Professional Documents
Culture Documents
Medicolegal Considerations
• When behavior, speech, and thoughts are erratic,
it can be difficult to communicate.
− Spend time with the patient.
− Obtain consent when possible.
− Be clear in your explanations
Causes of Abnormal Behavior
• Four broad categories
− Biologic or organic in nature
− Resulting from the environment
− Resulting from acute injury or illness symptoms
− Substance-related
• Biologic or organic
− Organic brain syndrome Patient Assessment
− Conditions alter the functioning of the • Assessment of the patient with a behavioral
brain emergency differs from other methods.
• Environmental − You are the diagnostic instrument.
− Psychosocial and sociocultural influences − The assessment is part of the treatment.
• When consistently exposed to stressful Scene Size-Up
events patients develop abnormal reactions. • Situations with a strong behavioral component
• Sociological factors affect biology, may have a sudden and unexpected turn of events.
− Determine whether it is dangerous to you − Stay alert to potential danger.
and your partner. • Airway and breathing
• The environment can give clues. − Assess the airway and evaluate breathing.
− Social history − Provide interventions based on your
− Living conditions findings.
− Availability of support • Circulation
− Activity level − Assess the pulse rate, quality, and
− Medications rhythm. − Obtain systolic and diastolic blood
− Overall appearance pressures.
− Attitude/well-being − Evaluate for shock and bleeding.
− Assess the patient’s perfusion level.
• Transport decision
− Disturbed patients should see a physician.
− If a patient withholds consent, they may
be taken against their will at the request of:
• Police
• Community mental health
physician
History Taking
• Mental status examination
− Key part of assessment
− Check each system using COASTMAP.
COASTMAP
• Consciousness
− Level
− Concentration
• Orientation
− Year/month
− Location
• Activity
− Behavior
− Movement
Primary Assessment
• Speech
• Clearly identify yourself.
− Rate, volume, flow, articulation, and
• Form a general impression.
intonation
− Assess appearance, posture, and pupils.
• Thought
− Limit the number of people around the
− Is the patient making sense?
patient.
• Memory
− Recent Crisis Intervention Skills
− Remote • Be as calm and direct as possible.
− Immediate • Exclude disruptive people.
• Affect and mood • Sit down.
− Do the inner feelings seem appropriate? − Preferably at a 45-degree angle
• Perception • Encourage some motor activity.
− “Do you hear things others can’t?” • Stay with the patient at all times.
Secondary Assessment • Bring all medications to the hospital.
• Obtain vital signs. • Never assume that it is impossible to talk with any
• Examine skin temperature and moisture. patient until you have tried.
• Inspect the head and pupils. Physical Restraint
• Note unusual odors on the breath. • Improvised or commercially made devices
• In examining the extremities, check for: • Be familiar with restraints used by your agency.
− Needle tracks • Make sure you have sufficient personnel.
− Tremors − Minimum of four trained, able-bodied
− Unilateral weakness or loss of sensation people
Reassessment • Discuss the plan of action before you begin.
• Routinely performed during transport − Include law enforcement.
• Your radio report should include: − Use the minimum force necessary.
− Medical and mental health history − Don’t immediately move toward the
− Medications prescribed patient.
− Assessment findings • If the show of force doesn’t calm the patient, move
− Information from the mental status quickly.
examination − Grasp at the elbows, knees, and head.
• Discuss with the hospital the need for restraints or − Apply restraints to all four extremities.
medications. − The best position is supine.
− If the patient is aggressive or violent, • Never:
provide advance notice to the emergency − Tie ankles and wrists together
department. − Hobble tie
Emergency Medical Care − Place a patient facedown in a Reeves
• If the erratic behavior could be caused by a stretcher
medical disorder: • Once in place:
− Treat that before presuming the behavior − Don’t remove restraints.
is due to an emotional or psychiatric cause. − Don’t negotiate or make deals.
Communication Techniques − Place a mask over the face of a spitting
• Begin with an open-ended question. patient.
• Let the patient talk. • Continuously monitor the patient.
• Listen, and show that you are listening • Never place your patient face down.
• Check peripheral circulation every few minutes. • Perception − Auditory hallucinations
• Be careful if a combative patient suddenly
becomes calm. • Management
• Document everything in the patient’s chart. − Reasoning doesn’t always work. –
• You may defend yourself against an attack. Explain what is being done.
Chemical Restraint − Directions should be simple and
• Use of medication to subdue a patient consistent.
− Only use with approval from medical − Keep orienting the patient.
control − Before pharmacologic treatments, try:
− Follow local protocols and guidelines. • Maintaining an emotional distance
• Closely monitor the patient’s: • Explaining each step of the
− Pulse rate assessment
− Blood pressure • Involving people, the patient trusts
− Respiratory rate − When methods fail, it may be appropriate
• Be prepared to support ventilation. to:
Acute Psychosis • Safely restrain the patient.
• Pathophysiology • Administer a medication to help the
− Person is out of touch with reality behavior.
− Occur for many reasons Agitated Delirium
− Episodes can be brief or last a lifetime. • Pathophysiology
• Assessment − Delirium: a state of global cognitive
− Characteristic: profound thought disorder impairment
− A thorough examination is rarely possible. − Dementia: more chronic process
− Transport the patient in an atraumatic − Patients may become agitated and
fashion. violent.
− Use COASTMAP. • Assessment
• Consciousness − Try to reorient patients.
− Awake and alert − Perform a thorough assessment.
− Easily distracted • Management
• Orientation − Disturbances more common in − Identify the stressor or metabolic problem.
organic disorders Suicidal Ideation
• Activity − Most commonly accelerated • Pathophysiology
• Speech − Neologisms
• Thought − Disturbed in progression and content
• Memory − Relatively or entirely intact
• Affect and mood
− Mood is likely to be disturbed.
− Affect may reflect mood or be flat.
− Suicide: any willful act designed to end
one’s life
• Assessment
− Every depressed patient must be
evaluated for suicide risk.
− Most patients are relieved when the topic
is brought up.
− Broach the subject in a stepwise fashion.
− Higher-risk patients include patients who
have:
• Made previous attempts
• Detailed, concrete plans
• A history of suicide among close
relatives
• Management
− Don’t leave the patient alone.
− Collect implements of self-destruction.
− Acknowledge the patient’s feelings.
− Encourage transport