anger, aggression, and violence Flashcards
anger
emotional response to frustration or desire, threat to need, challenge
vary in intensity
normal emotion, allows + force to solve problems and make decisions when handled appropriately and expressed assertively (not aggressively)
capable of being under personal control
aggression
often synonymous with violence
action or behavior that results in verbal or phys attack
intended to threaten or injure the victim’s security or self esteem
can cause damage with many different things but is almost always designed to punish
not always inappropriate (protect)
violence
objectionable act, intentional use of force with the potential to injure
workplace epidemiology: 5x as likely, underreported, impair effective pt care, leads to psych distress, dissatisfaction, absenteeism
ED, psych, geriatric, ICU
feelings that precipitate anger
anx -> heightened
discounted, embarrassed, frightened, fear, humiliated, hurt, ignored, inadequate, insecure, unheard, out of control of the situation, rejected, threatened, tired, vulnerable
situations that precipitate anger
withdrawal/substance abuse or addictions
dx psych illness
internal stimuli (auditory hallucinations)
dif in expectations or goals
diff in knowledge
inaccurate or incomplete info, env (too hot/cold/loud)
attention seeking, sleep deprivation, pain, stress, past trauma, loss of personal power, poor communication
warning s/s of potential violence
hyperactivity (pacing, restless) - most important predictor
inc anx and tension: clenched jaw or fist, rigid posture, fixed or tensed facial expression, mumbling to self
loud voice, change of pitch, very soft voice, rate, rhythm
verbal abuse: profanity, argumentativeness
stone silence, intense eye contact or avoidance, recent acts of violence, possession of weapon or object that may be used as one, isolation that is uncharacteristic
milieu characteristics conducive to violence
env (temp, noise), overcrowding, staff inexperience, controlling staff, poor limit setting (other pts have more freedom), revoke privileges
assess anger and aggression
hx is best predictor -> our rxn to stimuli come from previous experiences - identify trigger
often occurs during limit setting
inc r with delusion, hyperactive, impulsive, predisposed to irritability, non adherent to meds
hx of limited coping, lack of assertiveness, use of intimidaiton
risk assessment identifiers for aggression
agitation, restless, escalating anx
resistance to suggested treatment
hx of assaultive or threatening behavior
aggression management has been required at time of a transfer
known hx of drug or OH misuse
cog changes that may cause the person to misinterpret the env or staff care activities (confusion, disorientation, delirium, psychosis/acute hallucinations, delusions)
assessment tools
BVC, DASA, ABRAT, MOAS, COVR, HCR-20, START, many more
self assessment
nurses have own hx
ability to effectively intervene depends on self awareness of strengths, needs, concerns, vulnerability
w/o self awareness, interventions can be impulsive or emotion based
be aware of word choice, tone, non verbal, communication (posture, expressions)
general interventions
begin before early s of escalations
have many brief and non threatening and non directive interactions to help dev therapeutic relationship
approach pt in controlled non threatening and caring manner
allow enough space to be perceived as less of a threat (1 ft further than reach)
make sure you have an escape route
pts may invade space or be verbally abusive - dont take this personally or respond in kind
speak slow and short in low and calm, model controlled behavior
open ended statements and Q’s, no challenging statements
identify what is behind the angry feelings and behaviors
identify pts options and encourage them to assume responsibility for choices made
pay close attention to env: choose quiet but visible place, let staff know you are working with pt
considerations for staff safety
appropriate eye contact
keep facial expressions even, caring, confident, engaged
try to get the pt to talk to you
avoid wearing items that dangle
ensure there is enough backup staff (only 1 talk)
always know layout of area
dont stand in front of pt or in front of doorway (confrontational), stand to side and encourage pt to sit
if behavior escalates, provide feedback, allow pt to explore feelings and hopefully deescalate
de-escalation techniques
respond asap
assess pt and situation
identify stressors and stress indicators
determine what the pt considers to be needed/goals
maintain calmness (own and pts)
use calm clear tone of voice
be genuine and empathetic
be assertive not aggressive
avoid arguing
give several clear options
invest time
remain honest
maintain pts self esteem and dignity
avoid invading personal space (need more space in times of high anx)
dont take chances, maint personal safety
individualized interventions
assess and educate
replace strategies that are no longer avail (drink, OH, tv, etc)
pharm interventions
prn
can prevent aggression when used with psychosocial interventions and deescalation techniques
