Excitement and Violence

Excitement

This is a severe form of aggressiveness. During this stage, a patient will be irrational, uncooperative, delusional, paranoid, and hallucinating. An excited patient is usually brought tied up in rope or chains.

Management of excitement 

• Remove the chains. A large proportion of aggression and violence is due to the patient feeling humiliated at being tied up in this manner. Removing the rope will reduce the excitement.
• Talk to the patient and see if the response is. A firm and kind approach by the nurse is essential.
• Sedate the patient.
• Once the patient is sedated, take a careful history from relatives. Rule out the possibility of organic pathology.
• Carry out a complete physical examination.
• Draw blood in Hb, WBC, ESR, RBC, etc.
• Look for evidence of dehydration and malnutrition.
• Plan for less furniture in the room and no sharp instruments, articles of ropes, glass, etc.
• Keep environmental stimuli, such as lighting and noise levels to a minimum, assign a single room, and limit interactions with others.
• If the patient is not calmed to talk down and refuses medication, restraint may become necessary.

Violence

The World Health Organization defines violence as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation," though the organization recognizes that the inclusion of "the use of power" expands on the conventional meaning of the word. The key element in this definition is one's deliberateness in carrying out the act itself, rather than focusing on the results of that act. Nonetheless, even if not intended as such, anything that causes injury or damage via excitement may be labeled as violent (by a person and against a person).

Causes of violence 

• Psychosis
• Withdrawal from alcohol and drugs abuse or intoxication with alcohol and drug
• Catatonic excitement
• Agitated depression
• Patient should be accompanied home or appropriate setting
• Personality disorders
• Epilepsy
• Mental retardation
• Organic disorders

Symptoms of violence 

• Loud, angry speech
• Hyperactivity
• Increased muscle tension
• Rigid posture
• Poor eye contact
• Diaphoresis
• Red face
• Tachycardia
• Widened pupil
• Slamming doors, chairs
• Suspiciousness
• Verbal and physical threat
• Blocking the doors

Violence management process 

• Reassurance
• Sedative: diazepam 10-20 mg IV slowly can be given
• Restraint
• Keep a comfortable distance away from the patient. Stay at least arm's length away from the patient.
• Be sure the patient has no weapons in his possession before approaching.
• Keep taking in a calm, reassuring, and natural tone in the voice. A scared or angry tone could cause the patient to become more frightened.
• Try to make and keep eye contact with the patient looking in other directions making the patient feel that he or she cannot trust the nurse.
• Avoid excessive stimulation.
• Avoid excessive environmental stimuli, such as lightning and noise. Keep in a room, and limit interactions with others.
• Never interview a potentially violent patient alone or in an office with the door closed.
• Do not be close to a paranoid patient.
• Talk to him about why he is doing this and the consequences of his action.
• If aggression is not reduced, he should be confronted by overwhelming force and should be sedated.
• Assess the nutritional state, if there is dehydration, IV fluids may be started.
• Keep a close watch or enough security for a violent patient.
• Send blood specimens for hemoglobin, and total cell count.