restraints (versi staf sokongan)

SECLUSION AND RESTRAINTS DI DALAM SITUASI KECEMASAN

Dr Tuti Iryani Mohd Daud Senior Lecturer & Psychiatrist,

National University of Malaysia Medical Centre.

Seclusion and restraints in emergency psychiatry by Tuti Mohd Daud is licensed under a Creative Commons Attribution-NonCommercial 4.0

International License.

DI AKHIR SESI INI, ANDA DAPAT:

Menggambarkan jenis-jenis seclusion and restraints

Menjelaskan prinsip seclusion and restraints

Membincangkan indikasi, kelebihan dan kekurang untuk pelbagai jenis restraints

Menjelaskan isu etika berkaitan seclusion and restraints

Mebincangkan cara-cara seclusion and restraints dapat dikurangkan

Trigger

Escalation phase

Crisis phase

Recovery phase

Post-crisis depression

phase

CYCLE OF ASSAULT (Kaplan & Wheeler,1983)

Perceived as serious threat

body and mind prepare for a fight.

Violent act

body and mind relaxes

fatigue, depression, and

guilt.

Source: Wolf,K & Knight,M. The Assault Cycle and Verbal Diffusion Handout. Retrieved from http://www.ala.org/pla/sites/ala.org.pla/files/content/onlinelearning/webinars/Assault_Cycle_Rev.pdf

Seclusion & restraints Breakaway techniques

APAKAH MATLAMAT SECLUSION & RESTRAINTS?

memastikan keselamatan untuk setiap individu yang berada di tempat rawatan

(safety of everyone in the treatment environment)

Intervensi semasa fasa krisis

Teknik Breakaway

Restraints

TEKNIK BREAKAWAY

“Kemahiran fizikal untuk bantu sesorang untuk melepaskan diri dari seseorang yang bertindak agresif dengan cara yang selamat. Ianya tidak

melibatkan restraint”

“A set of physical skills to help separate or break away from an aggressor in a safe manner. They do not involve the use of restraint.”

(NICE, 2015)

Reference:

NICE (2015). NICE Guideline: Violence and aggression: short-term management in mental health, health and community settings. Retrieved from http://www.nice.org.uk/guidance/ng10

Hair Grab (front)

Headlocks (rear /

dari belakang)

Bear Hugs

Intervensi semasa fasa krisis

Teknik Breakaway

Restraints

Fizikal Kimia / ubat-

ubatan

Persekitaran

KIMIA / UBAT-UBATAN

CHEMICAL RESTRAINT

Oral IM or IV

Sublingual

Antipsychotic

Olanzepine (Zydis)

BDZ

clonazepam, lorazepam

Tablet

RESTRAINTRapid tranquilisation:

“Menggunakan ubat secara injection (IM atau IV), apabila ubat secara makan tidak dapat

diberi / tidak sesuai dan pesakit perlu ditenangkan / ditidurkan menggunakan ubat-

ubatan dengan segera”

“Use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate

and urgent sedation with medication is needed.”

(NICE, 2015)

Reference:

NICE (2015). NICE Guideline: Violence and aggression: short-term management in mental health, health and community settings. Retrieved from http://www.nice.org.uk/guidance/ng10

side effects: EPS

prolonged QT ataxia

sedation additive CNS depression geriatric over-sedation

CHEMICAL RESTRAINT

Oral Intramuscular or intravenous

Antipsychotic Benzodiazepine

Haloperidol Lorazepam (in our setting - Midazolam)

IM procyclidine

A f t e r p a r e n t e r a l a n t i -psychotic & BDZ • Temperature, pulse, BP &

respiratory rate • Every 5-10 min for 1 hr,

then hal f -hour ly unt i l patient is ambulatory

• If patient is asleep: pulse oximetry

From: Neurobiology of Aggression and Violence American Journal of Psychiatry

Figure 4. Pretreatment Abnormalities in the Pathophysiology of Aggression

a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure appeared in Davidson et al., Science 2000; 289:591.

Copyright © American Psychiatric Association. All rights reserved.

Date of download: 09/19/2015

• memberi kesan yang sesegera mungkin kepada pesakit

• mudah memperolehi ubat I.M., IV, atau ubat sublingual

• pesakit pernah mengambil ubat tersebut, dan ianya berkesan

• kurang kesan sampingan

• pilihan pesakit (patient’s preference)

• mudah untuk diberi

(tidak perlu mengambil darah dan rejim dos yang mudah)

CIRI-CIRI UBAT YANG DIBERIKAN:

References:Allen, M. H., et al. (2005). "The expert consensus guideline series. Treatment of behavioral emergencies 2005." Journal of Psychiatric Practice 11 Suppl 1: 5-108; quiz 110-102.

