Aggression 4

Anger, Aggression, and Violence in Health Care Settings

Overview

  • Management of anger, aggression, and violence in healthcare settings is crucial for ensuring safety.

  • Most patients show signs of anxiety before escalating to violence, allowing for early intervention.

  • Some cases may already involve aggression or imminent violence, requiring other strategies.

Assessment of Risk Factors

  • History of Violence: Past behavior is the best predictor of future behavior.

  • Psychological Factors:

    • Paranoia

    • Alcohol or drug use

    • Mania or agitated depression

    • Personality disorders (e.g., antisocial, borderline, narcissistic)

    • Oppositional defiant disorder or conduct disorder

    • Psychosis (hallucinations, delusions, disorganized thought)

    • Command hallucinations

    • Neurocognitive disorder

    • Intermittent explosive disorder

  • Physical Health Factors:

    • Chronic illness

    • Pain

    • Loss of body function

Key Assessment Questions

  • Is there a history of violence?

  • Does the patient express a violent wish or intention to harm others?

  • Does the patient have a plan and the means to carry it out?

  • Evaluate demographics:

    • Sex: Male

    • Age: 14-24 years

    • Socioeconomic Status: Low

    • Support Systems: Few

Intervention Strategies

  • Follow guidelines to help patients gain control using the least restrictive means.

    • Verbal and Nonverbal Interventions:

    • Begin by expressing concern and willingness to listen.

    • Clearly state expectations for behavior (e.g., "I expect that you will stay in control.").

    • Approach in a controlled, non-threatening, and caring manner.

    • Maintain personal space (stay 1 foot beyond reach).

    • Ensure the patient is not between you and the exit.

    • Select a quiet, visible location for discussions.

    • Inform staff of the situation to prepare for possible escalation.

Continued Verbal & Nonverbal Interventions

  • Understand that a patient's ability to process information declines as anger escalates.

  • Speak in a calm, slow manner using short sentences.

  • Use open-ended questions to explore underlying feelings (e.g., "You think people are treating you unfairly?").

  • Offer choices to empower the patient (e.g., "Do you want to go to your room or to the quiet room for a while?").

Pharmacological Interventions

  • Appropriate when patients exhibit signs of agitation (e.g., pacing, yelling).

  • Offer as-needed medications to relieve anxiety.

  • Inhaled Loxapine (Adasuve): Approved for acute treatment of agitation associated with schizophrenia or bipolar I disorder in adults but limited due to potential fatal bronchospasm.

  • Second-Generation Antipsychotics:

    • Olanzapine (Zyprexa) and Ziprasidone (Geodon): Useful for reducing agitation.

    • An orally disintegrating tablet of Olanzapine (Zyprexa Zydis) provides rapid effects.

    • A combination of an antipsychotic and a benzodiazepine can be administered intramuscularly.

    • Add Diphenhydramine or Benztropine to reduce extrapyramidal side effects.

Seclusion and Restraints

  • Indicated when aggression poses safety threats.

  • Seclusion: Confinement to a room not controllable by the patient.

  • Restraint: Immobilizes or reduces movement of any part of the body.

    • Requires a licensed provider’s order, which may be obtained after an emergency event.

  • Guidelines for Use:

    • Indicated for patient protection from self-harm or preventing harm to others.

  • Legal Requirements:

    • Involvement of multidisciplinary teams.

    • Health care provider’s signature per state law.

    • Notification of patient advocates or relatives.

    • Discontinue as soon as feasible.

Documentation

  • Record behaviors leading to seclusion/restraint.

  • Note least restrictive interventions attempted before resorting to restraint.

  • Document response to interventions and modified care plan for seclusion/restraint use.

  • Clinical Assessments:

    • Mental status at time of restraint.

    • Physical examinations for aspects contributing to behaviors.

  • Observation:

    • One-on-one observation.

    • Document every 15 minutes:

    • Patient's range of movement

    • Vital signs

    • Blood flow and chafing if restrained

    • Ensure adequate nutrition, hydration, and needs related to elimination.

  • Release Procedure:

    • Only terminate when the patient follows instructions and maintains control and discuss the experience afterward.

Other Important Considerations

  • Physical holding is considered restraint.

  • Having all four side rails up is restraint except during seizure precautions.

  • Tightly tucking sheets so a patient cannot move is also restraint.

  • Orders for seclusion or restraint must never take the form of as-needed policies.

Predictors of Imminent Violence

  • Hyperactivity: Most important predictor (e.g., pacing, restlessness).

  • Signs of Anxiety and Tension:

    • Clenched jaw or fist

    • Rigid posture

    • Tense facial expression

    • Mumbling to self

    • Shortness of breath

    • Sweating

    • Rapid pulse

  • Verbal Aggression: Profanity, argumentative behavior, and intrusive demands.

  • Behavioral Indicators: Loud voice, sudden changes in tone, confusion, or disorientation.

  • Recent violence: property violence can indicate risk.

  • Keep an eye on patients under the influence of alcohol or drugs, or possessing potential weapons (e.g., forks, knives).

  • Environmental Conditions Conducive to Violence:

    • Overcrowding

    • Inexperienced staff members

    • Confrontational behavior from staff

    • Poor limit-setting and arbitrary policy enforcement.