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Promoting a Nonviolent Health Care Module 2. Crisis. Definition- All patients and visitors are in some type of perceived crisis when seeking medical attention. Pre-Escalation. Goal is to manipulate the environment to make it as inviting as possible and eliminate potential triggers. Strategy.
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Crisis • Definition- All patients and visitors are in some type of perceived crisis when seeking medical attention.
Pre-Escalation • Goal is to manipulate the environment to make it as inviting as possible and eliminate potential triggers
Strategy • Staff need to identify an early pre-escalation strategy. • Strategy can be introduced at earliest warning sign or even suggested on initial assessment • Strategy is a calming mechanism to manage and minimize stress and to prevent a perceived crisis from escalating
Examples of Strategy • Stress balls in a basket • Coloring activities • Stretching • Deep breathing • Music • Reading materials • Massage chair • Rubber band on wrist • Prayer books • Run hands under cold or warm water • Blankets • Note cards • Aromatherapy • Games • Progressive muscle relaxation • Snacks on hand
Triggers • A trigger is something that sets off a reaction. It could be anything that the patient associates with negative thoughts or feelings. • Examples include: • Loud voice • Excessive hand motions • People too close or attempting to touch • Bedtime • Men • Not being listened to • Lack of privacy • Room checks
Early Warning Signs • Early warning signs may be difficult to assess in a high stress/traffic area. Initial assessment is a key so a change from baseline behavior is recognized. • Restlessness • Agitation • Pacing • Shortness of breath • Sensing a tightness in the chest • Sweating • Becoming mute and dissociative
Examples of Early Warning Signs • Restlessness • Agitation • Pacing • Shortness of breath • Sensing a tightness in the chest • Sweating • Becoming mute and dissociative • Breathing hard • Rocking • Clenching teeth • Wringing hands • Bouncing legs • Shaking • Crying • Giggling • Heart pounding • Singing • Excessive eating • Swearing
De-Escalation • Person is already in crisis mode and starting to escalate. • In phase one or two of crisis cycle • Recognize possible transference and counter- transference interactions
De-Escalation Strategies • Does initial Nursing assessment include a de-escalation assessment? • Is it possible to designate an area to address sensory needs? If not, what about a comfort box? • 75% reduction in restraints/seclusion over 2 year period after introduction of sensory sessions in a MA hospital
What Makes you Feel Upset? • Circle all that make you feel sad, mad, scared or other Time of year Dark/night Being touched Time of day Crowds Loud noises Yelling/shouting Storms
How do I know I am Angry, Scared or Upset? Cry Clench Teeth Flush, hot face Loud Voice Clench fists Rocking/withdraw/preoccupy Pace/hyper Heart Pounding Breath hard
HALT • Easy acronym to employ in your training: • H- Hungry? • A- Angry? • L- Lonely? • T- Tired? Thirsty?
Case Studies • Review case studies and discuss
Joint Commission and CMS Standards • Comparing Joint Commission Restraint Standards and CMS Standards document • Common themes between hospital not deemed, deemed, behavioral health, and CMS guidelines. • Philosophy and definition • Appropriate staffing • Physician/LIP order • Monitoring and assessing the patient • Documentation • Staff training
Definition of Restraint • Restraint= Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely • A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. • A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets or other methods that involve the physical holding of a patient for the purpose of conducting routine physical exam or tests, or to protect the patient from falling out of bed or to permit the patient to participate in activities w/out the risk of physical harm (this does not include a physical escort)
Definition of Seclusion • Seclusion= the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior.
Philosophy Vs. Practice • Organization must develop a philosophy related to the use of seclusion and restraint • Must ensure that practice supports philosophy
Other things to Include • Trauma Informed Care • Debriefing
Intervention techniques Hands on Approach with a combative person Holds Take Down Lift Carry
Protective stance… Wide stance at legs (feet apart) and open arms/palms.
Blocking an over-head strike… Cross hands over head to block blow to head and deflect down.
Blocking a Kick… Rotate body so kick strikes lateral side of leg. video
Blocking a Punch Block punch between shoulder and elbow and between elbow and wrist; keep moving in downward direction of fist. video
Biting… Push and hold head into bite.
Ponytail hair pull… Grab arm and stabilize hands to head, then bend forward to throw them off balance. video
Hair Pull… Stabilize hair pull and bend forward to promote release. video
Choking or strangle… Lift arms, shrug shoulders and twist out for release. video
Choke from behind… Lean forward as you bump with your hip and back out of hold. video
Restrain and Walk… Hold under arms and hold at wrist, push hip into person and walk forward keeping hip pressure. video 1, video 2, video 3
Take Down… Hold under arms and at wrist; place inside leg behind calf; rotate backwards and take down to the floor; third staff member protects head. video
Roll over onto abdomen… Roll in the direction of crossed leg. Person at the head checks airway. *see next slide for complete video
Lift… Support under arms, link with staff at the head, 2 staff members support and lift legs (knees and ankles). video
