V

• Remain free from vascular trauma

• Remain free from signs and symptoms that indicate vascular trauma

• Remain free from impaired tissue and/or skin

• Maintain skin integrity, tissue perfusion, usual tissue temperature, color and pigment

• Report any altered sensation or pain

• State site is comfortable

 Verify objective and estimate duration of treatment. Check physician’s order. Verify if client will remain hospitalized during the whole treatment or will go home with the device (Phillips, 2010).

• Assess client’s clinical situation when venous infusion is indicated. Consider possible clinical conditions that cause changes in temperature, color, and sensitivity of the possible venous access site. Verify situations that alter venous return (e.g., mastectomy, stroke) (Phillips, 2010). The site of catheter insertion influences the risk of infection and phlebitis, such as preexisting catheters, anatomic deformity, and bleeding diathesis (Joanna Briggs Institute, 2008).

• Assess if client is prepared for an IV procedure. Explain the procedure if necessary to decrease stress. Stress may cause vasoconstriction that can interfere in the visualization of the vein and flow of the infused solution (Wells, 2008).

• Provide privacy and make the client comfortable during the intravenous insertion. Privacy and comfort help to decrease stress (Phillips, 2010). The nurse should minimize discomfort to the client and utilize measures to reduce the fear, pain, and anxiety associated with intravenous insertion (RCN, 2010).

• Teach the client what symptoms of possible vascular trauma he should be alert to and to immediately inform staff if they notice any of these symptoms. Prompt attention to adverse changes decreases chance of adverse effects from complications (Dougherty, 2008).

• Wash hands before and after touching the client, as well as when inserting, replacing, accessing, repairing or dressing an intravascular catheter (O’Grady et al, 2011).

• Maintain aseptic technique for the insertion and care of intravascular catheters. Use gloves and always reduce the number of staff present in the environment during the procedure if possible. CEB: These measures reduce the risk of infection (Ingram & Lavery, 2007).

• Assess the condition of the client’s veins, possible age-related influence, and previous intravenous site use. In order to minimize the risk of complications, thorough patient assessment and careful catheter management are essential (McCallum & Higgins, 2012).

• In cases of hard-to-access veins, consider strategies such as the use of ultrasound (US) to assist in vein localization and safe venipuncture. Ultrasound-guided cannulations have a high success rate in clients with difficult venous access (Elia et al, 2012).

• Avoid areas of joint flexion or bony prominences. Movement in these sites can cause mechanical trauma in veins (RCN, 2010).

• Choose an appropriate vascular access device (VAD) based on the types and characteristics of the devices and insertion site. Consider the following:

 Choose a device with consideration of the nature, volume, and flow of prescribed solution. EBN: Choosing the right gauge size reduces the risk of vascular trauma (Trim, 2005). Verify that the osmolarity of the solution to be infused is compatible with the available access site and device (Phillips, 2010).

• If possible, choose the venous access site considering the client’s preference.

• Select the gauge of the venous device according to the duration of treatment, purpose of the procedure, and size of the vein. Emergency situations require short, large-bore cannulae. Hydration fluids and antibiotics can be delivered through much smaller cannulae (Scales, 2008). Select the smallest gauge necessary to achieve the prescribed flow rate (INS, 2011). The time of infusion of the drug, especially chemotherapy agents, can contribute to the occurrence of phlebitis (Kohno et al, 2008). EB: The use of an infusion pump is a factor that predisposes the occurrence of phlebitis (Uslusoy & Mete, 2008).

• Verify if client is allergic to fixation or device material.

• Disinfect the venipuncture site. Assess that skin is dry before puncturing.

• Provide a comfortable, safe, hypoallergenic, easily removable stabilization dressing, allowing for visualization of the access site. Catheter stabilization should be used to preserve the integrity of the access device, to minimize catheter movement at the hub, and to prevent catheter migration and loss of access (INS, 2011). Some peripheral cannulae have stabilization wings (which increase the external surface area) and/or ports (which are used to administer bolus medication) incorporated into their design (Gabriel, 2008).

• Use either sterile gauze or sterile, transparent, semipermeable dressing to cover catheter site. Replace dressing used on short-term CVC sites every 2 days for gauze dressings and replace it at least every 7 days for transparent dressings (INS, 2011; O’Grady et al, 2011). The use of a transparent occlusive dressing can facilitate regular monitoring by visually inspecting the vascular access device (Lavery & Ingram, 2006). If the client has local tenderness or signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually (O’Grady et al, 2011). Use of gauze is preferable if the client is diaphoretic, if the site is oozing or bleeding, or if it becomes damp (INS, 2011; O’Grady et al, 2011).

• Document insertion date, site, type of VAD, number of punctures performed, other occurrences, and measures/arrangements taken.

• Always decontaminate the device before infusing medication or manipulating IV equipment (Scales, 2008).

 Verify the sequence of drugs to be administrated. Vesicants should always be administered first in a sequence of drugs (Dougherty, 2008).

• Monitor permeability and flow rate at regular intervals.

