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Evaluating Psychiatric Patients Risk Of Violence

By: Abbas El Subai Medical University of Lodz

Objectives
Recognize the importance of symptom management for psychiatric patients Gain understanding of psychiatric diagnoses and associated symptoms Identify patients at high risk for suicidality or agression Learn specific strategies for dealing with a variety of behavioral issues Identify characteristics of special populations

The Importance Of Symptom Management


Anxiety drives many problematic behavioral symptoms Anxiety AgitationAggression Symptom management reduces anxiety, acting out, need for restraints and enhances cooperation of patient and family Avoid the attitudes and behaviors that increase patient anxiety and frustration dont REACT:
R: restrict E: escalate A: avoid C: coerce T: threaten

The Importance of Symptom Management cont


Anticipation of symptoms based on diagnosis and initial nursing assessment of patient Prevention of symptoms by use of early intervention, building trust, conveying nonjudgmental attitude, establishing therapeutic rapport and alliance with patient Management of symptoms saves time, energy and resources; reduces chaos, noise; improves patient outcomes and satisfaction Goal is to keep patients and staff safe by enlisting cooperation of pt. to stay in control

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Common Psychiatric Disorders


Borderline Personality Disorder Bipolar Disorder (Manic Depression) Psychosis/Schizophrenia Depression (Major Depressive Disorder) Anxiety Disorders
**Symptoms can range from mild to severe.

Psychotic Patients Risk For Violence.

Persecutory delusions
command auditory hallucinations

1. Who or what do you believe wants to harm you? 2. How is this person attempting to harm you? (Ask about specific threat/control-override beliefs)

Evaluating persecutory delusions

3. How certain are you that this is happening? 4. Is there anything that could convince you that this isnt true? 5. How does your belief make you feel (eg, unhappy, frightened, anxious, or angry)?

6. Have you thought about any actions to take as a result of these beliefs? If so, what? 7. Have you taken any action as a result of your beliefs? If so, what specific actions? 8. Has your concern about being harmed stopped you from doing any action that you would normally do? Have you changed your routine in any way? 9. How much time do you spend thinking about this each day? 10. In what ways have these beliefs impacted your life?

Evaluating persecutory delusions cont

Evaluating command auditory hallucinations


1. What are the voices telling you to do? 2. Do you have any thoughts or beliefs that are associated with what you are hearing? If so, what are they? 3. Do you know the voices identity? If so, who is it? 4. How convinced are you that these voices are real? 5. Are these voices wishing you well or do you think that they wish you harm?

Evaluating command auditory hallucinations cont


6. Have you done anything to help make the voices go away? If so, what? 7. Do you feel you have control of the voices or do you feel they control you? 8. Do you believe the voice is powerful? 9. How do the voices make you feel? 10. Have you ever done what the voice has told you to do? If so, describe what you did.

Specific Strategies:

o AVOID POWER STRUGGLES! o Give choices as often as possible; clear, reasonable limits o Dont react emotionally to behaviors, know your own buttons o No punitive treatments, threats, ultimatums or excessive restrictions-they will give the patient a reason to escalate

o Spend time (if you can) talking with the patient to find out what they need and want; try to accommodate them if you are able (explain why if you cant) o Be aware of non-verbal communication o Explain the process involved, try to decrease anxiety as much as possible o Check back with the patient often o Expedite process of evaluation

o Low stimulus, keep directions/statements short and simple (may have to repeat them) o Dont argue with the pt.; say youre right as much as possible in order to make it easier to set limits when necessary o Medicate early for agitation, get a reliable sitter o New onset mania needs medical workup and probably hospitalization o Assume patient will be unpredictable and plan for it o Check medication levels

o Approach slowly, using non-threatening body language o Dont feed into delusions, but dont directly contradict them either e.g. That sounds very frightening. o Ask about voices, what they are saying, how the patient feels about them (some are friendly voices) o Assess cognitive functioning to determine level of disorganization

o If the patient is there due to safety issues, ask what would be helpful to them to feel safe o Low stimulus, medicate for agitation, consider medical etiology if new symptoms o New onset? Plan for hospitalization and family education

o Ask what they need from ER visit, explain options e.g. connect with services o Assess extent of depression to avoid excessive restrictions o Be kind, explain what is happening; give reassurance that you want to help them. o Specifically ask what would be most helpful to them

o Offer food, warmth, comfort; may need to ask more than once o Ask about stressors, supports, therapists, allow family/friends if patient wants them o Ask about (vague thoughts vs. plan with intent, can help pinpoint how far the depression has progressed)

o Recognize, treat the physical symptoms as real o Assess the patients understanding of what is happening o Offer reassurance e.g. I know you are frightened but we are going to take care of you.

o Needle phobias, hyperventilation o Ask what has worked for them in the past when dealing with their anxiety o Family/friends involvement o Humor, distraction are helpful with mildmoderate anxiety

o Listen in a nonjudgmental way, avoid offering advice o Check with patient before allowing visitors, phone calls o Safety contract o Explain to pt. what the process involved in formal assessment

Summary
Both patients and staff benefit when we: Understand psychiatric diagnoses Anticipate, manage and prevent symptoms Avoid punitive, controlling strategies Increase cooperation by establishing a therapeutic rapport and alliance

And finally
References: 1. Gilbert, Sara Barr. Psychiatric Crash Cart: Treatment Strategies for the Emergency Department. Advanced Emergency Nursing Journal. 31(4):298-308, October/December 2009. 2. Stefan, Susan, Emergency Department Treatment of the Psychiatric Patient: Policy Issues and Legal Requirements, Oxford University Press, 2006. 3. National Alliance for Mental Health, www.nami.org 4. Psychiatric Services, www.psychservices.psychiatryonline.org 5. Help Guide, www.helpguide.org/mental

Many Thanks