Abuse, Agression, and Violence

abuse

systematic strategies to obtain dominace and control of others

people who experience abuse → higher risk of SUD, anxiety D, depressive disorders, eating disorders, BPD, PTSD

physical abuse findings

body: bruises, lacerations, burn marks, fracture bones, puncture wounds, wounds in various stages of healing

emotional abuse

threats, insults, intimidation

emotional abuse signs

social withdrawal or non-responsive communication

loss of esteem

anxiety provoked by certain people

pt own report of verbal or mental mistreatment

sexual abuse

forced, inappropriate, unwanted sexual contact, and actual or threatened sexual violence

photographs that are sexually explicit, indecent exposure, unwanted touching, rape, forcing individuals to engage in sexual acts, or coerced nudity

grooming, luring, exposure to unwanted sexual content

sexual abuse s/s

fear of people or places

sexually explicit behavior or sex play

regression behaviors

developmentally inappropriate interest in human sexuality

discomfort, bruising, bleeding around breasts, genitals

unexplained STIs

underclothing that is damaged or contains bloodstains

pt’s report

neglect or abandonment

leaving at-risk individuals alone or without means to acquire basic life necessities

neglect, abandonment s/s

• unattended/ untreated health problems

• malnutrition, untreated pressure injuries, poor hygene

• hazardous/poor living conditions

• desertion of vulnerable individual

• pt report

economic abuse

misuse of another’s financial resources

stealing, forging checks, promising to pay bills for a person but keeping the money for themselves, and falsifying wills or financial records

exploitation s/s

sudden banking changes

abrupt changes in availability of funds, possession, wills, or other financial doc

individual does not remember signing financial records

pt report

aggression

the deliberate attempt to harm or destroy and is referred to as hostile aggression

anger

intense emotion

when controlled and expressed in appropiate manner = good

unrestrained → physical and emotional effects => HTN, h/a, insomnia, GI issue, inc possibility of harming self-or other

anger displayed as

cursing, sarcasm, yelling, breaking an inanimate object, or making a fist, but is not often followed by an aggressive act.

anger and neurotransmitter

high 5-TH

schizo, ASD, ADHD

ASD more likely to exhibit self-harm but can act aggressively for perceived threats

violence predisposed disorders

SUD, TBI, PTSD, Bipolar I, impulse control disorders, ADHD

Adverse childhood experiences (ACEs)

before 18 → can affect later in life

• Experiencing violence, abuse, or neglect

• Family member attempted or died by suicide 

• Observing violence in the home

• Unsafe or unstable home environment (substance misuse, mental illness, parental or sibling separation)

comorbidities

schizophrenia, psychosis, anxiety disorders, substance use disorders, bipolar disorder with mania, major depressive disorder (MDD), attention-deficit/hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), conduct disorders, and personality disorders.

• TBI, brain tumors, inflammatory brain disease

risk factors for violence

• History of violence

• Being the victim of a crime

• Witnessing abuse or violence

• Poor self-esteem and inadequate coping skills 

• No presence of positive role models throughout childhood

• Adverse childhood experiences

predictors of violence

• Inability to control aggressive impulses

• Not being able to understand the consequences of their actions

• Lack of remorse when interacting with others

• Substance use

The inclination to be violent, angry, or aggressive can occur when a person feels

deceived, invalidated, frustrated, attacked, threatened, powerless, and/or treated unfairly, feelings or possessions are not being respected.

Brunner syndrome

deficit of MAO-A that disintegrated 5-TH

impulsivity, aggression, mild cognitive impairment, and violence

recessive X

Medical conditions and violence

brain tumors, traumatic brain injuries, and clients who have Alzheimer’s disease or temporal lobe epilepsy

injury to prefrontal cortex, limbic system, amygdala

release of endorphins from

screaming at, embarrassing, or injuring others can provide a high similar to an adrenaline surge