long term tm of anger = tm of underlying psych disorder
nurse response
notice changes in expressions of anger, anx, frustration
being observant of non verbal cues
approach as soon as you suspect problem
acknowledge feelings - ok to guess wrong
initiate dialogue
encourage talking
do’s
stay calm and in control - calm voice
try to understand concern
reflect their emotion
appear as personable as possible
offer comfort measures
dont’s
take the bait
get defensive
counterattack
be easily offended
defensiveness looks like
asking challenging questions
standing in personal space, staring/glaring
refusing: requests, loud and adamant about tm, cooperate for own care, adherence to policy/safety, becoming v angry/defensive
releasing: table pounding, loud sighing, throwing but not meant to cause harm
respond to defensiveness
isolate interaction: move pt, move others way, allow an exit
reduce stim in env
speak clearly and slowly
use non verbal communication to show what you want person to do
use few words
be firm but with empathy
allow loud verbal expression of anger as long as not threatening (release of emotion)
its not a win-lose situation
watch your paraverbal - its how you say what you say
intimidation/acting out
looks like: when angry expression turns to hostility and abuse or aggression (any activity that is intended to cause or can cause physical harm), may begin as accusation, comments about competence, irrelevant personal remarks
danger signs: persistent swearing, sexist or racist comments, personal or specific threats of harm, intimidating comments, terroristic type threats, any physical behavior directed at a person
intimidation/acting out: nurse’s response
call for help/assistance/security/law enforcement
protect self: remove from situation, remove objects in reach of patient, position btw patient and exit
verbal interventions: limit words and actions, focus on directing patient’s actions, avoid agreeing just to agree, explain that aggression will not achieve desired goal
non verbal: dont sigh, roll eyes, show frustration, impatience, mutter, laugh, or other actions that may provoke
tension reduction
decrease in energy, rationality returns, reachable teachable moment
interventions: re-est therapeutic rapport, revise poc to include the behaviors that may result in repeat subsequent interventions using restraint or seclusion
seclusion
invol confine alone, phys prevented from leaving
goal is safety, not punitive
only used for management of violent or self destructive behavior that jeopardizes immediate phys safety of pt, staff, others
restraint
manual method, phys, mech device, material or equip that immobilizes or decreases ability of pt to move freely
r/o phys, emotional harm
seclusion/restraint only used when
last resort
danger
less restrictive ineffective
order
in accordance with safe and appropriate techniques
mech restraints: legal req
indication = protect
multidisciplinary involvement, appropriate hcp order (w/n 1 hr), advocate or relative notified, d/c asap
mech restraints: doc
I
least restrictive used
pt response
plan of care
ongoing eval - never left alone
mech restraints: assess
mental state prior
phys exam
need for restraint
mech restraints: observation
constant
assess at req and reg intervals
level of awareness, VS, ROM, blood flow, skin, nutrition, hydration, elimination, comfort
mech restraints: release procedure
follow instruction, stay in control
debrief
mech restraints: tips
never prone, no objects in room for self harm
not prn
seclusion = keep in room by phys intervention
restraint = sheet tuck, 4 rails, phys holding
seclusion and restraint: organization
who is in charge
who is going to talk to pt
check seclusion area to determine readiness
clear path and remove others from area
prep and admin med
1:1 once in seclusion
doc
debrief
monitoring considerations: children
underdev trachea
intercostal muscles and diaphragm are more pliable and more easily restricted by restraint device
monitoring considerations
always respond to difficulty breathing - look for intercostal muscle retractions, use of accessory muscles
struggling movements may indicate attempt to increase airflow, look for s/s resp distress, check O2 sat, late s/s = cyanosis around lips and mouth; dec LOC
medical dx that compromise breathing in restraints
asthma and obesity -> semifowlers, PE d/t dec movement
intox and withdrawal -> observe for s/s
contraindications for seclusion and restraint
v unstable
COPD (extreme wedge pillow)
spinal injury
seizure disorder
preg
delirium or dementia
critical incident debriefing
immediate and mandatory debriefing for staff and pt who took part and witnesses seclusion/restraint episode
components: prevention? respond as team? safety? policies followed? restraining process, different? lessons learned, dignity respected? need for additional staff eduction?
teaching and health promo
model appropriate responses and ways to cope
teach variety of methods to appropriately express anger
educate about coping skills, de-escalation techniques and self soothing skills to manage behavior
assist in identifying triggers for anger and aggression
