) and cloudy urine. If the bladder is infected (e.g. in interstitial cystitis) and / or the kidneys are infected (e.g. in pyelonephritis), the patient's symptoms may be more severe, and include haematuria, malodorous urine, fever, nausea and vomiting, and severe pain. UTI, interstitial cystitis and pyelonephritis are treated with broad-spectrum antibiotics; supportive therapies - including analgesia and fluid therapy - may also be administered in the emergency care setting.
• Urinary calculi - these are formed when the urine is supersaturated with salt and minerals (e.g. calcium oxalate, struvite, uric acid and cysteine). Calculi may occur anywhere in the renal and / or genitourinary systems, but particularly the kidneys, ureters, bladder and urethra. Patients typically present with moderate to severe pain (which may occur in the lower back, lower abdomen or groin), the urge to void, dysuria and haematuria. The treatment of urinary calculi in the emergency care setting focuses on fluid therapy and the administration of analgesic medication. In some cases, procedures such as extracorporeal shock wave lithotripsy (ESWL - which uses sound waves to break up a large calculus) or laparoscopic surgery (to remove a calculus resulting in a severe obstruction) may be used.

Endocrine emergencies

The endocrine system is a complex integration of hormone-secreting glands. The dysfunction of one gland in this system may have catastrophic systemic effects, and result in severe disability or death. The majority of endocrine emergencies seen in emergency care settings in the UK are related to diabetes, and these will be the focus of this section of the chapter. However, it is also important for nurses in emergency care settings to be aware that endocrine emergencies can also relate to the pituitary gland (e.g. diabetes insipidus, syndrome of inappropriate antidiuretic hormone [SIADH]), thyroid gland (e.g. thyroid storm, myxoedema coma) and / or adrenal glands (e.g. acute adrenal insufficiency), as well as other medical conditions (e.g. alcoholic ketoacidosis, etc.).

Nurses working in emergency care settings must be familiar with their organisation's policies and procedures for endocrine assessment, and work within these. As always, the assessment of the patient with endocrine dysfunction must begin with an assessment of airway, breathing and circulation (ABC). A more focused assessment of the endocrine system can then be undertaken; this will involve:

• A detailed neurological assessment (e.g. using the Glasgow Coma Scale [GCS]). As you saw in the previous chapter of this module, tools such as the GCS assess the functioning of a patient's central nervous system, including their level of consciousness, via their response to verbal and / or painful stimuli. Changes in a patient's mental status are one of the key indicators of acute endocrine dysfunction.
• Additional assessments to assist with diagnosis - including blood assays (in particular, blood glucose levels), urinalysis and arterial blood gasses, etc.

During assessment, a nurse may identify one or more of a variety of medical conditions related to the endocrine system. The most common conditions, and their management in the emergency care setting, are described following:

• Diabetic ketoacidosis (DKA) - this occurs when there is a depletion of insulin in a patient's body, often when a person with diabetes poorly manages their condition or when their system is exposed to stressors (e.g. infection, pregnancy, etc.). Patients typically present with hyperglycaemia, polyuria, dehydration (sometimes with severe hypotension), electrolyte depletion (sometimes with cardiac dysrhythmias), metabolic acidosis (with the characteristic 'fruity-smelling' breath) and fatigue. Treatment involves aggressive insulin therapy and intravenous fluid replacement.
• Hyperosmolar hyperglycaemic state (HHS) - this occurs when a patient with (often undiagnosed) diabetes develops hyperglycaemia (i.e. high levels of blood glucose) and hyperosmolarity (i.e. where the body fluids become concentrated). Patients may complain of a range of non-specific symptoms, including polydipsia and polyuria, but the condition often progresses to cause decreased levels of consciousness and seizures. As with DKA, HHS is treated with aggressive insulin therapy and intravenous fluid replacement.
• Hypoglycaemia - this is defined as a pathologically low serum glucose level, and it occurs most often in patients with diabetes. The brain depends on a continuous supply of glucose to function effectively; therefore, patients with hypoglycaemia often with altered levels of consciousness (e.g. irritability, confusion, difficulty speaking, ataxia, paresthesias, etc.), or even seizures and coma. Intravenous or intramuscular glucagon is administered to correct hypoglycaemia; glucagon stimulates the liver to release glycogen, which is subsequently converted to glycose by the body. It is important for nurses working in emergency care settings to note that glucagon often causes vomiting, and neurologically-impaired patients must be positioned to minimise their risk of aspiration.

