Aggression and violence

 Aggression and violence are not unique to mental illness,

nor are they necessarily common features or symptoms of
mental illness.
 They can be associated with mental illness, because of the
higher likelihood of experiencing emotional states
including anger, anxiety, guilt, frustration
 Aggressive behaviors can be classified as:

1. mild (e.g., sarcasm)

2. moderate (e.g., slamming doors)
3. severe (e.g., threats of physical violence against others)
4. extreme (e.g., physical acts of violence against others).
Why are some people aggressive or violent?

 Aggression can occur when people have inappropriate

skills for dealing with feelings of frustration, fear and
anxiety.
 In some cases, an increased risk of violence and
impulsive behavior may be associated with:
1) people with active psychotic symptoms (who may be
responding to command hallucinations or delusions).
2) people with substance abuse and mental disorders
 Both men and women can display aggressive or violent
behavior
Agitation and aggressive behavior related to mental
illness
 Criteriato assess the patient for the potential to direct
violence toward others:
1.Violent ideation.
2. Plan: means of carrying out plans.
3. Intent.
4. History of violence.
5. Specific persons whose patient has identified as a target of violence.
6. Level of impulsivity.
7. Signs of heightened anxiety, fear, aggression ( pacing, clenched
fists, verbal escalation)
Communication strategies during monitoring a patient
who has assaultive behaviors
 1. present a calm appearance.
 2. speak softly.
 3. speak in a non-proactive and non-judgmental manner.
 4. speak in a neutral and concrete way.
 5. put space between yourself and the patient.
 6. show respect to the patient.
 7. avoid intense direct eye contact.
 8. Demonstrate control over the situation without assuming an
overly authoritarian stance.
 9. Facilitate the patient's stance.
 10.Listen to the patient.
 11. Avoid early interpretations.
 12. Do not make promises that cannot keep.
Nursing Diagnosis / outcome 1
 Risk for self-directed or other-directed violence related
to history of violence, substance abuse and mental
disorders.
 Outcome Criteria: The Client:
 Is able to recognize when he or she is angry.
 Is able to take responsibility for own feelings of anger.
 Demonstrates the ability to exert internal control over
feelings of anger.
 Does not cause harm to self or others.
 Is able to use steps of the problem-solving process.
rather than becoming violent.
Nursing Intervention:
 Encourage the patient to verbalize feelings/stressors.
 Have the client keep a diary of angry feelings, what
triggered them, and how they were handled.
 Avoid touching the client when he or she becomes angry
because The client may view touch as threatening and
could become violent.
 Help the client find alternate ways of releasing tension,
such as physical outlets and seeking out staff when
feelings emerge.
 Provide patient with appropriate options/choices
 Allow patients as much control as is safely indicated.
Nursing Intervention
 Ifthe patient continues to escalate or verbalizes
difficulty maintaining control. Begin with less restrictive
measures:
 Sharps restrictions.
 Use of own room to decrease stimulation and provide
the opportunity to de-escalate
 Time out in the room.
 One-to-one or constant observation.
 Open door seclusion.
 Locked door seclusion.
 Physical restraint.
Nursing Intervention
Observe client for escalation of anger (called the prodromal
syndrome): increased motor activity, pounding, slamming, tense
posture, defiant affect, clenched teeth and fists, arguing.

Educate patient regarding the use of more effective coping

mechanisms:
A. Verbalizing feelings.
B. Journaling.
C. Distraction.
D. Relaxation
Seclusion and restraint orders for the psychiatric
patients
 Few situations cause as much anxiety for the psychiatric
nurses as placing a patient in a restraint or seclusion
room, who may feel his or her personal freedom is being
taken away.
 In certain situations, using a seclusion room or
restraining a patient is the only option that ensures the
safety of the patient and others.
 As nurses, we’re ethically obligated to ensure the
patient’s basic right not to be subjected to inappropriate
restraint and seclusion room use.
 Restraints and seclusion order must not be used for
coercion, punishment, discipline, or staff convenience.
Categories of Restraints
1. physical restraint.
 2. chemical restraint (medications).
3. seclusion.
Seclusion for psychiatric patients
 Definition: a type of restraint, is a specific and separate
room that confines a person in a room from which the
person cannot exit freely.
 Uses:
 when a person is unable to control his or her violent
emotions
 and there is the potential for immediate and harmful
behavior to self or to others.
 These rooms are designed to keep the person safe (i.e.
they are free of hazards that the person could use to
harm him or herself) and allow for observation by
clinical staff.
Seclusion for psychiatric patients
 The seclusion room should be used only for:
 behaviors that are destructive to property,
 Aggressive to self or others
 severely disruptive to the environment.
 After all other less restrictive measures have been
attempted and failed.
 Seclusion room is last resort when less restrictive means
of controlling behavior have proven ineffective.
Seclusion for psychiatric patients
 Seclusion is a temporary measure and should not be
used for persons who:
- May be experiencing suicidal ideation.
 or May otherwise be at risk of harm to themselves (e.g.,
banging head against wall)
 uncontrolled risks of falls.
 stated fears of being alone in a locked room
Seclusion room in KAUH
Instructions of the seclusion order for psychiatric
patients

