Anger, Aggression, and Violence Flashcards
what is anger?
–emotional response to frustration of desires, a threat to one’s needs, or a challenge
–normal human emotion that can provide an individual with a positive force to solve problems and make decisions concerning life situations
–becomes a problem when it’s not expressed and when it is expressed aggressively
what is aggression?
–action or behavior that results in a verbal or physical attack
–tends to be used synonymously with violence
–behavior that is intended to threaten or injure the victim’s security or self-esteem
–virtually always designed to punish
–sometimes necessary for self-promotion
what is violence?
always an objectionable act that involves intentional use of force that results in or has the potential to result in injury to another individual
what is trauma informed care?
–notion that disruptive patients often histories that include violence and victimization
–can impede patients’ ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions by staff
where is violence most often seen in the hospital?
–psych units
–ED
–geriatric units
biological factors for anger/aggression/violence
–areas of the brain
–neurotransmitters
–predisposition
psych factors of anger/aggression/violence
–behavioral therapy
–learned response
–social learning theory
–imitate others
modeling
–role modeling is one of the strongest forms of learning
–positive or negative
neurophysiological disorders connected to aggression and violence
–temporal or frontal lobe epilepsy
–brain tumors
–brain trauma
–encephalitis
–traumatic brain injury
–psychosis
operant conditioning
–specific behavior is positively or negatively reinforced
–voluntary behavior change occurs
–appropriate or aggressive expressions of anger can be learned
how can positive reinforcement be learned?
response to the specific behavior that is pleasurable or produces the desired results
how can negative reinforcement be learned?
response to the specific behavior that prevents an undesirable result from occurring
biochemical factors for anger and aggression
–hyperthyroidism
–low serotonin levels
–thiamine and niacin in ETOH
medical factors for anger and aggression
–UTI
–infections
–dehydration
–electrolyte imbalances
–blood sugar imbalances
–sensory changes
SES and anger/aggression
poverty d/t associated deprivation, disruption of families, and unemployment
environmental factors and anger/aggression
–physical crowding of people
–availability of firearms
–discomfort associated with a moderate increase in environmental temp
–use of alcohol and some drugs
comorbidities for anger/aggression
–PTSD
–SUD
–coexists with: depression, anxiety, psychosis, and personality disorders
–CV disease
–strokes
what is the best single predictor of future violence?
history of violence
predisposing factors for anger and aggression
–delusions, hyperactivity, impulsivity, or predisposed to irritability
–non-adherence to meds
–happens in response to limit-setting by nurses
–hx of limited coping skills (lack of assertiveness or intimidation)
risk factors for aggression
–agitation, restlessness, escalating anxiety
–resistance to suggested treatment
–hx of assaultive or threatening behavior
–known hx of drug or alcohol misuse
–cognitive changes that may cause the person to misinterpret the environment or staff actions
s/s that usually precede violence
–hyperactivity
–increasing anxiety and tension
–verbal abuse
–loud voice, change of pitch, very soft voice
–stone silence
–intense eye contact or avoidance of eye contact
–recent acts of violence
–possession of weapon or object that may be used as a weapon
–isolation that is uncharacteristic
psychosocial actions to take
–begin prior to any signs of escalation
–approach in controlled, nonthreatening and caring manner
–allow patient enough space so that you are perceived as less of a threat (approx. 1 ft away)
–escape route
–do not take verbal abuse or space invasion personally and don’t match energy
psychosocial interventions for angry patients
–speak slowly in short sentences and calm
–find out what is behind angry feelings and behaviors
–choose a quiet place to talk
–use open ended questions
–identify patient’s choices and encourage taking responsibility
environmental youth violence risk factors
peer influence and gang related behavior
biological youth violence risk factors
impulse control or self-regulation problems
family youth violence risk factors
–attachment problems
–family stress
–autocratic parenting
–disengaged parenting
–lack of supervision
level 1 behavior
–patient asking simple, normal questions
–anxiety, frustration, impatience, irritability
–raised voice, highly animated, reddened face, clenched fist, restlessness, repetitive movements
–change in behavior
interventions/responses to level 1 behavior
–answer the question
–avoid institutional/systems language/jargon
–avoid coming off as cold and uncaring
–come across as a real human being
–avoid talking about how you feel about it/the situation
level 2 patient behavior
–defensiveness
–patient asks challenging questions
–standing in personal space; staring/glaring
–refusing everything
–releasing: pounding tables, loud sighing, throwing things but not at people, not causing harm
interventions for level 2 behavior
–isolate the interaction
–reduce stimulation
–speak clearly, slowly
–non-verbal communication
–use few words
–be firm but with empathy
–allow loud, verbal expression of anger as long as not threatening
–watch your tone
what do level 3 patient behaviors look like?