From: Neurobiology of Aggression and Violence American Journal of Psychiatry

Figure 5. Posttreatment Abnormalities in the Pathophysiology of Aggression

a Figure adapted/modified with permission from S.J. DeArmond et al., “Structure of the Human Brain: A Photographic Atlas, Third Edition” [Oxford University Press, New York, 1989]. Copyright © Oxford University Press. A modified version of this figure appeared in Davidson et al., Science 2000; 289:591.

Copyright © American Psychiatric Association. All rights reserved.

Date of download: 09/19/2015

ISU BERKAITAN

menjejaskan hubungan di antara pesakit dan perawat

kecederaan needle-stick kepada staff

Intervensi semasa fasa krisis

Teknik Breakaway

Seclusion

Restraints

Fizikal Ubat-ubatan

Persekitaran

PERSEKITARAN

SECLUSION

“Ianya melibatkan mengurung pesakit di dalam bilik yang mungkin berkunci dan selia

oleh perawat atau staff. Tujuannya ialah untuk memastikan kelakuan

agresif tidak membahayakan orang lain”

(Department of Health, 2015)

Reference:

Department of Health (2015). Mental Health Act 1983 Code of Practice. Surrey: The Stationery Office: Surrey. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/435512/MHA_Code_of_Practice.PDF

(i) keselamatan pesakit dan orang lain

(ii)kurangkan stimulation (i.e. bunyi bising, provokasi dari orang lain)

TIDAK sesuai, sekiranya pesakit merbahaya untuk dirinya

BILA IANYA DIGUNAKAN?

Intervensi semasa fasa krisis

Teknik Breakaway

Restraints

Fizikal Ubat-ubatan

Persekitaran

Manual

Mekanikal

RESTRAINTManual restraint:

“Satu kemahiran untuk restraint pesakit secara fizikal yang digunakan oleh perawat kesihatan yang terlatih, untuk mengelakkan pesakit dari mencerderakan orang lain. Ianya bertujuan untuk mengelakkan pesakit daripada boleh

bergerak dan dilaksanakan dengan cara selamat.”

Reference:

NICE (2015). NICE Guideline: Violence and aggression: short-term management in mental health, health and community settings. Retrieved from http://www.nice.org.uk/guidance/ng10

(NICE, 2015)

RESTRAINTMechanical restraint:

“Satu kaedah intervensi fizikal yang menggunakan peralatan yang dibenarkan,

contohnya handcuffs atau tali restraint, digunakan dengan cara tertentu oleh perawat

kesihatan terlatih”

(NICE, 2015)Reference:

NICE (2015). NICE Guideline: Violence and aggression: short-term management in mental health, health and community settings.

Restraint fizikal hendaklah digunakan sebagai kaedah

terakhir untuk menangani pesakit agresif (Allen et al. ,2003)

Reference: Allen, M. H. M., et al. (2003). "Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines." Journal of Psychiatric Practice 9(1): 16-38.

RISKSPatients

dehidrasi

rhabdomyolysis

lactic acidosis

kematian

Staff

Cedera

Tekanan mental

References: Stewart D, Bowers L, Simpson A, Ryan C & Tziggili M (2009). Manual restraint of adult psychiatric inpatients: a literature review. Journal of Psychiatric and Mental Health Nursing 16 pp 749-757. Stubbs B, Leadbetter D, Paterson B, Yorston G, Knight C & Davis S (2009). Physical intervention: a review of the literature on its use, staff and patient views, and the impact of training. Journal of Psychiatric and Mental Health Nursing, 16, pp 99- 105.

• Keselamatan staff (dan pesakit)

• Jangkamasa yang pendek

• Wajar mengikut kelakuan agresif pesakit

• Paling kurang restrictive

• Diawasi dengan baik (close monitoring)

PRINSIP SECLUSION & RESTRAINT

• pernafasan • kelakuan • warna kulit • hati-hati terhadap kepala dan salur pernafasan

pesakit • tiada tekanan (pressure) terhadap leher, dada,

perut dan kawasan pelvik

PENGAWASAN

ISU ETIKA

Hak asasi manusia (autonomi)

Penderaan:

digunakan sebagai satu cara mendenda pesakit

untuk memudahkan staff

References: Hay D, Cromwell R. Reducing the use of full-leather restraints on an acute adult inpatient ward. Hospital and Community Psychiatry 1980; 31: 198-200.Moosa, M. and F. Jeenah (2009). "The use of restraints in psychiatric patients." South African Journal of Psychiatry 15(3): 72-75.

Photo: Minas, H. and H. Diatri (2008). "Pasung: Physical restraint and confinement of the mentally ill in the community.” International Journal of Mental Health Systems 2(1): 8.

Pasung: ”physical restraint or confinement of criminals, crazy and dangerously aggressive people." (Broch, 2001 cited in Minas &

Diatri, 2008)

• Minas & Diatri (2008) • location: Samosir Island, Sumatra • duration 6 months • 15 cases • Pasung was built by family

members • duration of pasung: 2-21 years • diagnosis: Schizophrenia, dementia,

epilepsy • Main reason for pasung: prevent

harm to others and ill person • Treatment was not affordable

Iron shackles are fixed to the wooden floor of a hut in which the person is confined.