Intoxication emergencies

A person is considered to be intoxicated if a substance they have taken is impairing their capacity to act or reason. People may present to emergency care settings in the UK intoxicated with one or more of a variety of different types of substances - for example:

• Narcotics (e.g. heroin, morphine, fentanyl).
• Stimulants (e.g. cocaine, methamphetamine).
• Depressants (e.g. alcohol, ketamine).
• Hallucinogens (e.g. phencyclidine [PCP]).
• Club drugs (e.g. ecstasy, gamma-hydroxybutyrate [GHB]).
• Inhalants (e.g. marijuana, glues, paints, petrol, aerosols).
• Prescribed medications (e.g. salicylates, acetaminophen, opiates, central nervous system (CNS) stimulants, benzodiazepines, tricyclic antidepressants, etc.).

People may become intoxicated by substances intentionally (e.g. in an attempt to get 'high', or to self-harm / commit suicide, etc.) or accidentally (e.g. medication errors, unexpected drug interactions, via drink 'spiking', etc.). The symptoms of intoxication vary depending on the substance taken; however, typically a patient will usually present with changes in their level of conscious, cognition, perception, affect, behaviour and motor coordination, etc. In cases of severe intoxication, a patient may be significantly compromised and present with seizures or in a coma. Although it is impossible to be familiar with the effects of all the various substances on which a patient may become intoxicated, it is important that nurses know the effects of the substances most often seen in the emergency care setting and region where they work.

The management of intoxication in the emergency care setting focuses on the support of the airway, breathing and circulation using the resuscitative interventions described in an earlier chapter of this module. Care then involves: (1) limiting the absorption of the substance, and (2) enhancing the elimination of the substance. This may involve strategies such as gastric lavage, the administration of activated charcoal or binding agents, whole bowel irrigation or even emergency haemodialysis, etc. Some substances have antidotes which may be administered intravenously to reverse their effects; for example, overdoses of narcotics are frequently treated with naloxone, which acts to cancel their action.

In addition to acute intoxication, it is important to note that patients in emergency care settings may present with a variety of other substance-related complications. In particular, if a person takes a substance on which they have become dependent, the person may present with the signs of acute withdrawal from the substance. Withdrawal occurs when a person abruptly discontinues the use of a substance on which they are dependent, causing a range of negative symptoms (which may be significant and life-threatening - even for common substances such as alcohol). The exact symptoms experienced during withdrawal depend on the substance used, how the substance is taken, the dose taken, the length of time the patient has been dependent, and a variety of other physiological and psychological factors. It is important for nurses working in emergency care settings to be aware that patients may become dependent on prescribed medications, even if they are taking them correctly. It is important for nurses working in emergency care settings to be familiar with their organisation's policies and procedures when caring for patients who are withdrawing.

It is essential that nurses working in emergency care settings realise that patients who are intoxicated frequently present as violent and aggressive - and therefore pose a risk to themselves, their colleagues and others in the environment. You will study the management of violent and aggressive patients in the emergency care setting in detail in a later chapter of this module.

Mental health emergencies

It is very common for patients to present to emergency care settings in the UK with acute complications of mental illness. The most common types of mental illness in the UK are:

• Depression - a complex disorder where a person experiences prolonged melancholy (or feelings of sadness). Patients with depression may present to emergency care settings with self-harm / suicidal ideologies, feelings that they may harm others (a known complication of postnatal depression, for example), and / or psychosis (i.e. loss of touch with reality) etc.
• Anxiety disorders - a group of disorders where patients experience severe, disproportionate worry and / or phobias. Patients with an anxiety disorder may present to emergency care settings during or following an acute onset of their disorder, such as a panic attack.
• Psychotic disorders - including schizophrenia and bipolar disorder. Patients with psychotic disorders may present to emergency care settings during or following an acute onset of their disorder, particularly during or following a psychotic event (i.e. an event where the person temporarily loses contact with reality).

