Anger, Aggression, and Violence Flashcards
Anger
■ Anger is a normal healthy response to violation of one’s integrity. Can strengthen relationships
■ Maladaptive anger is detrimental to oneself and others.
■ Violence portrayed in the media is harmful to children, TV programs are limited during children’s hours, but video games reward for violence
Aggression
◆ Verbal statements or physical behavior that is intended to threaten, belittle, dominate or control
◆ Must consider the situation (psychosis, history of rape, exhaustion)
Violence
◆ Extreme aggression intended to cause harm to or kill a person
◆ Conveys a message that the perpetrator’s point of view is correct, not the victim’s
What is the best predictor of violence?
a history of violence
◆ MOST mentally ill people do NOT commit violent acts
Patients who are at increased risk of violence:
✦ Active psychotic symptoms (perceived threat)
✦ Substance abuse disorders (withdrawal, intoxication = inhibited impulses)
• ETOH abuse increases risk 12X normal
• Drug abuse increases risk 16X normal
◆ Head trauma, tumor, toxic chemicals or lead, history of anoxia (lack of oxygen to the brain), inadequate maternal nutrition –> cause brain damage
What are the more common diagnoses in psychiatric patients? (other than violence)
✦ Antisocial PD and intermittent explosive disorder more than other diagnoses
Nursing Management for Violence
Psychiatric nurses staffing inpatient facilities have as a top priority the prevention of violence
Dimensions of keeping the unit safe include:
◆ Maintenance of a structured and respectful
therapeutic milieu
◆ Careful timing of admissions and discharges (ex. having more “confused” patients in rooms near nurses desk)
◆ Expert use of space and personnel
◆ A conviction that staff need to understand the meaning of patients’ behaviors (ex. agitated pt with psychosis who could not find bathroom, APD patient who was threatening others & Dr. set limits )
Assessment of Anger
■ Anger expression (threats, property destruction, assault, suppression, assertive)
■ Pervasive chronic anger (life-long) vs. anger at an ongoing situation (ex. mean boss –> help them problem solve) vs. adjustment to a stressor
■ Problems caused by anger expression
■ Presence or absence of self-soothing techniques (ex. deep breathing)
■ The Spielberger State-Trait Anger Expression Inventory measures:
- The general propensity to be angry (trait anger) - are they angry a lot?
- Current feelings (state anger)
- Several styles of anger expression –> controlling it through calming techniques
Predictors of Violence
■ Unwillingness to follow unit rules
–> most common in mental health
■ Involuntary hospitalization in a locked unit
■ Crowding, heat and density during high patient census
■ Anger-producing staff actions (such as limit setting, ignoring patient)
■ Inadequate staffing
■ Precursors: staring and eye contact, tone and volume of voice, anxiety, mumbling and pacing
Mental Status Exam Questions (Assaultive or Homicidal Ideation)
■ Do you intend to harm someone? If yes, who?
■ Do you have a plan? If yes, what are the details of the plan?
■ Do you have the means to carry out the plan? (If the plan requires a weapon, is it readily available?)
Need to make sure patient is safe to discharge.
Violence Preventative Strategies
■ Be aware of your OWN stress and don’t take out frustrations on patients (countertransference)
■ Patient education - how to manage/control anger, healthy outlets for anger/aggression Assertiveness training:
–>how to help patients be more assertive
- DESCRIBE: “When you refuse to talk to me about our financial situation.” (don’t label)
- EMOTIONS: “I feel frustrated” (not “You make me. . .”)
- SUGGEST: “I would prefer that you would take some time to discuss it with me.” specific behavior
- CONSEQUENCES: “so we can get along better. If not I will continue to be frustrated and angry” spell out, specific and reasonable
Promoting De-escalation
◆ Respect personal space and boundaries
◆ Violence prone people need 4X more personal space
-have a relaxed position, make them feel comfortable
◆ Don’t push, listen
◆ Hearing impaired or deaf patients at risk for more seclusion/restraints
■ Be honest and matter-of-fact, genuine concern
■ Individualize interventions specific to the patient, non-judgmental
■ Clarify what upset the patient, if they can tell you
■ Offer quiet calmness, soft voice
■ Use non-threatening body language, open stance avoid eye contact–> (may be perceived as a threat)
■ Remove jewelry etc. that could be harmful
■ Increase problem-solving
■ Decrease physical catharsis (like punching bags)
■ Soothing environment
How do you create a soothing environment?
