Evaluating Psychiatric Patients’ Risk Of Violence

7/27/2019 Evaluating Psychiatric Patients Risk Of Violence

1/26

Evaluating Psychiatric

Patients Risk Of ViolenceBy: Abbas El Subai

Medical University of Lodz


2/26

ObjectivesRecognize the importance of symptom

management for psychiatric patients

Gain understanding of psychiatric diagnoses andassociated symptoms

Identify patients at high risk for suicidality oragression

Learn specific strategies for dealing with avariety of behavioral issues

Identify characteristics ofspecialpopulations


3/26

The Importance Of SymptomManagement Anxiety drives many problematic behavioral symptoms AnxietyAgitationAggression 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: restrictE: escalateA: avoid

C: coerceT: threaten


4/26

The Importance of Symptom Managementcont Anticipation of symptoms based on diagnosis and

initial nursing assessment of patientPrevention of symptoms by use of early intervention,

building trust, conveying nonjudgmental attitude,establishing therapeutic rapport and alliance withpatient

Management of symptoms saves time, energy and

resources; reduces chaos, noise; improves patientoutcomes and satisfactionGoal is to keep patients and staff safe by enlisting

cooperation of pt. to stay in control


5/26

Whats your problem?


6/26

Common Psychiatric DisordersBorderline Personality Disorder

Bipolar Disorder (Manic Depression)Psychosis/SchizophreniaDepression (Major Depressive

Disorder)Anxiety Disorders

**Symptoms can range from mild to severe.


7/26

Psychotic

PatientsRisk For

Violence.


8/26

Persecutory delusions

command auditory

hallucinations


9/26

Evaluating persecutory delusions1. Who or what do you believe wants to harm you?

2. How is this person attempting to harm you? (Askabout specific threat/control-override beliefs)

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)?


10/26

Evaluating persecutory delusionscont 6. Have you thought about any actions to take asa 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 harmedstopped you from doing any action that youwould normally do? Have you changed yourroutine in any way?

9. How much time do you spend thinking aboutthis each day?

10. In what ways have these beliefs impacted

your life?


11/26

Evaluating command auditoryhallucinations

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 isit?

4. How convinced are you that these voices arereal?

5. Are these voices wishing you well or do youthink that they wish you harm?


12/26

Evaluating command auditoryhallucinations cont6. Have you done anything to help make the

voices go away? If so, what?

7. Do you feel you have control of the voices ordo 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 toldyou to do? If so, describe what you did.


13/26

SpecificStrategies:


14/26

o AVOID POWER STRUGGLES!

o Give choices as often as possible; clear,

reasonable limitso Dont react emotionally to behaviors, know

your own buttons

o No punitive treatments, threats, ultimatums orexcessive restrictions-they will give thepatient a reason to escalate


15/26

o Spend time (if you can) talking with thepatient 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 possibleo Check back with the patient often

o Expedite process of evaluation


16/26

o Low stimulus, keep directions/statements short and

simple (may have to repeat them)o Dont argue with the pt.; sayyoureright as much as

possible in order to make it easier to set limits whennecessary

o Medicate early for agitation, get a reliable sittero New onset mania needs medical workup and probably

hospitalizationo Assume patient will be unpredictable and plan for ito Check medication levels


17/26

o Approach slowly, using non-threatening body

languageo

Dont feed into delusions, but dont directlycontradict them either e.g. That sounds veryfrightening.

o Ask about voices, what they are saying, how the

patient feels about them (some are friendlyvoices)o Assess cognitive functioning to determine level of

disorganization


18/26

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, considermedical etiology if new symptoms

o New onset? Plan for hospitalization andfamily education


19/26

o Ask what they need from ER visit, explain

options e.g. connect with services

o Assess extent of depression to avoid excessiverestrictions

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


20/26

o Offer food, warmth, comfort; may need to ask

more than once

o Ask about stressors, supports, therapists, allowfamily/friends if patient wants them

o Ask about (vague thoughts vs. plan withintent, can help pinpoint how far thedepression has progressed)


21/26

o Recognize, treat the physical symptoms as real

o

Assess the patients understanding of what ishappening

o Offer reassurance e.g. I know you arefrightened but we are going to take care ofyou.


22/26

o Needle phobias, hyperventilation

o

Ask what has worked for them in the pastwhen dealing with their anxiety

o Family/friends involvement

o

Humor, distraction are helpful with mild-moderate anxiety


23/26

o Listen in a nonjudgmental way, avoid offeringadvice

o Check with patient before allowing visitors,phone calls

o Safety contract

o Explain to pt. what the process involved informal assessment


24/26

SummaryBoth patients and staff benefit when we:

Understand psychiatric diagnosesAnticipate, manage and prevent symptoms

Avoid punitive, controlling strategies

Increase cooperation by establishing atherapeutic rapport and alliance


25/26

And finally References:1. Gilbert, Sara Barr. Psychiatric Crash Cart: Treatment

Strategies for the Emergency Department. AdvancedEmergency Nursing Journal. 31(4):298-308,

October/December 2009.2. Stefan, Susan, Emergency Department Treatment of

the Psychiatric Patient: Policy Issues and LegalRequirements, Oxford University Press, 2006.

3. National Alliance for Mental Health, www.nami.org4. Psychiatric Services,www.psychservices.psychiatryonline.org

5. Help Guide, www.helpguide.org/mental
http://www.nami.org/http://www.psychservices.psychiatryonline.org/http://www.psychservices.psychiatryonline.org/http://www.helpguide.org/mentalhttp://www.helpguide.org/mentalhttp://www.helpguide.org/mentalhttp://www.helpguide.org/mentalhttp://www.helpguide.org/mentalhttp://www.helpguide.org/mentalhttp://www.psychservices.psychiatryonline.org/http://www.psychservices.psychiatryonline.org/http://www.psychservices.psychiatryonline.org/http://www.psychservices.psychiatryonline.org/http://www.psychservices.psychiatryonline.org/http://www.psychservices.psychiatryonline.org/http://www.psychservices.psychiatryonline.org/http://www.nami.org/http://www.nami.org/http://www.nami.org/http://www.nami.org/http://www.nami.org/


26/26

Many Thanks

Documents

Evaluating Psychiatric Patients’ Risk Of Violence