Anger, Aggression, and Violence

Question 1

what is anger?

Answer 1

–emotional response to frustration of desires, a threat to one’s needs, or a challenge
–normal human emotion that can provide an individual with a positive force to solve problems and make decisions concerning life situations
–becomes a problem when it’s not expressed and when it is expressed aggressively

Question 2

what is aggression?

Answer 2

–action or behavior that results in a verbal or physical attack
–tends to be used synonymously with violence
–behavior that is intended to threaten or injure the victim’s security or self-esteem
–virtually always designed to punish
–sometimes necessary for self-promotion

Question 3

what is violence?

Answer 3

always an objectionable act that involves intentional use of force that results in or has the potential to result in injury to another individual

Question 4

what is trauma informed care?

Answer 4

–notion that disruptive patients often histories that include violence and victimization
–can impede patients’ ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions by staff

Question 5

where is violence most often seen in the hospital?

Answer 5

–psych units
–ED
–geriatric units

Question 6

biological factors for anger/aggression/violence

Answer 6

–areas of the brain
–neurotransmitters
–predisposition

Question 7

psych factors of anger/aggression/violence

Answer 7

–behavioral therapy
–learned response
–social learning theory
–imitate others

Question 8

modeling

Answer 8

–role modeling is one of the strongest forms of learning
–positive or negative

Question 9

neurophysiological disorders connected to aggression and violence

Answer 9

–temporal or frontal lobe epilepsy
–brain tumors
–brain trauma
–encephalitis
–traumatic brain injury
–psychosis

Question 10

operant conditioning

Answer 10

–specific behavior is positively or negatively reinforced
–voluntary behavior change occurs
–appropriate or aggressive expressions of anger can be learned

Question 11

how can positive reinforcement be learned?

Answer 11

response to the specific behavior that is pleasurable or produces the desired results

Question 12

how can negative reinforcement be learned?

Answer 12

response to the specific behavior that prevents an undesirable result from occurring

Question 13

biochemical factors for anger and aggression

Answer 13

–hyperthyroidism
–low serotonin levels
–thiamine and niacin in ETOH

Question 14

medical factors for anger and aggression

Answer 14

–UTI
–infections
–dehydration
–electrolyte imbalances
–blood sugar imbalances
–sensory changes

Question 15

SES and anger/aggression

Answer 15

poverty d/t associated deprivation, disruption of families, and unemployment

Question 16

environmental factors and anger/aggression

Answer 16

–physical crowding of people
–availability of firearms
–discomfort associated with a moderate increase in environmental temp
–use of alcohol and some drugs

Question 17

comorbidities for anger/aggression

Answer 17

–PTSD
–SUD
–coexists with: depression, anxiety, psychosis, and personality disorders
–CV disease
–strokes

Question 18

what is the best single predictor of future violence?

Answer 18

history of violence

Question 19

predisposing factors for anger and aggression

Answer 19

–delusions, hyperactivity, impulsivity, or predisposed to irritability
–non-adherence to meds
–happens in response to limit-setting by nurses
–hx of limited coping skills (lack of assertiveness or intimidation)

Question 20

risk factors for aggression

Answer 20

–agitation, restlessness, escalating anxiety
–resistance to suggested treatment
–hx of assaultive or threatening behavior
–known hx of drug or alcohol misuse
–cognitive changes that may cause the person to misinterpret the environment or staff actions

Question 21

s/s that usually precede violence

Answer 21

–hyperactivity
–increasing anxiety and tension
–verbal abuse
–loud voice, change of pitch, very soft voice
–stone silence
–intense eye contact or avoidance of eye contact
–recent acts of violence
–possession of weapon or object that may be used as a weapon
–isolation that is uncharacteristic

Question 22

psychosocial actions to take

Answer 22

–begin prior to any signs of escalation
–approach in controlled, nonthreatening and caring manner
–allow patient enough space so that you are perceived as less of a threat (approx. 1 ft away)
–escape route
–do not take verbal abuse or space invasion personally and don’t match energy

Question 23

psychosocial interventions for angry patients

Answer 23

–speak slowly in short sentences and calm
–find out what is behind angry feelings and behaviors
–choose a quiet place to talk
–use open ended questions
–identify patient’s choices and encourage taking responsibility

Question 24

environmental youth violence risk factors

Answer 24

peer influence and gang related behavior

Question 25

biological youth violence risk factors

Answer 25

impulse control or self-regulation problems

Question 26

family youth violence risk factors

Answer 26

–attachment problems
–family stress
–autocratic parenting
–disengaged parenting
–lack of supervision

Question 27

level 1 behavior

Answer 27

–patient asking simple, normal questions
–anxiety, frustration, impatience, irritability
–raised voice, highly animated, reddened face, clenched fist, restlessness, repetitive movements
–change in behavior

