NUR 3105-002 Anger and Agression Lecture

Anger is a ____ emotion

Secondary

Anger (Emotion) S/S

● Pinched eyebrows / pursed lips

● Clenched fists / tense body

● Arguing/yelling

● Defensive to criticism

Aggression (Behavior) is a __ Behavior

Secondary

Aggression (Behavior) S/S

● Threatening violence

● Slamming doors / throwing things

● Destroying property

● Physical violence

Expression of anger depends on?

Social setting

Culture

Personality

Mental state

Risk factors for Violence: Extreme Aggression

Defined as Violence:

An overreaction to feelings of hopelessness, humiliation, fear, and anger

- physically harming others

Risk factors for Violence: Past Behavior

#1 Predictor of future behavior

Past history of violence is a risk factor for future violence

Risk Factors for Violence: Violence-Diagnosis Correlation

Substance abuse (alone or in combination with a mental illness) is the largest risk factor for violence

Safety Plan

If a client has a history of violent behavior, create a safety plan

- Just like you would do with a client who has a history of suicidal behavior

- The client should be an active participant in this process

Broset Violence Checklist (BVC)

Rate 1 point for each behavior

-- De-escalate if 1 to 2 points

-- 3 points or more: the client is agitated, and the risk of violence is high

-- De-escalate, suggest PRN medication, suggest timeout, show support

Broset Violence Checklist (BVC) Implicatioms

If behavior is normal for a well-known client, only an increase in behavior scores 1

(e.g., if a well-known client normally is confused and has been so for a long time) This will give a score of 0. If an increase in confusion is observed this gives a score of 1.

Broset Violence Checklist (BVC): Confused

Appears obviously confused or disoriented

May be unaware of time, place, or person

Broset Violence Checklist (BVC): Irritable

Easily annoyed or angered. Unable to tolerate the presence of others.

Broset Violence Checklist (BVC): Boisterous

Behavior is overly "loud" or noisy. For example, slams doors, shouts while walking, etc.

Broset Violence Checklist (BVC): Physically Threatening

When there is a definite intent to physically another person.

For example, the taking of an aggressive stance, grabbing another person's clothing, raising arm, making a fist, or modeling a headbutt.

Broset Violence Checklist (BVC): Verbally Threatening

A verbal outburst that is more than just a raised voice; and where there is a definite intent to intimidate or threaten another person.

Broset Violence Checklist (BVC): Attacking Objects

An attack directed at an object. For example, the indiscriminate throwing of an object; banging or smashing windows; kicking, banging, or head-butting an object; or smashing furniture.

De-escalation Techniques: Meet Basic Needs

- Offer food and drink

- Assess for pain

- Suggest rest in the room if tired

De-escalation Techniques: Distraction with a Positive Activity

- Quiet room

- Soft music

- Engage in easy task like changing a bed

De-escalation Techniques: Encourage verbalization of emotions to staff

- Or allow the client to call friend/family

- Or suggest pt journal their thoughts

De-escalation Techniques: Reduce Stimulation

- Reduce loud noises

De-escalation Techniques: Express Your Concern for the Client

" I'd like to help, how can I help you?"

" What do you need from me right now?"

" Let's figure this out together"

De-escalation Techniques: Relaxation techniques:

- Yoga/stretching / stress ball

- Progressive muscle relaxation

- Walk with pt around the unit

De-escalation Techniques: Calm Voice

Calm voice, assertive attitude, open hands, non-tense posture

If a client feels out of control, they tend to get more upset if they think you are also out of control

De-escalation Techniques: Poor Attitude

Your attitude to the client can worsen their aggression:

- Poor communication with the client like lying, arguing, not explaining things to the client

- Not treating the client with respect or responding to client's insults

- Under or over reacting to a client's aggression

Ex: Ignoring the client completely or getting loud when the client yells

De-escalation Techniques: Staff

Not having one leader talk to the client

- Multiple staff members are talking to the client at once

Assertive Communication

Be assertive - not passive or aggressive

Assertiveness: showing respect or self and others

Matter-of-fact, calm, neutral tone

Express confidence - do not overly apologise or offer excuses

Examples of Assertive Communication

- "I can't do that for you, what I can do is..."

