Define psychiatric emergency.  To distinguish between major and minor

To discuss how to do an emergency psychiatric

 Discuss the general factors that may cause an

alteration in a patient’s behavior.
Discuss the special considerations for assessing

a patient with behavioral problems.

To discuss some basic interventional skills in

dealing with aggressive behaviors , including the dos and don’ts in a video form. To discuss proper technique in restraining patient. Video demonstration of self defense in a ward setting.

. and significant. presence of delusions. thought or mood of a patient which if untreated may lead to harm. Conditions requiring psychiatric interventions may include attempted suicide. acute depression. rapid changes in behavior. alcohol intoxication. violence. panic attacks. substance dependence. either to the individual or to others in the environment.Psychiatric emergency is an acute disturbance of behavior.

Grief Panic attacks Disaster Rape .Major Psychiatric Emergency Threat to life: • Suicidal patients •Agitated and violent patients Minor Psychiatric Emergency Severely distressing but not a threat to life.

Patients maybe highly motivated to reveal themselves or to conceal innermost feelings. Supplemental history must be obtained. . Focus on the presenting complaint. imposed by the potential sense of urgency in assessing the risk to the patient or others.Similar to standard psychiatric interview except for the time limitation.

observation and interpretation. calm and nonthreatening is very important. Being straightforward. .Large a portion of the interview involves specific and sophisticated techniques of listening. The greatest potential error is overlooking a physical illness. honest.

. Give yourself and the patient equal access to the door. or things that can be thrown.Look for potential weapons such as ball pen. Look for objects that the patient could use for self harm.

When you do a physical exam and you invade their space they may react defensively. .The comfort zone for most people is hand shaking distance. The comfort zone for paranoid or agitated patients may be 2-3 X the usual distance. Remember the patients history when you are in their personal space.

Substance dependence or abuse carries a 30X increase risk than the general population!! . Circumstances of violence and characteristics of people involved are important.Immediate past. recent past and more distant history of violence is the best predictor of future violence.

High level of aggression before admission and absence of sign of anxiety at admission are believe to be good predictors of violence.  Poor impulse control or strong aggressive drive may also be significant in predicting patient assaultiveness. .Mental illness carries a 9X greater risk than the general population particularly paranoid schizophrenia and confused states related to medical problems.

clenching. pacing.Angry words Loud and pressured speech Abuse language suspiciousness Physical agitation such as making fists. Inability to sit still .

 Verbal cues such as. imagined objects. . intrusive demands for attention Movement away from the nurse. Pounding fists Tightening of the jaw or facial muscles Posture may be threatening.

Inflict serious harm requiring medical care Inflict low-grade harm requiring no medical care Made verbal threat w/ plan to inflict harm Touch another in a threatening way Made a verbal threat w/o plan to inflict harm Approached another in threatening way Was loud and demanding Exhibit low-grade hostility .


Sample Video of Aggressive/Violent Behavior .

Two types of Intervention  Environmental Strategies  Behavioral Strategies .

either visually or aurally. The treatment setting should be structured by unit rules so that levels of sensory stimulation are low to moderate.Environmental Strategies – Violent behavior is more likely to occur in a poorly structured milieu. . may also increase aggressive behavior. Units that are overstimulating.

and air quality should not be over stimulating. temperature. stereos. lighting. . wall colors.Television.

what is not acceptable. Clear. firm. and nonpunitive enforcement of limits is the goal.•Limit Setting – is a nonpunitive. nonmanipulative act in which the patient is told what behavior is acceptable. . and the consequences of behaving unacceptably.

•Behavioral Contracts .

Attempt to establish rapport Listen to the patients concerns No quick movements . Use calm and reassuring tone Sit down with the patient Maintain adequate physical distance of at least 6 feet.Identify yourself and your role. Show you are listening to the patient by rephrasing back parts of what s/he says.

calm and relaxed posture Use non threatening body language exp. Crossing the arms across the chest. Never threaten. challenge. argue .Respond honestly. Hands should be kept open and out of pockets The nurse’s eye should be at the level of the patient. belittle.

. Always remain at an angle when facing the patient Be alert for changes in the patient’s emotional status. stay about 3` away. Do not enter the patient’s space.Always tell the truth Do NOT “play along” with hallucinations.

non-competitive tasks Disperse crowds that have gathered .Involve trusted family. friends Be prepared to spend time NEVER leave patient alone Avoid using restraints if possible Do NOT force patient to make decisions Encourage patient to perform simple.

When there is risk of imminent harm and verbal de-escalation has been ineffective either pharmacologic supports or physical restraints may be needed. .

Restraining patient A patient may be restrained if you have good reason to believe he is a danger to: You Himself Other people .

. fastened to bed frame to curtail the client’s physical aggression. to restraint his or her freedom of movement. HUMAN RESTRAINT – staff member physically control the client and move him or her to a seclusion room. without his or her permission.RESTRAINT – direct application of physical force to a person . MECHANICAL RESTRAINT – devices usually ankle and restraint .

A physician’s order is required within 1 hour. Members must receive special training and demonstrate competency in restraining patient. himself or to others. Although nurses might be allowed to implement restraint in emergent situation. . Staff members have duty under the common law to restrain a patient when they feel that such immediate action is necessary to prevent serious bodily harm to the patient.

inhumane or degrading treatment. .As needed (PRN) orders are not permitted. Never use restraints as a punishment or a cruel. Each episode must be based on eminent risk. Staff should assess the mental and physical condition to determine the least restraint necessary to use.

with documentation of safety and comfort. Personal care needs include fluids.Restraint should be reevaluate every 2 hours. exercise. . access to hygiene activities. intervention at least every 15 minutes. limb massage. Patient must be observed constantly during restraint. meals. clothing and rotation of restraint. Document intervention during restraint.

•Try to talk the patient into lying on the stretcher .•Have restraints. stretcher and restraint keys ready •Use a show of force with 5 or more trained staff who may need to physically lay hands on the patient. Sometimes gathering that many clinicians will persuade the patient to comply.

•Remember people can bite and spit so one of the team will control the head during the restraining procedure •A minimum of two points ( one arm and one leg) .•If the patient will not comply the team will put the patient in restraints.

knives. ect.•Search the patient for potentially harmful objects such as lighters. . •Perform a brief survey for any physical injuries to the patient including head injury and observe movement in all 4 limbs.

Restraining patient by Dr. Hermino .

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