pscyh wk 3-violence and aggression Flashcards
__ are more likley to be assaulted than police officers
nurses
if you use restraints improperly what can you be accused of in court
assault
what are common elements to trauma (emotional not phys)
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
how do we meas trauma
Measured by the individual’s experience of the event and the meaning they make of it
why might a person who is recounting a traumatic experience look as though they are not affected by their story
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!
what is another term for toxic stress
developmental trauma
what are examples of historical trauma and what is it
residential schools
holocaust
cumulative emot, psych trauma across the lifespan
what is intergenerational trauma
• 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
what kind of trauma might an ER nurse be at risk of developing
who else might be at risk of this
• Complex or repetitive trauma-complex PTSD (gen to people in military or healthcare exposed to multiple traumatic situations, ongoing betrayal or trust)
if someone witnesses a murder what kind of trauma are they at risk of. what other incidents might cause this
• Single incident trauma-gen r/t an unexpected or overwhelming event, natural disaster, witnessing violence
how does developmental trauma/toic stress occur and what ocurs
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
which system is activated by physiological trauma
what kind of behavioural responses might you see
the ANS
• Behave response includes hypervigilnce fear anxiety
what kind of Permanent biochem changes can occur from early trauma
hypervigilance, anxiety, hyperarousal, maybe dev disability
how can toxic stress be avoided
a stable, nurturing environment
will trauma always have a negative effect on pt (from graphic)
what affects this
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
what is the focus of trauma informed practice
Focus is on the overall approach or way of being in the relationship rather then a specific treatment strategy or method
what is trauma informed practice and what is its focus
-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
what does trauma informed practice recognize and try to prevent
-Recognize the need for physical and emotional safety
Create an environment where patients do not experience further trauma or re-traumatization
what kind of things might be traumatic for pt
implication of this
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
what does it mean to have trauma awareness
• Trauma awareness—look at the impact of trauma r/t substance use, behave changes etc…realize how globally trauma can impact person
when using trauma informed practice there is an emphasis on safety and trustworthiness
who does safety refer to here
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
how does trauma inf care empower the pt
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
t or f using a trauma informed care framework issues such as staffing and management are addressed
t
TIC looks at all things
not having enough staff can lead to trauma for pts and staff
what is anger
what kind of response is it/what system is activated
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
anger is the feeling and ____ is the behaviour
aggression
what are 3 forms of behavioural expressions of anger and a description of each
- 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
aside from the fact that they are angry why might someone use verbal hostility
because it has worked as a way to get what they want
maybe to get attn
because it is a behavioural patern
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
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
what are some early warning signs of anger
pacing, posturing (clenching fists, puffing out chest), walking intently, intense eye contact, facial expressions
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?
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
what are the pscyholgic theories that explain Anger, Aggression and Violence
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
sociocultural theories that explain Anger, Aggression and Violence
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
what is the NUMBER ONE risk factor for aggression
why might someone in hospital be triggered in this manner by us
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)
why arent angry people more receptive to your rationale about why youre doing something/seeing things from your view
• 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
t or f violence is rarely unpredictable
t
what is the umber one predictor of violence
o number one predictor is past history
what is necessary now to give someone a purple dot
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…
what kind of GI concerns could make someone violent
o Constipation-can become floridly psychotic, delirious, in discomfort
o Incontinent and unable to verbalize
a mnemonic for escalating behaviour
- STAMP
- Staring
- Tone of voice
- Anxiety
- Mumbling
- Pacing
what should your response to behaviour be
• 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
how far away from an agitated person should you be (minimum)
leg length
if someone has risk of getting violent how should you adapt their env
o Try not to keep room clear and eliminate clutter
o Keep env free from projectiles, self harm items
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
no! dont have the pt between you and the exit
where should your hands be if with agitated/angry person
in front of you and visible not crossed. open positon
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
- use soft tone of voice. choose words carefully.
- tell your coworkers where you are going
two ways you can validate the angry person
o Acknowledge that you hear and understand what the pt is saying
o Might sit and let them vent
should you be assertive if someone is being aggressive
what approach should you use
sentence example
calm respecful assertive approach
• i hear what youre sayin but right now the way youre talking to me im unable to help you
if someone is aggressive how can you adapt their environment for them
• Reduce stimulus-loud noises, interruption, bright lights—turn off the lights and dim them
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
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
is it appropriate to attempt to distract someone who is aggressive
yes. this might be effective sometimes
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
no
you can cut your losses and make sure you are safe
what do you do if violence is imminent
call securty or intiiate code white
headingsof de-escalating behaviour (i didnt make cards above for the obvious ones)
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
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
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
what kind of env interventions
aside from dec stimulus with lighting
o Maybe they need visitors to leave
o Minimal stimulation
o Maybe ask them to return to their room
what kind of PRNs might you see being used to dec agitation
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
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
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.
when is it approp to use physical restraints
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
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
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
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
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.
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
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
when might you want to give risperidone
. Risperidone is gen best for delirium (given as PRN). Haldol or loxpine are heavier duty (typical AP with more side effects)
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
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)
what are the criteria for emergency use of restraints ***
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…
should you use physical restraints and have the pt be aware of their surroundings
no. it is best to have hem heavily sedated
what are you monitoring for a restrained pt
what do you want the pt to do to prevent complications
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
what kind of debriefing should occur after restraint use
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
what does behav care planning focus on
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
what should a behavioural care plan include
is this a problem focused approach
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?)
