3. 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.
4. Patient Factors
Young age (<40 years old)
Gender (Female > Male)
History of violence
Compulsive behavior
Diagnosis of schizophrenia
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. Crowds can exacerbate the sense of threat, so clear the scene of other people.
One person should take charge, with one or two colleagues or security staff in
support. family members may or may not be able or willing to help, and you may or
may not wish to ask them to leave as well.
Bear in mind that the patient may have urgent medical needs
Immediate physical separation may be needed if a patient is holding another
patient, a staff member or visitor.
Physical restraint of the patient may be required to prevent injury or harm, or to
enable the giving of parenteral medication or other medical treatment.
7. 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
8. 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
9. 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
10. Stress behaviours indicating increasing agitation
use of profanity and verbal outbursts
pacing or frequent alteration of body position or posture
Recognize aggression towards an individual aiming to create fear
Eye contact – direct / non-hostile
Personal space
Door position
Body language
Move chairs, hide scissors, remove lanyards etc
11. Levels of agitation
Mild: slightly agitated but still cooperative
Moderate: interrupts the flow of things and is oblivious to danger
Severe: excited delirium (combative, does not feel pain and are very strong)
12. Evaluation Space
1. Calm room, without noise and with natural lighting
2. Maintain a safe distance between your seating with the patient
3. The mental health personnel should be closer to the door/exit
4. No dangerous objects should be in the room, furniture should be grounded
5. Interview may be conducted in the presence of a family member or another health
personnel
6. Have means of restraint and sedation close by and accessible
7. Have other people (at least 5) available to restrain the patient if necessary
13. 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
16. 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”)
17. Ask the patient voluntarily moves out of the aggressive situation to a less
stimulating environment.
Engage positively with the patient, and observation must be done discreetly
19. Verbal Restraint
The first step is to try to control the patient’s behavior
Only one person should be talking to the patient
Maintain a professional attitude
Treat patient with respect (Ms, Mr)
Get relatively close, introduce yourself and offer help
Remove any distraction and speak directly to the patient
Transmit your intention to protect the patient
Transmit security and control of the situation but be firm
Do not show fear (ensure first that the area is secure)
Attend to patient’s immediate needs
20. 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 tranquillisation)
Deliberate use of pain can be used in exceptional circumstances
21.
22. Mechanical Restraint
Not ethically acceptable (but sometimes necessary)
Used to prevent escape, suicide and serious injury
Avoid it being to tight that it interrupts circulation
23. Used when…
risk of harm or flight
failed negotiations
usually combined with chemical restrain
secure large joints
documentation – regular review of need to continue restraints – neurovascular
observation
24. 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 of patient, you should have the opportunity to document your
account, and care plans updated if necessary.
25. Benzodiazepines
Midazolam - IM or IV - max effect 10 min, lasts 2 hrs
Diazepam - PO or IV; erratic absorption IM - painful when administered IV - longer
acting than midazolam, Lorazepam - only available as PO
Complications
Oversedation
Hypotension
Airway or ventilatory compromise
Paradoxical reactions
Delirium Tolerance
26. Neuroleptics
Haloperidol - IM or IV - 2.5 – 10 mg (100mg max dose) c/30-45mins
Olanzapine – 10mg IM or SL or PO - max 30 mg / 24 hrs
Risperidone – 2-9 mg PO/SL - works well in elderly - orthostatic hypotension
Common Complications:
Over-sedation
Hypotension
Acute dystonia
Anticholinergic delirium
(Seizures)
(QT prolongation)
27. Benzodiazepines:
Lorazepam 1-6mg IM/PO 10mg max dose
Diazepam 5-10mg IM/PO/IV repeat dose c/30 mins 40mg max dose
Midazolam 2.5-15mg IM/IV 20mg max dose
When given IM they may have erratic absorption
Elderly patient may become more agitated
Respiratory depression
Hypotension (falls, accidents)
28. Post sedation care
BP checked 5 minutely for 20 minutes post each sedation dose, then half hourly –
Bladder care
bladder scans every 3-4 hrs if they do not void OR postvoid
IDC should be inserted when bladder volume is > 400 mls
BSL checked 2 hourly if ≥ 4 mmol/L, or hourly if it is < 4 mmol/L (Rx if < 3.5
mmol/L)
Pressure care
turn every 2 hours to prevent pressure areas
Temperature control
29. What do you do after physically restraining
a patient?
American Joint Commission on Accreditation of Hospital Organizations
1. Protection and preservation of patient rights, dignity, and well-being (Use based
on patient’s assessed needs )
2. Use of least restrictive method
3. Safe application and removal by competent staff
4. Monitoring and reassessment of the patient during use
5. Meeting of patient needs during use
6. Time limitation of orders that are provided by licensed practitioners
7. Documentation in the medical record
30. Don’t….
Assume aggression has a psychiatric cause
Restrain patient without treating
Isolate patient without observation
Use unnecessary physical force to restrain patient (hitting in the head, neck and
chest)
