pscyh wk 3-violence and aggression

Question 1

__ are more likley to be assaulted than police officers

Answer 1

nurses

Question 2

if you use restraints improperly what can you be accused of in court

Answer 2

assault

Question 3

what are common elements to trauma (emotional not phys)

Answer 3

Involves a single or multiple experiences
Contains common elements:
-It was unexpected
-The person was unprepared
-There was nothing the person could do to stop it from happening
Trauma is beyond a person’s control

Question 4

how do we meas trauma

Answer 4

Measured by the individual’s experience of the event and the meaning they make of it

Question 5

why might a person who is recounting a traumatic experience look as though they are not affected by their story

Answer 5

We have protective mechanisms that can shield us from the event.
A lot of people react to trauma differently. We must go to what the persons experience of the trauma was!

Question 6

what is another term for toxic stress

Answer 6

developmental trauma

Question 7

what are examples of historical trauma and what is it

Answer 7

residential schools
holocaust

cumulative emot, psych trauma across the lifespan

Question 8

what is intergenerational trauma

Answer 8

• Intergenerational trauma—the cycle of abuse. People who have had trauma and then their kids will also exp the trauma through the parents response to that trauma

Question 9

what kind of trauma might an ER nurse be at risk of developing
who else might be at risk of this

Answer 9

• Complex or repetitive trauma-complex PTSD (gen to people in military or healthcare exposed to multiple traumatic situations, ongoing betrayal or trust)

Question 10

if someone witnesses a murder what kind of trauma are they at risk of. what other incidents might cause this

Answer 10

• Single incident trauma-gen r/t an unexpected or overwhelming event, natural disaster, witnessing violence

Question 11

how does developmental trauma/toic stress occur and what ocurs

Answer 11

Usually infants-adolescents-can involve neglect, trauma, abuse. The caregiver of the person. People think that some dev disabilities may be d/t this. Kids require comforting and soothing to dec their stress response. If the kid cant get that feedback and relief of stress this can impact the str of the brain.
• The extended absence of comforting–>continued stress response which is set at high alert
• The neural connections dec d/t prolonged activation of stress hormones
It is like an inadvertent head injury

Question 12

which system is activated by physiological trauma

what kind of behavioural responses might you see

Answer 12

the ANS

• Behave response includes hypervigilnce fear anxiety

Question 13

what kind of Permanent biochem changes can occur from early trauma

Answer 13

hypervigilance, anxiety, hyperarousal, maybe dev disability

Question 14

how can toxic stress be avoided

Answer 14

a stable, nurturing environment

Question 15

will trauma always have a negative effect on pt (from graphic)

what affects this

Answer 15

not necessarily it may help them grow and positively affect them

the person may react differently based on their experience, health, upbringing etc.

they might be able to make positive meaning from the experience, develop resilience, grow and enhance their mental, physical health, relationships, community etc

Question 16

what is the focus of trauma informed practice

Answer 16

Focus is on the overall approach or way of being in the relationship rather then a specific treatment strategy or method

Question 17

what is trauma informed practice and what is its focus

Answer 17

-Services take into account an understanding of trauma in all aspects of service delivery

Focus is on the overall approach or way of being in the relationship rather then a specific treatment strategy or method

Question 18

what does trauma informed practice recognize and try to prevent

Answer 18

-Recognize the need for physical and emotional safety

Create an environment where patients do not experience further trauma or re-traumatization

Question 19

what kind of things might be traumatic for pt

implication of this

Answer 19

just coming into hospital
anything we do could be traumatic, depending ont heir experience

always inform pts what you are going to do and ask their permission before doing it

Question 20

what does it mean to have trauma awareness

Answer 20

• Trauma awareness—look at the impact of trauma r/t substance use, behave changes etc…realize how globally trauma can impact person

Question 21

when using trauma informed practice there is an emphasis on safety and trustworthiness

who does safety refer to here

Answer 21

this isn’t just to do with the pt. Also safety for staff. Keep in mind the impact that witnessing trauma can have on you as the nurse

safety for everyone eg other staff, family etc

Question 22

how does trauma inf care empower the pt

Answer 22

gives Opportunity for Choice, Collaboration and Connection

Strengths Based and Skill Building–• When doing a behave care plan we always start w the pts strengths, what do they have that can work rather than whats wrong with you and how can we fix it

we ask their permission and involve them in care

it is a person centred framework

Question 23

t or f using a trauma informed care framework issues such as staffing and management are addressed

