Transcript Crises Intervention

Psychiatric / Mental Health Nursing
West Coast University
Objectives
 Describe theoretical perspective in understanding
violence
 Identify the presence of behavioral and verbal cues
that indicate impeding violence
 Describe 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.
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 evasion
Violence in the Healthcare Setting
Definition:
 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.
Basic Premise
 Students 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.
Biopsychosocial Theories
 Biologic 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)
Biopsychosocial Theories continued
 Psychosocial Theories
 Psychoanalytic – aggression an innate drive
 Psychological – impairment in impulse control, coping,
and social skills
 Sociocultural – child abuse, dysfunctional family
Biopsychosocial Theories continued
 Psychosocial Theories
 Psychoanalytic – aggression an innate drive
 Psychological – impairment in impulse control, coping,
and social skills
 Sociocultural – child abuse, dysfunctional family
Biopsychosocial Theories continued
 Behavioral Theory
 Learned behavior (exposure to violence
in media/entertainment)
 Humanistic Theory
 Basic drives unmet
Aggression and the Brain
 Hypothalamus
 Alarm system, controls pituitary function
 Dysfunction leads to overreaction to stress and
overactivation of pituitary
 Hippocampus
 Regulates the recall of recent experiences and new
information
 Dysfunction associated with impulsivity
Aggression and the Brain continued
 Amygdala (limbic system)
 Frontal cortex
Behavioral Cues
 Clenched jaws and fists
 Dilated pupils
 Intense staring
 Flushing of face and neck
 Frowning, glaring, or smirking
 Pacing
 Increased vigilance
 Anxiety
 Destruction of property
Verbal Cues
 Threats of harm
 Loud demanding tone
 Abrupt silence
 Sarcastic remarks
 Pressured speech
 Illogical responses
 Yelling, screaming, cursing
 Statements of fear or suspicion
Exercise
Kinds 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
Professionalism
Our 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
Preparation
We 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, wellpracticed observational strategies, and an organized
plan for self-control.
Attire
Mobility
Precautions (Psychiatric and Medical Problems)
Observation
Self-Control
Nursing Process: Assessment
Risk factors:
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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
Assessment
Assess client’s:
 Perception of precipitating event/current situation
 Support system
 Usual coping patterns
 Withdrawal symptoms
 Confusion
 Pain
Assessment - continued
 Environmental factors
 Availability of dangerous objects
 Overcrowding
 Staffing
 Supervision
 Activity level
Nursing Diagnoses: NANDA
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Risk for Other-Directed Violence
Risk for Self-Directed Violence
Anxiety
Ineffective Coping
Chronic Low Self-Esteem, and Situational Low SelfEsteem
Other Considerations
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Impulse control
Sensory-perceptual functioning
Cognitive functioning
Social skills
Impaired communication
Helplessness
Powerlessness
Protection of vital interest
An aggressive or hostile staff member
Changes in role identity
Lack of personal space
Implementation
 Develop a therapeutic relationship.
 Establish trust, maintain safety, and convey respect.
 Use active listening and calm demeanor
 Address client needs.
 Use problem solving with the individual
 Be empathetic
 Offer assistance and avoid an argumentative stance
 Allow venting and pacing
 Use open ended questions and give the client time to
think
Interventions
 Avoid saying “you must” or “you need to”
 Avoid power struggles and judgements
 Be aware of your nonverbal behavior
 Be clear and use simple language
 Decrease environmental stimuli
Five Phases of “The Assault
Cycle”
 Phase 1: The triggering event
 Phase 2: Escalation
 Phase 3: Crises
 Phase 4: Recovery
 Phase 5: Post-crises depression
Nonpharmacologic Strategies continued
 De-escalation
 Assemble 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
Pharmacologic Interventions
 Pharmacologic agents
 Antipsychotics (typical and atypical)
 Benzodiazepines
 combinations
Restrictive Measures
 Restrictive measures
 Pharmacologic
 Seclusion
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Involuntary confinement
 Restraint
 Device attached or adjacent to client’s body which restricts
movement or normal access to one’s body
 Documentation required
 Denial of Rights
Safety
 Minimizing personal risk
 Nonthreatening communication
 Awareness of environment
 Availability of other staff members
 Awareness of clothing and objects
Health Professional’s Role
 Help 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
Professional Education and
Support
 Behavioral 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 environment
 Reduces long-term negative consequences
Nursing Self-Awareness
 How do I feel about this patient/setting?
 How are my feelings affecting my behavior?
 Fear is a normal response.
 Avoid personalizing.
 Use intuition.
Self-Awareness
Practice Evasion From Attacks
 Evasion from punches, slaps and scratches
 Evasion from kicks, and knee
 Cover and deflect when trapped or cornered
 Evasion from blows with heavy objects
 Evasion from holding attacks:
 To the skin: pinching, digging nails, biting
 To the hair
 To the limb
 To the torso
 To the neck
Principles of Evasion
 Control yourself
 Track the attack
 Keep “talking”
 Move in an arc
 Be patient
 close the attack
 Stay out of the way
 Escape holding attacks
 Minimize, release,
evade
 Call for help
 Get out of the way
 Pat attention
 Make a plan
 Avoid inflicting pain and
injury