Anger

is an emotional response to frustration of desires, a threat to one's ego.

A normal emotion that can be view as positive when expressed in a healthy way.

comorbidities:

depression, anxiety, psychosis, personality disorders

Aggression

action or behavior that results in verbal or physical atack.

synonymous w/violence; not always inappropriate & sometimes necessary for self-protection.

Violence

always an objectible act that involves intentional use of force that results in, or has the potential to result in, injury to another person.

Trauma-informed care

older concept that has been reintroduced

based on the notion that disruptive psychiatric pts often hace HX of violence & victimization

This HX can:

impede the pt's ability to self-soothe

result in neg. coping responses

create vunerability to coercive interventions: restraints by staff

TIC:

focuses on pts past HX of violence & trauma & the role it currently plays in their lives.

Predictors

of

violence

1) s/sx that usu. (but not always) preced violence:

-hyperactivity: pacing, restlessness

-increased anxiety & tension: clenched fist or jaw

-verbal abuse: profanity, agruing

-Loud voice, change of pitch, very soft; so others have to strain to hear

-intense eye contact or avoidance of eye contact

2) Recent acts of violence

3) stone silence

4) ETOH or drug abuse

5) Possession of a weapon or object that may be used as  a weapon

6) isolation is new

7) Milieu characteristics conductive to violence:

overcrowding

staff inexperience

provactive or controlling staff

poor limit setting

arbitrary revocation of privileges

Assessment guidlines

for

anger & aggression

1) HX of violence is the single best predictor of future violence

2) Pts who are delusional, hyperactive, implusive,or predisposed to irritabilty are @higher risk for violence

3) Assess pt risk for violence:

-does pt wish or intent harm?

-does pt have plan?

-does pt have means to carry out plan?

-does pt have demographic risks:

-male

-14-24yrs old

-low socioeconominc status

-inadequate support system

-prison time

4) aggression by pts occurs most often in the context of limit setting by the nurse

5) pts w/Hx of limited coping skills:

-lack of assertiveness

-use of intimidation

are @higher risk of using violence

6) assess self for personal triggers & responses likely to esculate pt violence:

-pt characteristics or situations that trigger impatience, irritation, or defensiveness

7) assess personal sense of competence when in potential conflict: ask for help from other staff. 

Considerations

for

Staff safety

1) Avoid wearing earrings or necklaces that dangle

2) Ensure enough staff for backup (still only have one staff person talk to pt)

3) Know layout of area always

4) Do not stand directly in front of pt or doorway

5) Provide feedback for a pt w/escualting behavior:

"you seem to be very upset"

6) avoid confrontation w/pt:

either verbal or w/show of force

De-escalation techniques

maintain the pt's self-esteem & dignity

maintain calmness (your own & pt's)

assess the pt & situation

identify stressors & stress indicators

respond as early as possible

use a calm, clear tone of voice

invest time

remain honest

establish what the pt considers to be his/her needs

be goal oriented

maintain a large personal space

avoid verbal struggles

give several options

make clear the options

utilize a nonaggressive posture

use genuiness & empathy

attempt to be confidently aware

use verbal, nonverbal, & communication skills

be assertive ( not aggressive)

assess for personal safety

Medications

p.573

antianxiety

antipsychotics: conventional

combinations

long term:

SSRIs

Lithium

anticonvulsants

benzos

gabapentin

atypical antipsychotics

beta blockers

psychostimulants

Five types

of

Abuse

1)physcial abuse

2) sexual abuse

3) emotional abuse

4) neglect

5) economic abuse

*comorbidities:

anxiety, depression, suicidal ideation, PTSD

environmental factors:

1) Perpetrator: initiate violence, consider own needs to be more important than anyone else's and look toward others to meet their needs.

2) someone who by age or situation is vulnerable

3) a crisis situation

Physical abuse

the infliction of physical pain or bodily harm

ex. slapping, hitting, choking, pushing

Sexual abuse

any form of sexual contact or exposure w/out consent, or in a situation in which the victim is incapable of giving consent

ex. sexual assault or rape for adults

Emotional abuse

infliction of mental anguish

ex. threatening, humiliating, intimidating, isolating

In forms of:

-terrorizing w/verbal threats

-directing blatant or subtle hate or hostility

-persistently ignoring needs

-belittling & criticizing

-w/holding warmth & affection 

-threatening w/abandonment or institutionalizing 

Neglect

several forms:

physical neglect; failure to provide basic needs or to protect from harm

emotional neglect; failure to attend to basic emotional needs & nuturing

educational neglect; failure to provide a chilf w/experiences: formal education

medical neglect; failure to provide basic medical, dentalm or psychiatric care

Cycle

of

violence

tension building stage:

minor incidents

abuser rationalize abuse as acceptable

may try to reduce tension w/drugs & ETOH or excuses for abuse

acute battering stage:

abuser releases built up tension by brutal beatings

severe injury can result

honeymoon phase:

kindness & loving behaviors

remorse

*without intervention the cycle will repeat itself.

Family violence

intentional intimidation, abuse, or neglect of children, adults, or elders by a family member, intimate partner or caretaker  in order to gain power and control over victim.