Topic 9: Anger, Aggression, and Violence (Ch 27)

anger

a normal emotional response to and frustration of desires, a threat to one’s needs (emotional or physical), or a challenge; can be positive if expressed appropriately or in a healthy way, and varies from mild irritation to intense fury and rage

aggression

A goal directed action or behavior that results in a verbal or physical attack that is not the same as violence, and is not always inappropriate, as it can be necessary for self-protection; the act of initiating hostilities that arouses thoughts of attack and/or a disposition to behave aggresively

violence

An objectable act that involves the intentional use of force that results in or has the potential to result in injury to another person and does not always have roots in anger but does have the discrete intention of harming a specific person or group; is unjust, unwarranted, or unlawful display; can occur at home, in communities, and in the workplace

bullying

offensive, intimidating, malicious, and condescending behavior designed to humiliate and to terrorize that infers persistent, systemic violence toward a person or group and is an intentional display and use of violence, even if subtle; is common among nurses

• genetic

• environmental

• brain tumors, Alzheimer’s, temporal lobe epilepsy, traumatic injury to certain parts of the brain that results in changes to personality

• imbalanced serotonin, dopamine, GABA, and glutamate

• demographic: males, aged 14-24, low socioeconomic status, inadequate support system, and prison time

what are the RF for aggression, anger, and violence

• on admission, gather the client’s medical and psychological/psychiatric history from a variety of sources, such as the client (when calm), family, and friends

• obtain an accurate history of the client’s background and usual coping skills, the client’s perception of the issues, if possible, history of previous violence, substance abuse, or psychotic behavior

• ask direct questions

  • have you ever thought of harming someone else

  • have you ever seriously injured another person

  • what is the most violent thing you have ever done

• *the best predictor of violence is a history of violence

what does assessment of the subjective data for a patient experiencing aggression, anger, and violence

history of violence

what is the best predictor of violence

• anger, anxious, or irritable affect

• hyperactivity

• increasing anxiety and tension: clenched jaw/fist, rigid posture, fixed/tense facial expression, and/or mumbling to self, and is expressed through verbal abuse, SOB, sweating, and rapid pulse

• verbal abuse: profanity, argumentativeness

• loud voice, change of pitch, or very soft voice, forcing others to strain to hear

• stone silence

• intense eye contact or avoidance of eye contact

• recent acts of violence, including property violence

• history of violence

• alcohol or drug intoxication

• possession of a weapon or object that may be used as a weapon

• isolation that is uncharacteristic

• suspicion and/or paranoid thinking

• suicidal ideation, overt/covert statements regarding killing oneself

• feelings of worthlessness, hopelessness, helplessness

• difficulty with simple tasks

• inability to function at the previous level

• poor problem-solving, decision-making, and cognitive functioning

• verbalization of inability to cope

• reports feelings of pressure, tension, difficulty in functioning, anger, and impatience

what S/S usually precede violence

hyperactivity

what is the most important predictor of imminent violence characterized by pacing, restlessness, and slamming doors

• loud

• overcrowded

• warm

• inexperienced staff

• provocative or controlling staff

• poor limit setting

• arbitrary revocation or privileges → staff inconsistency

what milieu characteristics may cause/precede violence

trauma-informed care

recognizing and responding to the effects of all types of traumas, focusing on the client’s past experiences of violence and the role those currently play in their lives; these can impede a patient’s ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions by staff

• risk for self-directed or other-directed violence

• ineffective coping

• risk for stress overload

• confusion

• disturbed thought process

• disturbed sensory perception

what nursing diagnosis are associated with clients who are/are at risk for anger, aggression, or violence

• develop a relationships of trust with the client and utilize therapeutic communication techniques

• approach the client in a controlled, nonthreatening, and caring manner

• emphasize that you are on the person’s side

  • doesn’t mean you must agree with them on their behavior or that you should make them feel that you are

  • means that you are there to help the agitated individual and you are not against them, even if they may interpret your actions and words that way

• stand at an angle to appear nonconfrontational

• always stay approximately 1 foot farther than the patient can reach with arms or legs

• make sure the patient is not between you and the door

• assess and provide for personal safety

• do not try to speak while the person is yelling

• speak softly, be non-provocative, and non-judgmental

• demonstrate genuineness and concern

• do not treat the individual in a humiliating manner

• ask “What will help now?”

