management of aggression

management of a aggressive patient

1. MANAGEMENT OF AN AGGRESSIVE/VIOLENT PATIENT

2. Aggression In social psychology, aggression is most commonly defined as a behavior that is intended to harm another person who is motivated to avoid that harm (Bushman & Huesmann , 2010; DeWall , Anderson, & Bushman, 2012 ). harm can take many forms such as physical injury, hurt feelings, or damaged social relationships Anderson and Bushman (2002) more specifically defined human aggression as “ any behavior directed toward another individual that is carried out with the proximate (immediate) intent to cause harm. In addition, the per- petrator must believe that the behavior will harm the target, and that the target is motivated to avoid the behavior”

3. Characteristics aggression is an observable behavior —not a thought or feeling the act must be intentional and be carried out with the goal of harming another. aggression involves people, meaning that damaging inanimate objects (e.g., kicking a wall, smashing plates, or pounding one’s fists on a table) is not considered aggression unless it is carried out with the intention of harming another person (e.g., slashing the tires on your enemy’s car). the recipient of the harm must be motivated to avoid that harm.

4. VIOLENCE the most common scientific definition of violence is as an extreme form of aggression that has severe physical harm (e.g., serious injury or death) as its goal (Anderson & Bushman, 2002; Bushman & Huesmann , 2010; Huesmann & Taylor, 2006).

5. CAUSES OF AGGRESSION/VIOLENCE?

6. physical health mental health family structure relationships with others work or school environment societal or socioeconomic factors individual traits life experiences

7. Hypoglycemia hypoxia Head trauma meningitis/encephalitis Drug intoxication or withdrawal HIV virus complications Sepsis brain abscesses Hepatic encephalopathy Endocrinopathy,including cushing's syndrome CO2 retention CNS tumors Paradoxical drug reaction in elderly Dementia

8. Violence assessment risk factors PAST HISTORY OF VIOLENCE Agitation, anger, disorganized behavior Poor compliance during interview Detailed or planned threat of violence Possession of weapons History of childhood physical or sexual abuse

9. Presence of organic disorder Presence of psychotic psychopathology- delusions and command hallucinations Substance use Borderline or antisocial personality Belonging to a demographic group with increased risk of violence (young, male, socioeconomic group)

10. To express hostility To assert dominance To intimidate or threaten To achieve a goal A response to fear A reaction to pain To compete with others Anger

11. Characteristics of aggressive people behavior is communicated verbally or non verbally invade the personal space of others speak loudly and with greater emphasis maintain intrusive eye contact over a prolonged period Threatening gestures -point their finger -shake their fists -stamp their feet or -make slashing motion with their hands Posture -erect - lean forward slightly towards the other person.

12. 4 levels of behavior that accompany violent activity have been discovered. 1) Anxiety 2) Defensiveness 3) Acting Out and 4) Tension Reduction

13. DE- ESC ALA TION “reduce the intensity of ” aimed at defusing anger and averting aggression. When you de-escalate someone or some situation, you  act to improve the situation   "One Response Does Not Fit All“

14. De-escalation skills

15. Before approaching a potentially violent patient Inform the staff members, colleagues about the situation and at the same time obtain information from the person who called you for assistance. Assess the environment for potential dangers Assess the physical demeanor of the patient Clear the area of other patients. If a person becomes aggressive or seems potentially violent,  first ensure your own safety.   Establish your role

16. Verbal de-escalation It is generally helpful to meet in private to r educe stimulation.  Door should be behind you, not between you and the patient. The door should remain open. Use low, deeper tones, and avoid raising your voice or talking too fast . Make soft eye contact Be gentle , but assertive , speaking slowly and confidently . Allow the person to tell you what is upsetting them . Ask OPEN-ENDED questions. Avoid a "toe to toe, eye to eye" "showdown" position

17. Do not ever leave the patient alone and don’t turn your back to the patient Take verbal threats seriously. Remain several feet away to avoid crowding the patient.

