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Triage of psychiatric emergencies
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Triage in health care :
The sorting of patients in an emergency department
according to the urgency of need for care
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Triage in psychiatric emergency
assessing the immediate needs of individuals
presenting across a variety of priority concerns
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Components of a comprehensive psychiatric triage
Establish a therapeutic rapport with the patient
Helping the individual feel safe & secure in stressful /stimulating environment
Systematic assessment of the patient
Data gathering
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Components of triage evaluation
ASSAULTS : A: assess S : safety S : suicidality A : aggressive / assaultive behavior U : underlying medical condition L : lethality T : trauma s :substance
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Safety
Evaluation of safety : safety evaluation lead to reducing the
anxiety of practitioner & patient
Safety considerations :
patients must have been searched & disarmed
security personnel must be available may require that a patient be in restraints
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Suicidality behavior
Suicidal attempts : degrees of intent & leathality
Completed suicide
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Assessing suicidality
Psychiatric illness : mood disorders schizophrenia substance abuse anxiety disorders BPD Physical illness : chronic pain delirium Psychopathology in family & social milieu(life
stress /crisis )Family history psychiatric illness (especially
suicide)
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Stress-diathesis model :
Diathesis =preposition to suicidal behavior
Elements of diathesis :
1) aggressive ,impulsive trait 2) tendency toward pessimism and hoplessness
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Aggressive /assaultive potential Risk assessment scheme : 1) historical risk f. data concerning the individual’s social & economic state 2) prior history of violence 3) mental health /substance history Clinical risk f. 1) lack of insight 2) presence of negative attitude 3) impulsivity 4) lack of responsiveness to prior treatment Risk management 1) lack of support 2) prior failure with treatment 3) potential for increased stressors
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Underlying medical condition :
DSM a five-axes diagnosisMost important aspect of triageAssess CRISES : C : cardiovascular/chest pain R : respiratory ;increase/decrease in rate altered breathing pattern I : intense/persistent pain S : sensory changes ;motoric(change in
strength /asymmetry );cognitive (aphasias ) E : elimination problems S : significant vital sign changes
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Lethality:
Degree of risk of a patient for
1)self –destructive behaviors (suicidal )
2)dangerous toward others (homicidal )
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Trauma:
physical ;emotional ;sexual abuse neglect war experiences alcoholism physical illness sickness in their family loss of a close family member/
friends natural disasters
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Trauma Defined (DSM-IV)“Loss of Control”
To experience, witness, or confront an event involving actual or threatened death or serious injury or threat to physical integrity to self or others
Response to event involved intense fear, helplessness or horror
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Responses During Trauma
EmotionalShockEmotional numbingDenialDissociation/unrealityPanic/fearHopeless/helplessGuilt
PhysiologicalElevated BP, HRFatigue, HyperventilationHeadache
CognitivePoor concentrationDifficulty making decisionsPerseveration
BehavioralWithdrawalPacing,Exaggerated startleRegressive behaviors
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substance use/abuse
Importance :
1)increased prevalence & use of illegal substances
2) substance –induced disorders can mimic &
contribute to the range of psychiatric dis
3)often abuse of substances coexists with primary axis I,II diagnosis
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نکات مهم در شرح حال
مشاهداتتعریف
سطح تریاژ
شرح حال کاربردی ندارد
پرخاشکری دراورژانس یا
آژیتاسیون شدید
خود زنی یا اقدامبه خودکشی در
اورژانس یا تهدید جدی به آن
خطر قطعی برای بیمار یا دیگران
l
1
افکار خودکشی یااقدام به آن
پرخاشگری
عالیم سایکوتیک
عالیم خلقی مانندافسردگی شدید
اضطراب شدید
بی قراری یاآژیتاسیون
بیمار گیج یا بدونهمکاری
بیماری کهاحتمال فرار دارد
خطر احتمالی برای بیمار یا دیگران
2
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عالیم افسردگی یا اضطراب بدون افکار خودکشی
تحریک پذیریبدون
پرخاشکری تغییر در
وضعیت روانی بدون
پرخاشکری یا آژیتاسیون
ن خطر فعلی بدوبرای بیمار یا
دیگران
3
عالیم مزمنسایکوتیک
عالیم مزمنجسمی غیر قابل توجیه
مشکالت بینفردی یا اجتماعی
بیماری که برای تجدید نسخه
مراجعه کرده عوارض دارویی
خفیف همکاری و
برقراری ارتباط مناسب
ون خطربد 4
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اقدامات الزم فوریت درمان سطح تریاژ بالفاصله به پزشک
اورژانس اطالع داده شود
بالفاصله به پرسنل برای حضور 100کد
در کنار بیمار اطالع داده شود
در صورت ضرورتبیمار فیکس شود.
بالفاصله1
به پزشک اطالع دادهشود.
در 100پرسنل کد محل حضور داشته
باشند. بیمار بدون همراه
تنها نماند. بسته به اولویت در
.نوبت بماند
2 دقیقه30حداکثر در عرض
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به پزشک اطالعداده شود.
بسته به اولویت درنوبت بماند
60حداکثر در عرض دقیقه
3
به پزشک اطالعداده شود.
بسته به اولویت درنوبت بماند
120حداکثر در عرض دقیقه
4
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Agitation :
Abnormal & excessive verbal/physical agression
Purposeless motor behaviors
heightened arousal
Significant disruption of patient’s functioning
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Management of agitation & aggression:
Agitation is a nonspecific symptom Untreated agitation can lead to violence interventions : 1) core clinical strategy is interpersonal that emphasize verbal intervention affect management 2) pharmacological goal is calm without sedation 3) restraints
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موفق باشید