• remember to provide trauma-informed care

what do the nursing interventions for a patient who is at risk/experiencing anger, aggression, and violence

• set clear, consistent, and enforceable limits

• maintain the patient’s self-esteem and dignity

• maintain calmness (your own and the patient’s), use a calm, clear tone of voice

• invest time

• remain honest

• Determine what the patient considered to be needed

• identify goals

• avoid invading personal space and arguing

• give several clear options

• use genuineness and empathy

• be assertive rather than aggressive

• do not take chances, maintain personal safety

• assess the patient and the situation

• identity stressors and stress indicators

• if the patient is willing, the nurse and patient should sit at a 45-degree angle

• do not tower over or stare at the patient

• listen and use clarification

• acknowledge the patient’s needs, whether rational or irrational, possible or impossible

• show respect and ask the person for the reason they are upset or what they wish to achieve

• you will receive a faster resolution with the person when you work togeher, not against eachother

• one response does not fill all

• the “thinking” brain of an agitated person is disengaged, and escalation time is not teaching time or a good time for discusion

• appeal to the survival brain, do not attempt to reason, teach, or discuss

what de-escalation techniques that are helpful when communicating with aggressive, angry, and/or violent patients

• role model the use of effective coping skills

• teach effective coping mechanisms, de-escalation techniques, and self-soothing skills to manage behavior

what does health promotion is aggressive, angry, and/or violent patients include

• A multidisciplinary approach is important for all clients

• The consistency of intervention among all team members is key to the client’s success

• when providing care, safety is always the priority

• avoid wearing dangling jewelry or scarves

• have enough staff for backup; only one person should talk to the patient

• always know the layout of the area

• do not stand directly in front of the client or the doorway, as the patient might consider this confrontational

• if the client begins to escalate, provide feedback as soon as possible

• avoid confrontation with the client

what does teamwork and safety look like when dealing with angry, aggressive, or violent patients

seclusion

involuntary confinement alone in a room or area that the client is physically prevented from leaving; is less restrictive that restraints and may be helpful in reducing sensory overstimulation

restraints

any manual method, physical or mechanical device, or material or equipment that restricts freedom of movement

medication restraint

IM injection of a barbiturate, antihistamine, or antipsychotic, depending on the provider’s order and any underlying conditions

chemical restraint

medication administration without client consent that requires a provider’s order

• those with extremely unstable and psychiatric conditions are not considered safe candidates for these treatments

• COPD

• spinal injury

• seizure disorder

• pregnancy

• dementia and delirium may make it intolerable due to the absence of stimulation

• those who are overtly suicidal

• those who require monitoring for severe drug reactions or overdoses

what are the contraindications for the use of seclusion and restraints

• requires an order from a licensed practitioner, but in emergency situations, one may be received after the fact

• Once in a restraint, a patient must be directly observed and formally assessed at frequent regular intervals for level of awareness, level of activity, safety within the restraints, hydration, toileting needs, nutrition, and comfort

• Each hospital will have its own rules to mandate how frequently to observe patients in it

• Each team member should be trained in the correct use

• once in restraints, close monitoring to determine the patient’s ability to re-integrate into the unit activities is mandatory

• Reintegration should be gradual and geared toward the patient’s ability to handle increasing amounts of stimulation

• if reintegration proves to be too much for the patient and results in increased agitation, the individual is returned to the room or another quiet area

• the patient must be able to follow commands and control behaviors before reintegration can occur

what are the interventions for seclusion/restraints

to protect the patient from self-harm and/or to prevent the patient from assaulting others

what are the indications for use of mechanical restraints

• multidisciplinary involvement

• appropriate HCP according to state law

• patient advocate or relative notification

• discontinuation as soon as possible

• cannot be PRN

what are the legal requirements for use of mechanical restraints

• behavior leading to restraint/seclusion

• the least restrictive intervention/method used before restraint

• interventions used and patients’ response to interventions

• plan of care for restraint/seclusion implemented

• ongoing evaluation by nursing staff and appropriate HCPs

what does documentation for the use of mechanical restraints include

• mental state at the time of restraint

• physical exam for medical problems possibly causing behavioral changes

• need for restraints

what clinical assessments are requires when mechanical restraints are used

• Staff are in constant attendance

• Complete a written record every 15 minutes

• monitor VS

• assess ROM

• Observe blood flow in hands/feet

• observe that restraint is not rubbing

• provide for nutrition, hydration, and elimination

what does observation for a patient in mechanical restraints include

• the patient must be able to follow instructions and stay in control

• termination of restraints

• debrief with patients

what does the release procedure for a patient in mechanical restraints include

• physical holding of a patient against their will

• four side rails up, except in seizure precautions

• keeping patients in their rooms by physical interventions

• tucking sheets in so tightly that patients cannot move

what are the types of restraints

critical incident debriefing

occurs immediately after the seclusion or restraint episode, in which staff analysis of the episode of violence occurs and each staff member critically examines their response to the client

staff analysis

assures quality of care and provides opportunity for self-care for staff members

• the violent episode itself, staff responses, and the client’s response

• behaviors that occurred as the patient was escalating

• nursing interventions and patients’ responses to them

• Evaluation of the interventions used

• detailed description of the patient’s behaviors during the assaultive state

• all nursing interventions used to defuse the crisis

• patient’s response to those interventions

• observations of the patient and interventions performed while the patient was in restraints and/or seclusion

what does documentation for critical incident debriefing including

1. meet the needs of the person you’re dealing with

2. reflect respect and dignity toward the person you’re dealing with

3. maintain the safety of everyone involved

what are 3 guiding principles for every situation

• discounted

• embarrassed

• frightened

• found out guilty

• humiliated

• hurt

• ignored

• inadequate

• insecure

• unheard

• out of control of the situation

• rejected

• threatened

• tired

• vulerable

what feelings may precipitate anger

PRN medication

appropriate to offer when the patient is showing increased S/S of anxiety or agitation to alleviate the symptoms, and when used, can prevent an aggressive or violent incident

antipsychotics and antianxiety meds

what classes of meds are used for the treatment of acute symptoms of anger and aggression