• Monitor catheter-skin junction and surrounding tissues at regular intervals, observing possible appearance of burning, pain, erythema, altered local temperature, infiltration, extravasation, edema, secretion, tenderness, or induration. Remove promptly. The infusion should be discontinued at the first sign of infiltration or extravasation, the administration set disconnected, and all fluid aspirated from the catheter with a small syringe (INS, 2011).

 Replace device according to institution protocol. EB: Note: There are variations regarding catheter permanence time in the literature. Recommended catheter permanence time varies from 72 (Scales, 2008) to 96 hours or less if there are any clinical signs (Ingram & Lavery, 2007). EBN: In a systematic review including five trials (3408 participants) on the replacement of peripheral venous catheters, authors did not identify evidence of the benefit of the replacement of catheters between 72 and 96 hours; thus, it is recommended that catheters be replaced only when presenting clinical signs (Webster et al, 2010).

 Flush vascular access according to organizational policies and procedures, and as recommended by the manufacturer. Vascular access devices should be flushed after each infusion to clear the infused medication from the catheter lumen, preventing contact between incompatible medications (INS, 2011). Sodium chloride 0.9% or heparinized sodium chloride have been applied in peripheral IV cannulae, although there are controversies regarding the best choice (Tripathi, Kaushik, & Singh, 2008).

• Remove catheter on suspected contamination, if the client develops signs of phlebitis, infection, or a malfunctioning catheter, or when no longer required. Vascular access devices should be removed on unresolved complication, therapy discontinuation, or if deemed unnecessary (INS, 2011). Replace any SPVC inserted under emergency conditions within 24 hours (Couzigou et al, 2005).

• Clients need to be encouraged to report any discomfort such as pain, burning, swelling, or bleeding (Joanna Briggs Institute, 2008).

Pediatric:

Geriatric:

Home Care:

• Maintain arterial blood gases within safe parameters

• Remain free of dyspnea or restlessness

• Effectively maintain airway

• Effectively mobilize secretions

 Explain the intubation and mechanical ventilation process to the client and family as appropriate, and during intubation administer sedation for client comfort according to the physician’s orders. EBN: Explanation of the procedure decreases anxiety and reinforces information; premedication allows for a more controlled intubation with decreased incidence of insertion problems (Burns, 2011).

• Secure the endotracheal tube in place using either tape or a commercially available device, auscultate bilateral breath sounds, use a CO₂ detector, and obtain a chest radiograph to confirm endotracheal tube placement. EBN: Secure taping is needed to prevent inadvertent extubation. Nursing studies have shown conflicting results regarding the preferable way to secure the endotracheal tube (Goodrich, 2011a). EB: Auscultation alone is an unreliable method for checking endotracheal tube placement. A CO₂ detector can be used to confirm tube placement in the trachea (Goodrich, 2011b); however, correct position of the endotracheal tube in the trachea (3 to 5 cm above the carina) must be confirmed by chest radiograph (Goodrich, 2011b). Calorimetric CO₂ detectors have also been used successfully to detect inadvertent airway intubation during gastric tube placement (Goodrich, 2011b).

• Ensure that ventilator settings are appropriate to meet the client’s minute ventilation requirements (Grossbach, Stanberg, & Chlan, 2011). Ventilator settings should be adjusted to prevent hyperventilation or hypoventilation. A variety of new modes of ventilation are currently available that are responsive to client effort (pressure support). Few data are available to support the best use of these ventilator modes or their effect on client outcome (Burns, 2008, 2011; Grossbach, Stanberg, & Chlan, 2011).

 Suction as needed and hyperoxygenate according to unit policy. Refer to the care plan Ineffective Airway Clearance for further information on suctioning.

• Check that monitor alarms are set appropriately at the start of each shift. This action helps ensure client safety (Burns, 2011).

• Respond to ventilator alarms promptly. If unable to immediately locate the source/cause of an alarm, use a manual self-inflating resuscitation bag to ventilate the client while waiting for assistance. Common causes of a high-pressure alarm include secretions, condensation in the tubing, biting of the endotracheal tube, decreased compliance of the lungs, and compression of the tubing. Common causes of a low-pressure alarm are ventilator disconnection, leaks in the circuit, and changing compliance. Using a manual self-inflating resuscitation bag with supplemental oxygen, the nurse can provide immediate ventilation and oxygenation as needed (Burns, 2011, Goodrich, 2011a; Grossbach, Stanberg, & Chlan, 2011).

• Prevent unplanned extubation by maintaining stability of endotracheal tube with careful taping or use of a device for stabilization of the tube, also use of restraints if needed with physician’s order. EB: Prevent unplanned extubation with use of weaning protocol (Jarachovic et al, 2011).

• Drain collected fluid from condensation out of ventilator tubing as needed. This action reduces the risk of infection by decreasing inhalation of contaminated water droplets (Burns, 2011).

• Note ventilator settings of flow of inspired oxygen, peak inspiratory pressure, tidal volume, and alarm activation at intervals and when removing the client from the ventilator for any reason (Burns, 2011; Grossbach, Stanberg, & Chlan, 2011). Checking the settings ensures that safety measures are taken and that the client is not left on 100% oxygen after suctioning (Burns, 2011).

