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Preventing and Managing Aggressive Behavior, Chapter 28
Preventing and Managing Aggressive Behavior
• Aggressive behavior
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Assaultive
Injuries
Emergency services called to scene
Increasing violence in society
Increasing patient acuity
Preventing and Managing Aggressive Behavior
• Response to threatening situations:
• Respond passively: Subordinate own rights to perception of rights of others
• Respond aggressively: Ignore rights of others
• Respond assertively: Self-assurance and respect for others
Preventing and Managing Aggressive
Behavior
• Theories on aggressive behavior
• Psychological
• Predisposing life experiences that limits capacity to select
nonviolent coping mechanisms
• Organic brain damage, MR, etc.
• Severe emotional deprivation, rejection in childhood, parental
seduction
• Exposure to violence in formative years as victim or observer
Intergenerational Transmission of Violence
(Stuart, 2013, p. 575)
Preventing and Managing Aggressive Behavior
• Theories on aggressive behavior (cont.)
• Sociocultural
• Cultural norms define unacceptable/acceptable behaviors
• Biological
• Limbic system, frontal lobes, and hypothalamus
Brain Structures Implicated in Aggression (Stuart,
2013, p. 576)
Preventing and Managing Aggressive Behavior
• Neurotransmitters
• Low levels of serotonin associated with irritability, overreacting to
provocation, and rage
• Impulsive arson, suicide, homicide: Low levels of 5-HIAA (breakdown product
of serotonin) in spinal fluid
• Other neurotransmitter associated with aggression: GABA, dopamine,
norepinephrine, acetylcholine
Preventing and Managing Aggressive Behavior
• Expect aggression
• Active psychotic symptoms
• Substance abuse disorders
• History of violence
• Behaviors associated with aggression
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Motor agitation
Verbalizations
Affect
Level of consciousness
Hierarchy of Aggressive and Violent Patient Behaviors
(Stuart, 2013, p. 578)
Preventing and Managing Aggressive Behavior
Nursing Interventions-assessment tool is Assault and Violence
Assessment Tool (See Stuart text, p. 579)
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Self-awareness
Patient education
Assertiveness training
Communication strategies (verbal & non-verbal)
Environmental strategies (comfort rooms, exercise)
Behavioral strategies- (limit setting, time out, token economy)
Psychopharmacology (examples next slide)
Preventing and Managing Aggressive Behavior
• Psychopharmacology examples for aggression:
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Antianxiety - Benzodiazepines: Lorazepam [Ativan])
Antidepressants (SSRIs)
Mood stabilizers (Valproate, Lithium, Carbamazepine [Tegretol])
Antipsychotics (Haldol given with Ativan and/or Benadryl; Risperidone with
Ativan)
• Others: Beta-blockers, e.g., Propranolol
Preventing and Managing Aggressive Behavior
• Crisis response
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Team: Show of force
Identified crisis leader
Notifications – (security)
Move others to safe distance
Leader uses calm, steady voice
Follow leaders plan
Debrief (staff and patients)
Preventing and Managing Aggressive Behavior
Containment Strategies – patient must be removed from any
containment as soon as possible
• Seclusion – involuntary confinement
• Purpose: Quiet room with minimal furnishings to decrease stimuli or
sensory input
• Must have continual assessment, monitoring, and reevaluation
• Always use least restrictive measures
Preventing and Managing Aggressive Behavior
Containment Strategies (cont.)
• Restraint (physical or chemical)
• Emergency intervention for safety when less restrictive methods have failed
• Purpose: Protect patient from self/others
• Must have continual assessment, monitoring, and reevaluation
Preventing and Managing Aggressive Behavior
Containment Strategies (cont.)
• Chemical restraints
• Medications used to restrict patient’s freedom
• Emergency control of behavior
Preventing and Managing Aggressive Behavior
Debriefing
• Team debriefs and discusses
• Patient feedback
• What helped the patient
• What could have been done better
• What to do different next time
Preventing and Managing Aggressive Behavior
• Employers have a duty to provide a safe and hazard free environment
• A written plan is required by JACHO describing how security is provided to
patients, staff, and visitors.
• Nurses may be subjected to aggressive behavior and abuse from their
nursing and physician colleagues (Stuart, 2013, p. 588)
Preventing and Managing Aggressive Behavior
• Horizontal or Lateral Violence
• Aggression and intergroup conflicts
• Verbal abuse
• Intimidation
• Bullying
• Excessive criticism
• Denial to career opportunities
• Withholding of information
Preventing and Managing Aggressive Behavior
• OSHA guidelines for a safe workplace environment include:
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Management commitment & employee involvement
Worksite analysis
Prevention & control
Safety and health training
Response plan
Preventing and Managing Aggressive Behavior
• Staff Development:
• Education
• What to do, what to say, who to notify, how to manage
• Nursing interventions grounded in theory and current research
• Pharmacological interventions
• Crisis management
Preventing and Managing Aggressive Behavior
• Staff Support
• Allow adequate time off after assault
• Validation from others re: clinical competence and appropriate interventions
can help in healing
• Peer support group
• use a nursing consultation support service for the victims of assault