◆ Soft music, low lights, structured activities
◆ Comfort room, decreased stimuli, allow space
✦ Position for immediate access to door
✦ Leave door open when talking to patient
✦ Know where colleagues are, let them know where you are
True or False: “She made me so angry” is a cognitive distortion.
True
Affective Interventions
◆ Validating (reflection, empathy)
◆ Listening to patient’s experience
◆ Exploring beliefs about anger
Cognitive Interventions
◆ Affirmations
◆ Offering information
◆ Classes & teachable moments
–> address the behavior right when it happens
◆ Problem solving
◆ Contracting for rewards & consequences
Behavioral Interventions
◆ Assigning behavioral tasks (homework) ◆ Bibliotherapy ◆ Identify patterns & plan ways to change ◆ Providing concrete choices (meals) ◆ Relaxation ◆ Distraction
What are the three types of nursing interventions?
- Affective
- Cognitive
- Behavioral
What is CARE?
■ Clarify the problematic behavior
■ Articulate why their behavior is a problem
■ Request a change tentatively and respectfully
■ Encourage change (pros & cons)
Psychopharmacology
■ Meds are considered a chemical restraint when given to control current aggression, this requires LOTS of documentation about previous interventions
■ The same med is NOT considered a chemical restraint if it is a standard treatment for the patient’s illness
–> cannot just restrain patients chemically with no reason
Psychopharmacology: Antipsychotics
Typical- (more research to show effectiveness, used for acute agitation) haloperidol IM (haldol)
–> watch for akasthisia which can look like increased agitation
Atypical- oral risperdone (risperdal)
–> just as effective, not as much research
Psychopharmacology: Sedatives/Anxiety Control
◆ Lorazepam (Ativan): a benzodiazepine antianxiety drug, quick onset, often used with antipsychotics in acute agitation
–> Benzos can be addictive…
◆ Buspirone (Buspar): use for aggression related to anxiety/ depression, head injury, dementia or developmental disabilities
Psychopharmacology: Mood Stabilizers
◆ Lithium
◆ Valproic acid/Divalproex sodium ER (Depakene/ Depakote)
◆ Carbamazepine (Tegretol)
Psychopharmacology: Antidepressants
Selective Serotonin Reuptake inhibitors (SSRI)
Acute Aggression Control Techniques
■ Team assistance
■ Seclusion and Restraint (a 1998 report of 142 deaths related to S and R changed how this is done nationally)
Seclusion/Restraint
Use as a LAST resort; if de-escalation does not work
◆ Can cause psychological harm to patients with previous significant physical or emotional trauma
◆ Not to be used as punitive measure
◆ Protective measure for patient and others
◆ Informed consent obtained at time of admission
◆ Physician’s order can be obtained after emergency
Nursing Care for Restrained Patient
■ Explain reason for restraint, reassure & support: confused, delirious, frightened
■ SR requires constant observation (audio/video or face to face)
■ Check VS every hour unless sleeping
■ Check extremities, Range of motion q 2 hours
–>Remove only one restraint at a time
–>Never leave patient in only one restraint
■ Offer fluids, bathroom or bedpan q hour
■ Remove restraints or unlock door when calm and able to control behavior gradual integration back into the unit
***Document thoroughly
What to document on restraints:
- Other interventions used before restraint
- Behaviors observed, mental status, mood, signs of decreased aggression
- Safety measures-check pockets
- PRN medication
How long to doctors orders last for restraints on adults? Adolescents? Children under 9 y/o? How often must physician see patient in restraints?
- -> Lasts 4 hours for adults, 2 hours for adolescents, and 1 hour for children under age 9
- -> Physician must see patient within 1 hour and every 24 hours
What are the differences in restraints?
- 2-point (both wrists)
- 3-point (both wrists and one leg)
- 4-point (both wrists, both legs)
- 6- point (both wrists, both legs, waist, upper torso)
Terminating Seclusion/Restraints
■ Talk to patient, assess readiness to move to less restrictive measures
■ Remove restraints gradually as self control returns - one extremity at a time (if 4-point)
■ Monitor patient’s response to removal
■ Debrief:
1. patient - talk about concerns regarding S and R
2. staff - what led up to event, future prevention
3. other patients
Responding to Assault on Nurses
■ Nurses must be provided with training programs in the prevention and management of aggressive behavior
■ Assaults tend to occur in situations in which the patient perceives the nurse’s actions as restricting, controlling, or aggressive
■ Reported assaults range from verbal threats and minor altercations to severe injuries, rape, and murder
■ Nurses may suppress the normal range of feelings after an assault
■ Support groups for nurses to express anger, blame, and anxiety