 Seclusion order should be obtained by the doctor.

However, it may be ordered in an emergency by the
nurse in-charge nurse , in that case, call the doctor order,
tell the doctor order of the situation, and obtain an order
for continuing seclusion.
 Seclusion orders must be renewed by the Doctor every
24 hours.
 Explain concisely to the patient why seclusion is to be
used.
 Emphasize that the staff are here to protect the patient
and that the staff will check the patient frequently.
Instructions of the seclusion

 Do not use any physical abuse or abusive language.

 If the patient cooperates, take the patient to seclusion
and search the patient for objects that might be harmful.
A staff member of the same sex should conduct the
search.
 Remove belts, shoes, jewelry, hairpins, glasses, contacts,
and restrictive clothing.
 If the patient is not cooperative, you will call for help
from other nurses to get the patient into the seclusion
room without using abusive language.
 Inform and educate the patient again regarding the
rationale for the use of the seclusion
Instructions of the seclusion

 Leave seclusion room one at a time, backing out and quickly

closing the door after the last staff member.
 The following outlines the standards for monitoring and
performing care while seclusion is utilized:
 1. Vital Signs every 24 hours.
 2. Behavioral assessment every 1 hour.
 3. Offer food & fluid every 8 hours.
 4. Offer bathed/oral care every 24 hours.

➢ Ensure that food and drink utensils are free of sharp objects.
➢ Check the number of food and drink utensils before and
after inserting the isolation room, it should be the same
number.
Walking a client to staff restraint of a client in Transporting a client
the seclusion room. supine position. The to the seclusion
client’s head is controlled room.
to prevent biting.
Physical Restraint
 Physical restraint: is a specific intervention or device that prevents
the patient from moving freely or restricts normal access to the
patient’s own body, material or equipment and cannot be easily
removed or eliminated by the client.
 Physical restraints are any manual methods, or physical or
mechanical device attached to the patient’s body that she/he cannot
easily remove.
 physical restraints used in the treatment of an adult Psychiatric
patient who has displayed behaviors that places the patient(s) or
others in imminent danger.
 These restraints are devices for patients who are violent or
aggressive, threatening to hit or striking staff, or banging their head
on the wall, who need to be stopped from causing further injury to
themselves or others.
Physical restraint
 Physical and manual restraints are an intervention of
last resort where the person’s behavior cannot be
managed by any other means.
 need for continued verbal interventions from staff to
help calm the person.
 Extreme caution is needed in their application to prevent
injury.
 A mechanical restraint: Such devices can include vest
restraints, lap belts, pelvic restraints, wrist restraints,
and sheets.
Instructions of the physical restraint for psychiatric
patients
 A team of four or five staff with a designated leader, who
will direct the team and talk with the patient, approaches the
patient.
 The team leader explains to the patient that the staffs are
here to control behavior, the leader tasks the patient to go to
restraint room. The statement must be simple, short, direct
and clear.
 The leader must allow the patient only a few seconds to
comply and avoid humiliating the patient or using an
excessively threatening manner.
 While the team leader talks to the patient, the other team
members locate themselves so that one is near each
extremity and head
Instructions of the physical restraint for psychiatric
patients

 On signal from the leader, each staff member takes

control of an extremity (four point fixation which
distributes two on the arms and two on the leg) one staff
at each point .
 staff should be holding the arms to the side, legs
together at knees, and control head movement.
 Each pieces of the device should fill or cover with a soft
material before applying restraints to the extremities of
the patient and securing them to the bed frame.
 Staffs check the circulation in each extremity before
leaving the patient.
Instructions of the physical restraint for psychiatric
patients

