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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
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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
Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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/
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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.
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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.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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
Session Content methods Time
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
Session Content methods Time
Review Day 2 Review • Jeopardy 1 hour
9Review, Post-Test and Training evaluation
• Case studies• assessment• reflection
2 hours 15 minutes
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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
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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.
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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).
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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.
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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.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
SeSSIon 2: epidemiology, the Treatment Gap, and Stigma
methods: reflection journey, facilitator presentation, role play
Time: 1 hour 30 minutes
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.
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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.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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.
Animate the speech bubble. Ask the participants the following question:
• How would you define schizophrenia?
Wait for a few responses, and then respond by animating the answer.
9. Show Slide 12: Bipolar Disorder.
Animate the speech bubble. Ask the participants the following question:
• 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.
Animate the speech bubble. Ask the participants the following question:
• 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’.
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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/
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Nurses
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.
– Wait for the participants to raise their hands.
3. You have taken any medication during the last year.
– Wait for the participants to raise their hands.
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/
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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.
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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.”
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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.
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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
Time: 1 hour 15 minutes
Participant Handbook page: 7
materials: � PowerPoint (agitation, Delirium,
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.
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2. Show Slide 19: Psychosis Care Pathway.
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.
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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.
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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.
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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.
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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
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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.
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SeSSIon 4: Safety and management of Agitated Patients
methods: Facilitator presentation, role plays
Time: 1 hour 45 minutes
Participant Handbook page: 12
materials: � PowerPoint (agitation, Delirium,
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.
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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.
Animate the speech bubble. Ask the participants the following question:
• 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.
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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.
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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).
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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.
17. Show Slide 45: Agitated Patient 1.
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?
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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.
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24. Show Slide 50: Agitated Patient 2.
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.
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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.
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SeSSIon 5: medical evaluation and the management of Agitation, Delirium, and Psychosis
methods: Facilitator presentation, case studies
Time: 1 hour 15 minutes
Participant Handbook page: 15
materials: � PowerPoint (agitation, Delirium,
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.
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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.
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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.
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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.
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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.
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SeSSIon 6: medication management for Agitation, Delirium, and Psychosis
methods: Facilitator presentation, worksheet, role plays
Time: 2 hours
Participant Handbook page: 19
materials: � PowerPoint (agitation, Delirium,
and Psychosis), slides 64 – 78 � Medication Card for agitation,
Delirium and Psychosis
� Flip chart � Markers
Preparation:
• review PowerPoint (agitation, Delirium, and Psychosis), slides 64 – 78.
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.
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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.
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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.
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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.
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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.
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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
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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.
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SeSSIon 7: Follow-Up and Documentation
methods: Facilitator presentation, group discussion
Time: 45 minutes
Participant Handbook page: 24
materials: � PowerPoint (agitation, Delirium,
and Psychosis), slides 79 – 83 � Flip chart � Markers
Preparation:
• review PowerPoint (agitation, Delirium, and Psychosis), slides 79 – 83.
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.
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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.
4. Show Slide 80: Psychosis Care Pathway.
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.
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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)
• review PowerPoint (agitation, Delirium, and Psychosis), slides 84 – 85.
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.
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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!
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SeSSIon 8: Review, Post-Test and Training evaluation
methods: Case studies, assessment, evaluation
Time: 2 hours 15 minutes
Participant Handbook page: 26
materials: � PowerPoint (agitation, Delirium,
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.
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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.
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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.
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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
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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.
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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
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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.
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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.
