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

1. ASSESSMENT AND MANAGEMENT
OF A
VIOLENT PATIENT IN A GENERAL WARD
EMERGENCY PSYCHIATRY
Muhammad Redzwan
081303583
Group E2 Batch 25

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. ASSESSMENT

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. Environmental Factors
 Lack of structured activity
 Low staff-patient interaction
 Lack of privacy
 Overcrowding
 Poor physical facilities
 Availability of weapons

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. 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. 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. 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. MANAGEMENT

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. 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. 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. 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. Mechanical Restraint
 Not ethically acceptable. Used to prevent suicide and
serious injury

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. Example Drugs
PO/IM lorazepam 2-4 mg (for non-
psychotic patients)
IV diazepam 5-10 mg
IM haloperidol 5-10 mg ± IM lorazepam

19. 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.