–when angry expression turns to hostility and abuse or aggression
–may begin as accusations, comments about competence, irrelevant personal remarks
danger signs for level 3 patient behaviors
–persistent sweating
–sexist or racist comments
–personal or specific threats of harm
–intimidating comments
–terroristic type threats
–any physical behavior directed at a person
when should seclusion/restraint be used?
–last resort
–when less restrictive interventions haven’t worked
–in conjunction with written modification to patient’s care plan
–only in accordance with policy and law
what is seclusion?
involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving
goal of seclusion
safety for the patient and others
when is seclusion used?
may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others
what is restraint?
any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely
legal requirements for seclusion/restraint
–multidisciplinary involvement
–appropriate healthcare provider order according to state law
–client advocate/relative notified
–seclusion and restraint discontinued ASAP
documentation for seclusion/restraint
–behavior leading to seclusion and restraint
–least restrictive measures used prior to seclusion and restraint
–interventions used and client’s response
–plan of care for seclusion and restraint use implemented
–ongoing evaluation by the nursing staff
clinical assessment for seclusion/restraint
–client’s mental state at time of seclusion/restraint
–physical examination for medical problems possibly causing behavior changes
–need for restraint
observation for seclusion/restraint
–staff in constant attendance
–level of awareness
–complete written record every 15 minutes
–monitor vital signs
–assess ROM
–observe blood flow in hands and feet
–observe that restraints are not rubbing
–provide for nutrition, hydration, and elimination
–never restrain a client in the prone position
release procedure for seclusion/restraint
–client must be able to follow instructions and stay in control
–termination of restraints
–debrief with client
restraint tips
–room that is safe without any objects that can be used for self harm or harm to others
–physical holding of a client against will is a restraint
–four side rails up is a restraint except for seizure precautions
–keeping client in their room by physical intervention
–tucking sheets in so tightly client cannot move
–orders for seclusion/restraint cannot be PRN
increased danger in child restraint
–underdeveloped trachea
–intercostal muscles and diaphragm more pliable
what might a patient’s increased struggling movements indicate?
–attempt to increase air flow
–look for signs of respiratory distress
–check O2 saturations
–late signs include cyanosis around lips and mouth
what might decreased struggling in restraints indicate?
decreased LOC
which medical dx and patient condition might compromise breathing in a restrained patient?
–asthma and obesity
–restrain in semi-fowler’s position
–PE may occur due to decreased movement
–withdrawal s/s
contraindications for seclusion and restraint
–patients who have extremely unstable medical and psych conditions
–COPD
–spinal injury
–seizure disorder
–pregnancy
–delirium or dementia
chemical restraint
use of a medication to restrict a client’s movement or behavior
B52 dosage
Ativan: 1-2mg
Haldol: 5-10mg
Benadryl: 25-50mg
giving B52
–haldol and ativan can be given in same syringe
–benadryl in a separate syringe
what does level 4 tension reduction look like?
–a decrease in energy
–rationality returns
–reachable teachable moment
interventions/responses in level 4 tension reduction
–revise plan of care to include behaviors that may result in repeat restraints or seclusions
–re-establish therapeutic rapport with the patient
–using coping model with the patient
COPING (Level 4)
–Control
–Orient
–Patterns
–Investigate alternative methods to reduce acting out behavior
–Negotiate for changes in behavior
–Give control and responsibility for behavior back to patient
