Agitation
Agitation refers to a state of hyperarousal, increased tension, and irritability that can lead to confusion, hyperactivity, and overt hostility. Agitation can result from a toxic (poisons), metabolic, or infectious cause; brain injury; or a psychiatric disorder. It 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.
History
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 and known allergies.
Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Ask the patient about prescribed or over-the-counter drug use, including supplements and herbal medicines. Ask about alcohol intake.
Physical assessment
Perform a complete physical examination. Check for signs of drug abuse, such as needle tracks and dilated pupils. Obtain baseline vital signs and neurologic status for future comparison.
Medical causes
Affectivedisturbance
Agitation may occur in depressed and manic phases of affectivedisturbance and in personality disorders, such as borderline and antisocial personality disorders. In its depressive form, chronic anxiety occurs with varying severity. The hallmark is depressed mood upon awakening, which eases during the day. Psychomotor agitation may be characterized by an inability to sit still, hand-wringing, pacing, and irritability. Other findings in manic states may include decreased sleep, pressured speech, and grandiosity.
Alcohol withdrawal syndrome
With alcohol withdrawal syndrome, mild to severe agitation occurs. It may be accompanied by hyperactivity, tremors, and anxiety. With delirium tremens, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and depressed mood. 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.
Chronic renal failure
Moderate to severe agitation occurs with chronic renal failure, marked especially by confusion and memory loss. The agitation is accompanied by diverse signs and symptoms, such as nausea, vomiting, anorexia, mouth ulcers, ammonia breath odor, GI bleeding, pallor, edema, dry skin, and uremic frost.
Dementia
Mild to severe agitation related to dementia 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
In drug withdrawal syndrome, mild to severe agitation occurs. Related findings vary with the drug but include anxiety, abdominal cramps, diaphoresis, and anorexia. With narcotic 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 with fulminating hepatic encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus (musty, sweet breath odor), asterixis, and hyperreflexia. Lethargy, aberrant behavior, and apraxia may also occur.
Hypersensitivity reaction
Moderate to severe agitation may be the first sign of a hypersensitivity 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, skin that’s warm and moist, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.
Hypoxemia
Beginning as restlessness, agitation rapidly worsens with hypoxemia. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.
Increased intracranial pressure
With increased intracranial pressure (ICP), agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; decreased LOC; seizures; and motor changes, such as decerebrate or decorticate posture.
Organic brain syndrome
With organic brain syndrome, agitation is manifested as hyperactivity, emotional lability, confusion, and memory loss. Slurred or incoherent speech and paranoid behavior may also occur.
Post–head trauma syndrome
Shortly after — or even years after — head trauma, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.
Vitamin B6 deficiency
With 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.
Special considerations
Because agitation can be an early sign of many different disorders, continue to 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. Use restraints sparingly because they tend to increase agitation. If appropriate, prepare the patient for diagnostic tests, such as computed tomography scanning, skull X-rays, magnetic resonance imaging, and blood studies.
Pediatric pointers
A common sign in children, agitation accompanies the expected childhood diseases as well as more severe disorders that can lead to brain damage: hyperbilirubinemia, phenylketonuria, vitamin A deficiency, hepatitis, frontal lobe syndrome, increased ICP, and lead poisoning. In neonates, agitation can stem from alcohol or drug withdrawal if the mother abused these substances.
When evaluating an agitated child, remember to use words that he can understand and to look for nonverbal clues. For instance, if you suspect that pain is causing agitation, ask him to tell you where it hurts, but be sure to watch for other indicators, such as wincing, crying, or moving away.
Geriatric pointers
Any deviation from an older person’s usual activities or rituals may provoke anxiety or agitation. Any environmental change, such as a transfer to a nursing home or a visit from a stranger in the patient’s home, may trigger a need for treatment.
Patient counseling
Orient the patient with agitation to the unit and its procedures and routines. Provide reassurance and emotional support. Explain the need to reduce stressors and maintain a quiet environment.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Hyperactivity
Read excerpts from these other book chapters related to Hyperactivity:
Medical Books Excerpts
- Agitation
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Agitation
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Agitation
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Agitation
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Hyperactivity
» Next page: Deep tendon reflexes, hyperactive (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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