Exam 1 Mental Health Chapter 21

Chapter 21 Variables Affecting the Therapeutic Environment: Violence & Sui Current!Trends -Patients must be an imminent danger to self or others or grave disability to be admitted to an inpatient u -Patients are discharged from hospitals rapidly for less expensive treatment options -High patient turnover & acuity rates -Nurses must use less restrictive measures prior to using seclusion & restraints Aggression!&!Violence -These actions disturb the patients, staff, and therapeutic environment -Violence cannot always be predicted; intervene when clear warning signs are evident -Nurses must spend time interacting with patients at frequent, regular intervals -Assess and interpret inappropriate behavior within the context and knowledge of the patient's pathology -Strategies to reduce potential for violence: >enhance nurse-patient relationship with communication >advocating for client >being available >using continuous assessment >provide education in open dialog >collaborate with patient in treatment planning >provide meaningful patient activities and levels of stimulation >maintain safe unit staffing -Nurses are ineffective if they become angry, aggressive, fearful, or withdrawfrom hostile or demanding -Staff attitude reduces risk for aggression -Focus on assisting with coping skills Management!of!IInpatient!Aggression -Reduce & prevent the use of restraints & seclusion - 75% of reduction in seclusion and restraint events as a result of. >complete assessment at admission >great communication >staff education >therapeutic relationships with patients >individualized care plans, preventative, and emphasis on self management and responsibility Nursing!Interventions!Based!on!Assault!cycle! -The assault cycle can be used as a framework for nursing interventions to prevent aggression and violen -Patients who have multiple assault I’ve behavior patterns are ritualistic, stereotypical, and automatic -Increase acuity of aggressive response, and a decrease in problem solving, creativity, spontaneity, & be -Stress producing event, initiating the stress response -Escalating behaviors that indicate a movement toward the loss of control -Patient may have muscle tension, pacing, irritability, -Patient may be screaming, swearing, agitation, glaring, tremors, anxiety loss of reasoning ability, hypersensitivity, thr -NI: convert empathetic support, encourage ventilation, ask patient to maintain control, give PRN medicaiton, demand -NI: take charge with calm & firm directions, of ask patient to go to quiet room PRN oral medications, ask staff to be on stan at a distance, use voluntary seclusion or restraints -Emotional & physical crisis, loss of control -Patient may be fighting, hitting, rage, kicking, scratching, throwing things -NI: use involuntary seclusion’s, restraints, or IM -Cooling down, returning to normal responses medications, initiate intensive nursing care -Patient may be making accusations, recriminat lowering of voice, decreased body tension, change in conversational content, more norm -Person attempting to reconcile with others responses, relaxation -Patient may be crying, apologizing, reconciliatory -NI: continue intensive nursing care, process th interactions, repression of assaultive incident with staff and other patients, assess feelings patient & staff injuries, evaluate patient’s -NI: process incident with patient, discuss alternative progress toward self control solutions to the situation & feelings, progressively reduce the degree of restraint & seclusion, facilitate reentry to unit -Immediate action when assaults occur -6 to 8 staff members, including hospital security officers, if insufficient unit staff members -Control patient safely & ensure no injuries to st -Placing a patient alone in a specially designed, lockable room equipped with a security patients, or others -Staff members need to remove glasses, rings, window or a camera for observation earrings, pens, watches, that can cause injury -Containment of restricting patients so they do not hurt self or others; decreasing stimulation & the patient or staff -Approach the patient calmly, with a “show of increasing intensive nursing care concern” -Agitation and disruptive or inappropriate sexual -Patient is told the team is “here to help” behaviors are reasons for seclusion -Inform the patient that the physical contact is la -Preventative strategy to avoid aggressive assaults resort -Time out, closer supervision, quiet interactions, & -Use minimum amount of force to ensure that medication are therapeutically effective when everyone is safe used appropriately for brief periods -Immediate action when assaults occur -6 to 8 staff members, including hospital security officers, if insufficient unit staff members -Control patient safely & ensure no injuries to staff, patients, or others -Staff members need to remove glasses, rings, earrings, pens, watches, that can cause injury to patient or -Approach the patient calmly, with a “show of concern” -Patient is told the team is “here to help” -Inform the patient that the physical contact is last resort -Use minimum amount of force to ensure that everyone is safe -During the physical contact, continue to interact with the aggressive patient -Physical contact is protective & defensive, not aggressive -Secure restraints safely, not too tight -Administer medications -Check patient