Answer 23

t
TIC looks at all things

not having enough staff can lead to trauma for pts and staff

Question 24

what is anger

what kind of response is it/what system is activated

Answer 24

Affective state experienced as the motivation to act in ways to warn, intimidate or attack those who are perceived as challenging or threatening

Part of the flight/fight response to help resolve a situation

Question 25

anger is the feeling and ____ is the behaviour

Answer 25

aggression

Question 26

what are 3 forms of behavioural expressions of anger and a description of each

Answer 26

• Suspicious behaviour–then starts out w suspicious or anxious behave. asking lots of questions
• Verbal hostility—they aren’t hearing what you are saying. Sarcastic comments, blaming, threats,
• Physical violence—striking, throwing…with the motivation and intent to cause harm. Sometimes there might not be direct intent eg in delirium

Question 27

aside from the fact that they are angry why might someone use verbal hostility

Answer 27

because it has worked as a way to get what they want

maybe to get attn

because it is a behavioural patern

Question 28

angry people exhibiting suspicious behaviour are often anxiously asking lots of questions why is this and how much does it help calm them to answer their question

Answer 28

Theyre asking lots of Qs but not getting their perceived needs met. They might have underlying paranoia. Might be that no matter what you say they cannot take in what you are saying

Question 29

what are some early warning signs of anger

Answer 29

pacing, posturing (clenching fists, puffing out chest), walking intently, intense eye contact, facial expressions

Question 30

there are
Biologic Theories
Psychological Theories
Sociocultural Theories

of why peope get angry. what are some biologic reasons? and what is the best way to address it?

Answer 30

treat the cause, delirium, malnutrition, hypoxia, neurodegenerative, TBI (the injury would be in frontal lobe)—often with TBI pts they can turn on a dime, no forewarning

o delirium
o infection
o brain injury
o substance use
o dementia
o pain—look for alternatives if they have substance use history. She tries to get PRN drugs for them as she doesn’t think it is her job to detox the pt
o CIWA—if youre seeing tremors, ahlluciantions, etc youre way too late..if you have older lady who hs a small aount of alcohol use each day and comes in and stops drinking you should investigate the pt for ETOH use.
o Trauma—always ask permission even just for BP. Don’t assume that you ahve trust
o Constipation-can become floridly psychotic, delirious, in discomfort
o Incontinent and unable to verbalize
o Hypo/hyperglycemia
o Sleep disturbances
o Nicotine withdrawal
o Sensory deficits

Question 31

what are the pscyholgic theories that explain Anger, Aggression and Violence

Answer 31

o Bandura….the kid throws a temper tantrum (when they aren’t getting their way/getting attention) and the parent wants the kid to stop so they will take time and calm the kid down. Consequently the kid may see anger/aggressio as a way to get attn.
o BPD-maladaptive cog schema-taking in info and skewing it
o From book-cognitive theories suggest that we all have cognitive schemas (organized patterns of thought/information eg judgements, self esteem) that influence our anger response. For example someone will be react more intensely if the person agitating them is undesirable or if the other persons intent is to harm them. In people with maladaptive cognitive schemas eg borderline personality disorder they will take in reality and perceive it in a skewed way

Question 32

sociocultural theories that explain Anger, Aggression and Violence

Answer 32

Violent behave has multiple determinants
o	Peer settings
o	Cultural influences
o	Formation of their ethics
o	Social consequences of aggression, is it being condoned
o	Inequalities in relationships

Question 33

what is the NUMBER ONE risk factor for aggression

why might someone in hospital be triggered in this manner by us

Answer 33

perceived disrespect

We almost always have the power position
• The imposition of restrictions on people is a trigger/getting into power struggles with them

(i assume they could feel we are enacting our will without taking into account their needs/wishes)

Question 34

why arent angry people more receptive to your rationale about why youre doing something/seeing things from your view

Answer 34

• Anger and aggression often arise fromt eh belief that his or her view of a situation is the only correct one—youre tring to explain something but they aren’t hearin you

Question 35

t or f violence is rarely unpredictable

Answer 35

t

Question 36

what is the umber one predictor of violence

Answer 36

o number one predictor is past history

Question 37

what is necessary now to give someone a purple dot

Answer 37

Nowadays we need two nurses to initiate a purple dot on a patient. Now we must write a specific behave care plan as to why the pt is now a violence risk..what happened, triggers…