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Annex
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� 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
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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
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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
61Partners In Health | FaCilitator Manual | Annex
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
62 Partners In Health | FaCilitator Manual | Annex
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
63Partners In Health | FaCilitator Manual | Annex
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
64 Partners In Health | FaCilitator Manual | Annex
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
65Partners In Health | FaCilitator Manual | Annex
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
66 Partners In Health | FaCilitator Manual | Annex
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
67Partners In Health | FaCilitator Manual | Annex
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
68 Partners In Health | FaCilitator Manual | Annex
PS
yC
HO
SIS
CA
Re
PA
TH
wA
y
CA
Se I
Den
tIFIC
AtI
on
A
nD
ReFeR
RA
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ALU
AtI
on
, D
IAG
no
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A
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tR
eA
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t
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•id
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fer
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ycho
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are
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riage
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fer
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ycho
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-up
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alua
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and
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•C
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re w
ith
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n an
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hW
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ycho
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list
ReFeR
Fo
LLo
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ysic
ian
Psy
chol
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t or
So
cial
wor
ker
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w
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69Partners In Health | FaCilitator Manual | Annex
AG
ITA
TIO
N,
De
lIR
IUm
AN
D P
Sy
CH
OS
IS C
He
Ck
lIS
T
Dat
e __
____
____
____
____
____
____
dd
/mm
/yy
CH
wP
SYC
Ho
Lo
GIS
t/S
oC
IAL
wo
RK
eR
nU
RS
eS
PH
YS
ICIA
n
AG
ITA
TeD
PA
TIeN
T
�
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
imm
edia
tely
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
�
if s
uici
dal/
viol
ent,
acc
ompa
ny
patie
nt a
nd f
amily
to
the
clin
ic
imm
edia
tely
�
Dec
reas
e ris
k an
d re
info
rce
safe
ty
if ris
k fo
r su
icid
e or
vio
lenc
e
�
Com
plet
e th
e in
itial
Vis
it Fo
rm
�
use
the
ZlD
si
�
Do
psyc
hoed
ucat
ion
�
giv
e th
e r
efer
ral F
orm
and
initi
al
Vis
it Fo
rm t
o ps
ycho
logi
st/s
W
FOll
Ow
-UP
�
if s
uici
dal/
viol
ent,
acc
ompa
ny
patie
nt a
nd f
amily
to
the
clin
ic
imm
edia
tely
�
Dec
reas
e ris
k an
d re
info
rce
safe
ty
if ris
k fo
r su
icid
e or
vio
lenc
e
�
Doc
umen
t w
ith t
he M
enta
l h
ealth
Fol
low
-up
Form
�
use
the
ZlD
si
�
Do
psyc
hoed
ucat
ion
�
giv
e th
e r
efer
ral F
orm
and
initi
al
