AGGRESSION AND VIOLENCE

Aggression and Violence

Aggression: It is harsh physical or verbal action intended to harm or injure another person.     OR     Aggression is verbal expression of readiness to cause an attack with threats.

Violence: is threat with physical attack that results into harm.   OR    Violence is showing marked physical force causing harm being inflicted on another person or
object.

Causes of aggression and violence

  1.  Mental illnesses: Patient experiencing hallucinations where a patient may hear voices telling him/her to fight or may see the health service provide as a lion and so she is fighting in self defence.
    >  The patient may also be experiencing delusions for example a patient may be having persecutory delusions whereby she is suspecting her and planning to do evil to the patient so she gets violent in self-defense.
  2. Forced admission of a patient with mental illness
  3.  Forced discharges of patients who prefer to stay in hospital than going back to the community (institutional neurosis)
  4.  Forced procedures such as Female Genital Mutilation.
  5.  Delusions and hallucinations especially auditory or visual
    types.
  6.  Pre or post ictal phase of epilepsy
  7.  Boredom and being idle on the ward
  8.  Monotonous routine activities on the ward
  9.  The ward environment may be boring or filthy
  10.  Provocation: by fellow patients, Staff , friends or relatives
  11.  Lack of communication between patient and staff
  12.  Staff may not be therapeutic to the patient. Poor nurse- patient relationship or patient being neglected by the health service provider. 
  13.  Learnt behaviour from friends or parents.
  14.  Inherited from the parents (genetic)
  15.  Violent and aggressive behaviour is associated with hormonal
    dysfunction for example Cushing’s disease. (hyperthyroidism)
  16.  Common in poor families due to lack essentials for life.
  17.  Frustration i.e. if one does not know what to do.
  18. Impulsive behaviour might be the cause if there is history of such behaviour
  19.  Medication might have been forced so the patient looks at relatives as enemies
  20.  Alcohol and drug misuse
  21. Stigmatization by community members or family members whereby the patient is called such names like, “wire”, “zolo” hence making the patient become violent
  22. Lack of financial support to the patient to return to hospital for review as prescribed by the psychiatrist or lack of review due to negligence of relatives.
  23.  Peer group influence for example living with people who have naturally aggressive behaviour (learnt behaviour)

Indicators of violence and aggression

  •  Restlessness moving up and down unable to sit still
  •  Tense facial expression and body language
  • Verbal or physical threats
  • Loud voice
  • Abusive language
  • Disturbed sleep
  • Tendencies to move with harmful objects
  • Shouting
  • Use of obscenities
  • Argumentative.
  • Threats of homicide or suicide
  • Panic attacks
  • Disturbed thought process
  • Suspiciousness
  • Angry mood often inappropriate to the situation
  • Crying without any clear reason
  •  Isolated or withdrawn
  • Temper tantrums (sudden outbursts and falling off)
  •  Scolding or annoying others
  • Negativism- Doing the opposite of what is expected
  •  Quietness- Not being able to say anything due to too much anger

Management of Aggression and Violence

This is psychiatric emergency
Aims of management
1. To safe guide the public or patient.
2. To treat and monitor the patient.

  1. Admission:  Patient should be admitted on acute ward and ensuring there are no harmful objects near the vicinity, Remain calm when dealing with this patient.

  2. Assessment: Common observations eg vitals, specific and general. Any physical illness, Patients mental status
    > Risk of violence and aggression or indicators.
    >  Assess for possible causes of violence and aggression. If any
    try to eliminate the cause.
  3. Establish a positive nurse-patient relationship.
  4.  In case the patient is hospitalized do not take her by surprise, explain all the procedures you are
    going to do assure the individual of his or her security
  5.  As a health worker should try to understand why he patient is aggressive before resorting to
    restraining methods
  6.  Show the aggressive patients that you are in control of the situation
  7.  Welcome the patient on the ward and address her by her name.
  8.  Move towards the patient with open hands
  9.  Talk to the patient and hear her response. Be firm and kind
  10.  Ensure that there is enough man power to help you in case the patient gets more violent
  11.  If the patient is chained, remove the chains and observe patient’s response
  12.  Ensure that there is no weapon or dangerous tool available before approaching the patient.
    Remove any dangerous objects such as knives by requesting the patient to place them on the
    table or floor.
  13. Distract the patient’s attention as the rest of the manpower is getting close to the patient to
    restrain her.
  14.  Make sure that in the process of restraining nobody is hurt. Also minimize damage to property.
  15.  The patient should be approached convincingly but if he/she is still resistant, should be put on the bed swiftly or on the floor where he must readily be immobilized.
  16.  Restraining the Patient, Firmly hold the joints and limbs in firm position so as to avoid fractures and dislocation or
    hurting/injuries.
  17.  Observe if the patient is still aggressive or violent. Ask if patient can promise not to repeat the behaviours
  18.  Administer sedatives or tranquilizers if available in injection form. i.e. diazepam 10mg to 20mg
    t.d.s
  19.  If still the same, put him/her in the side room (seclusion room) and indicate the duration of the
    seclusion.
  20.  Observe if still aggressive or violent, if yes repeat the sedation
  21.  Make plans to release the patient
  22.  Gradually tell the patient to avoid aggression and violence and avoid provoking situations
  23.  The nurse should talk to the patient to promise that he will not resort to violence if released back
    to his freedom.
  24.  The clinical team should discuss the future of the patient
Management after Discharge (while at home)
  •  Encourage family members to support the patient
  •  Community should be taught about the dangers of stigmatisation
  •  Relatives should be educated about the signs of aggression and violence so that early intervention can be made.
  •  Patient should be told to control emotions and be taught the skill of stress management
  •  Advise family members to always refer patient when he becomes violent or aggressive.

NURSING CARE

  • Avoid touching the patient when he becomes violent
  • Set or establish contract with the patient that he will not become violent
  •  Help the patient to establish the true cause of anger.
  •  If possible ignore initial derogatory remarks by the patient.
  •  Encourage the client to keep records of angry feelings that
    triggered him to become violent and how they were handled.
  •  Continuous observation of client for escalation of anger.
  •  Ensure sufficient staff are available.
  •  If becomes violent call for assistance and remove all other patients from the immediate environment

Physical Restraint

If not calmed down.

  •  Approach the client from in front with open hands to indicate
    no signs of harm.
  •  Call the patient by names when approaching him or her.
  •  Let patient express his feelings
  •  Ensure that patient and staff are not injured during the restraint. Do not sit on the patient. Ensure that patients are not involved in the restraint.
  •  Do not lift the patient when taking him to the side room. Let the patient walk to the seclusion room.
  •  Seclude the patient for specific period and indicate the reasons and goals of managing him in the side room.
  •  Continue observing if he has calmed down. If so remove him but if not continue to seclude with treatment.


Chemotherapy

  • Administer medication to calm the patient down. The drugs
    include: Tranquillizers for example chlorpromazine,
    haloperidol. Sedatives are also important for example
    diazepam intramuscularly.
  •  Document your care
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