ASSESSMENT AND MANAGEMENT of a VIOLENT PATIENT in a GENERAL WARD

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ASSESSMENT AND MANAGEMENT of a VIOLENT PATIENT in a GENERAL WARD. Emergency Psychiatry.

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ASSESSMENT AND MANAGEMENT of a VIOLENT PATIENT in a GENERAL WARD

  1. 1. ASSESSMENT AND MANAGEMENT OF A VIOLENT PATIENT IN A GENERAL WARD EMERGENCY PSYCHIATRY Muhammad Redzwan 081303583 Group E2 Batch 25
  2. 2. INTRODUCTION  Disturbed/violent behavior can never be predicted with complete accuracy and accurate prediction is not the aim of risk assessment.  Structured, evidenced based and comprehensive risk assessment that takes into account the patient’s history and circumstances will assist in formulating clinical management strategies.  Majority of the patient is not violent.
  3. 3. ASSESSMENT
  4. 4. Patient Factors  Young age (<40 years old)  Gender (Female > Male)  History of violence  Compulsory admission  Diagnosis of schizophrenia  Acute phase  History of substance abuse
  5. 5. Environmental Factors  Lack of structured activity  Low staff-patient interaction  Lack of privacy  Overcrowding  Poor physical facilities  Availability of weapons
  6. 6. Staff Factors  Young age  Low level of experience  Inadequate training in professional mental health  Gender (male staff for male patient & vice versa)  Involvement in restraining and managing the violent patient
  7. 7. Clinical Assessment  Facial expressions tense and angry  Increased or prolonged restlessness, body tension, pacing  General over-arousal of body systems (increased breathing and heart rate, muscle  twitching, dilating pupils  Increased volume of speech, erratic movements  Prolonged eye contact  Discontentment, refusal to communicate, withdrawal, fear, irritation
  8. 8. Clinical Assessment (cont.)  Thought processes unclear, poor concentration  Delusions or hallucinations with violent content  Verbal threats or gestures  Replicating, or behaviour similar to that, which preceded earlier disturbed/violent episodes  Reporting anger or violent feelings  Blocking escape routes
  9. 9. PREVENTION  pleasant environment in which there is no overcrowding  predictable ward routine  good range of meaningful activities  well-defined staffing roles  good staffing levels  privacy and dignity without compromising observation of the ward
  10. 10. MANAGEMENT
  11. 11. NON-COERCIVE METHODS De-escalation (talking down)  Acknowledge the confrontation (“Your words are threatening and causing me fear”)  Interpret the confrontation (“Your words are pushing people away”)  Express our reaction to the confrontation (“I can’t help you if you are acting like this”)  Advise (“Police is routinely called in these situations”)
  12. 12. Time out  Ask the patient voluntarily moves out of the aggressive situation to a less stimulating environment. Observation  Engage positively with the patient, and observation must be done discreetly.
  13. 13. RESTRAINT Geographical Restraint  moving the patient to a quieter place  a more secure ward or seclusion  increase the risk of suicide  for patients medicated before being moved, the risks associated with rapid tranquillisation
  14. 14. Physical Restraint  Done by trained staff  Avoid pressure to neck, thorax, abdomen, back and pelvic area  Prop prone patients up so they can breathe more easily  Make one team member responsible for ensuring that airway and breathing are not compromised  Restrain patients for the shortest period possible (this will depend on access to alternatives such as seclusion and ranquillisation)  Deliberate use of pain can be used in exceptional circumstances
  15. 15. Mechanical Restraint  Not ethically acceptable. Used to prevent suicide and serious injury
  16. 16. Chemical Restraint  The specific properties or risks of the individual drugs should be taken into consideration.  Oral medication should be offered first before parenteral medication.  The dignity of the patients must be respected during sedation, and the reasons for using medications explained as much as possible.  Staff must be trained for basic resuscitation. A crash cart must be available and a doctor available to attend an alert by staff.  Following sedation patients should have the opportunity to document their account, and their care plans updated if necessary.
  17. 17. Example Drugs PO/IM lorazepam 2-4 mg (for non- psychotic patients) IV diazepam 5-10 mg IM haloperidol 5-10 mg ± IM lorazepam
  18. 18. References 1. Buchanan A., Binder R., Norko M., Swartz M.2012.’Psychiatric Violence Risk Assessment’. Am J Psychiatry 2012;169:340-340. 2. ‘Guideline: The Management of Disturbed/Violent Behavior in Inpatient Psychiatric Setting’.2005.Department of Health Gov Western Australia. 3. ‘Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency department’.2005.National Institute of Health and Clinical Excellence.Royal College of Nursing.

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