Help the patient identify coping strategies and find more acceptable ways to express feelings.

1st Generation Antipsychotics
Haloperidol (Haldol)
Perphenazine
Chlorpramazine (Thorazine)
Loxapine (Adasuve)

Predictors (Signs and Symptoms) of Violence

• Hyperactivity (e.g. pacing, restlessness)
• Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self (patient may have shortness of breath, sweating, and rapid pulse)
• Verbal abuse: profanity, argumentativeness
• Loud voice, change of pitch, or a very soft voice, forcing others to strain to hear
• Stone silence
• Intense eye contact or avoidance of eye contact
• Recent acts of violence, including property violence
• Alcohol or drug intoxication
• Possession of a weapon or object that may be used as a weapon (e.g. fork, knife, rock)
• Isolation that is uncharacteristic

Milieu Characteristics Conducive to Violence

• Overcrowding
• Staff inexperience
• Provocative or controlling staff
• Poor limit setting
• Arbitrary revocation of privileges

Subjective Data

• Assess the patient's history of aggression and violence
• Identify the patient's triggers

Assessment Guidelines
1) A history of violence is the single best predictor of future violence.
2) Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk of violence.
3) Major factors associated with violence can be assessed with these questions:

• Does the patient have a wish or intent to harm?
• Does the patient have a plan?
• Does the patient have the means available to carry out the plan?
• Does the patient have demographic risk factors: male gender, aged 14-24 years, low socioeconomic status, inadequate support system, and prison time?
  4) Aggression by patients occurs most often in the context of limit-setting by the nurse.
  5) History of limited coping skills, including lack of assertiveness or use of intimidation, indicates a higher risk of using violence.
  

Risk for other-directed violence
Manifestations: body language (rigid posture, clenching of fists and jaw, hyperactivity, pacing), history of violence, history of family violence, history of substance abuse

Risk for self-directed violence
Manifestations: impulsivity, suicidal ideation (detail, method, access), overt or covert statements regarding killing self, feelings of worthlessness, hopelessness, helplessness

Ineffective coping (overwhelmed or maladaptive)
Manifestations: difficulty with simple tasks, inability to function at previous level, poor problem solving, poor cognitive functioning, verbalizations of inability to cope

Stress overload
Manifestations: demonstrates feelings of anger, impatience; reports feelings of pressure, tension, difficulty in functioning, anger, impatience; experiences negative impact from stress; reports problems with decision making

Risk for self-directed violence
Expresses feeling, verbalizes suicidal ideas, refrains from suicide attempts, plans for the future

Ineffective coping
Identifies ineffective and effective coping, uses support system, uses new coping strategies, engages in personal action to manage stressors effectively

Risk for other-directed violence
Identifies when angry, identifies alternative to aggression, refrains from verbal outbursts, avoids violating others' personal space, maintains self-control

Stress overload
Expresses feelings constructively, reports feelings of calmness and acceptance; physical symptoms of stress are reduced or absent; decision making is optimal

2nd Generation Antipsychotics
Risperidone (Risperidal)
Olanzapine (Zyprexa, Zydis)
Ziprasidone (Geodon)

Antianxiety Agents (Benzodiazepines)
DRUG OF CHOICE = Lorazepam (Ativan)
Alprazolam (Xanax)
Diazepam (Valium)

Combinations of antipsychotics and benzodiazepines may also be ordered IM.

All pharmacological interventions are used on a PRN basis.

Assess for signs and symptoms of labile or escalating emotions

The patient redirects anger into socially appropriate behaviors.

The patient verbalizes frustration and anger appropriately.

The patient demonstrates self-control, as evidenced by relaxed posture and nonviolent behavior.

The patient verbalizes an understanding of own behavior and precipitating factors and implements measures to prevent violent behavior.

Obtain the patient's history including previous acts of violence, comorbid illnesses, and past triggers.

Assess the patient's readiness to learn alternative and nonviolent ways of handling angry feelings.

Implement the use of restraints and seclusion as necessary and only when appropriate.

Apply anger control assistance techniques to assist the patient in facilitation of the expression of anger in an adaptive, nonviolent manner.

There is no DSM-5 diagnosis criteria for violence as it is not an actual diagnosis rather an objectable act that results from anger and aggression.

Patient will redirect anger into socially appropriate behaviors.

Patient will verbalize frustration and anger appropriately

Patient will verbalize an understanding of own behavior and precipitating factors and will implement measure to prevent violent behavior in the future.

Perform a self-assessment to prevent issues in providing treatment to the patient.

The patient remained safe from injury and did not injure others.

Maintain a calm exterior and approach the patient in a nonthreatening manner.

Provide a safe environment by removing hazardous objects and decreasing environmental stimuli.

Use open-ended statements rather than challenging statements.

Give the patient two options to decrease the sense of powerlessness.

Choose a quiet place to talk to the patient but one that is visible to staff.

Remove other patients from the area and make sure no hazardous objects are within the vicinity.

Avoid wearing dangling earrings, necklaces, and scarves in acute care environments.

Do not stand directly in front of the patient or in front of the doorway.

Administer PRN medications to control violent behavior when appropriate.

Model appropriate responses and ways to cope with anger

Teach patients a variety of methods to appropriately express anger.

Educate patients regarding coping mechanisms, deescalation techniques, and self-soothing skills to manage behavior.

Assist the patient in identifying triggers for the angry or aggressive behavior.