 Keys for restraints are kept in the same place at the

nurses' station when not in use. In an emergency, the key
of the device and the keys of the room must be available
with the in-charge nurse all the time.
 The patient must be checked carefully for any objects
that could cause injury to the patient.
 Psychiatry nurse releases each restraint pieces, one piece
at a time, every two hours, to check skin condition and
circulation, and provide skincare and exercise. during
the night, staffs follow this procedure every four hours
Instructions of the physical restraint for psychiatric
patients
 Psychiatry nurse use a bedpan. Patient may request toileting.
 Food and fluids are provided with care to prevent aspiration,
only paper dishes and blunt utensils are provided.
 The psychiatry nurse writes a progress note indicating the
time, date, patient's behavior, action, doctor called, and the
patient's response to the action.
 It is important not to ignore the patient; psychiatry nurse
should speak with the patient and not keep the patient
completely isolated.
 the nurse helps the patient identify what precipitated the
incident, feelings about the restraints, and possible ways of
coping if loss of control occurs again.
De-Restraining order

 The team leader begins by negotiating with patient to

demonstrate calmer behavior in exchange for
comfortable adjustment situation for him/her.
 If a verbal contract is made and the patient became
calm, The nurse will gradually loosen the restraints
pieces one by one. Always ensure a contingency plan for
return to the previous safe position.
 The importance of the verbal contract with the patient is
that it opens up a new channel of communication with
him/here.
De-Restraining order

 it is restraint removal process includes the removal of

the straps individually (one piece at a time), and in a
reverse manner, for example:
-remove restraints from the left hand with the right leg to
reduce the harm,.
-if the patient tries to return to aggression again, the
patient will have less control over his limbs when the
restraints removed reversely, and this gives nurse more
time to evaluate the patient status.
Important instruction prior to entering to a seclusion &
restraint room

1. Plan for tasks that need to be completed (e.g., prepare

dietary tray, medication, vital signs).
2. Provide additional staff available as required.
3. Identify each staff’s responsibility to accomplish
patient care (who is in charge, communicates with
patient, and completes vital signs).
4. Identify plan for exit (e.g., which staff member will
be last to exit.).
Important instruction upon staff entering to a seclusion
& restraint room

 ifyou will enter the seclusion room, Inform the patient

that you are entering and request the patient to move a
safe distance away from the door.
 Open the door of the seclusion or restraint only when
two staff members are present.
 Whenever the patient receives oral medications, make
sure they are swallowed. Liquid medication may be
required.
 patients may resort to kicking, biting, verbal abuse,
spitting, and head hitting. Appropriate safety measures
need to be initiated by staff as following:
 Spitting:
• Apply the mask to patient’s mouth area.
• Staff will wear protective eyewear.
 Kicking/Hitting:
• .Avoid being in close proximity to patient’s extremities.
• Obtain help from additional staff members when
needed.
 Biting:
• Avoid close proximity to patient’s mouth.
• The staff member should wear safety gloves to protect
self, ensuring patient’s head is secured to prevent biting.
Important instruction for the preparation for staff
leaving

 In the seclusion room:

 ensure the patient is at a safe distance from the door or
direct patient to sit on the mattress.
 The last staff member to exit will close door while
maintaining eye contact with the patient.
 In the restraint room:
-it must be ensured that the restraints device is well fixed.
- and that they do not adversely affect the patient body.
 The key of the device remains with the leader nurse.
The termination of the Seclusion and Restraint orders

 Releasing the patients from the seclusion or restraint room

occurs when the patient meets the behavior criteria as
following:
1. The patient must verbalize understanding of the
reason for seclusion or restraint order.
2. The patient must make a verbal contract that the
behavior will not be repeated.
3. The patient must present clinical signs that he/she
can fulfill their verbal contract (i.e. absence of
physical threats, stabilized mood, ability to
control behavior, improved reality testing ).
chemical restraint (medications).

 If agitation continues to escalate, offer client choice of taking

medication voluntarily.
 Medicines can be a useful management option, particularly if the
behaviour is specifically of a psychiatric origin
 The most commonly recommended options are:
 Lorazepam is safer first-line option short-acting Benzodiazepines
(im). (no active metabolites, and respiratory depression)
 Haloperidol: is not recommended as first-line monotherapy. This is
because lead to cardiac arrhythmias so haloperidol combined with
benzodiazepines .