 Administer analgesics and sedatives as needed to facilitate client comfort and rest. Pain and sedation scales provide a consistent way of monitoring sedation levels and ensuring that therapeutic outcomes are being met (Girard et al, 2008; Grap, 2009). Clients receiving mechanical ventilation require sedation to help attenuate the anxiety, pain, and agitation associated with this intervention (Grap, 2009). The overall goal of sedation in critical care settings is to provide physiological stability, ventilator synchrony, and comfort for clients (Grap, 2009).

 Initiate a “sedation vacation” daily, with lightening of analgesics and sedatives until the client becomes awake. During this time carefully monitor the client to protect from inadvertent self-extubation, pain and anxiety, and periods of desaturation from asynchrony of breathing with the ventilator. EB: Sedation vacations have been associated with decreased length of intubation, and decreased incidence of ventilator-associated pneumonia (Institute for Health Care Improvement, 2012). CEB: A randomized controlled trial found that use of a sedation vacation resulted in decreased days of intubation (Kress, 2000).

• Utilize tools such as the Riker Sedation-Agitation Scale, the Motor Activity Assessment Scale, the Ramsey Scale, or the Richmond Agitation-Sedation Scale because they can be useful in monitoring levels of sedation (Grap, 2009). EB: Each of these instruments has established reliability and validity and can be used to monitor the effect of sedative therapy (Girard et al, 2008; Grap, 2009). However, recent research suggests that the use of sedation and pain scales may not decrease duration of mechanical ventilation (Williams et al, 2008). Actigraphy measurements correlate well with clients’ observed activity and with subjective scores on agitation and sedation scales, and may be important for use in recognizing excessive agitation (Grap, 2009).

• Alternatives to medications for decreasing anxiety should be attempted, such as music therapy with selections of the client’s choice played on headphones at intervals. EBN: Music therapy has been reported to decrease anxiety and reduce heart and respiratory rate in critically ill and intubated clients (Hunter et al, 2010; Tracy & Chlan, 2011).

• Analyze and respond to arterial blood gas results, end-tidal CO₂ levels, and pulse oximetry values. Ventilatory support must be closely monitored to ensure adequate oxygenation and acid-base balance. EBN: End-tidal CO₂ monitoring is best used as an adjunct to direct client observation and is used to monitor a client’s ventilatory status and pulmonary blood flow (Burns, 2011; Rasera et al, 2011).

• Use an effective means of verbal and nonverbal communication with the client such as an alphabet board, picture board, electronic voice output communication aids, computers, and writing slates. Ask the client for input into his or her care as appropriate. Barriers to communication include endotracheal tubes, sedation, and general weakness associated with a critical illness. Basic technologies should be readily available to the client, including eyeglasses and hearing aids (Grossbach, Stanberg, & Chlan, 2011; Henneman, 2009; Khalaila et al, 2011). Inadequate communication with the client and family may increase the risk for medical errors and adverse events (Kleinpell et al, 2008).

• Move the endotracheal tube from side to side every 24 hours, and tape it or secure it with a commercially available device. Assess and document client’s skin condition, and ensure correct tube placement at lip line (Vollman & Sole, 2011).

• Implement steps to prevent ventilator-associated pneumonia (VAP), including continuous removal of subglottic secretions, elevation of the head of bed to 30 to 45 degrees (Siela, 2010; Vollman & Sole, 2011) unless medically contraindicated, change of the ventilator circuit no more than every 48 hours, and handwashing before and after contact with each client (Lacherade et al, 2010). See details in the sections that follow. The accumulation of contaminated oropharyngeal secretions above the endotracheal tube may contribute to the risk of aspiration.

 Use endotracheal tubes that allow for the continuous aspiration of subglottic secretions (Siela, 2010; Vollman & Sole, 2011). EB: Subglottic secretion drainage during mechanical ventilation results in a significant reduction in VAP, including late-onset VAP (Lacherade et al, 2010; Vollman & Sole, 2011). Use of continuous subglottic suctioning endotracheal tubes for intubation in clients who are predicted to require intubation for more than 48 hours likely results in decreased incidence of VAP and costs of care (Speroni et al, 2011).

• Position the client in a semirecumbent position with the head of the bed at a 30- to 45-degree angle to decrease the aspiration of gastric, oral, and nasal secretions (Grap, 2009; Siela, 2010; Vollman & Sole, 2011). Historically, evidence shows that mechanically ventilated clients have a decreased incidence of VAP if the client is placed in a 30- to 45-degree semirecumbent position as opposed to a supine position.

• Consider use of kinetic therapy, using a kinetic bed that slowly moves the client with 40-degree turns. Rotational therapy may decrease the incidence of pulmonary complications in high-risk clients with increasing ventilator support requirements, at risk for VAP, and clinical indications for acute lung injury or acute respiratory distress syndrome (ARDS) with worsening PaO₂:FIO₂ ratio, presence of fluffy infiltrates via chest radiograph concomitant with pulmonary edema, and refractory hypoxemia (Johnson, 2011).

• Perform handwashing using both soap and water and alcohol-based solution before and after all mechanically ventilated client contact to prevent VAP (Lacherade et al, 2010).