This man has his ankles in wooden stocks

Photo: Minas, H. and H. Diatri (2008). "Pasung: Physical restraint and confinement of the mentally ill in the community.”International Journal of Mental Health Systems 2(1): 8.

MENANGANI PESAKIT AGRESIF

Penilaian medikal: • kenalpasti sebarang penyakit medikal (i.e. delirium)

• vital signs dan sejarah medikal, periksa pesakit secara visual, ujian air kencing,ujian kognitif dan ujian kehamilan sekiranya pesakit adalah wanita dan masih muda

• trauma kepada kepala, respiration, heart rhythm, bau alkohol, diameter pupils, sebarang kecederaan, leher yang tegang (nuchal rigidity), dan patah tulang

• glukometer dan ujian air kencing

Penilaian psikiatri

• dilaksanakan secara ringkas, sekadar untuk dapatkan diagnosis umum (general category of diagnosis)

References:Allen, M. H., et al. (2005). "The expert consensus guideline series. Treatment of behavioral emergencies 2005." Journal of Psychiatric Practice 11 Suppl 1: 5-108; quiz 110-102.

PENILAIAN AWAL

Tiada makluman tambahan mengenai pesakit: Pesakit memberi kerjasama untuk makan ubat: lorazepam, risperidone, olanzapine, haloperidol, quetiapine. (Allen, 2005) (our setting: lorazepam, risperidone, olanzapine)

Sekiranya ubat I.M. diperlukan sebelum penilaian dapat dilaksanakan: I.M. lorazepam, with I.M. ziprasidone, olanzapine, and haloperidol. (di PPUKM: IM Midazolam + IM Haloperidol)

Pesakit terus bertindak agresif walaupun telah restraint

•IM (atau IV) + restraints

•Pesakit yang telah direstraint, perlu diberikan ubat-ubatan untuk mengurangkan kelakuan agresif beliau

•Tujuannya supaya ubat itu dapat mengurangkan masa untuk pesakit berada di dalam restraint dan komplikasi akibat restraints.

References:Allen, M. H., et al. (2005). "The expert consensus guideline series. Treatment of behavioral emergencies 2005." Journal of Psychiatric Practice 11 Suppl 1: 5-108; quiz 110-102.

RAWATAN

Source:Knox, D. K. and G. H. Holloman (2012). "Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup." Western Journal of Emergency Medicine 13(1): 35-40.

Algorithm untuk seclusion and restraint (Knox and Holloman, 2012)

MENGURANGKAN SECLUSION & RESTRAINTS

Setiap tahap (polisi, infrastruktur, latihan, sikap)

• Penilaian pesakit dengan kadar segera (timely) dan menyeluruh • intervensi awal bersama dengan rawatan yang sewajarnya boleh

mengelakkan suasana kecemasan

• Tentukan sama ada restraint mesti dielakkan, atau jikanya perlu digunakan, ianya hendaklah digunakan di dalam keadan berhati-hati

• Latihan untuk staff (i.e. teknik de-escalation dan kemahiran menguruskan krisis)

• Restraints perlu dianggap intervensi luarbiasa dan perlu dihadkan

• Maruah pesakit perlu dilindungi, e.g. kebersihan diri, bilikair, senaman, nutrisi dan minum air.

References: Currier, G. W. M. M. (2003). "The Controversy over "Chemical Restraint" in Acute Care Psychiatry." Journal of Psychiatric Practice 9(1): 59-70. Moosa, M. and F. Jeenah (2009). "The use of restraints in psychiatric patients." South African Journal of Psychiatry 15(3): 72-75. SCANLAN, J. N. (2009). "Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far. A review of the literature." International

Journal of Social Psychiatry.

Sebelum discaj: Bincang bersama pesakit

Galakkan pesakit untuk bertanya soalan Berikan maklumat kepada pesakit (dan keluarga) tentang

ubat-ubatan

References:Allen, M. H., et al. (2005). "The expert consensus guideline series. Treatment of behavioral emergencies 2005." Journal of Psychiatric Practice 11 Suppl 1: 5-108; quiz 110-102.

Mengurangkan impak negatif ke atas: hubungan pesakit dan doktor

keinginan pesakit untuk meneruskan rawatan susulan

RINGKASAN• Matlamat restraint ialah untuk memastikan

keselamatan pesakit, staff dan orang di sekeliling

• Ada beberapa jenis restraints, setiap jenis ada kelebihan dan kekurangan

• Seclusion and restraint hendaklah digunakan dengan berhati-hati

• Gunakan teknik de-escalation untuk mengelakkan seclusion and restraint

Seclusion and restraints in emergency psychiatry by Tuti Mohd Daud is licensed under a Creative Commons Attribution-NonCommercial 4.0

International License.