psychiatric / mental health nursing west coast university
DESCRIPTION
Objectives Analyze personal feelings and attitudes that may affect professional practice when caring for clients with aggressive behaviors. Identify problem-solving framework. Identify principles of documentation Review types of restraints Practice evasions from attacks Identify principles of evasionTRANSCRIPT
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Psychiatric / Mental Health NursingWest Coast University
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ObjectivesDescribe theoretical perspective in understanding
violenceIdentify the presence of behavioral and verbal
cues that indicate impeding violenceDescribe nursing measures to de-escalate
potentially violent behavior within the context of the principle of least restrictiveness.
Implement a variety of nonpharmacological nursing strategies for intervening with violent clients.
Identify common staff responses to violence.
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Objectives Analyze personal feelings and attitudes that
may affect professional practice when caring for clients with aggressive behaviors.
Identify problem-solving framework.Identify principles of documentationReview types of restraintsPractice evasions from attacksIdentify principles of evasion
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Violence in the Healthcare SettingDefinition:Verbal or physical threats and/or injury to
persons or destruction of property 60-90% of nurses experience violence.Psychiatric setting is area of high risk and
incidence.
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Basic PremiseStudents who have reviewed the systematic
approach to intervention during incidents of potential assault are less likely to injure or be injured than those who have not.
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Biopsychosocial TheoriesBiologic Theories
– Imbalances of hormones (↑ testosterone), neurotransmitters (↑D and NE, ↓Achm 5HT, and GABA)
– Genetic abnormalities– Neurophysiologic injuries (trauma, anoxia,
metabolic imbalance, encephalitis, organic brain injury)
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Biopsychosocial Theories - continuedPsychosocial Theories
Psychoanalytic – aggression an innate drivePsychological – impairment in impulse control,
coping, and social skillsSociocultural – child abuse, dysfunctional
family
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Biopsychosocial Theories - continuedPsychosocial Theories
Psychoanalytic – aggression an innate drivePsychological – impairment in impulse control,
coping, and social skillsSociocultural – child abuse, dysfunctional
family
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Biopsychosocial Theories - continuedBehavioral Theory
Learned behavior (exposure to violence in media/entertainment)
Humanistic TheoryBasic drives unmet
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Aggression and the BrainHypothalamus
Alarm system, controls pituitary functionDysfunction leads to overreaction to stress and
overactivation of pituitaryHippocampus
Regulates the recall of recent experiences and new information
Dysfunction associated with impulsivity
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Aggression and the Brain - continuedAmygdala (limbic system)Frontal cortex
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Behavioral CuesClenched jaws and fistsDilated pupilsIntense staringFlushing of face and neckFrowning, glaring, or smirking PacingIncreased vigilanceAnxietyDestruction of property
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Verbal CuesThreats of harmLoud demanding toneAbrupt silenceSarcastic remarksPressured speechIllogical responsesYelling, screaming, cursingStatements of fear or suspicion
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ExerciseKinds of physically injurious behaviors that you may observe in the clinical setting?What needs clients are trying to meet?What alternative behavior will your patients use to meet these needs
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ProfessionalismOur attitudes influence client’s behavior. Cynicism, pessimism, and other destructive attitudes frequently aggravate assaultive incidents. When we accept responsibility for our career choice, then we are less likely to contribute to unnecessary violence.
Attitude
Mood
Motivation
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PreparationWe should prepare to respond to aggressive
behavior before they enter the workplace. Then they are less likely to injure during an assault. The fully prepared student has proper attire, adequate mobility, well-practiced observational strategies, and an organized plan for self-control.
Attire
MobilityPrecautions (Psychiatric and Medical Problems)Observation
Self-Control
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Nursing Process: AssessmentRisk factors:• History of violence• Severity of psychopathology• Higher levels of hostility• Length of time in the hospital• Early age of onset of psychiatric symptoms• Frequency of admission to psychiatric hospitals• Agitated delirium / Acute excited state• Substance abuse
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AssessmentAssess client’s:Perception of precipitating event/current
situationSupport systemUsual coping patternsWithdrawal symptomsConfusion Pain
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Assessment - continuedEnvironmental factors
Availability of dangerous objectsOvercrowdingStaffingSupervisionActivity level
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Nursing Diagnoses: NANDARisk for Other-Directed ViolenceRisk for Self-Directed ViolenceAnxietyIneffective CopingChronic Low Self-Esteem, and Situational
Low Self-Esteem
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Other ConsiderationsImpulse controlSensory-perceptual functioningCognitive functioningSocial skillsImpaired communicationHelplessnessPowerlessnessProtection of vital interestAn aggressive or hostile staff memberChanges in role identityLack of personal space
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ImplementationDevelop a therapeutic relationship.Establish trust, maintain safety, and convey respect.Use active listening and calm demeanorAddress client needs.Use problem solving with the individualBe empatheticOffer assistance and avoid an argumentative stanceAllow venting and pacingUse open ended questions and give the client time to
think
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InterventionsAvoid saying “you must” or “you need to”Avoid power struggles and judgementsBe aware of your nonverbal behaviorBe clear and use simple languageDecrease environmental stimuli
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Five Phases of “The Assault Cycle”Phase 1: The triggering eventPhase 2: EscalationPhase 3: CrisesPhase 4: RecoveryPhase 5: Post-crises depression
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Nonpharmacologic Strategies - continuedDe-escalationAssemble a team and brief team members.Clear the area of other clients.Choose a leader.Evasion
Appropriate for responding to situation in which assault and battery is attempted
Prevents injury and avoids the pitfall of retaliation or over-reaction
Reasonable force
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Pharmacologic InterventionsPharmacologic agents
Antipsychotics (typical and atypical)Benzodiazepinescombinations
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Restrictive MeasuresRestrictive measures
PharmacologicSeclusion
Involuntary confinement Restraint
Device attached or adjacent to client’s body which restricts movement or normal access to one’s body
Documentation requiredDenial of Rights
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SafetyMinimizing personal riskNonthreatening communicationAwareness of environmentAvailability of other staff membersAwareness of clothing and objects
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Health Professional’s RoleHelp person in crisis understand what led to
the crisis and guide him/her toward positive resolution
Acute phase: restore the person to pre-crisis level of functioning as quickly as possible
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Professional Education and SupportBehavioral crisis management programs
Increase awareness of risk factors, teach staff de-escalation strategies and teamwork for behavior management/restraint
Critical Incident Stress Debriefing (CISD) Staff who experience violent situation discuss
feelings in safe, supportive environmentReduces long-term negative consequences
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Nursing Self-AwarenessHow do I feel about this patient/setting? How are my feelings affecting my behavior?Fear is a normal response.Avoid personalizing.Use intuition.
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Practice Evasion From AttacksEvasion from punches, slaps and scratchesEvasion from kicks, and kneeCover and deflect when trapped or corneredEvasion from blows with heavy objectsEvasion from holding attacks:
To the skin: pinching, digging nails, bitingTo the hairTo the limbTo the torsoTo the neck
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Principles of EvasionControl yourselfKeep “talking”Be patientStay out of the wayGet out of the wayPat attentionMake a plan
Track the attackMove in an arc close the attackEscape holding
attacksMinimize, release,
evadeCall for helpAvoid inflicting pain
and injury