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• Kids need a court order/advocate
• Patient can refuse treatment unless incompetent or in emergency situations
• Psych crisis may cause immanent harm

Care for Patient with Restraints

• Right to the least restrictive environment, use de-escalation techniques
• Document every 15 minutes with an eyeball check, use restraints for the shortest time possible
• An RN can put restraints on in an emergency, but must get an order within 1 hour and debrief ASAP
• Use the least restrictive restraints and discontinue as soon as possible
• Frequent assessment every 15-30 minutes includes vital signs, circulation, skin, mental status, toileting, and hydration
• Restraint orders are good for 4 hours for adults, 2 hours for teens, and 1 hour for kids
• False imprisonment means no means for using restraints

Grief and Loss

• Physiological loss is the loss of a limb, hysterectomy, or mastectomy
• Safety loss is not feeling safe in the environment
• Loss of security/belonging is the loss of security in relationships resulting from losing a loved one, divorce or illness
• Loss of self-esteem includes changes in values/self-perception from a job loss or lost relationship
• Loss of self/actualization threatens personal goals/fulfillment, either external or internal

Therapeutic Communication

• Perception is asking, "Tell me how you feel about..."
• Support is providing situational support or asking the patient what they need
• Coping is sympathizing with presented behavior

Kubler Ross Stages of Grief

• Denial is disbelief/shock
• Anger is expressed towards family/God/providers
• Bargaining involves asking God/faith for more time
• Depression is stage four
• Acceptance is coming to terms with death

Dysfunctional Grieving

• Prolonged/unresolved grief impairs functioning
• Chronic grief involves an extended period of intense sorrow that does not lessen over time
• Delayed grief is grief that is postponed or suppressed, often surfacing later in a more intense form
• Exaggerated grief is an overwhelming reaction to loss that may lead to severe emotional or physical symptoms, such as depression or anxiety
• Masked grief manifests as physical illness or behavioral changes, where individuals do not recognize their grief symptoms
• Encouraging open communication about feelings and providing a supportive environment can help individuals process their grief more healthily

Complicated Grief

• It affects daily living and involves multiple deaths

Disenfranchised Grieving

• It is not accepted by the community, such as the death of a pet

Outcomes for Grieving Client

• Know when to get professional help
• Provide support/emotional/social/coping strategies/functional improvement/exploring what the loss means to the patient
• Ineffective denial means not accepting the reality of the death/loss/illness or seeking help, which can cause compromised relationships/anxiety/depression/physical illness

Anger

• A normal human behavior that is physical or emotional, varying from mild to severe; how a person expresses and deals with it determines the problem
• Signs and symptoms include negative feelings; increased heart rate and blood pressure; muscle tension; clenched fists; flushed face; pacing; and rapid breathing
• Behavioral signs and symptoms include verbal aggression, shouting, threatening, non-compliance with rules, and defensiveness
• Emotional signs and symptoms include impaired judgement, poor impulse control, blaming others, feeling disrespected or threatened, inability to think clearly, racing thoughts, and intrusive thinking
• Interventions for anger relief include catharsis, which is a safe release of anger through activities like using a punching bag or yelling, and cognitive behavior therapy

Aggression

• Meant to harm/punish another person/force into compliance
• It can be verbal or physical

Behavioral Escalation

• Triggering includes restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger
• Interventions for the triggering phase include approaching in a non-threatening/calm manner, encouraging expression, using clear and simple statements, allowing time to express, providing a quiet room, PRN medications, and physical activity
• Escalation shows an increase in behavior and loss of control; pale/flushed/swearing/yelling/agitation/threatening/demanding/clenched fists/hostility/inability to think clearly and solve problems
• During the escalation phase, provide direction in a firm-calm voice; communicate that the behavior is unacceptable, administer medications, and show force

Crisis

• Signs of crisis are emotional/physical loss of control; throwing, kicking, spitting, biting, and cant communicate clearly
• Interventions for crisis involve taking charge for safety, using restraints, 4-6 trained people, and educating the patient that it is for safety
• Recovery involves regaining physical and emotional control, lowering the voice, decreasing muscle tension, and more rational communication
• Interventions for recovery involve talking about the trigger or situation, helping the patient relax, exploring alternatives, activity, and debriefing the staff
• Post-crisis is reconciliation and return to baseline; remorse, apologies, crying, quiet, withdrawn behavior
• Interventions for post-crisis involve removing restraints, calmly discussing the situation, giving feedback, and not lecturing to regain control

Medications Used for Aggression

• Carbamazepine is used for BPD and as an anticonvulsant; monitor CBC for blood dyscrasias
• Lithium is used for bipolar/conduct disorder/intellectual disability with a range of 0.6-1.2
• Valproic Acid is used for dementia, personality disorders, and psychosis; increases GABA, decreases manic episodes, monitor LFT for risk of thrombocytopenia
• Atypical Antipsychotics like Risperidone, Olanzapine, and clozapine control positive and negative symptoms; they are serotonin and dopamine antagonists; side effects include weight gain, diabetes, and agranulocytosis
• Benzodiazepines like lorazepam, diazepam, midazolam, and chlordiazepoxide treat anxiety, seizures, and muscle spasms; enhance GABA; monitor for sedation/RR
• Haldol is a typical antipsychotic; controls positive symptoms (delusions/hallucinations); alters the action of dopamine; side effects include EPS, NMS, agranulocytosis, and sedation
  • Benztropene treats EPS
  • Dantrolene treats NMS

Trauma/PTSD

• PTSD includes patterns of behavior due to traumatic events
• Primary response is intense fear, helplessness, and terror
• Secondary response is re-living the trauma, dreams, intrusive thoughts, reoccurring thoughts, hyper-arousal, and being on guard
• Chronic is greater than 3 months; acute is 3 days-1 month
• Medications are given for anxiety/depression
  • SSRIs like Fluoxetine, Sertraline (zoloft), Paroxetine (Paxil), Citalopram (Celexa), Escitalopram (Lexapro), and Fluvocamine (Luvox) take 4-6 weeks to work, monitor for serotonin syndrome, do not stop abruptly, do not take with MAOIs or St. John's Wort, risk of suicide
  • SNRIs like Venlaxine (Effexor) and Duloxetine (Cymbalta) take 4-6 weeks, monitor for serotonin syndrome, may increase blood pressure, avoid alcohol, risk of suicide
  • Selective Medications Fluoxetine, Paroxetine, Sertraline, Venlafaxine,