How to Care for the Insane: A Manual for Nurses

by William D. Granger

It is better not to visit the room of a violent patient alone, and if an attack is feared, especially with a weapon, the door should be slowly opened, and held so it can be quickly closed. The patient usually makes an immediate attack, and, before he has recovered for a second, can generally be disarmed and controlled.

Violence usually consists of noise, tearing the clothing, breaking glass or furniture, biting, scratching, striking, hair pulling, kicking, or attacking others with weapons. It is sometimes secretly and deliberately planned and skilfully executed, though generally without reasoning or direction, but blind and fierce.

The care of the violent insane involves the careful study of each case, with constant watchfulness, and the exercise of a control that is kind, but firm and unyielding, that does not repress except when necessary, nor restrict without reason, that indulges whenever possible, that never drives, scolds, or threatens, but influences, guides, and directs. The greatest liberty possible should be allowed, and self-control encouraged, and work, occupation, and amusement should be furnished. An attendant must always remember that fear is the lowest motive to govern by, and that kindness will often be appreciated and returned.

Care of the Destructive Patients.—Besides the violently destructive patients, there are some who are maliciously destructive, and who exercise all their ingenuity to escape the watchfulness of the attendants; who glory in their wrong-doing; who openly say they cannot be punished, and exultantly tell the physician how they have outwitted the attendant, or proclaim before him his shortcomings and neglect. Such patients will destroy their own or others clothing, they will steal and hide, or throw it out the window or down the water-closet, or erase the name by which it is marked. They will destroy bedding, windows, crockery, pictures, or furniture. With a pin, a nail, or a bit of glass or wood, they will mar and deface their room or the ward, and often do damage that cannot be repaired. The only way to meet such cases is by watchfulness. They should be kept, if possible, at work, or at least with a company of workers, and therefore under constant observation. When put to bed their clothing, mouth, hair, and person should be thoroughly searched. Kindness often has but little effect, but a threat is apt to make them more determined to destroy.

The Care of Patients by Mechanical Restraint and Seclusion.—All the restriction of an asylum is restraint. The locking of bedroom doors at night is very restricted restraint. Most patients in an asylum have a feeling that they are under great compulsion and restraint, in being deprived of their liberty. It has already been taught that patients are to be given all the liberty possible, that restraint over their freedom is to be exercised no more than is absolutely necessary, and that the greatest good of the patients alone is to be thought of.

These teachings are equally true of special forms of restraint. If used at all they are to be used for the good of the patient alone, and an attendant should be able to care for any case without restraint.

Restraining apparatus should never be kept on the ward. An attendant should never ask that it be used, nor say he cannot get along without it.

If ordered by the physician it is the attendant’s duty to see that it is so applied as to do no injury, that it does not bind or tie the patient down, that it does not irritate and make the skin sore, nor restrict the free movement of the limbs.

Patients who are restrained are not to be further confined to a chair without specific order. Restraint used during the day is not, unless so ordered, to be continued at night nor reapplied the next day. Patients are to be taken frequently to the closet. Restraint should be taken off several times a day, and kept off long enough to give relief to any feeling of discomfort, and free movement should be allowed. When patients are restrained they need unusual care and watching, and should never be left alone.

The attendant should be informed why restraint is used, and what is hoped to be gained by its use. He should closely observe the effect upon the patient and compare his condition with what it is when not restrained. The result of these observations should be reported.