Nursing and Psychiatric Care
This is especially important in comatose patients, and involves the following measures:
· Attention to pressure points to prevent the development of decubitus ulcers—hourly turning, a pillow between the legs, use of a ripple mattress if available, etc.
· In the absence of spontaneous blinking, avoid exposure keratitis by methyl cellulose eye drops, and if necessary, secure the eyelids with adhesive tape.
· Change bed linen frequently if it gets soaked with urine or stained with faeces.
· Urinary incontinence can be managed with a sheath urinal for a male, but for a female, an indwelling silastic catheter inserted with aseptic precautions is necessary.
· Inhalation of gastric contents is a frequent problem which can lead to pneumonitis. This can be prevented by positioning the patient semiprone with the head slightly dependent, and intubating if necessary.
· Adequate bronchial toilet is essential, with regular aspira- tion of secretions.
· Passive physiotherapy may be advisable to prevent stiffness and muscle atrophy.
· Prophylactic antibiotics, if necessary.
A significant proportion of overdose cases comprise suicide attempts. After medical stabilisation, the most important aspect of management consists of psychiatric counselling in order to prevent recurrence of suicide ideation once the patient has been discharged.
Any patient who has taken an overdose or manifests suicidal ideation should get psychosocial assessment and support as early as possible. The initial evaluation can be performed prior to a total clearing of the patient’s sensorium, but a final assess-ment should not be made unless the patient is completely alert. Recognition that the patient is possibly suicidal, with a precise analysis of the potential for suicide is essential. Carefully analysing the patient’s psychologic state (depressed, uncoopera-tive, unresponsive, agitated, anxious, violent, or psychotic), willallow for a realistic appraisal of the psychosocial alternatives with respect to immediate and long-term treatment, disposition, and continued follow-up, or outpatient care.
It is estimated that among adolescents, suicide accounts for a third of all unnatural deaths, while in college students, suicide is the second leading cause of unnatural death. According to one survey, oral ingestions account for 78% of the cases, 13% are inhalational, while 5% are due to parenteral intake. Patients suffering from depression commit suicide 50 times more frequently than the general population. Alcoholics and chronic dialysis patients have a suicide rate 6 times higher than the population at large. After the age of 40 years, the suicide rate begins to climb, with a dramatic increase after 65. Women attempt suicide 3 times more often than men, but men are more successful by a ratio of 3:1.
Significantly, 75% of all those who commit suicide do so shortly after seeing a doctor. Usually it is the family physi-cian, not a psychiatrist who sees these patients, many of whom clearly need psychiatric support. With prompt recognition and referral, many suicides may be prevented. A patient with a past history of previous suicide attempts, vague health prob-lems of recent onset, recent surgery, alcoholism, drug abuse, and mental unsoundness (especially psychosis), is at high risk. Stress is also a major factor leading to suicide ideation; recent bereavement, loss of a job, financial loss, etc. are well recognised as trigger factors. Hypochondriasis, pessimism, hopelessness, and other signs of depression may signal a potential suicide and should alert the clinician.
Unfortunately, there are a number of misconceptions about suicide. For example, many people believe that those who talk about suicide will never actually commit suicide and those who resort to frequent suicide “gestures” are not really serious. However, studies show that of all those who successfully commit suicide, 80% have threatened to do so in the past, and may have even made previous attempts. It is therefore essential that every patient who talks about suicide or who presents with a suicide gesture no matter how trivial, should be referred to a psychiatrist before leaving the emer-gency department.
Today, psychosocial assessment has become an important component in the comprehensive evaluation of toxicologic emergencies. It has to be initiated in every case by interviewing collateral sources (accompanying family members or friends), before talking to the patient himself. Delay in obtaining psychosocial information can have serious consequences, for example, in cases where an overdosed adult patient may have small children who were left unattended.