• Provide routine oral care using toothbrushing and oral rinsing with an antimicrobial agent if needed (Siela, 2010; Vollman & Sole, 2011). EB: Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in clients without pneumonia at baseline (Munro et al, 2009). Toothbrushing may be an important intervention in the prevention of VAP (Ames, 2011, Halm, & Armola, 2009). Reducing bacterial colonization of oral cavity includes interventions of daily oral assessment, deep suctioning every 4 hours, toothbrushing twice per day with a plaque reducer, oral tissue cleaning with peroxide every 4 hours. Add these to standard VAP prevention measures and VAP rates can be further reduced (Garcia et al, 2009). Oral care with toothpaste was performed on clients in a neuroscience intensive care unit and did not increase intracranial pressure; thus, oral care may be performed safely (Prendergast et al, 2009).

• Maintain proper cuff inflation for both endotracheal tubes and cuffed tracheostomy tubes with minimal leak volume or minimal occlusion volume to decrease risk of aspiration and reduce incidence of ventilator-associated pneumonia (Siela, 2010; Skillings & Curtis, 2011; Sole et al, 2009; Vollman & Sole, 2011).

• Reposition the client as needed. Use rotational bed or kinetic bed therapy in clients for whom side-to-side turning is contraindicated or difficult. EBN: Changing position frequently decreases the incidence of atelectasis, pooling of secretions, and resultant ventilator-associated pneumonia (Burns, 2011; Johnson, 2011). EB & EBN: Continuous, lateral rotational therapy has been shown to improve oxygenation and decrease the incidence of VAP (Burns, 2011; Johnson, 2011).

 If the client is intubated and is stable, consider getting the client up to sit at the edge of the bed, transfer to a chair, or walk as appropriate, if an effective interdisciplinary team is developed to keep the client safe (Gosselink et al, 2008). For every week of bed rest, muscle strength can decrease 20%; early ambulation helped clients develop a positive outlook (Perme & Chandrashekar, 2009).

• Assess bilateral anterior and posterior breath sounds every 2 to 4 hours and PRN; respond to any relevant changes (Burns, 2011).

• Assess responsiveness to ventilator support; monitor for subjective complaints and sensation of dyspnea (Burns, 2011).

 Collaborate with the interdisciplinary team in treating clients with acute respiratory failure (Grap, 2009). Collaborate with the health care team to meet ventilator care needs and avoid complications (Grossbach, Stanberg, & Chlan, 2011). EB: A collaborative approach to caring for mechanically ventilated clients has been demonstrated to reduce length of time on the ventilator and length of stay in the ICU (Grap, 2009).

Geriatric:

Home Care:

Client/Family Teaching and Discharge Planning:

• Wean from ventilator with adequate arterial blood gases

• Remain free of unresolved dyspnea or restlessness

• Effectively clear secretions

 Physiological readiness. There has been little research devoted to the study of physiological readiness to wean. EBN: Assess fears and anxieties that can contribute to prolonged and repeated failure of ventilator weaning (Chen et al, 2011).

 Resolution of initial medical problem that led to ventilator dependence

 Hemodynamic stability

 Normal hemoglobin levels

 Absence of fever

 Normal state of consciousness

 Metabolic, fluid, and electrolyte balance

 Adequate nutritional status with serum albumin levels >2.5 g/dL

 Adequate sleep

 Adequate pain management and sedation

 Tachypnea, dyspnea, or chest and abdominal asynchrony

 Agitation or mental status changes

 Decreased oxygen saturation: SaO₂ less than 90%

 Increased PaCO₂ or ETCO₂

 Change in pulse rate or blood pressure or onset of new dysrhythmias

Geriatric:

Home Care:

• Stop all forms of abuse (physical, emotional, sexual; neglect; financial exploitation)

• Have cessation of abuse reported by victim

• Display no aggressive activity

• Refrain from verbal outbursts

• Refrain from violating others’ personal space

• Refrain from antisocial behaviors

• Maintain relaxed body language and decreased motor activity

• Identify factors contributing to abusive/aggressive behavior

• Demonstrate impulse control or state feelings of control

• Identify impulsive behaviors

• Identify feelings/behaviors that lead to impulsive actions

• Identify consequences of impulsive actions to self or others

• Avoid high-risk environments and situations

• Identify and talk about feelings; express anger appropriately

• Express decreased anxiety and control of hallucinations as applicable

• Displace anger to meaningful activities

• Communicate needs appropriately

• Identify responsibility to maintain control

• Express empathy for victim

• Obtain no access or yield access to harmful objects

• Use alternative coping mechanisms for stress

• Obtain and follow through with counseling

• Demonstrate knowledge of correct role behaviors

• Have safe plan for leaving situation or avoiding abuse

• Resolve depression or traumatic response

• Monitor social/play contacts

• Provide supervision and nurturing environment

• Intervene to prevent high-risk social behaviors

 Monitor the environment, evaluate situations that could become violent, and intervene early to deescalate the situation. Know and follow institution’s policies and procedures concerning violence. Consider that family members or other staff may initiate violence in all settings. Enlist support from other staff rather than attempting to handle the situation alone. EBN: APNA guidelines (2008) warn that workplace violence can occur in all settings, from a variety of sources. Nurses need to be aware and informed of department policies and procedures. Policies should be developed, and training programs should be provided in proper use and application of restraints. All nursing units should develop a proactive plan for dealing with violent situations.

