Chapter 27- aggression and violence

Question 1

Anger is?

Answer 1

An emotional response to frustration of desires, a threat to one’s needs (emotional or physical) or a challenge.

Question 2

Aggression is ?

Answer 2

An action or behavior that results in a verbal or physical attack.

Question 3

Violence: is?

Answer 3

Is always an objectionable act that involves intentional use of force that results in or has the potential to result in injury to another person.

Question 4

Aggression vs. Violence?

Answer 4

• Do not use two terms interchangeably
  
  • Aggression is not always bad and is sometimes necessary for self protection, can be good!
  • Violence (comes from ill intent) is bad and can cause harm

Question 5

Factors that can lead to anger, aggression and violence?

Answer 5

1. Nature:
   
   • Some individuals are biologically more predisposed than others to respond to life events with irritability, easy frustration and anger.
2. Neurological conditions can lead to anger-
   
   • brain tumors, Alzheimer’s disease, temporal lobe epilepsy and traumatic brain injury. Why, b/c of the damaged structure of the brain.
   • These changes in brain structure can effect the limbic system which is responsible for combining higher mental functions and primitive emotion into one system, learning and the formation of memories.
   • The amygdala is the emotional center of the brain , helps to evaluate emotional content of our experiences and helps to activate FIGHT or FLIGHT.
   • Men with lower amygdala volume exhibit higher levels of aggression from childhood to adulthood.
   • GABA can help to decrease aggression, in absence can lead to aggressive behavior
   • Low serotonin can lead to aggression
3. Nurture: Learned behavior
   
   • Societal norms ( domestic violence)
   • Observing and imitating behaviors
     
     • Media, family, friends
   • Exposure to trauma as a child (Trauma-Informed Care)

Question 6

Ways to prevent violence?

Answer 6

1. Be assertive
2. Identify Triggers and practice coping skills
3. Cognitive Behavioral Therapy

Question 7

How to be assertive?

Answer 7

1. Be responsible for your own behavior
2. Avoid being influenced
3. Be honest
4. Say no without guilt
5. Do not apologize for advocating for yourself
6. Learn to say no!
7. Use “I” and “We” statements instead of “You” ( dont blame them)
8. Avoid exaggerations and emotional outburst

• Note: We do not always have to be assertive about everything…in times of danger we may need to be aggressive and remember protecting yourself is not violence (for the sake of this class).

Question 8

How do we make our patients angry?

Answer 8

1. Setting limits; enforcing orders (no room mate orders, diet restrictions, no sharp objects orders, patient not having access to shoes or belt because of safety).
   
   • This can be dangerous.
   • This is necessary for a professional nurse-patient relationship. Ensures safety of self, patient and unit.
2. Note: Avoid using arbitrary ex: “Because I said so.”, TELL THEM WHY! Arbitrary: decisions based on random choice, personal whim rather than a sound and legit reason

Question 9

You set a limit, it upsets your patient…how do you know your patient is upset?

Answer 9

1. Increased demands
2. Irritability
3. Frowning
4. Redness of face
5. Pacing
6. Twisting of hands
7. Speech: rate, volume,
8. isolation

Question 10

Two Assessment for Predictor of Violence?

Answer 10

1. Two best predictors are:
   
   1. history of violence
   2. 2- impulsiveness

• ***Most important sign preceding violence = hyperactivity and or change in baseline.

Question 11

Initial Assessment of Client for Violence/ danger to self (DTS) or others (DTO), what do you do?

Answer 11

• Ask patient to assess own potential for violence.
  
  • “Have you ever physically hit or hurt someone? Could this happen while you are in the hospital?”
• IF YES:
  
  • create a CONTRACT with pt to use non-violent means.
    
    • “Talk with staff when feeling angry.”

Question 12

How to Assess for Violence?

Answer 12

• Does the person have…
  
  • Wish or intent to harm?
  • A plan?
  • Available means? How lethal is plan?
  • Gun, knife, car, poison???

Question 13

Trauma-Informed Care: Assess for violence to increase safety, how?

Answer 13

• Ask patient: Have you experienced violence or trauma? (Trauma-Informed Therapy)
  
  • What happened to you? NOT What did you do…( make them feel bad)
  • What triggers your anger?
  • How do you like to be treated when You’re upset?
    
    • We do not want to re-traumatize patient. Trauma informed care reduces use of seclusion & restraints.
• Don’t tell the patient to “calm down!” BUT…
  
  • Ask: “What helps you to calm yourself?

Question 14

PHYSICAL Signs of potential Violence?

Answer 14

1. Staring
2. Tone
3. ANXIETY – Dilated pupils, Hyperventilation
4. Mumbling
5. pacing

Question 15

When You see someone appearing angry, what do you do?

Answer 15

• De-escalation of Agitated Patient
• Pre-Assault Stage– Use verbal interventions
  
  • Identify anxiety and aggressive signs early. Talk with pt. to reduce anxiety:
  • “I see something is bothering you. I’d like to help. May we talk? Would you like to walk or sit? Give choices as possible (this empowers them).

Question 16

Learn This De-escalation, what is it?

Answer 16

• USED Before seclusion or restraints
• “Verbal Loop”Takes 5-10 minutes
  
  • Listen to patient
  • Respond in a way that agrees with or validates patient’s position
  • State what you want the patient to do: sit down, Go to Room, accept medication etc.
  • Repeat loop
    
    • listen again to the patient’s response: agree with or validate the patient’s position, state what you want pt to do.
• May have to repeat a dozen times before pt hears you.

Question 17

Talking with the agitated PATIENT?

Answer 17

• Tell the patient that: “I want to help you.”
  