for injuries -Observe for ability to move safely in restraints -Obtain a physician’s order within 1 hour -Physician performs a face to face evaluation -Intensive nursing care -Continuously observed directly or by video -Assess mental status, response of medications, and side effects of medications -Hydration, nutrition, elimination, ROM, vital signs, hygiene, immediate attention to injuries -Document & assess: >ROM >skin care -Restrict the following: >visitors >phone calls >reduce stimuli >have regular staff contact >decrease patient sense of isolation and loneliness -Assure patient they are not being punished and will be back in the milieu when safe -Assist the patient relax, sleep, & benefit from phase of cooling down and reconciliation -When patient is calm, encourage discussion of the incident where the patietn lost control and offer alter for handling similar situations in the future -Ready to be released from restraints when: >less anxious & agitated >increased attention span >oriented to reality >demonstrates sound judgement >assess reaction to release from restraints >assist to reenter the unit with as little fear & embarrassment as possible >assist other patients to accept the patient back to the unit -Immediately after the patient has been secluded or restrained -Patient behavior before, during, & after -Assess staff for injuries incident -Evaluate the way the situation was handled -Rationale for physical control intervent -Descriptive, sequential, organized, spec -Provide support & feedback -Focus on specifics of the event -Physician’s order for seclusion or restra -Discuss success and what did not work well -Reinforce safety education, and identify areas for improvement -A milieu meeting should be called to dis ! openly that a patient was restrained an or secluded -Suicide may serve several functions: an escape, a means -The reason for and purpose of seclusion of ensuring control, a solution, a cry for help restraint should be presented -Suicide for some people becomes a solution to coping -Encourage patients to share concerns, with overwhelming feelings of emotional pain -Suicide is a coping mechanisms, a failure to cope, and a means reactions, and fears of losing control -Encourage all patients to approach staff i to enhancing a sense of control over life -Fantasizing about the time, place, & method of one’s own death upset & angry to help de-escalate the issues early allows a sense of escape from suffering -RF: recent losses, history of prior attempts, substance abuse, family history of psych disorders, having a family member who committed suicide, hopelessness, poor impulse control, last of social support, recent release from inpatient setting, Suicide Assessment!of!suicidal!Patients! -Frequent assessment: >on admission >changes in mental status >changes in medication or treatment protocol >prior to discharge -Suicidal assessment includes: >suicidal thoughts >suicidal intent >plan >lethality of plan -Patient is often conflicted & ambiguous about future -The more depressed & hopeless, the more detailed the plan, the more lethal & accessible the method, the greater the likelihood that a suicide effort will end in death -Some impulsive behaviors can prove to be fatal Suicide!Interventions -Develop a nurse patient relationship build on tr & understanding -Assess potential suicidal thought daily >Have you been having thoughts of harmin yourself? >Have you been feeling as if you do not wa to live anymore? -If positive for suicidal ideation, ask about a pla >a well-developed plan is a high risk for sui >lethality is r/t accessibility of a weapon >if the patient mentions use of a gun, notify family to remove firearms from home or lock them up >if patient mentions overdosing on drugs, restrict access to lethal prescriptions, OT medications, and alcohol -Used for patient not considered to be at immediate -Assess for a suicidal plan, nurse must understa risk of suicide, every 15 minutes, and monitor >talking to patients about suicidal ideation s potential dangerous devices does not drive them to suicide -Asked to sign a “no suicide contract” >asking direct questions elicits useful info & -Not legally binding may provide patients with sense of relief -Serves to deter harmful and potentially fatal behavior >many people die as a result of suicide -Safe environment helps the patient to feel better, tragically miscalculated because structure and a safe environment can -Ask about previous suicide attempts elicit hopefulness >previous method of attempt -Communicate openness & acceptance of the patient’s >how patient was rescued or interrupted feelings and life situation >patient response to treatment and follow up -Encourage exploration and open expression of suicidal -Evaluate for major depression or psych sympto feelings >recent losses >alcohol and/or drug abuse >common hallucinations -Uninterrupted observation -Patients at risk are usually confined to the unit & haveSuicide!Discharge restrictions on visitors and where meals are taken -Explain uneven recovery path -Inform family & friends about signs of high suicid and have bathroom supervision -Document if patient does not with to contact famil -Follow up appointment -If presence of firearms has been identified, docum instructions given to patient and SO -Prescriptions that allow for enough to last until fir follow up appointment -Provide local resources