→ can become addictive

another ex. cutting from BPD

displacement

redirect troublesome thoughts to a safer person, animal, or inanimate

undoing

unacceptable action → doing something good to compensate

warning signs that may potentially exhibit aggressive or violent behavior

• Declining to eat or drink

• Attempting to leave the area before discharge 

• Verbally antagonistic toward staff or visitors 

• Harming self 

• Staring 

• Pacing 

• Destroying inanimate objects

Perpetrator: develops excuse or rationalizes behavior

Victim: blames self for reason of abuse and reports feeling guilty

perpetrator: noncommunicative and does not cooperate to arrange a solution

victim: feels like there is no resolution to behaviors

perpetrator: uses intimidation to control others and to temporally resolve unwanted feeling or emotions

victim: does not feel like financial or emotional independence is possible

perpetrator: uses sex as a method to relieve unwanted thoughts

victim: lack of desire to engage in sexual behaviors and reports setting poor boundaries

perpetrator: insure about relationship/ fear of relationship ending

victim: attempts to anticipate needs and desires in effort to prevent tension in the relationship

child abuse and neglect

"any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm."

Neglect

generally defined as the failure of a caregiver to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child's health, safety, and well-being are threatened with harm. 

types of child neglect

failure to educate child

medical neglect ( failing to provide medical or mental care for the child)

abandonment

the individual has been left in circumstances in which they suffer serious harm,

a caregiver’s identity or whereabouts are unknown,

or the caregiver has failed to maintain contact or provide reasonable support for a specified period of time

intimate partner violence (IPV)

physical violence, sexual violence, stalking, or psychological aggression by a current or former partner or spouse

Cycle of violence

1. build up: can last for days to years. breakdown of communication → more arguments

2. acute battery (law enforcement may be involved)

3. honeymoon: perpetrator becomes affectionate and promises they will change

survivors of IPV

medical issues with reproductive, cardiac, digestive, neuromuscular, and skeletal systems, + PTSD/ or depressive disorder

unprotected sex, smoking, or excessive consumption of alcoholic beverages. 

preventing IPV

• Teach skills needed for healthy relationships to both youth and adults

• Empower peers to provide preventive strategies

• Provide early intervention and education to at-risk families/individuals

• Help create safer environments (school, workplace)

• Reinforce economic stability

• Intensify support to survivors

Rape

forced sexual intercourse, including both psychological coercion as well as physical force. Forced sexual intercourse involves penetration by the offender(s)

statutory rape

having sex with an individual younger than 18y

acquaintance rape

can involve friends, coworkers, classmates, or a relative

Sexual assault

defined by various crimes that include actual or attempted attacks that involve unwanted sexual contact between survivor and offender.

verbal threats,

fondling

grabbing. 

stalking

• Following and watching their target

• Obtaining entry into target’s car or house and leaving items to let them know they can enter at anytime

• Showing up unannounced at target’s home, workplace, or school 

• Nuisance phone calls, emails, text messages, etc. 

Bullying

ACE, uninvited behaviors from one youth or group of youths to another that are aggressive in nature

• Kicking, hitting, tripping 

• Teasing and name-calling 

• Excluding targets from group or spreading rumors

• Destruction of property belonging to target

bullying affects

self-esteem, social activities, problem-solving skills, emotional health, academic performance, psychosocial health, and physical health

Primary, Secondary, Tertiary preventions for bullying

1st: educating nurses, students, teachers, parents of bullying

2nd: questioning student of bullying behaviors, advise how to handle the situation, and coping mechanisms

3rd: caring for a student who has been bullied and reinforcing teaching how to decrease bullying occurrence.

use Cognitive behavior therapy, role playing, and dramatization

cyberbullying prevention

• Paying attention to what is posted online and knowing who can see it

• Keep caregivers aware of online activities 

• Tell an adult if you get a message that frightens you

• Keep your passwords secret from peers and friends but inform caregivers 

• Always be kind online

plan of care for violent behavior

1. comprehensive medical exam

   1. assessment and utilization of reliable anger measurement tools

   2. mental status exam

2. Give staff in-service for respectful and nonconfrontational and de-escalation techniques

3. environmental awareness for patient (for pt not to feel like they are confined to small, noisy, congested areas)

more:

• Visible list of standards of behavior that are discussed and agreed upon by clients and staff 

