NURSE 2100: EXAM 4
69 Cards in this Set
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Prevention of Violence
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The paramount aim of psychiatric nurses, staffing impatient facilities
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Demensions of keeping the unit safe include:
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Maintenance of a structured and respectful therapeutic milieu
Careful timing of admissions and discharges
Expert use of space and personnel
A convitction that staff need to understand the meaning of patients' behaviors
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Aggression
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Verbal statements that are intended to threaten or control
Must consider context
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Violence
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A physical act of force intended to cause harm to a person or an object
Conveys a message that the perpetrator's point of view is correct, not the victim's
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History of Violence
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Best single predictor of violence
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Patients who are at increased risk
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Active psychotic symptoms (percieved threat)
Substance abuse disorders (withdrawal, intoxication = inhibited impulses)
ETOH abuse increases risk 12x normal
Drug abuse increases risk 16x normal
Head trauma, tumor, exposure to toxic chemicals, history of anoxia
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Predictors of Violence
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Unwillingness to follow unit rules
Involuntary hospitilization in a locked unit
Crowding, heat & density during high patient census
Anger-producing staff actions (such as limit setting, ignoring patient)
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Risk Assessment
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Do you intend to harm someone? If yes, who?
Do you have a plan? If yes, what are the details of the plan?
Do you have the means to carry out the plan? (is the weapon readily available?)
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Assessment of Anger
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Anger expression (threats, property destruction, assault)
Pervasive chronic anger vs. anger at an ongoing situation (mean boss) vs. adjustment to a stressor
Problems cause by anger expression
Prescence or abscence of self-soothing techniques
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The Spielberger State-Trait Anger Expression Inventory (STAXI) measures
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The general propensity to be angry (trait anger)
Current feelings (state anger)
Several styles of anger expression
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Preventive Strategies
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Be aware of your own stress and don't take out frustrations on patients (counter transference)
Patient education- how to manage/control anger, healthy outlets for anger/aggression
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Aggressiveness Training
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Describe: "when you refuse to talk to me about our financial situation" (don't label)
Emotions: "I feel frustrated" (not "You make me...")
Suggest: "I would prefer that you would take some time to discuss it with me" (specific behavior)
Consequences: " so we can get along better. If no…
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Communication--Anticipatory Strategies
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Violence prone people need 4x more personal space
Calm, soft voice, nonjudgmental
Show respect, open stance, avoid eye contact
Don't push, listen, keep your distance
Be honest and matter-of-fact, genuine concern
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Soothing Environment--Anticipatory
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Soft music, low lights, structured activities
Quiet room, decreased stimuli, allow space
Positioning for immediate access to door
Leaving door open when talking to patient
Knowing where colleagues are, letting them know where you are
Removing jewelry, etc.
Increase problem-solving
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Affective Interventions
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Validating (reflection, empathy)
Listening to patient's illness experience
Exploring beliefs about anger
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Cognitive Interventions
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Giving commendations
Offering information
Classes & teachable moments
Planned distraction
Contracting for rewards & consequences
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Behavioral Interventions
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Assigning behavioral tasks
homework
using bibliotherapy
identify patterns & plan ways to change
providing concrete choices (meals)
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Antipsychotics
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usually used with lorazepam (ativan), considered a chemical restraint-when meds are given to control behavior, not as standard treatment for the patients
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Typical Antipsychotics
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more research to show effectiveness, used for acute agitation-- Haldool IM ( watch for akasthesia which can look like increased agitation)At
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Atypical Antipsychotics
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oral risperdone (risperdal)--just as effective
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Anxiety & Sedative--Psychopharmacology
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Lorazepam (Ativan)--quick onset, acute agitation
Buspirone (Buspar)-- Use for aggressoin related to anxiety/depression, head injury, dementia or developmental disabilities
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Mood Stabilizers--Psychopharmacology
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Lithium--use with mania, mental retardation, head injury, schizophrenia, personality disorders, conduct disorders & temporal lobe epilepsy
Depakote (Divalproex sodium)
Carbamazepine (Tegretol)--use with abnormal EEG & dementia
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Antidepressants
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SSRI's especially with PTSD
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Seclusion & Restraint
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Use as a last resort;if de-escalation does not work
Can cause psychological harm to patients with previous significant physical or emotional trauma
Not to be used as a punitive measure
Protective measure for patient and others
Informed consent obtained at time of admission
Physician'…
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Acute Aggression
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Explain reason for restraint, reassure & support: confused, delirious, frightened
SR requires constant observation (audio/video or fact to face)
Check VS every hour unless sleeping
Check extremities, ROM q 2 hrs
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Check Extremities--Restraints
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2-point (both wrists), 3-point (both wrists & one leg), 4-point (both wrists, both legs), 6-point (both wrists,both legs, waist, upper torso)
Remove only one restraint at a time
Never leave patient in only one restraint
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Acute Aggression
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offer fluids, bathroom or bedpan
Remove restraints or unblock door when calm and able to control behavior--gradual integration back into the unit
Document thoroughly
Other interventions used before restraint
Behaviors observed, mental status, mood, signs of decreased aggression
Safet…
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Terminating Seclusion/Restraints
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Talk to patient, assess readiness to move to less restrictive measures
Remove restraints gradually as self control returns--one extremity at a time
Monitor patient's response to removal
Debrief
patient- talk about concerns regarding S &R
staff - what led up to event, future preventio…
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Nurses Responding to Assault
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Nurses must be provided with training programs in the prevention and management of aggressive behavior
Assaults tend to occur in situations in which the patient perceives the nurses' actions as restricting, controlling, or aggressive
Reported assaults range form verbal threats and minor…
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CARE
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Be assertive to maintain self-respect & courtesy
May indicate lack of respect for our feelings
Pay attention to their feelings
Use CARE
C larify the problematic behavior
A rticulate why their behavior is a problem
R equest a change tentatively and respectfully
E ncourage change (st…
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Suicidality