It is essential for nurses working in emergency care settings to understand that intoxication emergencies (as described in the previous section of this chapter) and mental health emergencies often occur concurrently. Substance use may lead to a mental illness (including an acute episode of mental illness), and / or a person may choose to use substance/s in an attempt to manage their mental illness. Consider the following case study:

The assessment and management of a patient with an acute mental illness is a particularly important skill for nurses working in emergency care settings. Thus, this will be explored in greater detail in the example essay which accompanies this chapter.

Note

Nurses working in emergency care settings in the UK may encounter a variety of other common medical and surgical emergencies - including those related to the eyes (e.g. foreign bodies, ocular burns, infections, retinal artery occlusion, retinal detachment, glaucoma, etc.), to the dental / ear / nose regions (e.g. fractured or avulsed tooth, otitis, ruptured tympanic membrane, epistaxis, etc.), to haematologic complications (e.g. acute anaemia, sickle cell disease, haemophilia, disseminated intravascular coagulation [DIC], etc.) and to oncologic complications (e.g. acute neutropaenia). These are relatively uncommon conditions in emergency care settings in the UK; therefore, they will not be covered in this chapter. However, if you wish to extend your skills and knowledge, you are encouraged to consult a quality nursing textbook or website.

Conclusion

Patients may present to emergency care settings with a variety of general medical and surgical emergencies. It is essential that nurses working in emergency settings are able to assess and manage these diverse medical and surgical emergencies. This chapter has introduced the knowledge and skills required to accurately and rapidly assess, and effectively manage, a variety of general, acute medical and surgical problems in the emergency care setting - including those related to the gastrointestinal, renal / genitourinary and endocrine systems, and those due to intoxication and mental health emergencies. You have also studied the most common emergency presentations of these problems. Along with the previous chapter of this module, this chapter has provided a thorough grounding to prepare you to provide quality emergency care to patients with acute medical and surgical problems.

References

Care Quality Commission. (2015). People's Experiences of Help, Care and Support During a Mental Health Crisis. Retrieved from: https://www.cqc.org.uk/sites/default/files/20150630_righthere_mhcrisiscare_full.pdf

Diabetes UK. (2013). Hospital Management for Hypoglycaemia in Adults. Retrieved from: https://www.diabetes.org.uk/About_us/What-we-say/Specialist-care-for-children-and-adults-and-complications/The-hospital-management-of-Hypoglycaemia-in-adults-with-Diabetes-Mellitus/

Howard, P.K. & Steinmann, R.A. (Eds.). (2010). Sheehy's Emergency Nursing: Principles and Practice. Naperville, IL: Mosby Elsevier.

Joint British Diabetes Societies. (2011). Guideline for the Management of Diabetes Ketoacidosis. Retrieved from: http://www.bsped.org.uk/clinical/docs/jbdsdkaguidelines_may11.pdf

Jones, G., Endacott, R. & Crouch, R. (2007). Emergency Nursing Care: Principles and Practice. Cambridge: Cambridge University Press.

National Institute for Health and Clinical Excellence. (2010). Alcohol Use Disorders: Diagnosis and Management of Physical Complications. Retrieved from: https://www.nice.org.uk/guidance/cg100/resources/alcoholuse-disorders-diagnosis-and-management-of-physical-complications-35109322251973

National Institute for Health and Clinical Excellence. (2010). Common Mental Health Problems: Identification and Pathways to Care. Retrieved from: https://www.nice.org.uk/guidance/cg123/resources/common-mental-health-problems-identification-and-pathways-to-care-35109448223173

National Institute for Health and Clinical Excellence. (2013). Acute Kidney Injury: Prevention, Diagnosis and Management. Retrieved from: https://www.nice.org.uk/guidance/cg169/resources/acute-kidney-injury-prevention-detection-and-management-35109700165573

National Institute for Health and Clinical Excellence. (2016). Acute Upper Gastrointestinal Bleeding in Over-16s: Management. Retrieved from: https://www.nice.org.uk/guidance/cg141/resources/acute-upper-gastrointestinal-bleeding-in-over-16s-management-35109565796293

Sinclair, L., Hunter, R., Hagen, S., Nelson, D. & Hunt, J. (2006). How effective are mental health nurses in A&E departments? Emergency Medicine Journal, 23(9), 687-692.