• Sharing of effective de-escalation strategies amongst health care team 

• Frequent meetings among clients and staff with structured and limited sharing 

• Availability of sensory items that can distract agitated clients

• Displaying positive messages from previous clients anonymously around the unit 

Verbal escalation

1. respect personal space and remain calm

2. establish verbal contact by introducing self

3. keep directions and questions simple

4. use reflection techniques

5. make sure pt understands what is unacceptable and acceptable

6. empower with choices

dx and lab

thorough history and physical examination, a comprehensive neurological evaluation, and a psychiatric evaluation

behaviors should be evidenced by more than one source

radio or dx labs to check for underlying medical conditions

interviewing people who have experienced violence

interview should be away from the other person

approach non-threatening, allow injured to control process

do not touch w/o consent

traumatic effects might occur: memory loss, lack of focus, emotional reactivity, and multiple versions of a story

survivors may:

• Deny anything happened.

• Be fearful of what will happen to them once they leave the facility.

• Be wary of health care professionals.

• Demonstrate a lack of concern about their own needs.

• Be sleep deprived or malnourished

for children, older adults, cognitive or emotional disabilities

reporting is mandatory

trauma-informed interviewing

pt is victim of potential criminal act

1st build rapport and allow pt to control process

forensic interviewing

victims of abuse and severe trauma

person conducting interview is member of law enforcement and specifically trained nurses (SANEs) are there to collect evidence

implicit bias

ability to recognize unconscious attitudes that can trigger unintended discriminatory actions

to recognize use gut feeling. If the nurse experiences negative reactions towards the patient.

breaking implicit bias

habit breaking:

• recognizing bias → commit to breaking habit → practice desired behaviors

replacing stereotypes

Mindfulness:

• focus on present

• take breaths before entering room

• pay attention to feelings and assumptions

Abuse, aggression, and violence can be associated with multiple neuropsychiatric disorders, including, but not limited to,

oppositional defiant disorder, conduct disorder, antisocial personality disorder, and intermittent explosive disorder.

assessment tools for aggressive behavior

STAMP (Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing),

Overt Aggressive Scale (OAS),

Broset Violence Checklist (BVC),

Brief Rating of Aggression by Children and Adolescents (BRACHA). 

preventive strategies

• Environmental setup 

• Design spaces to minimize conflict 

• Noise reduction 

• Educate staff to present a non-judgmental, collaborative sense of culture 

• Strive for use of therapeutic communication 

• Assessment

• Early diagnosis and intervention as prescribed 

nonpharmacological interventions

• remove what is annoying the patient

• allow patient to have a quiet space so they can calm down

• ask what you can do in a calm manner

situational awareness

• do not stand in front of within arms reach of the pt

• avoid pt feeling that they are trapped by blocking the airway

• know the layout and how to remove yourself

• receive training on how to physically restrain

pharmacological interventions

BZ, antipsych, mood stabilizers, anticonvulsants, antidepressants

B52, olanzapine, diazepam, chlorpromazine, midazolam, droperidol, lorazepam, promethazine, and ziprasidone​​​​​. 

B52

IM 50mg diphenhydramine, 5mg haloperidol, 2mg lorazepam

debriefing process

to review data, actions, and outcomes following an aggressive or violent event

provide an avenue for staff to verbalize their thoughts in a nonthreatening and nonjudgmental atmosphere while reducing the possibility of psychological harm to self

stages of debriefing process

• Expectations are defined 

• Facts are stated 

• Thoughts are shared 

• Traumatic reactions are identified 

• Descriptions of cognitive or behavioral symptoms are noted 

• Effective coping strategies taught 

• Session ends on a positive note following summarization

nursing care during catastrophe

prevention of further injury,

ensuring a patent airway,

prevention of hypothermia,

and triage and transfer

Run Hide Fight

1. leave area and call 911

2. hide, close and lock door

3. try to disable intruder

forensic nurse works with

survivors of sexual assault or survivors of intimate partner violence (IPV),

child maltreatment/abuse,

older adult abuse,

death investigations, or

work in correctional facilities and assist with investigations following mass casualty events or disasters

provide testimony for civil and criminal proceedings

sexual assault nurse examiner (SANE)

/forensic nurse examiner (FNE), SAFE, sexual assault medical forensic nurse examiner (military)

• focused genital examinations,

• preserving specimens and collecting evidence,

• debriefing potentially traumatizing situations,

• and administering medications to treat or prevent sexually transmitted illnesses.

