Crises Intervention
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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
Risk for Other-Directed Violence
Risk for Self-Directed Violence
Anxiety
Ineffective Coping
Chronic Low Self-Esteem, and Situational Low SelfEsteem
Other Considerations
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
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