28TH ANNUAL MEDICAL- SURGICAL NURSING CONFERENCE

Transcription

1 28TH ANNUAL MEDICAL- SURGICAL NURSING CONFERENCE CARING FOR THE PSYCH PATIENT ON THE MEDICAL SURGICAL NURSING UNIT NATALIE CENTURIONI, MSN, RN, CNL

2 OBJECTIVES Understanding the cycle of aggression Identification, prevention and management through therapeutic communication and verbal de escalation practices Guide the patient to make healthy choices Learn how to regulate our own behavior in a crisis, even when it is not intuitive

3 AGGRESSION

4 AGGRESSION Usually starts out as anxiety and progresses to agitation Generally, does not occur abruptly or randomly May or may not result from a triggering event Escalates with frustration, when an expected goal is believed to have been intentionally impeded Presence of a perceived threat

5 CONTRIBUTING FACTORS Underlying medical conditions Delirium/dementia Physical or psychological discomfort Pain Psychosis Persecutory Delusions

6 CONTRIBUTING FACTORS Known history of aggression Cruelty toward animals History of trauma or physical/sexual abuse Intoxication/Substance abuse Age/gender/ethnicity

7 CONTRIBUTING FACTORS We draw beliefs from: 1) Our observations 2) Our past experiences

8 THE AGGRESSION CYCLE Every stage offers a chance to step in Our behavior influences the patient s behavior Always apply the least restrictive intervention(s) first Your de escalation interventions must reflect the patient s behavior

9 THE AGGRESSION CYCLE

10 THE AGGRESSION CYCLE Before escalation, patient is at baseline which is his or her version of calm. Now is your opportunity to PREVENT AGGRESSION

11 THE ESCALATION PHASE Recognizing Aggression Closed demeanor Facial expressions Gestures

12 THE ESCALATION PHASE Verbal Cues Persistent or frequent Questioning Suspiciousness Somatic complaints Yelling/Crying /Mumbling/Cursing/ Name calling Challenging/Increased complaining/ negative attitude Refusal

13 THE ESCALATION PHASE Behavioral Cues Tearing objects (such as paper) Chewing on patient ID band Slamming cabinets/doors Isolate/act detached Less re-directable Hyper-vigilance

14 THE EXPLOSION PHASE Imminent Danger to Self Scratching self Cutting self Banging head Attempting to choke/hang self Attempting to swallow something hazardous Attempting to elope

15 THE EXPLOSION PHASE Imminent Danger to Others Physically assaultive Kicking Biting Grabbing Scratching Throwing Posturing

16 THE POST EXPLOSION PHASE Patient is no longer imminent harm to self or others Situation is controlled and safe Patient was Able to calm down on his or her own OR Required physical hold, seclusion or restraints to help calm down

17 THE POST EXPLOSION PHASE Requires ongoing evaluation, patient at increased risk to be triggered again Debrief Restore therapeutic relationship Help patient to develop a safety plan for future Identify individual coping skills

18 PRECAUTIONS FOR THE HIGH RISK PATIENT

19 BUILDING YOUR BANK How to develop trust and rapport with your patient Should start from the moment you meet Yes opportunities when establishing boundaries

20 BUILDING YOUR BANK Follow through Anticipate needs Spend an extra 5 minutes Make yourself relatable Explain expectations honestly Make promises cautiously

21 ENVIRONMENTAL FACTORS Anything and Everything Temperature Light Sound Time of day (change of shift) People (family members or staff) Personal space

22 INITIATE A SAFETY STANCE Execute open body language Do not cross your arms, keep them at your side Keep your hands visible No clenched fists Avoid placing hands on your hips Remain at eye level

23 INITIATE A SAFETY STANCE Maintain eye contact, but do not glare Position your body to the side No sudden gestures Always remain closest to exit

24 INITIATE A SAFETY STANCE Maintain a leg s length distance Respect the patient s personal space (everyone is different) Ask before touching Be considerate when handling personal belongings Announce what you are doing

25 IT S NOT WHAT YOU SAY It s How You Say It! Non threatening tone Gentle/Soft voice Inflection Cadence Speed Simple/Concise words

26 IT S NOT WHAT YOU SAY It s How You Say It! Does your body language correspond to what you are saying?

27 WHAT TO AVOID Evading the question Ignoring the patient Engaging in a power struggle/ acting defensive Condescending attitude Acting as an authoritarian

28 WHAT TO AVOID Appearing impatient or distracted (do not be on computer or phone) Sarcasm Limit use of personal opinion or judgments Be mindful of medical verbiage Taking sides Having the last word