• Assess causes of aggression: social versus biological. EB: Knowing the client, having experience with similar clients, paying attention, and planning interventions are expert practices used by clinicians to predict and respond to aggressive behavior effectively. A nonconfrontational approach is the most effective (APA, 2011).

• Assess the client for risk factors of violence, including those in the following categories: personal history (e.g., past violent behavior); psychiatric disorders (particularly psychoses, paranoid or bipolar disorders, substance abuse, PTSD, antisocial personality or borderline personality disorder); neurological disorders (e.g., head injury, temporal lobe epilepsy, CVA, dementia or senility), medical disorders (e.g., hypoxia, hypo- or hyperglycemia), psychological precursors (e.g., low tolerance for stress, impulsivity), coping difficulties (e.g., inability to plan solutions or see long-term consequences of behavior), and childhood or adolescent disorders (e.g., conduct disorders, hyperactivity, autism, learning disability). EBN & EB: All of these risk factors have been implicated in aggressive, agitated, or violent behavior, with prior history a key indicator (APA, 2011; APNA, 2008; Fountoulakis, Leucht, & Kaprinis, 2008; Temcheff et al, 2008).

• Measures of violence may be useful in predicting or tracking behavior, and serving as outcome measures. EBN: The Broset Violence Checklist (BVC) has been developed for short-term prediction of violence in psychiatric inpatients (Clarke, Brown, & Griffith, 2010). The Domestic Violence Survivor Assessment (DVSA) measures survivor progress toward a lifestyle free from violence over time (Dienemann, Neese, & Lowry, 2009). The Caregiver Psychological Elder Abuse Behavior Scale may be used to identify elder abuse behavior (Hsieh et al, 2009). CEB: The Alert Assessment Form may be used to identify potentially aggressive clients with moderate (71%) sensitivity and high (94%) specificity (Kling et al, 2006).

• Assess the client with a history of previous assaults. Listen to and acknowledge feelings of anger, observe for increased motor activity, and prepare to intervene if the client becomes aggressive. EB: The most significant risk factor for physical violence is a past history of physically aggressive behavior (APA, 2011; Amore et al, 2008).

• Assess the client for physiological signs and external signs of anger. Internal signs of anger include increased pulse rate, respiration rate, and blood pressure; chills; prickly sensations; numbness; choking sensation; nausea; and vertigo. External signs include increased muscle tone, changes in body posture (clenched fists, set jaw), eye changes (eyebrows lower and drawn together, eyelids tense, eyes assuming a “hard” appearance), lips pressed together, flushing or pallor, goose bumps, twitching, and sweating. EBN: Anger is an early warning sign of possible violence (APA, 2011; Puskar et al, 2008).

• Assess for the presence of hallucinations. EB: Command hallucinations may direct the client to behave violently (APA, 2011; Shawyer et al, 2008).

• Apply STAMPEDAR as an acronym for assessing the immediate potential for violence. EBN: A study of nurses experienced in workplace violence identified the following as factors and behaviors indicating the likelihood of a violent episode: Staring, Tone of voice, Anxiety, Mumbling, Pacing, Emotions, Disease process, Assertive/nonassertive behavior, and access to resources that might be used for violent behavior (Chapman et al, 2009).

• Determine the presence and degree of homicidal or suicidal risk. A number of questions will elicit the necessary information. “Have you been thinking about harming someone? If yes, who? How often do you have these thoughts, and how long do they last? Do you have a plan? What is it? Do you have access to the means to carry out that plan? What has kept you from hurting the person until now?” Refer to the care plan for Risk for Suicide. Psychotherapists are required to report harm or threats of harm to another person, referred to as the duty to warn. State laws and mental health codes should be checked to determine local mandates for threat reporting by specific health care professionals.

• Take action to minimize personal risk: Use nonthreatening body language. Respect personal space and boundaries. Maintain at least an arm’s length distance from the client; do not touch the client without permission (unless physical restraint is the goal). Do not allow the client to block access to an exit. If speaking with the client alone, keep the door to the room open. Be aware of where other staff is at all times. Notify other staff of where you are at all times. Take verbal threats seriously and notify other staff. Wear clothing and accessories that are not restricting and that will not be dangerous (e.g., sandals or shoes with heels can lead to twisted ankles; necklaces or dangling earrings could be grabbed). Programs for violence prevention have been implemented that reduce workplace violence. For OSHA guidelines, visit http://www.osha.gov/SLTC/workplaceviolence/index.html.

• Remove potential weapons from the environment. Be prepared to remove obstructions to staff response from the environment. Search the client and his or her belongings for weapons or potential weapons on admission to the hospital as appropriate. Clients prone to violence may use available weapons opportunistically. If client restraint becomes necessary, environmental hazards (e.g., chairs, wastebaskets) should be moved out of the way to prevent injuries.