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all suicide-related behaviors and thoughts of completing or attempting suicide and suicidal ideation
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Suicidal Ideation
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Thinking about and planning one's own death; it includes excessive or unreasoned worrying about losing a loved one
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Suicide attempt
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nonfata, self-inflicted destructive act with explicit/implicit intent to die
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Parasuicide
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voluntary, apparent attempt at suicide, commonly called suicidal gesture, in which the aim is not death
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Lethality
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The probability that a person successfuly complete suicide
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Risk Factors for suicide
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psychological-drugs, psychosis, depression, 51% of abused children attempt
Social-problems with finances, legal, family, social isolation
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Male
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8th leading cause of death
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Caucasian males
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73% of all suicides, 80% use guns
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Native Americans
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highest rate of suicide
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Suicide Assessment
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Look for warning signs-giving away cherished belongings, depression, talk of suicide or death
Identification of suicidal ideation
Elicitation of a plan
Determination of the severity of intent
Evaluation of availability of means
Sudden improvement may mean the person has developed a p…
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Suicide Interventions
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Safety
Commitment to treatment
Psychoeducation
Developing support networks
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Postvention of Suicide
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Work through grief with others
Preserve treatment team integrity vs. blaming and splitting
Community meetin with patients
In house memorial service
Continuous Quality Improvement
Acknowledge anniversary reactions
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Short-term outcomes of suicide
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Maintaining the patient's safety
Averting suicide
Mobilizing the patient's resources
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Long-term outcomes of suicide
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Maintaining the patient in psychiatric treatment
Enabling the patient and family to identify and manage suicidal crises effectively
widening the patient's support network
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crisis
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time limited, lasting no more than 4 to 6 weeks
When humans reach a state of dysequilibrium from a stressful situation, a crisis will occur if any of the following balancing factors are absent
Distorted perception
Inadequate support
Inadequate coping skills
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Maturational crisis
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significant developmental events requiring role changes
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Situational crisis
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occur when a specific life event upsets an individual's psychological equilibrium
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Traumatic Crises
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unexpected or unusual events affecting a person or group of people dramatically as in violent crime, natural disasters, war
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Crisis Intervention
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First arrange for safety & to meet basic needs
Treat life-threatening physical injuries
Arrange for food and shelter
provide care for suicidal, homicidal self-mutilation risk
Do not give unrealistic or false reassurances of positive outcomes
Pharmacologic interventions can help reduc…
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ABCs of Psychological First Aid
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Arousal
Behavior
Cognition
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arousal
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when arousal is present decrease excitement by providing safety, comfort, and consolation
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behavior
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when irrational behavior is present, assist survivors to function more effectively in the disaster
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cognition
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when cognitive disorientation occurs, reality testing and clear information should be provided
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Prewarning of the disaster
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preparing victims for possible evacuation of the environment, mobilization of resources, and review of community disaster plans
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Disaster event occurs
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rescuers provide resources, assistance, and support as needed to preserve the biopsychosocial functioning and survival of the victims
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Recuperative Effort
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Implement strategies for healing the sick and injured, preventing complications from health problems, repairing damages, and reconstructing the community
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Disaster Crisis Intervention
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Help the victims prioritize and match available resources with their needs
The type & severity of the disaster will affect needs/resources
Implement disease control strategies (rash, shots)
Telephone hotlines
Physical and mental health crisis services
Initiate attempts to reunite vit…
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Grief
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An intense, biopsychosocial reaction to the loss of a loved one that often includes spontaneous expressoin of pain, sadness, and desolation
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Bereavement
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Process of mourning and coping, begins immediately, but can it can last months or years
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Phases of Bereavement
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Shock & Disbelief
Acute mourning
Resolution
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Shock and Disbelief stage
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Hours to weeks
Varying degrees of disbelief and denial of the loss
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Acute Mourning Phase
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Becomes gradually aware of the loss
Indent feeling
Social withdrawal
Identification with the deceased
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Resolution Phase
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The return of feelings of well-being
Acceptance of lossDu
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Dual Process Model of Grieving
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another explanation of how people deal with their loss is oscillation between confronting (loos-oriented coping) & avoiding (restoration-oriented coping)
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Loss oriented coping
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preoccupation with the diceased
EX. memories of special moments or wondering how the lost person would react to something
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Restoration orient coping
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preoccupation with stessful events as a result of the death including financial, funeral or new identity
EX. widow
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Traumatic Grieving
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Suddenness and lack of anticipation
Violence, mutilation, and destruction
Preventability and/or randomness of the death
Multiple deaths (bereavement overload)
Mourner experienced significant threat to personal survival, or a massive and shocking confrontation with the deaths (and/or m…
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Complicated Grief Disorder
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10-20% of people-occurs when the grieving person is stuck in a chronic state of mourning
Intense longing & grieving for a person who died over 6 months ago
Feelings of bitterness, lack of trust, life is meaningless
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Nursing Interventions
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Assess for suicide or self harm
Listen, they need to work through the stages
Link to support systems
Refer to therapist/psychiatrist
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NURSE 2100: EXAM 4