18. Summon additional help (a "show of force" or a "show of concern"); this is not a time for heroics . maintain a confident and competent demeanor, and attempt to deescalate by engaging the patient in conversation . Positive engagement   An intervention that aims to empower patients to actively participate in their care. Rather than 'having things done to' them, patients negotiate the level of engagement that will be most therapeutic.

19. Paraphrase your understanding of the person’s experiences.  Set aside your own thoughts and responses and focus on what you are hearing. Validate the person’s possible emotions and what is upsetting them. Be specific and gentle, but firmly directive about the behavior that you will accept.  “please sit down.”  “please lower your voice and do not scream at me.” “please do not thrash your arms like that’’ ‘’Please keep them lowered.’’ Explain your intent before making any moves

20. If the tension in the room is not dissipating, consider taking a quick break.  (Apologize in a calm tone for needing to step out just for a couple of minutes, stating for example that you would like to consult with a supervisor; that you would like to get a glass of water, and offer one to the person; etc .) Ask the person what would be helpful from you.  Ask for permission to problem-solve the issue.  The person may just be venting and may not want you to problem-solve with them . Summarize what the person has said, and summarize any agreed upon resolutions.  

21. DONT’s Do not argue.  (It is more helpful to show that you heard them and to de-escalate than to be correct .) Do not focus on the person, and do not use adjectives or labels to describe the person.  Instead, focus on the specific behavior . Do not restrict the person’s movement.  If he/she wants to stand, allow them.  Do not corner them.

22. Do not meet behind closed door if you foresee possible danger . Do not touch the person or make sudden moves . Avoid “why” questions; these tend to increase a person’s defenses . Do not take the person’s behavior or remarks personally. 

23. Don’t lean over with a stethoscope /id card around your neck Don’t have scissors , reflex hammers, pens in your pockets DON’T EVER TAKE A WEAPON DIRECTLY FROM THE PATIENT (always tell the person to leave the weapon on table or place it on the floor) Ignore challenge questions. When the person challenges our position, authority, training, policies, etc., redirect the individual's attention to the issue at hand . Answering a challenge question will just fuel a power struggle.

24. Indications for Restraining and sedating a violent and aggressive patient Preventing harm to the patient and others Preventing serious disruption or damage to the environment To assist in assessing and management off the patient Restraints should never be use for ease of convenience The use of physical restraint requires a doctors order. The order must specify the rationale or intent for use, the type of restraint, and the length of time to use the restraint.

25. Techniques to restrain Proper technique starts with having a sufficient number of personnel. Five people should coordinate with restraining the patient, one securing each limb, and a fifth member to control the patient's head, and prevent biting. (A sixth person could be used to apply restraints, while others hold the patient down) Hospital security should be called to help subdue a violent patient.. Staff members should be educated and equipped with skills

26. After restraint …. Offer liquid, nutrition, comfort, and bathroom every 2 hours Remove restraints every 2 hour for no less than 10-15 minutes for range of motion and skin care. Ideally open one hand and opposite lower limb for a brief period and then repeat with other hand and limb. Document the event details in the patients file and duration of restrain

27. Chemical restraints

28. ORAL I/M Lorazepam 1-2mg Olanzapine 10mg Risperidone 1-2 mg Haloperidol 5 mg I/M lorazepam 1-2mg Promethazine 50mg Olanzapine 10mg Aripiprazole 9.75mg Haloperidol 5mg

29. Rapid Tranquillisation If immediate tranquilization is needed: I/V benzodiazepine Diazepam 10mg in 5 mins , if adequate response is not obtained then repeat dose ( upto 3 times) RAPID TRANQUILLISATION CAN LEAD TO Acute dystonia Reduced respiratory rate Irregular slow pulse Fall in blood pressure Increased temperature

30. Debrief Be sure to debrief with coworkers, team members, or a supervisor after a major incident. Talking about it can relieve some of the stress and is also a good time to start planning for next time