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