Term
| 5 stages of the Assault cycle |
|
Definition
Triggering Phase
Escalation Phase
Crisis Phase
Recovery
Depression phase |
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|
Term
Triggering Phase
+1 +2
Level of anxiety
Behaviors |
|
Definition
Muscle tension
Change in voice quality
Tapping of fingers and pacing
Repeated verbalization
Noncompliance
Restlessness
Suspiciousness, glaring
Irritability and anxiety
Perspiration
Tremors
Change in breathing |
|
|
Term
Triggering Phase
+1 +2
Level of anxiety
Behaviors |
|
Definition
Muscle tension
Change in voice quality
Tapping of fingers and pacing
Repeated verbalization
Noncompliance
Restlessness
Suspiciousness, glaring
Irritability and anxiety
Perspiration
Tremors
Change in breathing |
|
|
Term
Triggering Phase
+1 +2
Level of anxiety
Nursing Intervention |
|
Definition
Convey empathy and support.
Encourage ventilation
Ask clear, calm, simple statements
Facilitate problem solving by discussing alternative solutions
Ask client to move to a quite area, Move client to quiet area
Offer safe tension reduction methods
Offer oral PRN meds, if needed
” |
|
|
Term
Escalation Phase
+2 +3
Level of anxiety
Behavior |
|
Definition
Loss of reasoning ability
Pale flushed face
Anger swearing and agitation
Hypersensitivity, threats, demand
Ready to retaliate and tautness
Provocative Behavior clinched fist |
|
|
Term
Escalation Phase
+2 +3
Level of anxiety
Nursing Intervention |
|
Definition
Take charge calmly but firmly
Take client to quite room for “time Out”
Give! oral PRN meds if ordered
Have staff on standby (at a distance) prepared for a “show of determination” or “show of Force |
|
|
Term
Crisis Phase
+3 +4
Level of anxiety
Behaviors |
|
Definition
Loss of self-control, rage
Fighting,
Hitting
Kicking
Scratching
Throwing things |
|
|
Term
Crisis Phase
+3 +4
Level of anxiety
Nursing Interventions |
|
Definition
Use involuntary seclusion, restraints, IM meds if ordered
Initiate intensive nursing care
Continue intensive Nursing care |
|
|
Term
Recovery Phase
+2 +3
Level of anxiety
Behaviors |
|
Definition
Lowering of voice
Decrease body tension
Change in conversation content.
More normal response to stimuli
Relaxed |
|
|
Term
Recovery Phase
+2 +3
Level of anxiety
Nursing interventions |
|
Definition
Process the incident with the staff and other patients
Access patient and staff injuries, if any
Access patient progress towards self-control |
|
|
Term
Post crisis depression Phase
+2 +1
Behaviors |
|
Definition
Crying
Apologies
Reconciliatory interactions
Repression of assaultive feelings |
|
|
Term
Post crisis depression Phase
+2 +1
Nursing Intervention |
|
Definition
Process incident with client
Offer alternative solutions to the situation and feeling
Progressively reduce the level of restraint and seclusion
Facilitate return to the unit. |
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