Example essay

A patient is bought to an A&E Department experiencing an acute psychotic episode of unknown origin. This is his first known episode of psychosis. He is admitted to hospital involuntarily under The Mental Health Act 1983. With reference to the relevant National Institute for Health and Clinical Excellence (NICE) guideline and the current literature, identify and critically discuss the key interventions to be used in the emergency care of this patient.

Psychosis is a psychiatric disorder characterised by major alterations in a person's thoughts, perception, mood and behaviour (National Institute for Health and Care Excellence [NICE], 2014). The development of psychosis is associated with a variety of causative factors - including biochemical and structural changes in the brain, life stress and dysfunctional family interactions (Walker, 2015). It is thought that approximately 1% of the population of the United Kingdom (UK) will experience a psychotic episode at least once on their lifetime (NICE, 2014) and psychosis is a common cause of admission to emergency care settings in the UK (Byrne, 2007). During an acute psychotic episode, patients present with a combination of symptoms including hallucinations, delusions and behavioural disturbances, often with agitation and distress (NICE, 2014).

If poorly managed, acute psychosis results in ongoing problems such as an increased risk of psychological comorbidity, social exclusion and problems re-engaging in work or study, etc. (NICE, 2014). It is therefore essential that nurses working in emergency care settings in the UK are able to assess and manage a patient who presents with an acute psychotic episode. With reference to the relevant National Institute for Health and Clinical Excellence (NICE) guideline, Psychosis and Schizophrenia in Adults: Prevention and Management, and the current literature, this paper identifies and critically discusses the key assessments and interventions to be used in the emergency care of a patient who is experiencing an acute psychotic episode, such as the one in the case study on which this paper is based.

The Psychosis and Schizophrenia in Adults: Prevention and Management guideline states that people presenting to emergency care settings with psychosis "should be assessed without delay" (NICE, 2014: p. 16). Assessment should include the following components:

• A comprehensive psychiatric assessment (e.g. of the patient's psychiatric symptoms, present risk of harm to self / others, level of insight, etc.) (NICE, 2014). In particular, patients with psychosis should be assessed for post-traumatic stress disorder (PTSD), as they are likely to have either: (a) experienced a traumatic event which resulted in the development of their psychotic disorder, and / or (b) experienced significant trauma as a result of their psychotic episode (NICE, 2014). The nurse should also monitor for co-existing mental illnesses, such as depression and anxiety (NICE, 2014), though these may be difficult to detect in an acutely psychotic patient.
• An assessment of the patient's medical history (e.g. focusing on possible organic brain disorders, neurodevelopmental disorders and medications which may have induced psychosis, etc.) (NICE, 2014).
• An assessment of the patient's psychosocial history - including their substance use patterns (if applicable), social situation, occupational and / or educational activity, economic status and perceived quality of life (NICE, 2014). The patient may also be assessed for cognitive functioning, as this provides important information about the patient's likely recovery outcomes (Fulford et al., 2014).

It is important to note that there are a variety of different tools which may be used to guide nurses' assessment of a patient with psychosis; however, using these tools in emergency care settings with patients presenting with acute psychosis is problematic because they have been largely validated for accuracy in patients with chronic psychosis (Fulford et al., 2014). Furthermore, the definitions used in assessment tools to describe psychotic experiences are varied, and this may make the accurate assessment of a patient with psychosis difficult (Lee, 2015). Tools which may be used to assess a patient with psychosis are not described or specified in the NICE (2015) Psychosis and Schizophrenia in Adults: Prevention and Management guideline; therefore, nurses should be guided by their local hospital policies and procedures in their use.

Once a patient presenting with acute psychosis has been assessed, management can commence. The Psychosis and Schizophrenia in Adults: Prevention and Management guideline highlights that the management of a person with psychosis "should aim to provide a full range of pharmacological, psychological, social, occupational and educational interventions" (NICE, 2014: p. 16). Interventions for a person with psychosis who has presented to an emergency care setting will be critically analysed in the following section of the paper; however, it is important to note that not all these interventions may be suitable for a particular client. Interventions must be selected after considering an individual client's situation and preferences, demonstrating patient-centred care (NICE, 2014). The interventions selected should be detailed in a care plan (NICE, 2014), which helps to coordinate the mental health services provided to the patient.