29 HOW TO DE ESCALATE USING VERBAL COMMUNICATION

30 DE ESCALATION INTERVENTIONS Address the situation Listen Validate/ Explain Redirect by distraction Limit Setting

31 DE ESCALATION INTERVENTIONS Physical Intervention Emergency Medicine Seclusion Mechanical Intervention/Restraint

32 EMPATHY Having an emotional understanding of the patient s experience Put yourself in the patient s shoes Essential in order develop and maintain a therapeutic relationship Remember, the client may be responding to the perceived threat instead of the true threat

33 ADDRESSING THE SITUATION Remain calm, maintain respect and dignity Give Charge RN a heads up of what you are doing, especially if you anticipate escalation Meet with the patient one on one (no group settings) Second team member for safety One person should speak at a time Ideally, the same person speaking should step into lead the situation Does the client need to cool down first?

34 LISTENING Remain attentive! Ask ACTIVE and open ended questions so the patient shares his or her perspective What happened? What were you feeling at the time? What made you respond the way you did?

35 LISTENING Listen reflectively Summarize what patient said in your own words and then confirm that you are understanding correctly The importance of silence

36 VALIDATE & EXPLAIN Acknowledge Refocus challenging questions/opinions Find common ground Validate emotional responses Agree to disagree (if applicable)

37 VALIDATION & ORIENTATION Figure out how we can move forward Recognize why patient was triggered Offer available resources or additional support How will they regain some self control?

38 EXPLORING SOLUTIONS Only promise what is possible If you are unable to offer the ideal, explain why and then offer an alternative Give realistic timeframes Offer choices (generally no more than 2)

39 REDIRECTION BY DISTRACTION Journaling/Drawing Writing a letter Watching TV/Reading Listening to Music Calling a friend/family member Make a gratitude list Cool face towel Relaxation techniques/meditat ion Exercise Take a nap Shower Crosswords/mind teasers

40 LIMIT SETTING Be firm, but polite Clearly verbalize what is acceptable What is inappropriate and why? Offer alternatives (no more than 2) Requests should be no longer than 5 words Focus on one issue at a time

41 LIMIT SETTING Is your direction realistic for patient? Hold the patient accountable, but do not reinforce self shame Avoid threatening, but state consequences Only if you can follow through with said consequence Consistency is key!

42 REFLECTIONS

43 PATIENT DEBRIEFING Opportunity to restore the therapeutic alliance between you and the patient How can I, as the provider do better next time? Do we all understand expectations moving forward?

44 PATIENT DEBRIEFING Ask open ended questions so patient can describe what happened in his or her own words What coping skills can you use next time you are feeling triggered? Is there a particular person you feel comfortable talking to if you start to feel upset? Do you have a safety plan?

45 STAFF DEBRIEFING A time to process emotions Encourages team work/helps to create a positive rapport with coworkers Learning opportunity What worked for you? What didn t work for you? Review the do s and don ts for next time Was it therapeutic for the patient?

46 HOW DO YOU REACT IN A CRISIS? Panic Overreacting Delayed reactions Hasty or rushed reactions Confusion Avoidance Overly emotional

47 HEADS UP! An Agitated Patient Will.. Attempt to get under your skin By insulting you Testing you Betraying you Reminder to always maintain appropriate boundaries and never share personal details about yourself

48 HEADS UP! Do not engage in the insult Practice your poker face! Know when to rely on the strengths of a coworker Embrace your individual traits and use them to your benefit i.e. wit, gender, age, ethnicity, physical characteristics, etc. Present a united front with your teammates (coworkers) Staff splitting

49 REFERENCES John Muir Behavioral Health Center (2017). Workplace Violence Training and Disruptive Behavioral Strategies. Concord, CA Reilly, P. & Shopshire, M. (2012). Anger management for substance abuse and mental health clients: A cognitive behavioral therapy manual. Substance Abuse and Mental Health Services Administration Retrieved from Richmond, J., Berlin, J., Fishkind, A., Holloman, G., Zeller, S., Wilson, R., Rifai, M., & Ng, A. (2012). Verbal de-escalation of the agitated patient: Consensus statement of the American association for emergency psychiatry project BETA de-escalation workgroup. Western Journal of Emergency Medicine. 13(1): DOI: /westjem Wain, T. & Khong, E. (2011). Aggressive behavior: Prevention and management in the general practice environment. Australian Family Physician, 40 (11),