Agitation

Agitation: Excerpt from Nursing: Interpreting Signs and Symptoms

Agitation refers to a state of hyperarousal, increased tension, and irritability that can lead to confusion, hyperactivity, and overt hostility. It can result from a toxic (poisons), metabolic, or infectious cause; brain injury; or a psychiatric disorder. Agitation can also result from pain, fever, anxiety, drug use and withdrawal, hypersensitivity reactions, and various disorders. It can arise gradually or suddenly and last for minutes or months. Whether it's mild or severe, agitation worsens with increased fever, pain, stress, or external stimuli.

Agitation alone merely signals a change in the patient's condition; however, it's a useful indicator of a developing disorder. Obtaining a good history is critical to determining the underlying cause of agitation.

History and physical examination

Determine the severity of the patient's agitation by examining the number and quality of agitation-induced behaviors, such as emotional lability, confusion, memory loss, hyperactivity, and hostility. Obtain a history from the patient or a family member, including diet, known allergies, and all medications, including the use of herbal medicine. Also ask the patient about substance abuse.

Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Observe the patient for signs of substance abuse, such as needle tracks, dilated pupils, jaundiced skin, or abdominal ascites. Ask him about alcohol intake. Obtain the patient's baseline vital signs and neurologic status for future comparison.

Medical causes

Alcohol withdrawal syndrome.Mild to severe agitation occurs in alcohol withdrawal syndrome, along with hyperactivity, tremors, and anxiety. With delirium, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and a depressed mood. The patient's pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac exhaustion, and shock can occur.

Anxiety.Anxiety produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.

Dementia.Mild to severe agitation can result from many common syndromes, such as Alzheimer's and Huntington's diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.

Drug withdrawal syndrome.Mild to severe agitation occurs in drug withdrawal syndrome. Related findings vary with the drug, but include anxiety, abdominal cramps, diaphoresis, and anorexia. With opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.

Hepatic encephalopathy.Agitation occurs only with fulminating hepatic encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.

Hypersensitivity reaction.Moderate to severe agitation appears, possibly as the first sign of a reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.

With anaphylactic shock,a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.

Hypoxemia.Beginning as restlessness, agitation rapidly worsens. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.

Increased intracranial pressure (ICP).Agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; a decreased LOC; seizures; and motor changes such as decerebrate or decorticate posture.

Post-head trauma syndrome.Shortly after, or even years after a head injury, mild to severe agitation may develop, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.

Vitamin B₆ deficiency.Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.

Other causes

Drugs.Mild to moderate agitation, which is commonly dose related, develops as an adverse reaction to central nervous system stimulants—especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics, such as ephedrine; caffeine; and theophylline.

Radiographic contrast media.Reaction to the contrast medium injected during various diagnostic tests produces moderate to severe agitation along with other signs of hypersensitivity.

Nursing considerations

▪ Because agitation can be an early sign of many different disorders, monitor the patient's vital signs and neurologic status while the cause is being determined.

▪ Eliminate stressors, which can increase agitation.

▪ Provide adequate lighting, maintain a calm environment, and allow the patient ample time to sleep.

▪ Ensure a balanced diet, and provide vitamin supplements and hydration.

▪ Remain calm, nonjudgmental, and nonargumentative.

▪ Avoid using restraints, unless absolutely necessary, because they tend to increase agitation.

▪ If appropriate, prepare the patient for diagnostic tests, such as a computed tomography scan, skull X-rays, magnetic resonance imaging, and blood studies.

Patient teaching

▪ Orient the patient to the unit and its procedures and routines.

▪ Explain stress-reduction measures.

▪ Offer reassurance and emotional support.

▪ Explain all tests and procedures, the underlying cause, and treatment plan.

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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