  • “But I need you to be safe first.”
  • It is appropriate to say something like: “I would like to help you, but I can’t hear you if you are screaming and yelling.“
• Do not react to verbal attacks from the patient.
  
  • Use a calm and level tone voice, DO NOT YELL OR CUSS BACK….this happens more than it should…sometimes we forget we are at work…especially if we have a history of anger ourselves…
• Self reflection: How are you when someone is yelling at you? Do you shut down? Get scared? Be assertive!

Question 18

If anxiety and anger is increasing in the patient?

Answer 18

• Talk may not be effective. Remember why?
• Assess need for PRN medications ( look at their chart)
  
  • Oral medications need to be given early on
  • IM may be needed if patient is seriously agitated
    Assess evaluate or estimate the nature, quality, ability, extent, or significance of More (Definitions, Synonyms, Translation)

Question 19

Pharmacological Interventions, what’s the process?

Answer 19

1. RRT (Rapid Response Team)
2. Code gray (All who are available come for “a show of force”)
3. Tell patient why the medication is being given and potential side effects
4. Get order from the MD or NP
5. Offer between pill or IM (when its safe, use discernment)
   
   1. give IM b/c of code gray
   2. May have to hold down patient to give injection (this can be traumatizing for you and the patient, discuss in debrief)
   3. IM injections for acute symptoms of anger and aggression
6. ***Use atypical antipsychotics 2nd Generation such as olanzapine (Zyprexa) or ziprasidone (Geodon); better than 1st generation because lower incidence of EPS***
   
   1. EPS is BAD

Question 20

Pharmacological Interventions points?

Answer 20

• You can also use an antihistamine such as Benadry; -sedation
• IM injections usually are thick and can be painful so it is given in the gluteal muscles (biggest muscles); Consider patients who are malnourished.
• So what happens when talk and medications are not working? seclusion and restraints

Question 21

Seclusion and Restraints?

Answer 21

• Seclusion: Involuntary confinement alone in a room that the patient is physically prevented from leaving
  
  • RARE
  • can be dangerouse b/c need to close door
• Restraints: Any manual method, physical or mechanical device, material or equipment that restricts freedom and movement.

Question 22

Mechanical Restraints (MR)?

Answer 22

• Indication:
  
  • To protect patient from self harm and to prevent the patient from harming others

1. Legal Requirements: Multidisciplinary involvement, MD or NP sign off according to state law.
2. Patient advocate or relative informed. MR need to be removed ASAP.
3. Documentation: Pt behavior leading to MR, least restrictive measures used prior to MR, interventions use and patient’s response, plan of care for MR used, on going observations by BCA, RN, MD, NP
   
   • Clinical Assessments: Pt’s mental state at time of MR, physical examination of any medical problems causing behavior issues
4. Observation: Pt is on a 1:1 ongoing observation for duration of MR, complete written record every 15 minutes, monitor vital signs, assess range of motion, observe blood flow in hands and feet, observe that restraint is not rubbing, provide for nutrition, hydration and elimination.

Question 23

restraints Release procedure?

Answer 23

1. Pt must be able to follow instructions and stay in control before removing.
2. Remove one restraint at a time.
3. Terminate restraints and Debrief with patient.

Question 24

Debriefing with Client about restraints?

Answer 24

1. WHy it happened?
2. Use as a learning experience
3. Do not blame
4. Identify stressors and triggers
5. Plan other ways to deal with stress
6. Include patients and see if they can make suggestions of their own to help keep themselves calm and safe

Question 25

main points about restraints!

Answer 25

• ONLY use S/R when
  
  • CLEAR danger to self or others.
  • S/R Requires physician or NP order (NP is a licensed independent practitioner; Physician’s Asst. is not “independent”)
• If physician not present, RN may use S/R but RN must call physician immediately after placing pt. in seclusion/restraint and receive order.
  
  • Medication may ALSO be required.
  • S & R not used as punishment!
  • Restraint needed if patient can not keep themselves safe in seclusion

Question 26

4-Point Restraints?

Answer 26

• Head raised 30 degrees
  
  • cant be flat on their back= b/c they can choke.
• one arm up and one arm down- helps circulation
• Hands and ankles restricted on stretcher.

Question 27

Death by Restraints in Prone Position, how?

Answer 27

• Asphyxiation –most common cause of death during restraint.
  
  • Avoid prone position—interferes with breathing.
  • Children need diaphragm to breath
    
    • Do Not put Children on stomach
• Pt’s on psychotropic drugs at higher risk for death.
  
  • USE Supine position with Head RAISED 30 DEGREES
• Aspiration
  
  • Head must be raised 30 Degrees to Prevent Aspiration
  • Danger of Above the neck vests… Strangulation
• Emotional Extremes – A person under restraint may release body chemicals that sensitize the heart, producing rhythm disturbances that can result in sudden death

Question 28

Nursing Diagnoses for Angry Patients?

Answer 28

1. Ineffective coping
2. Stress overload
3. Risk for self-directed violence
4. Risk for other-directed violence

Question 29

Nursing Interventions for Clients with Cognitive Deficits (Dementia)?

Answer 29

• 1st try Reality therapy:
  
  • Give time, place etc. If not sufficient try:
• 2nd try Validation (of pt’s emotions) therapy:
  
  • Good for disoriented elderly patients.
    
    • Use patient’s name.
    • Repeat some of what patient says.Focus on patient’s feelings.
    • Let patient tell you more. Empathize.

Question 30

Use of Seclusion and Restraint: is not a punishment…It may only be used?

Answer 30

1. When client presents clear and present
   
   • Danger to self
   • Danger to others
2. Client legally detained (5150) for involuntary treatment and considered escape risk.