Question 38

what kind of GI concerns could make someone violent

Answer 38

o Constipation-can become floridly psychotic, delirious, in discomfort
o Incontinent and unable to verbalize

Question 39

a mnemonic for escalating behaviour

Answer 39

• STAMP
• Staring
• Tone of voice
• Anxiety
• Mumbling
• Pacing

Question 40

what should your response to behaviour be

Answer 40

• Assess for trigger

• Identifying and treating the underlying cause
most of the time when you ID the early signs you can prevent the agitation
• Detect the early signs of agitation (and treat early eg with meds)
• Stance
o You become aware of your posture
• Vocal communication
o Let staff know where youre going
o Voice gets very soft and slow. Become very aware of the words that you are using
• Body language
• Validation
o Acknowledge that you hear and understand what the pt is saying
o Might sit and let them vent

Question 41

how far away from an agitated person should you be (minimum)

Answer 41

leg length

Question 42

if someone has risk of getting violent how should you adapt their env

Answer 42

o Try not to keep room clear and eliminate clutter

o Keep env free from projectiles, self harm items

Question 43

your pt is highly agitated and pacing near the entrance of her room
should you walk past her into her room and see if you can assess what is going on

Answer 43

no! dont have the pt between you and the exit

Question 44

where should your hands be if with agitated/angry person

Answer 44

in front of you and visible not crossed. open positon

Question 45

how should you adapt your verbal communication when dealing with angry person
what should you verbalize and to before you go into an angry pts room

Answer 45

• use soft tone of voice. choose words carefully.

- tell your coworkers where you are going

Question 46

two ways you can validate the angry person

Answer 46

o Acknowledge that you hear and understand what the pt is saying
o Might sit and let them vent

Question 47

should you be assertive if someone is being aggressive
what approach should you use
sentence example

Answer 47

calm respecful assertive approach

• i hear what youre sayin but right now the way youre talking to me im unable to help you

Question 48

if someone is aggressive how can you adapt their environment for them

Answer 48

• Reduce stimulus-loud noises, interruption, bright lights—turn off the lights and dim them

Question 49

t or f someone aggressive is to cognitively compromised to hear your explanations of rationale for your actions and explaining will only agitate them more because it is a demonstration of power

Answer 49

f
• Explain your actions and be fair about setting expectations eg this is why I am doing this. Make sure youre not making reactionary right now were going to have your visitors come back in awhile becaue youre upset right now

Question 50

is it appropriate to attempt to distract someone who is aggressive

Answer 50

yes. this might be effective sometimes

Question 51

if you are explaining something to a client and they suddenly get quite agitated iss it wrong to leave their room even if mid sentence

Answer 51

no

you can cut your losses and make sure you are safe

Question 52

what do you do if violence is imminent

Answer 52

call securty or intiiate code white

Question 53

headingsof de-escalating behaviour (i didnt make cards above for the obvious ones)

Answer 53

Offer choice whenever possible
Gently reality orient if appropriate
Avoid touching patient or use caution when doing so
Leave the situation or request help from a colleague
Never put yourself at risk
If violence is imminent, call security (18575; 222) or initiate Code White
Use a calm, respectful, assertive approach
Be aware of your verbal and non-verbal communication styles
Reduce stimulus
Explain your actions and be fair about setting expectations
Provide space and/or offer distractions when appropriate

Question 54

what order would you do the following in (in least resistive to most)

env intervention
verbal redirection and behavioural expectations (example?)
physical restraints
chemical restraints 
seclusion
use of PRNS

what can happen if you dont follow the order least to most

Answer 54

Verbal redirection and behavioral expectations eg 	I cant help you when youre yelling at me
Environmental intervention-
Use of PRNs
Chemical restraints
*Seclusion
Physical restraints

you can lose nursing licence and get sued if not

Question 55

what kind of env interventions

aside from dec stimulus with lighting

Answer 55

o Maybe they need visitors to leave
o Minimal stimulation
o Maybe ask them to return to their room

Question 56

what kind of PRNs might you see being used to dec agitation

Answer 56

o Meds that help to de escalate agitated behave
o Primarily benzos and antipsychotics
o Benzos don’t treat the cause just the symptoms
o The antipsychotics are more if you suspect delirium. Risperidone is gen best for delirium. Haldol or loxpine are heavier duty (typical AP with more side effects)
o Its like treating pain

Question 57

if you have a pt who is feeling anxious should you use IM ativan?

if giving chemical restraint how does your care of the pt change

Answer 57

o You need specific orders for chemical restraints. you must use PRNS for their ordered purpose (obviously). it should state that it is a restraint
o You cant use IM ativan regularly!! It is a chemical restraint!

