restraints (versi staf sokongan)
TRANSCRIPT
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.