Question 28

interventions/responses to level 1 behavior

Answer 28

–answer the question
–avoid institutional/systems language/jargon
–avoid coming off as cold and uncaring
–come across as a real human being
–avoid talking about how you feel about it/the situation

Question 29

level 2 patient behavior

Answer 29

–defensiveness
–patient asks challenging questions
–standing in personal space; staring/glaring
–refusing everything
–releasing: pounding tables, loud sighing, throwing things but not at people, not causing harm

Question 30

interventions for level 2 behavior

Answer 30

–isolate the interaction
–reduce stimulation
–speak clearly, slowly
–non-verbal communication
–use few words
–be firm but with empathy
–allow loud, verbal expression of anger as long as not threatening
–watch your tone

Question 31

what do level 3 patient behaviors look like?

Answer 31

–when angry expression turns to hostility and abuse or aggression
–may begin as accusations, comments about competence, irrelevant personal remarks

Question 32

danger signs for level 3 patient behaviors

Answer 32

–persistent sweating
–sexist or racist comments
–personal or specific threats of harm
–intimidating comments
–terroristic type threats
–any physical behavior directed at a person

Question 33

when should seclusion/restraint be used?

Answer 33

–last resort
–when less restrictive interventions haven’t worked
–in conjunction with written modification to patient’s care plan
–only in accordance with policy and law

Question 34

what is seclusion?

Answer 34

involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving

Question 35

goal of seclusion

Answer 35

safety for the patient and others

Question 36

when is seclusion used?

Answer 36

may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others

Question 37

what is restraint?

Answer 37

any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely

Question 38

legal requirements for seclusion/restraint

Answer 38

–multidisciplinary involvement
–appropriate healthcare provider order according to state law
–client advocate/relative notified
–seclusion and restraint discontinued ASAP

Question 39

documentation for seclusion/restraint

Answer 39

–behavior leading to seclusion and restraint
–least restrictive measures used prior to seclusion and restraint
–interventions used and client’s response
–plan of care for seclusion and restraint use implemented
–ongoing evaluation by the nursing staff

Question 40

clinical assessment for seclusion/restraint

Answer 40

–client’s mental state at time of seclusion/restraint
–physical examination for medical problems possibly causing behavior changes
–need for restraint

Question 41

observation for seclusion/restraint

Answer 41

–staff in constant attendance
–level of awareness
–complete written record every 15 minutes
–monitor vital signs
–assess ROM
–observe blood flow in hands and feet
–observe that restraints are not rubbing
–provide for nutrition, hydration, and elimination
–never restrain a client in the prone position

Question 42

release procedure for seclusion/restraint

Answer 42

–client must be able to follow instructions and stay in control
–termination of restraints
–debrief with client

Question 43

restraint tips

Answer 43

–room that is safe without any objects that can be used for self harm or harm to others
–physical holding of a client against will is a restraint
–four side rails up is a restraint except for seizure precautions
–keeping client in their room by physical intervention
–tucking sheets in so tightly client cannot move
–orders for seclusion/restraint cannot be PRN

Question 44

increased danger in child restraint

Answer 44

–underdeveloped trachea
–intercostal muscles and diaphragm more pliable

Question 45

what might a patient’s increased struggling movements indicate?

Answer 45

–attempt to increase air flow
–look for signs of respiratory distress
–check O2 saturations
–late signs include cyanosis around lips and mouth

Question 46

what might decreased struggling in restraints indicate?

Answer 46

decreased LOC

Question 47

which medical dx and patient condition might compromise breathing in a restrained patient?

Answer 47

–asthma and obesity
–restrain in semi-fowler’s position
–PE may occur due to decreased movement
–withdrawal s/s

Question 48

contraindications for seclusion and restraint

Answer 48

–patients who have extremely unstable medical and psych conditions
–COPD
–spinal injury
–seizure disorder
–pregnancy
–delirium or dementia

Question 49

chemical restraint

Answer 49

use of a medication to restrict a client’s movement or behavior

Question 50

B52 dosage

Answer 50

Ativan: 1-2mg
Haldol: 5-10mg
Benadryl: 25-50mg

Question 51

giving B52

Answer 51

–haldol and ativan can be given in same syringe
–benadryl in a separate syringe

Question 52

what does level 4 tension reduction look like?

Answer 52

–a decrease in energy
–rationality returns
–reachable teachable moment

Question 53

interventions/responses in level 4 tension reduction

Answer 53

–revise plan of care to include behaviors that may result in repeat restraints or seclusions
–re-establish therapeutic rapport with the patient
–using coping model with the patient

Question 54

COPING (Level 4)

Answer 54

–Control
–Orient
–Patterns
–Investigate alternative methods to reduce acting out behavior
–Negotiate for changes in behavior
–Give control and responsibility for behavior back to patient