Level of observation inc significantly. LOC, ABC, posture. Require almost constant observation 1:1 if providing IV midazolam. Usually effective but only manages behavior short term.

Question 58

when is it approp to use physical restraints

Answer 58

if youve tried the other methods from least to most

if its a sudden emergency and you dont have time to use the other methods and theyre in serious danger of hurting themselves or others eg trying to jump off toilet or baning their head against a wall

Question 59

t or f

it is never appropriate to use restraints without a drs order

you can use a feeding table or blankets as a restraint if necessary

a care aid or PSO can initiate restraints if the pt is being aggressive towards them

it is not appropriate to use restraints if someone is a fall risk at night

Answer 59

f in an emergency you can provided you satisfy a bunch of conditions explained later

f you cannot use anything but VIHA specified physical restraints

F
only a nurse can initiate restraints.

t. you cant use restraints for fall risks. this is workload issue

Question 60

if you use restraints for emergency without Drs orders and the pt i unable to give consent who do you contact and what are you seeking

Answer 60

o If attempted to use interventions and cant get consent for patient then can use restrains but there has to be an order within 12 hoursby the dr and have to have identified the underlying cause and used additional or alternative methods.

Question 61

if pt is in restraints how often do you need to trial them out of restraints?
is this done even if you know it will fail?

if you have pt in restraints what do you need to create

Answer 61

Trial the pt out of restraints q4 even if it will fail miserably. Having PSO there is a good idea

make a clear behavioural care plan

Question 62

when might you want to give risperidone

Answer 62

. Risperidone is gen best for delirium (given as PRN). Haldol or loxpine are heavier duty (typical AP with more side effects)

Question 63

if you have a pt who has a known violence histroy what might you want

if a pt has hx of delirium and is about to undergo sx or other thing that might trigger it what should you talk to them about

Answer 63

you should check their PRNs and maybe suggest ordering chemical restraints

talk to them about possibility of needing restraints after (you should have consent if restraining pts)

Question 64

what are the criteria for emergency use of restraints ***

Answer 64

The patient is a serious danger to him/herself (including interfering with life-sustaining treatment) or others and…
The patient does not appear to be capable of giving or refusing consent to the use of restraints and there is no substitute decision maker immediately available and…
The restraint is least restrictive for the situation and used for the least time possible and…
Assessment, intervention, care planning (including agreement to by a medical/nurse practitioner), and consent are completed within 12 hours
A health care provider is available and has been trained in:
assessment of unsafe behaviour and when restraint is appropriate
alternative strategies/approaches to managing unsafe behaviour
the use and monitoring of type of restraint required and…

Question 65

should you use physical restraints and have the pt be aware of their surroundings

Answer 65

no. it is best to have hem heavily sedated

Question 66

what are you monitoring for a restrained pt

what do you want the pt to do to prevent complications

Answer 66

Assess patient every 15-60 minutes - or constantly if required. (1:1 nursing as needed)
What am I watching for?
ABC’s
Level of sedation
His/her safety needs
Circulation/sensation of restrained extremities–have them doing ROM exercises
Proper body alignment/joint mobility
Health care providers must monitor the physical and emotional well-being of the restrained patient and reassess the ongoing need for restraint and the safe use of restraints

Question 67

what kind of debriefing should occur after restraint use

Answer 67

Monitoring the emotional well-being of the patient, their family, self and colleagues
May be a brief, informal check-in or a formal critical incident debrief
De-Brief

Question 68

what does behav care planning focus on

Answer 68

Maintaining both the safety of staff and the quality of patient care

• Decreasing the frequency or intensity of the behaviour
• Preventing secondary complications that may result from the behaviour
• Integrating violence prevention interventions into care plans

Question 69

what should a behavioural care plan include

is this a problem focused approach

Answer 69

from slides

• Description of the patient’s usual or baseline behaviour
• Description of the unsafe behaviour–be very very specific eg while washing pts legs pt spat at nurses face and threw tissue box blah blah
• History of prior traumatic experience
• Proposed action plan
• the kind of restraints to be used if required and the circumstances under which they would be used
• patient preference for type of restraints where possible
• that valid consent to the plan has been sought and received from the patient or patient’s substitute decision maker

So trigger, action and what youre going to do about it

not problem focused. include their strengths as well! (not sure how though?)