• provide expert testimony during legal proceedings.

(assessment) cues for angry → aggressive pt

clenched fists,

speak in a raised tone and volume,

tend to avoid direct eye contact

• Restlessness and pacing

• Increased agitation with verbal or physical threats to self or others

• Impaired thoughts

(assessment) factors that can indicate propensity for abuse

previous occurrence of violent, abusive aggressive acts

age and gender (older and women are less likely)

socioeconomic: lower are more likely

stress

(assessment) screening tools

• Dimensions of Anger Reactions 

• Patient-Reported Outcome Measurement Information System (PROMIS)

• State-Trait Anger Scale (STAS)

• Novaco Anger Scale 

• Clinical Anger Scale (CAS) 

• Multidimensional Anger Inventory (MAI) 

to decrease aggressive acts

prevent boredom

encourage physical activity, music and community groups, self-directed activities

contingency management: involves rewarding desired behavior (abstinence from illicit drugs, refraining from property destruction, maintaining a calm demeanor, etc.) with quantifiable rewards

Seclusion

limited to the treatment of self-injurious or violent clients, involves confining a client by themselves in a room or area in which they are physically prevented from leaving.

physical restrains

include equipment or materials that decrease the client’s ability to easily move the head, extremities, or trunk.

always attempt to use the minimal use of restrains

Restraints may become necessary if seclusion has not evoked the desired behavioral outcome and the client continues to be a risk for self-harm. 

physical restrained (followed by prescription)

Five staff members apply the restraints to ensure safety—one for each extremity and one for the head.

Restraints are applied to the upper extremities first and then the lower extremities.

Clients are placed in a supine position with one arm extended above their head and the other arm at their side.

Care should be taken to ensure restraints are not impeding circulation or causing pain. 

guidelines for physical restrain

• adhere to facility guidelines

• Rx, reason, length, type, and criteria to release from provider

• risk of harm prevented

• pt is evaluated by HCP, RN, or PA within one hour and pt is not to be left alone

• continuous monitoring q15h

  • observe for injuries

  • monitor for breathing

  • anticipate basic needs

• RN qh mental status, V/S, circulatory status, offer fluids

• document everything

• range of motion q2h

(evaluation; debriefing)

• Discussion of any misperceptions 

• Display of support for client’s return to unit milieu

• Identification of different approaches to prevent subsequent seclusion/restraint 

• Listening to the client’s point of view 

• Provide guidance to the client if they believe their rights have been violated 

• Recognition of any trauma that occurred 

• Adapt plan of care as needed 

NSSH

nonsuicidal self-harm → to cope with emotional pain, istress, to “feel something” , Loss of situational control, anger, anxiety, depression, and stress

cutting (most prevalent), scratching, biting, carving words or designs into skin, burning, hair pulling, headbanging, and any other self-inflicted destruction of body tissue

borderline personality disorders, substance use disorders, and eating disorders

can lead to suicide

NHHS in adolescent

clients’ unhappiness with their appearance and school-related pressures.

long term effects of NSSH

• Infections

• Scarring

• Excessive bleeding 

• Shame and guilt

• Reduced sense of self 

• Social isolation 

possible warning signs

• Unexplained scars

• Fresh cuts, burns, scratches, or bruises that cannot be explained 

• Excessive rubbing of skin that leads to a burn

• Keeping sharp objects available but hidden 

• Keeping arms and legs covered despite weather conditions

• Poor interpersonal relationships

• Personal identity issues 

• Unpredictable and impulsive emotions/behavior

• Feelings of worthlessness, helplessness, and/or hopelessness

NHHS interventions

• Early recognition

• Available and affordable treatment resources

• Educational and supportive services

strategies for NSSH

• Reaching out immediately (phone or text) to a trusted confidante or psychosocial professional/service 

• Exploring creative avenues of expressing emotions (coloring, drawing, journaling) or exercise

• Recentering thoughts and emotions by focusing on things that interest them 

• Developing an action plan that can be implemented when the desire to engage in NSSH occurs 

• Educating clients and significant others about NSSH thought processes 

• Establishing a support system of trusted individuals 

questions to ask for NSSH

• What prompted you to do this? 

• What happened prior to this? 

• What do you feel when you do this?