Vis
it Fo
rm t
o ps
ycho
logi
st/s
W
�
Do
follo
w-u
p of
pat
ient
in
the
com
mun
ity (
chec
k pa
tient
ad
here
nce,
sid
e ef
fect
s,
enco
urag
e pa
tient
s to
do
fo
llow
-ups
)
AG
ITA
TeD
PA
TIeN
T
�
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
�
ref
er t
o th
e a
gita
ted
Patie
nt P
roto
col;
supp
ort
nurs
e an
d ph
ysic
ian
�
Col
lect
info
rmat
ion
from
pat
ient
and
fam
ily
�
arr
ange
1:1
if n
eede
d
�
rem
ain
at b
edsi
de u
ntil
patie
nt is
sta
ble
�
Follo
w p
atie
nt 2
x/da
y, g
ive
phon
e nu
mbe
r to
pat
ient
’s fa
mily
& n
urse
/phy
sici
an
�
usi
ng a
gita
tion,
Del
irium
and
Psy
chos
is C
heck
list,
ens
ure
med
icat
ions
giv
en a
nd
med
ical
car
e pr
ovid
ed b
y nu
rse/
MD
�
giv
e pa
tient
/fam
ily p
sych
oedu
catio
n an
d su
ppor
t
�
ass
ess
& m
anag
e so
cioe
cono
mic
bur
den
of il
lnes
s
�
Proc
eed
to in
itial
eva
luat
ion
(onc
e ca
lm)
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
�
Com
plet
e Ps
ycho
sis
Che
cklis
t w
ith C
hW
/nur
se
�
Com
plet
e Zl
Dsi
�
Doc
umen
t in
initi
al M
enta
l hea
lth E
valu
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n Fo
rm
�
spea
k w
ith p
atie
nt a
nd t
Wo
fam
ily m
embe
rs &
rev
iew
phy
sici
an’s
agi
tate
d Pa
tient
For
m t
o co
mpl
ete
initi
al m
enta
l hea
lth e
valu
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n
�
Ensu
re v
itals
, wei
ght,
and
labs
are
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cked
�
acc
ompa
ny p
atie
nt t
o se
e ph
ysic
ian
(see
s al
l psy
chot
ic, s
uici
dal,
viol
ent
case
s)
�
hel
p ph
ysic
ian
follo
w c
heck
list
�
Mak
e pr
elim
inar
y di
agno
sis
of d
eliri
um/m
edic
al il
lnes
s or
men
tal i
llnes
s w
ith
the
phys
icia
n
�
if p
atie
nt n
eeds
med
ical
car
e, c
oord
inat
e w
ith p
hysi
cian
s, if
pat
ient
has
ps
ycho
tic d
isor
der,
sche
dule
fol
low
-up
with
in o
ne w
eek
�
Do
psyc
hoed
ucat
ion
and
supp
ort
rela
ted
to m
edic
atio
n an
d ps
ycho
sis
�
Com
plet
e C
gi/
Wh
oD
as,
reg
istr
y, C
heck
list
FOll
Ow
-UP
�
use
Men
tal h
ealth
Fol
low
-up
Form
�
see
whe
ther
pat
ient
is im
prov
ing
(che
ck m
enta
l sta
tus
exam
, fun
ctio
ning
, pa
tient
and
fam
ily r
epor
t)
�
Che
ck m
edic
atio
n co
mpl
ianc
e, s
ide
effe
cts
�
Ensu
re v
itals
, wei
ght,
and
labs
are
che
cked
�
acc
ompa
ny p
atie
nt t
o se
e ph
ysic
ian;
hel
p ph
ysic
ian
follo
w a
gita
tion,
Del
irium
an
d Ps
ycho
sis
Che
cklis
t
�
Plan
fol
low
-up
for
1– 2
wee
ks; c
oord
inat
e w
ith C
hW
�
Do
psyc
hoed
ucat
ion
and
supp
ort
for
med
icat
ion
and
psyc
hosi
s
�
Com
plet
e C
gi/
Wh
oD
as,
reg
istr
y, a
gita
tion,
Del
irium
and
Psy
chos
is C
heck
list
AG
ITA
TeD
PA
TIeN
T
�
ale
rt e
ither
psy
chol
ogis
t/so
cial
w
orke
r
�
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
�
ref
er t
o a
gita
ted
Patie
nt
Prot
ocol
�
Man
age
envi
ronm
ent
�
talk
to
patie
nt; s
uppo
rt f
amily
�
Do
vita
l sig
ns a
saP
�
Prep
are
oral
and
iM m
edic
atio
ns
if ne
eded
�
arr
ange
1:1
if n
eede
d
�
Mon
itor
antip
sych
otic
sid
e ef
fect
s, r
epor
t to
phy
sici
an
�
Con
tinue
to
follo
w p
atie
nt c
lose
ly
(at
leas
t ev
ery
15 m
in c
heck
)
�
ass
ist d
octo
r in
med
ical
eva
luat
ion
and
care
(vi
tal s
igns
, lab
tes
ts,
EKg
, flui
ds)
�
Prov
ide
psyc
hoed
ucat
ion
and
supp
ort
to p
atie
nt a
nd f
amily
�
Doc
umen
t al
l wor
k in
nur
sing
fo
rms
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
�
Det
erm
ine
whe
ther
pat
ient
may
be
psy
chot
ic
�
acc
ompa
ny p
atie
nt t
o se
e ps
ycho
logi
st/s
W; s
uppo
rt
colla
bora
tion
with
phy
sici
an
�
if p
sych
osis
is d
iagn
osed
, pro
vide
ps
ycho
educ
atio
n an
d su
ppor
t
�
Befo
re d
isch
arge
, ens
ure
the
patie
nt h
as a
fol
low
-up
appt
with
ps
ycho
logi
st/s
W
FOll
Ow
-UP
�
Do
vita
l sig
ns, w
eigh
t at
eac
h vi
sit
�
Che
ck la
bs w
hen
nece
ssar
y
�
Doc
umen
t in
Men
tal h
ealth
Fo
llow
-up
Form
AG
ITA
TeD
PA
TIeN
T
�
ale
rt e
ither
psy
chol
ogis
t/so
cial
wor
ker
�
Follo
w a
gita
ted
Patie
nt P
roto
col t
o de
term
ine
leve
l of
agita
tion
and
to p
resc
ribe
med
icat
ion
if ne
cess
ary
�
Con
tinue
med
ical
eva
luat
ion:
phy
sica
l/ne
uro
exam
, vita
l sig
ns, l
ab t
ests
�
use
Med
icat
ion
Car
d to
mon
itor
antip
sych
otic
si
de e
ffec
ts (
cons
ider
EK
g, fl
uids
)
�
Doc
umen
t in
agi
tate
d Pa
tient
For
m
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
�
rev
iew
initi
al M
enta
l hea
lth E
valu
atio
n
Form
with
psy
chol
ogis
t/sW
to
diag
nose
de
liriu
m/m
edic
al il
lnes
s or
men
tal d
isor
der
�
Do
com
plet
e m
edic
al e
valu
atio
n: v
ital s
igns
, ph
ysic
al/n
euro
exa
m, l
ab t
ests
. use
Med
ical
Ev
alua
tion
Prot
ocol
for
agi
tatio
n, D
eliri
um
and
Psyc
hosi
s
�
if p
atie
nt h
as a
psy
chot
ic d
isor
der
or d
eliri
um,
use
Med
icat
ion
Car
d to
dos
e
�
Do
base
line
aiM
s ex
am
�
Doc
umen
t ev
eryt
hing
in in
itial
Men
tal h
ealth
Ev
alua
tion
Form
�
Prov
ide
med
icat
ion
to la
st u
ntil
next
app
t
�
Do
psyc
hoed
ucat
ion
abou
t m
edic
atio
n
�
Plan
fol
low
-up
with
psy
chol
ogis
t/sW
FOll
Ow
-UP
�
rev
iew
the
Men
tal h
ealth
Fol
low
-up
Form
with
ps
ycho
logi
st/s
W t
o se
e if
patie
nt is
impr
ovin
g
�
Do
phys
ical
/neu
ro e
xam
�
Che
ck w
eigh
t/vi
tals
eac
h vi
sit;
lab
test
s an
d a
iMs
ever
y 6
mon
ths
�
use
Med
icat
ion
Car
d to
che
ck f
or s
ide
effe
cts
and
to a
djus
t do
se a
s ne
eded
�
Prov
ide
med
icat
ion
to la
st u
ntil
next
app
t
�
Dis
cuss
dis
cont
inua
tion
of a
ntip
sych
otic
with
M
enta
l hea
lth t
eam
�
Doc
umen
t pr
oper
ly in
Men
tal h
ealth
Fo
llow
-up
Form
�
Do
psyc
hoed
ucat
ion
abou
t m
edic
atio
n
�
Plan
fol
low
-up
with
psy
chol
ogis
t/sW
P
70 Partners In Health | FaCilitator Manual | Annex
1
me
DIC
Al
ev
Al
UA
TIO
N P
RO
TO
CO
lS
FO
R A
GIT
AT
ION
, D
el
IRIU
m A
ND
PS
yC
HO
SIS
SU
mm
AR
y
Pr
ot
oC
ol
iN
A C
liN
iC/H
os
Pit
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:
•V
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
•a
cute
ly p
aran
oid
•W
ringi
ng o
f ha
nds,
pac
ing,
tap
ping
han
d
•r
apid
spe
ech,
rai
sing
voi
ce
•Fr
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
71Partners In Health | FaCilitator Manual | Annex
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
72 Partners In Health | FaCilitator Manual | Annex
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)
73Partners In Health | FaCilitator Manual | Annex
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
74 Partners In Health | FaCilitator Manual | Annex
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
.
75Partners In Health | FaCilitator Manual | Annex
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
.
76 Partners In Health | FaCilitator Manual | Annex
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
77Partners In Health | FaCilitator Manual | Annex
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,
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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
78 Partners In Health | FaCilitator Manual | Annex
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
79Partners In Health | FaCilitator Manual | Annex
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
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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
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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?)
82 Partners In Health | FaCilitator Manual | Annex
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.
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