_________________________________________________________________ Managing Disruptive Patients
tion is the best choice because the safety of all in the area is a priority. At the same time, the lowest level of effective restraint is desirable. Knowledge of the hospital’s policies, state laws and regulations, the patient, and appropriate and available interven- tions is necessary for successful resolution of a violent episode. RESTRAINTS Each healthcare institution has, or should have, some guide- lines for the use of chemical or physical restraints in potentially violent situations, and all healthcare professionals should be aware of the procedures used in their institution. CHEMICAL RESTRAINTS The medication protocol generally consists of giving a patient who cannot be “talked down” an initial, low dose of a high- potency anti-psychotic (such as haloperidol) or a short-acting anti-anxiety medication (such as a benzodiazepine). Oral medications may be offered first, but if escalation is rapid, an intramuscular medication may be required. The patient is observed at 15-minute intervals or possibly on a continuous basis. In some instances, medication may be given as often as every half hour until the violent episode is in check or the maximum dose is reached. The healthcare professional’s responsibilities involved in han- dling a violent episode by medicating a patient with a potent pharmacologic agent include the following: • Checking for or obtaining a healthcare practitioner’s order to administer medication. • Preparing the medication: capsules, tablets, or liquid; intramuscular injection, intravenous drip, or butterfly infusion. • Assessing the patient’s vital signs before giving the drugs if this can be done safely. • Informing the patient of the procedure that will follow and providing reassurance and support if needed. • After the medication has been administered, observing the patient, assessing for a decrease in signs and symptoms of aggression, and noting any untoward side effects of medication given. • Periodically checking the patient’s vital signs. • Documenting the incident and the medications given by recording the information in the patient’s medical record or as the ins titution directs. MECHANICAL RESTRAINTS As with protocols for using medications, each healthcare institution should have a procedure to follow for mechanically restraining a patient. Without an order for an involuntary commitment, however, the patient cannot be held against their will (Halter, 2021). When a patient in a general hospital setting is at high risk for harm, the number of staff members needed to restrain the
patient depends on the patient’s size, strength, and potential for violence (Thomann et al., 2021). The general recommenda- tion is that one staff member needs to be available to hold each extremity and an additional staff member must be available to apply the restraints; if six staff members are available, one person can support the patient’s head. The patient is held by the arms and legs and walked, carried, or placed in as comfortable a position as possible (usually in a hospital bed with the side rails up) and put in wrist and ankle restraints. These restraints may be cotton, gauze, cloth, or leather, depending on the patient’s size and strength. Ideally, one person (one of the registered healthcare profession- als) should be in charge of a group of five or six staff members. If no one is in charge, the possibility of miscommunication can produce a disjointed effort. Consequently, the patient may escape and be harmed or do harm. The confusion that ensues when no one is in charge invariably adds to the patient’s sense of being out of control and thus escalates the situation. The decision as to which staff member will be in charge should be made before any action is taken. A “show of force” of five or six staff members may be enough to defuse the situation. The best approach toward the patient is a uniform one. All staff members should move or walk toward the patient together. Sometimes, this simple show of force subdues a patient. Before the approach is undertaken, to avoid confusion, the team leader should assign which staff member will hold which extremity. Staff members should try to be calm themselves. They should not speak loudly; instead, they should be firm and speak slowly, clearly, and precisely. A soft voice may have a quieting effect on the patient. The healthcare professional responsibilities involved in han- dling a violent episode by mechanically restraining a patient include the following: • Staff should monitor the patient frequently, according to the facility’s protocol. • At least every 2 hours, the restraints should be untied and the patient’s position should be changed (Halter, 2021). However, the patient may not need to be restrained this long. • Staff should not negotiate with the patient. • Staff should not confuse the patient with options. • Staff should remember that this patient is out of control. • Staff can say something like the following: “We feel you are not in good control of yourself right now. We will help you calm down.” The room should be checked for potentially dangerous objects. Healthcare professionals should remove any watches, eyeglasses, jewelry, shoes, belts, and other items that could be a hazard. No place is free of danger. Patients have broken light bulbs and cut themselves with the shards or used pajama waist cords to hang themselves. Healthcare professionals should
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