Ch 24 Anger, Aggression , Violence

true or false

workplace violence in health care system is higher than for private sector industries

true

true or false: those w/ psychiatric disorders are five times more violent than those w/ out (r/t disconnection to reality, lack of impulse control)

what are examples of some that have an increased risk of being the perpetrator and victums of violence?

true

ADHD, ODD, PTSD, dementia paranoid delusions, and personality disorders

true or false

medical/neuro disorders like TBI, temporal lobe epilepsy, brain tumor, infections, intoxicated w/ drugs and alcohol increase risk for violence

true

these 2 structures are a part of what system that contibute to our emotional responses?

- hippocampus

- amygdala (vital nexus in neural network supporting aggression and violence)

limbic (system)

these are _______ that contribute to our emotional responses

serotonin and GABA tend to lower aggression

more serotonin and GABA tends to have less risk for aggression

neurotransmitters

MALES OR FEMALES age 15-24 may have a higher risk of violent episodes

males

w/ kids: if they had serious episodes of aggression (fire setting, animal cruelty)

these are ______ flags for conduct disorder that often later in life becomes manifested w/ a lot of violence

red

true or false

childhood aggression is a really strong predictor of adult violence

true

these are signs and symptoms that usually (but not always) precede violence

- anger, _____ effect

- _________: most important predictor of imminent violence (ex: pacing, restlessness, slamming doors)

- increasing _____ and tension: clenched jaw or first, rigid posture, fixed or tense facial expression, mumbling to self (pt may have shortness of breath, sweating, and rapid pulse)

- _____ acts of violence, including property violence

- ____ silence

- suspiciousness or ______ thinking

- alcohol or drug intoxication (_______)

- _________ of weapon or object that may be used as a weapon like a fork

irritable
hyperactivity
anxiety
recent
stone
paranoid
withdrawal
possession

these are ___________ characteristics conductive to violence

- loud

- overcrowding

- staff inexperience

- provocative or controlling staff

- poor limit setting

- staff inconsistency

milieu - pay attention to these. these are our responsibility

when you are assessing a patient:

identify patient _________ before it escalates into acting out behavior

deescalate the situation so you can communicate w/ patient, meet their needs, and avoid aggression and violence

anxiety

a strong factor for violent outcomes is

history of recent acts of violence

true or false

TRUE!

what is always the first priority?

safety

most important aspect is _____________ of the staff response (use of well trained staff skilled in use of de escalation techniques)

does staff know how to work together during an emergency incident?

do they know how to safely restrain a client together?

do they know the unit norms and limits that have to be enforced?

if there is inconsistency with the staff, it tends to escalate anger in the clients

consistency

true or false

you should search belongings to make sure they don't have cig lighters, hair dryers

true

true or false

give yourselves plenty of space w/ patients. be in b/w patient and the door

true

true or false

if you are ever uncomfy and you need help, step out, tell the patient "I will be back in just a moment"

true

true or false

if you have to intervene in an incident of violence on the unit, make sure there is enough staff (how many?)

true - 5 staff and 1 team leader

true or false

typically give patient a choice if they're going to go to seclusion or be put in restraints (typically won't want to do that)

true

true or false

if we have to put someone in restraints, need a team leader that helps bc that one nurse will talk to the patient (don't want it to seem like a bunch of staff is ganging up on them)

true

make the patients aware of _____ and consequences of not adhering to the ______ before incidents occur. the patient should be told in a clear, polite, and ____ manner what the limits and consequences are and should be given the opportunity to discuss any feelings or reactions to them

limits x2
firm

all _______ should be supported by the entire staff, written in the care plan, and communicated verbally to all involved

limits

when a decision to discontinue the _______ is made by the entire staff, the decision is based on consistent desired behavior, not ______ or sporadic efforts

limits
promises

what stage of the violence cycle

- try to keep the patient calm

- figure out what the patient needs (if we able to meet a need, may be able to avoid incident)

- emphasize that we are to help the patient

- use de escalation approaches

- use verbal de escalation

- have calm and in control person- pt will pick up on our emotions

- speak softly and in a reassuring nonjudgemental tone

- if we are sitting with them, sit at an angle

preassaultive

what stage of the violence cycle

- includes medication, restraint, seclusion (try not to do these unless needed - it really affects the relationship and trust)

- have to get client's behavior under control to prevent them from injuring themselves and others and property

assaultive (stage)

in the assaultive stage of the violence cycle we typically need to use an __________ in most cases

injection (it's hard to get a client to take an oral med and they take 30-60 min before they start to calm down)

what stage of the violence cycle

- removing them from seclusion or restraints

- they have calmed down

- think about how to reintegrate them into the unit- if other patients saw them be aggressive or violent it can be a strange vibe between patients on the unit

- how are we going to help them process the event they just experienced where they were assaultive and led them to be secluded or in restraint

- manage relationship in terms of trust bc we just put them into seclusion or restraints- may be hard for patient to trust the staff

- crisis debriefing- is there anything different we could have done?

postassaultive (stage)

these patients are vulnerable to use of violence as a way to handle ____________

- poor coping skills

- suffer from mental health disorders

- w/ neuro problems

- someone w/ substance use issues

anxiety

these are techniques to decrease ________

- communicate w/ patient

- distraction

- teaching basic coping skills to manage heightened anxiety

anxiety

reality ________ may not work because of a patient's deficits (neurocognitively impaired patient)

orientation

for a neurocognitively impaired patient,

use ________ therapy where you ask patient to describe setting or situation reported

validation

for a neurocognitively impaired patient,

adopt a _______, unhuried manner when responding to patient's agitation/aggression

calm

this is a type of psychotherapy for angre/aggression that teaches anger managements skills

the gold standard for treating anger/aggression

CBT (cognitive behavioral therapy)

these are behavioral interventions based on ____________ theory (use of token economy)

type of psychotherapy

social learning

this is based on social learning: works well with kids and adolescents. working/trying to display better behaviors in hopes of earning enough points or tokens to get a reward

token economy

a type of psychotherapy that is useful in treating violence and anger in male forensic patients, those w/ personality disorders

special form of CBT that focuses on mindfulness and thinking intensely about your won thoughts and being aware of those in the moment before you react

dialectical behavioral therapy (DBT)

what do you give for acute aggression

high potency typical antipsychotics and atypical antipsychotics

benzodiazepines

what meds are for chronic aggression?

- anticonvulsants: carbamazepine

- antipsychotics

- beta blockers

- lithium carbonate

- SSRI

- buspirone

(may have a combo of these classes to treat chronic aggression. also want to use therapy which might be the most beneficial piece)

when intervening with an aggresive patient clarify without a lot of __________
don’t ask what?

reflection

(in an escalating situation, there's not a lot of time for open ended questions and reflection. be more simple and short for questions and responses)

Don’t ask why, stay with who, what, when, where, how

Interventions for Catastrophic Reactions of Neurocognitively Impaired Patient (theres 12)

1. Face the patient from 2 feet, remaining as calm and unhurried as possible.

2. Say the patient’s name.

3. Gain eye contact.

4. Smile.

5. Repeat steps 2 through 4 several times if necessary, to gain and maintain eye contact.

6. Use gentle touch, and keep your voice soft (the person often matches this tone and lowers his or her voice also).

7. Ask the patient if there is a need to use the bathroom.

8. Help the patient regain a sense of control—ask what is needed.

9. Validate the patient’s feelings: “You look upset. This can be a confusing place.”

10. Use short, simple sentences. Complex explanations just represent more noise.

11. Decrease sensory stimulation.

12. Get the patient to use rhythmic sources of self-stimulation (e.g., humming, a rocking chair).