• Haloperidol (Haldol)

• Loxapine (Adasuve)

• Olanzapine (Zyprexa)

• Ziprasidone (Geodone)

what antipsychotics are used in the treatment of acute anger and aggression

• Lorazepam (Ativan)

• Alprazolam (Xanax)

• Diazepam (Valium)

what antianxiety meds are used in the treatment of acute anger and aggression

• diphenhydramine (Benadryl)

• benztropine (Cogentin)

what non antipsychotics/antianxiety meds are used in the treatment of acute anger and aggression

the underlying psychiatric disorder

what is long term treatment of anger, aggression, and violence based on

• SSRIs

• lithium

• anticonvulsants (Gabapentin)

• benzodiazepines

• SGAs

• Beta blockers

• psychostimulants (ADHD)

what are some meds used for the long term treatment of anger, aggression, and violence

• find ways to reestablish or substitute similar means of dealing with hospitalization

• Problem solving occurs in collaboration with the patient in interactions that demonstrate the nurse acknowledges the patient’s distress, validates it as understandable under the circumstances, and indicates a willingness to search for a solution

• Validation includes making an apology to the patient when appropriate, such as when a promised intervention has not been delivered on

• may be unable to moderate emotion or communication

• Naming this feeling can lead to a dissipation of the anger, help the patient feel understood, and lead to a calmer discussion of the distress

What do interventions for patients with healthy coping skills who are overwhelmed include

• lose of autonomy and control

• uncertainty of illness

what can overwhelm/cause distress in patients with healthy coping skills

• begin with attempts to understand and meet the patient’s needs

• moderate baseline anxiety by providing comfort items before they are requested to build rapport and act symbolically to reassure

• reducing ambiguity or uncertainty can also help to minimize anxiety, and using clear and concrete communication

• use distractions like magazines, action comics, and video games

• make the treatment team predictable

• once anxiety is moderated than the nurse can teach alternative behaviors and strategies

• for those who externalize blame, precede teaching gently

• avoid a punitive or demeaning response that might have fueled the escalation of the patient’s anger

• teach a number of strategies

• provide the patient with choices

What do interventions for patients with marginal coping skills who are overwhelmed include

marginal coping skills

• these patients are poorly equipped to use alternatives when their initial attempts to cop are unsuccessful or inappropriate

• frequently manifests anger and intimidation that moves quickly from anxiety to aggression

• anger and violence are particular risks in inpatient settings, especially for hospitalized patients with chemical dependence who may be anxious about being cut off

• most have personality styles that externalize pain, and relief must also com efrom an outside source

• leave the room at the point where verbal abuse begins

• avoid arguing, threatening, or responding negatively to the patient

• withdrawal of attention to verbal abuse is successful only if a second intervention is also used, attending positively to and thus reinforcing appropriate communication like discussing non-illness related topics, responding to requests, and providing emotional support

• a predictable routine may reduce anxiety

If attempts to teach alternatives to a patient with marginal skills have not been successful, you should…

cognitive deficits

patients with what are at risk for acting aggressively due to Alzheimer’s, dementia, delirium, or brain injury

• reality orientation: correct information to the patient about place, data, and current life circumstances

• some may not be able to “enter into our reality” and become frightened and more agitated

• orientation aids like calendars and clocks can provide easy reference and increase autonomy

• sedating meds may calm agitation, but the risks outweigh the benefits as they cloud a patient’s sensorium, making disorientation worse, and increasing the risk of falls

• if delirious, treat the medical/underlying cause

• medicate symptoms of delirium with low-dose antipsychotics

• make the environment simple, predicatble, and as comfortable as possible

  • place the patient’s bed away form doorways that enter to the hall, choosing not to turn on the TV, establish a routine of activities for each day, display the client’s schedule prominently in the room, provide familiar photos and objects from home, a rocking chair can provide a rhythmic source of self-soothing

what are interventions when dealing with patients with cognitive deficits who are experiencing anger, aggression, or violence

catastrophic reaction

severe agitation and aggression that a patient with a cognitive disorder experiences; the patient may scream, cry, or strike out because of overwhelming fear

• calm and unhurried care

• identify what preceded the episode

what are the interventions for a patient with cognitive deficits who is having a catastrophic reaction

validation therapy

can be used in patients who misperceive their setting or life situation to calm themselves

• it is not helpful to reorient the patient, instead reflect back to the patient the feelings behind their demand

• show understanding and concern for their worry

• ask the patient to describe the setting/situation reported to be a problem

• comment on what appears to be underlying the distress, thus validating it

what are interventions for patients who misperceive their setting or life situation to calm themselves; aka what does validation therapy consist of