- "I won't stand here while you curse at me, I will check on you in 10 mins."

- "I cannot give you more oxycodone; I can give you ibuprofen."

Simple Commands: Explain why the current behavior is unacceptable:

- "Banging on the nursing station makes it difficult for me to concentrate on pouring meds safely and it can upset other client too."

Simple Commands: Ask / tell the client to do a more acceptable replacement behavior:

- "Can you stop banging on the nursing station? Please wait for me in the day room. I am going to finish pouring meds, then I will come to you. I can give you my full attention then."

Simple Commands: If asking and explaining does not help, then explain consequences with two firm choices:

"I've asked you to stop banging on the nursing station, and you continue to do so. One option is that you can sit in this chair next to the nursing station so you will know exactly when I am done. If you are unable to do that, you will have to sit in your room until I am ready."

Responding to self- or other-directed violence: Locking Mechanical Restraints

Equipment to reduce the ability of a client to move their arms, legs, head, or body

- No condition is contraindicated, but there is always the risk of injury or death

For example: The goal could be to get the client out of restraints by an hour after initiation

Responding to self- or other-directed violence: Follow state law and your institution's protocol

A restraint order only lasts 4 hours for an adult, 2 hours for adolescents / children, 1 hour for children under 9 years old

Responding to self- or other-directed violence: Seclusion

- Involuntary confinement of a client in an area the client is physically prevented from leaving

- Often seen as less restrictive than mechanical restraints but could be dangerous for clients who are trying to harm self

Responding to self- or other-directed violence: Chemical Restraint

The use of PRN medication that results in sedation against the client's desire

- A chemical restraint is not a therapeutic intervention, but it is used to prevent harm

- A chemical restraint should not be used as punishment or for convenience

- A chemical restraint is used as a last resort when verbal de-escalation fails

When are chemical restraints used?

- The medication is used in an emergency to manage violent behavior

Common Tranquilizers used as chemical restraints: IV Anesthetics

Ketamine

Propofol

Common Tranquilizers used as chemical restraints: Antipsychotics

Haloperidol (Haldol)

Chlorpromazine (Thorazine)

Olanzapine (Zyprexa)

Ziprasidone (Geodon)

Common Tranquilizers used as chemical restraints: Benzo

Lorazepam (Ativan)

Midazolam (Versed)

Common Tranquilizers used as chemical restraints: Combo Medications

B52 (benadryl 50 mg + haldol 5 mg + ativan 2 mg) IM or IV)

HAC (haldol 5 mg + ativan 2 mg + cogentin 2 mg) IM or IV)

Restraining a Client:

Applying restraints is an emergency situation which you get an order for afterwards.

Team leader (which is often the charge nurse) should assign client roles - go in with a plan!

Only the leader should be talking to the client

Restraining a Client: Contraindications

Never put pressure or restraints on the client's chest; get vitals and reposition

Never leave the client alone; start unofficial 1:1 while awaiting an order

Restraining a Client: 1:1

Must be taking q15 vitals, offering hydration/nutrition, offering a bedpan for elimination, and documenting

Restraining a Client: Implications

Low- fowler's to fowler's position (promotes lung expansion and prevents aspiration)

- One arm up, one arm down prevents client of rolling over

Restraining a Client: Nurse Assessments

Consciousness, vitals, circulation, injury, comfort

Restraining a Client: Documentation

- Make sure you clearly document what behavior resulted in restraint use

- Make sure you clearly document interventions tried before the episode escalated

- Document during the restraint episode what behavior justifies the continued use of restraints

Restraining a Client: Cessation of Restraints

- Updating the safety plan with the client

- Talk to the client about what was the client's perception of the event