• Inform the client of unit expectations for appropriate behavior and the consequences of not meeting these expectations. Emphasize that the client must comply with the rules of the unit. Give positive reinforcement for compliance. Increase surveillance of the hospitalized client at smoking, meal, and medication times. CEB & EB: Clients benefit from clear guidance and positive reinforcement regarding behavioral expectations and consequences, providing much-needed structure and emphasizing client responsibility for his or her own behavior (APA, 2011; APNA, 2007a). The unit serves as a microcosm of the client’s outside world, so adherence to social norms while on the unit models adherence on discharge and provides the client with staff support to learn appropriate coping skills and alternative behaviors.

• Assign a single room to the client with a potential for violence toward others. The client will be able to take time away from unit stimulation to calm self as needed. Another client will not be placed at risk as a roommate.

• Maintain a calm attitude in response to the client. Provide a low level of stimulation in the client’s environment; place the client in a safe, quiet place, and speak slowly and quietly. Anxiety is contagious. CEB & EB: Maintenance of a calm environment contributes to the prevention of aggression (APA, 2011; APNA, 2007a).

• Redirect possible violent behaviors into physical activities (e.g., walking, jogging) if the client is physically able. Using a punching bag or hitting a pillow is not indicated, because they are not calming activities and they continue patterning violent behavior. However, activities that distract while draining excess energy help to build a repertoire of alternative behaviors for stress reduction.

• Provide sufficient staff if a show of force is necessary to demonstrate control to the client. EBN: When staff responds to an escalating or violent situation, it can reassure clients that they will not be allowed to lose control. On the other hand, leave immediately if the client becomes violent and you are not trained to handle it (APNA, 2011).

• Protect other clients in the environment from harm. Remove other individuals from the vicinity of a violent or potentially violent client. Follow safety protocols of the department. The risk of a violent client to others in the area (other clients, visitors) should be anticipated, even as efforts proceed to deescalate the situation with the client.

• Maintain a secluded area for the client to be placed when violent. Ensure that staff are continuously present and available to client during seclusion. CEB: Staff presence is necessary to prevent the harmful effects of social isolation and to honor clients’ motivation to connect with staff (APNA, 2007b).

 Recognize legal requirements that the least restrictive alternative of treatment should be used with aggressive clients. The hierarchy of intervention is: promote a milieu that provides structure and calmness, with negotiation and collaboration taking precedence over control; maintain vigilance of the unit and respond to behavioral changes early; talk with client to calm and promote understanding of emotional state; use chemical restraints as ordered; increase to manual restraint if needed; increase to mechanical restraint and seclusion as a last resort. CEB: APNA guidelines (2007a, 2007b) support early assessment and intervention to prevent aggression, with nursing actions to reduce stimulation, divert client from aggressive thought patterns, set appropriate limits on behavior, and provide medications as needed.

 Use mechanical restraints if ordered and as necessary. Physical restraint can be therapeutic to keep the client and others safe. CEB: Restraint skill training, audits of adverse events, and examination of the safe use of restraints and medications are important to safe restraint practices (APNA, 2007b).

 Follow the institution’s protocol for releasing restraints. Observe the client closely, remain calm, and provide positive feedback as the client’s behavior becomes controlled. The period during which restraints are removed can be dangerous for staff if they do not recognize that the client may choose to reinitiate violence. Protocols will specify safe procedures for removing restraints.

 After a violent event on a unit, debriefing and support of both staff and clients should be made available. Allowing discussion of a violent episode, either individually or in a group, among other clients present reveals clients’ responses to the event and provides the opportunity for staff to offer reassurance and support. Clients may have concerns that staff will attempt to restrain them without reason or may feel uncertain whether staff can keep them safe. EBN: A study of the impact of serious events on psychiatric units found that staff reported a variety of negative emotional responses; levels of containment increased; the provision of care could be affected; and client reactions were largely ignored (APNA, 2008; Lim, 2011).

• Form a therapeutic alliance with the client, remaining calm, identifying the source of anger as external to both nurse and client, and using the therapeutic relationship to prevent the need for seclusion or restraint. The development of a therapeutic relationship before aggressive behavior occurs provides an alternative for working through anger and frustration. Assisting the client to identify a source of anger or frustration that is external to both the nurse and client prevents the need for defensiveness by both and directs energy at solving an external problem.

• Allow, encourage, and assist the client to verbalize feelings appropriately either one-on-one or in a group setting. Actively listen to the client; explore the source of the client’s anger, and negotiate resolution when possible. Teach healthy ways to express feelings/anger, appropriate gender roles, and how to communicate needs appropriately. EBN: When clients’ feelings are not addressed, when an individual feels threatened, or when gratification is delayed or denied, violence may be used as a manifestation of the internal feeling state (APNA, 2008).

• Identify with client the stimuli that initiate violence and the means of dealing with the stimuli. Have the client keep an anger diary and discuss alternative responses together. Teach cognitive-behavioral techniques. Assisting the client to identify situations and people that upset him or her provides information needed for problem solving. The client may then identify alternative responses (e.g., leaving the stimulus; using relaxation techniques, such as deep breathing; initiating thought stopping; initiating a distracting activity; responding assertively rather than aggressively).

 Initiate and promote staff attendance at aggression management training programs. EBN & EB: Multiple studies have supported the positive influence of aggression management training programs on the ability and confidence of nurses in responding to aggressive or violent behavior (APNA, 2011; Hills, 2008; Oostrom & Mierlo, 2008).