The Psychosis and Schizophrenia in Adults: Prevention and Management guideline recommends that patients experiencing their first psychotic episode, such as the one in the case study on which this paper is based, are offered an oral anti-psychotic medication in the emergency care setting (NICE, 2014). Anti-psychotic medications aim to stabilise the function of the dopaminergic system in the patient's brain, and thereby provide relief from psychotic symptoms (Kantrowitz, 2011). There are a variety of anti-psychotic medications which may be used; a choice of one is made with the patient, based on a discussion of the likely benefits and possible side-effects of each available medication (NICE, 2014). The oral anti-psychotic medications appropriate for prescription are not detailed in the NICE guideline; however, the Royal College of Psychiatrists (2016) recommends either: (1) typical antipsychotics (e.g. chlorpromazine, haloperidol, sulpiride), or (2) atypical antipsychotics (e.g. amisulpride, clozapine, risperidone, etc.). The Royal College of Psychiatrists (2016: NP) highlights clozapine in particular as "the anti-psychotic medication which works better than any of the others".

Despite anti-psychotic medications being the frontline intervention for patients with psychotic disorders, it is important for nurses working in emergency care settings to bear in mind that the side-effects of anti-psychotic medications can be severe; they may include negative metabolic, extrapyramidal, cardiovascular and / or hormonal changes (NICE, 2014; Royal College of Psychiatrists, 2016). The literature also suggests that adherence to prescribed medications is a significant problem for patients with psychosis (Pringle, 2013); indeed, in a study conducted by Chan et al. (2014), nearly 44% of patients with a psychotic disorder did not take their anti-psychotic medication as prescribed. Furthermore, psychotic medications may be ineffective in people who use (or abuse) other substances, such as cannabis (Hjorthoj et al., 2013); a problem, considering that concurrent substance use is commonly seen in patients with psychotic disorders. Additionally, long-term cohort studies such as that conducted by Harrow et al. (2014), suggest that whilst anti-psychotic medications are highly effective in the short-term, they may not reduce the frequency or severity of post-acute psychosis.

The literature suggests a variety of other interventions which may be suitable for a patient with acute psychosis. Some of the treatments which recent research suggest may be effective include medications to stimulate glutamate production in the brain (Kantrowitz, 2011), therapies for immune dysregulation (Leboyer et al., 2016), and even electroconvulsive therapy for atypical psychosis (Montgomery & Vasu, 2007). It is important to highlight that the evidence on the effectiveness of these interventions in the management of psychosis is of variable quality; furthermore, the suitability of these interventions for implementation in the emergency care context is unclear. Because the NICE (2015) Psychosis and Schizophrenia in Adults: Prevention and Management guideline does not discuss or recommend any of these interventions, nurses should be guided by their local hospital policies and procedures in their use.

Once a patient has recovered from their acute psychotic episode, there are a number of other longer-term management interventions recommended by the Psychosis and Schizophrenia in Adults: Prevention and Management guideline. These interventions include psychological therapies, such as cognitive behavioural therapy (CBT), (NICE, 2014). Research suggests that such community-based psychosocial support programs can significantly reduce the psychopathology of patients with first-episode psychosis, and improve their quality of life (Kane et al., 2016). Whilst these interventions are unsuitable for implementation in an emergency care setting, as it is an acute care context, they may be initiated by nurses working in this setting; for example, nurses may organise a referral for a patient to a cognitive behavioural therapist. The literature suggests that such integrated pathways between acute and non-acute care settings may improve outcomes for patients with psychosis in the UK (Bhui et al., 2014). 

This paper has identified and critically discussed the key assessments and interventions to be used in the emergency care of a patient who is experiencing an acute psychotic episode, with reference to the relevant National Institute for Health and Clinical Excellence (NICE) guideline, Psychosis and Schizophrenia in Adults: Prevention and Management, and the current literature. In particular, this paper has discussed anti-psychotic medication as a frontline treatment for patients presenting with first-episode psychosis. This paper has demonstrated that the assessment and management by nurses, as part of multidisciplinary teams, can significantly improve outcomes for patients, such as the one in the case study on which this discussion is based, who present to emergency care settings with acute psychosis.

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