• Screen for possible abuse in women or children with a pattern of multiple injuries, particularly if any suspicion exists that the physical findings are inconsistent with the explanation of how the injuries were incurred. EBN: IPV/domestic violence is recognized as a nationwide public health issue. In one study, nurses cited insufficient evidence as a reason for not reporting IPV. Nurses with a personal history of IPV were more likely to report (Smith et al, 2008).

 Report suspected child abuse to Child Protective Services. Refer women suspected of being in a spousal abuse situation to an area crisis center and provide phone number of area crisis hotline. Rapid screening tools are helpful to identify IPV. All nurses are required by law to report suspected child abuse. EB: Child and spouse maltreatment often occur together; all family members should be evaluated and provided with assistance as needed (Taylor et al, 2009).

• Assess for physical and mental concerns of women, including risk of HIV. EB: Major health needs of women with a history of IPV were found to include chronic pain, chronic diseases, and mental illness, as well as concerns regarding risk of HIV. Barriers to health care created by the IPV may prevent these concerns from being addressed (Cole, Logan, & Shannon, 2008; Macy, Ferron, & Crosby, 2009).

• Assist the client in negotiating the health care system and overcoming barriers. EBN: Victims of IPV were found to experience barriers, including inappropriate responses from providers, when attempting to access health care services (Robinson & Spilsbury, 2008).

• With women who repeatedly experience injuries from domestic violence, maintain a nonjudgmental approach and continue to offer resources/referrals. If the woman voices a willingness to leave her situation, assist with developing an emergency plan that will consider all contingencies possible (e.g., safe location, financial resources, care of children, when to leave safely). A woman in a domestic violence situation may change her mind several times before actually leaving. Proactive organization of an emergency plan helps to increase the possibility that women will be able to leave safely. The most dangerous time of a domestic violence situation is when the spouse tries to leave.

• Maintain a nonjudgmental response when clients return to husbands or refuse to leave them. Women have many reasons for remaining in an abusive relationship, including economic concerns (especially with children), socialization about the women’s role, political or legal obstacles, powerlessness, and a realistic fear of retaliation or death. Refer to the care plan for Powerlessness. Experienced nurses working with abused women define success as client personal growth over time, rather than leaving the relationship.

• Focus on providing support, ensuring safety, and promoting self-efficacy while encouraging disclosure about IPV events. CEB: A review of evidence concluded that nursing care should focus on providing physical, psychological, and emotional support; ensuring safety of the client and family; and promoting the self-efficacy of the woman (Olive, 2007).

• Screen pregnant women for the potential for domestic violence during pregnancy, especially with teenage pregnancies. EBN: In a study of high-risk teen mothers, IPV was reported by 61% of the participants, with 37.5% reporting IPV during pregnancy (Mylant & Mann, 2008). Psychological health was found to be predicted by a history of abuse among women in a high-risk prenatal care clinic (Svavarsdottir & Orlygsdottir, 2008). CEB: Pregnant women will remain in an abusive relationship if they perceive it to be in the best interest of the child, part of a process of “double-binding” with child and abusive spouse (Lutz et al, 2006). Systematic screening of pregnant women is recommended, and choking is a danger that should be added to routine screening (Jeanjot, Barlow, & Rozenberg, 2008). Women afraid of IPV before and during pregnancy had poorer physical and psychological outcomes (Brown, McDonald, & Krastev, 2008).

• Screen women and children for effects of domestic violence during the postpartum period. CEB: Less educated women, women who reported substance abuse by spouse, and women who reported unwanted pregnancies were at risk of IPV both during and after pregnancy. Violence during pregnancy predicted postpartum violence. U.S. women employed during pregnancy were most likely to leave an abusive partner at 1 year postpartum (Charles & Perreira, 2007). In cases of high IPV, less than optimal infant health and difficult temperament were found (Burke, Lee, & O’Campo, 2008).

• Women with physical or mental disabilities require extended assessment, including a comprehensive functional assessment, with attention to cultural issues, the nature of the disability, and needed resources. Women with disabilities may experience abuse from multiple sources, and particular attention should be paid to the additional emotional stressors present. Difficulties leaving home, physical needs that shelter may not be able to accommodate, and the undesirability of nursing home placement are just a few stressors. Personal assistance providers may be abusive or take advantage financially. CEB: Women with disabilities may follow a unique model of IPV progression, requiring adaptation of the usual interventions, and may be slower in returning to usual routines (Copel, 2006; Focht-New et al, 2008). Women with schizophrenia are especially vulnerable and have complex needs (Bengtsson-Tops & Tops, 2007; Rice, 2006).

 Referral for spiritual counseling may be considered, but be aware that clergy vary in their helpfulness. EBN: Survivors of sexual violence described being able to cope with their situation through spiritual connection, spiritual journey, and spiritual transformation (Knapik, Martsolf, & Draucker, 2008). A study of women in abusive relationships who sought spiritual guidance from male clergy revealed themes of spiritual suffering, devaluation, loss, and powerlessness consistent with old societal biases. The authors noted that conclusions could not be drawn regarding the helpfulness of female clergy (Copel, 2008).

• Identify risk factors such as ongoing mental illness of a parent, and monitor family closely. CEB: Concern for the children of parents with a mental illness has been identified in light of the potential for family dysfunction and violence among the mentally ill (Copeland, 2007; Mason, Subedi, & Davis, 2007).

 In cases where spouse or child abuse accompanies substance abuse, refer the abusive client to a substance abuse treatment program. Refer the spouse receiving abuse to Al-Anon and the children to Alateen. EB: Use of drugs or alcohol may decrease impulse control and aggravate abusive behavior, depending on specific drug used and culture (Caetano, Ramisetty-Mikler, & Harris, 2008; Stalans & Ritchie, 2008).

 In cases where an adult reveals a history of unresolved/untreated sexual abuse as a child, referral to a local Adults Molested as Children (AMAC) group may be helpful. CEB: Childhood sexual abuse has been associated with adult depression, attempted suicide, self-harm, and higher risk for later interpersonal violence (Murrell, Christoff, & Henning, 2007). Interventions tailored to the AMAC experience may be helpful. Refer to the care plans for Risk for Suicide, Self-Mutilation, and Risk for Self-Mutilation.

 Referral of women for psychiatric/psychological treatment or parenting classes should be considered as an appropriate intervention. CEB: Overcoming shame, building a stable sense of identity, and becoming less dependent on others’ approval should be addressed, along with physical health and PTSD symptoms (Woods et al, 2008). EB: In a study of 3429 women enrolled in an HMO, 46% reported a lifetime history and 14.7% reported a history within the previous 5 years of physical, sexual, and/or nonphysical abuse, with post-traumatic disorder a potential outcome (Dutton, 2009). Self-blame was associated with all factors involved in IPV, with outcomes of PTSD, depression, suicidality, and substance abuse (Campbell, Dworkin, & Cabral, 2009).

 Referral of children for psychiatric/psychological treatment should be considered as an appropriate intervention. CEB: Children living with domestic violence were found to express fear and anxiety, self-esteem issues, ambivalent relationships with the abuser, and a sense of a lost childhood (Buckley, Holt, & Whelan, 2007).

 Batterer intervention programs are often available and may be court mandated. CEB: Batterers believe behaviors toward them are not justified, and their behaviors toward others are justified and minimized. Treatment should include emotional skills training that addresses these areas (Smith, 2007).

• Assess for acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) among victims of violence. CEB: In the acute phase following an assault, women reported high rates of ASD symptoms. Four months after an attack, dissatisfaction with previous life, prior mental health problems, recent life events, and earlier abuse were risk factors for PTSD (Renck, 2006).

 Assess the support network of women who become victims of violent crime and refer for appropriate levels of assistance. Of particular concern would be women who do not have family or friends to provide support or who have difficulty accessing other types of assistance.

• Be aware that hate crime is increasing, particularly toward gay and transgendered individuals, and it requires support and advocacy for victims. CEB: Gay men who experienced antigay abuse reported that the events affected their self-image. In addition to verbal and physical abuse, spiritual abuse emerged as the men internalized schemas of Outcast and Sinner (Lucies & Yick, 2007).

 Victims of violence seen in the ED should receive an assessment for needed services and assignment to case management. Establishment of linkages with social service agencies can provide important services for referral.

• Assist client to cope with potential stalking activity. EBN: The usual coping of college students in response to stalking was found to include ignoring or minimizing the problem; distancing or depersonalizing; using verbal escape strategies, attempting to end the relationship; and restricting availability (Amar & Alexy, 2010). Emphasizing the need to take stalking behavior seriously and problem-solving interventions may prevent a rape situation.

• Approach client with sensitivity. EBN: Using Peplau’s theory of nursing roles, researchers found that the roles of counselor and technical expert were most helpful, with interpersonal sensitivity important to clients (Courey et al, 2008).

 Monitor for paradoxical drug reactions, and report any to the physician. Violent behavior can be stimulated by a medication intended to calm the client.

• Assess for brain insults, such as recent falls or injuries, strokes, or transient ischemic attacks. Clients with brain injuries may respond to stimulus control, problem solving, social skills training, relaxation training, and anger management to reduce aggressive behaviors. Brain injuries, lowered impulse control, and reduced coping can cause violent reactions to self or others. Brain injury symptoms may be mistaken for mental illness.

• Decrease environmental stimuli if violence is directed at others. Removal of the client to a quiet area can reduce violent impulses. Use a calm voice to “talk down” the client.

• Assess holistic needs of the client. EBN: Risk factors for negative mental health outcomes following sexual violence were found to be low income, low education level, lack of social support, and poor health promotion (Vandemark & Mueller, 2008).

• Discuss with client her wishes regarding use of an emergency contraceptive. EBN: If emergency contraception were offered to every female victim of sexual assault, researchers concluded that unintended pregnancies would decline. However, the findings are limited, as only 15% of women who are raped seek health care promptly (Womack, 2008).

 If abuse or neglect of an elderly client is suspected, report the suspicion to an adult protective services agency with jurisdiction over the geographical area where the client lives.

Pediatric:

Geriatric:

Multicultural:

Home Care:

Client/Family Teaching and Discharge Planning: