Anger, Aggression, and Violence

Question 1

Anger

Answer 1

■ Anger is a normal healthy response to violation of one’s integrity. Can strengthen relationships
■ Maladaptive anger is detrimental to oneself and others.
■ Violence portrayed in the media is harmful to children, TV programs are limited during children’s hours, but video games reward for violence

Question 2

Aggression

Answer 2

◆ Verbal statements or physical behavior that is intended to threaten, belittle, dominate or control
◆ Must consider the situation (psychosis, history of rape, exhaustion)

Question 3

Violence

Answer 3

◆ Extreme aggression intended to cause harm to or kill a person
◆ Conveys a message that the perpetrator’s point of view is correct, not the victim’s

Question 4

What is the best predictor of violence?

Answer 4

a history of violence

◆ MOST mentally ill people do NOT commit violent acts

Question 5

Patients who are at increased risk of violence:

Answer 5

✦ Active psychotic symptoms (perceived threat)
✦ Substance abuse disorders (withdrawal, intoxication = inhibited impulses)
• ETOH abuse increases risk 12X normal
• Drug abuse increases risk 16X normal
◆ Head trauma, tumor, toxic chemicals or lead, history of anoxia (lack of oxygen to the brain), inadequate maternal nutrition –> cause brain damage

Question 6

What are the more common diagnoses in psychiatric patients? (other than violence)

Answer 6

✦ Antisocial PD and intermittent explosive disorder more than other diagnoses

Question 7

Nursing Management for Violence

Answer 7

Psychiatric nurses staffing inpatient facilities have as a top priority the prevention of violence

Dimensions of keeping the unit safe include:
◆ Maintenance of a structured and respectful
therapeutic milieu
◆ Careful timing of admissions and discharges (ex. having more “confused” patients in rooms near nurses desk)
◆ Expert use of space and personnel
◆ A conviction that staff need to understand the meaning of patients’ behaviors (ex. agitated pt with psychosis who could not find bathroom, APD patient who was threatening others & Dr. set limits )

Question 8

Assessment of Anger

Answer 8

■ Anger expression (threats, property destruction, assault, suppression, assertive)
■ Pervasive chronic anger (life-long) vs. anger at an ongoing situation (ex. mean boss –> help them problem solve) vs. adjustment to a stressor
■ Problems caused by anger expression
■ Presence or absence of self-soothing techniques (ex. deep breathing)

■ The Spielberger State-Trait Anger Expression Inventory measures:

1. The general propensity to be angry (trait anger) - are they angry a lot?
2. Current feelings (state anger)
3. Several styles of anger expression –> controlling it through calming techniques

Question 9

Predictors of Violence

Answer 9

■ Unwillingness to follow unit rules
–> most common in mental health
■ Involuntary hospitalization in a locked unit
■ Crowding, heat and density during high patient census
■ Anger-producing staff actions (such as limit setting, ignoring patient)
■ Inadequate staffing
■ Precursors: staring and eye contact, tone and volume of voice, anxiety, mumbling and pacing

Question 10

Mental Status Exam Questions (Assaultive or Homicidal Ideation)

Answer 10

■ Do you intend to harm someone? If yes, who?
■ Do you have a plan? If yes, what are the details of the plan?
■ Do you have the means to carry out the plan? (If the plan requires a weapon, is it readily available?)

Need to make sure patient is safe to discharge.

Question 11

Violence Preventative Strategies

Answer 11

■ Be aware of your OWN stress and don’t take out frustrations on patients (countertransference)

■ Patient education - how to manage/control anger, healthy outlets for anger/aggression Assertiveness training:
–>how to help patients be more assertive

1. DESCRIBE: “When you refuse to talk to me about our financial situation.” (don’t label)
2. EMOTIONS: “I feel frustrated” (not “You make me. . .”)
3. SUGGEST: “I would prefer that you would take some time to discuss it with me.” specific behavior
4. CONSEQUENCES: “so we can get along better. If not I will continue to be frustrated and angry” spell out, specific and reasonable

Question 12

Promoting De-escalation

Answer 12

◆ Respect personal space and boundaries
◆ Violence prone people need 4X more personal space
-have a relaxed position, make them feel comfortable
◆ Don’t push, listen
◆ Hearing impaired or deaf patients at risk for more seclusion/restraints
■ Be honest and matter-of-fact, genuine concern
■ Individualize interventions specific to the patient, non-judgmental
■ Clarify what upset the patient, if they can tell you
■ Offer quiet calmness, soft voice
■ Use non-threatening body language, open stance avoid eye contact–> (may be perceived as a threat)
■ Remove jewelry etc. that could be harmful
■ Increase problem-solving
■ Decrease physical catharsis (like punching bags)
■ Soothing environment

Question 13

How do you create a soothing environment?

Answer 13

◆ Soft music, low lights, structured activities
◆ Comfort room, decreased stimuli, allow space
✦ Position for immediate access to door
✦ Leave door open when talking to patient
✦ Know where colleagues are, let them know where you are

Question 14

True or False: “She made me so angry” is a cognitive distortion.

Answer 14

True

Question 15

Affective Interventions

Answer 15

◆ Validating (reflection, empathy)
◆ Listening to patient’s experience
◆ Exploring beliefs about anger

Question 16

Cognitive Interventions

Answer 16

◆ Affirmations
◆ Offering information
◆ Classes & teachable moments
–> address the behavior right when it happens
◆ Problem solving
◆ Contracting for rewards & consequences

Question 17

Behavioral Interventions

Answer 17

◆  Assigning behavioral tasks (homework)
◆  Bibliotherapy
◆  Identify patterns & plan ways to change
◆  Providing concrete choices (meals)
◆  Relaxation 
◆  Distraction

Question 18

What are the three types of nursing interventions?

Answer 18

1. Affective
2. Cognitive
3. Behavioral

Question 19

What is CARE?

Answer 19

■ Clarify the problematic behavior
■ Articulate why their behavior is a problem
■ Request a change tentatively and respectfully
■ Encourage change (pros & cons)

Question 20

Psychopharmacology

Answer 20

■ Meds are considered a chemical restraint when given to control current aggression, this requires LOTS of documentation about previous interventions
■ The same med is NOT considered a chemical restraint if it is a standard treatment for the patient’s illness

–> cannot just restrain patients chemically with no reason

Question 21

Psychopharmacology: Antipsychotics

Answer 21

Typical- (more research to show effectiveness, used for acute agitation) haloperidol IM (haldol)
–> watch for akasthisia which can look like increased agitation

Atypical- oral risperdone (risperdal)
–> just as effective, not as much research

Question 22

Psychopharmacology: Sedatives/Anxiety Control

Answer 22

◆ Lorazepam (Ativan): a benzodiazepine antianxiety drug, quick onset, often used with antipsychotics in acute agitation
–> Benzos can be addictive…

◆ Buspirone (Buspar): use for aggression related to anxiety/ depression, head injury, dementia or developmental disabilities

Question 23

Psychopharmacology: Mood Stabilizers

Answer 23

◆ Lithium
◆ Valproic acid/Divalproex sodium ER (Depakene/ Depakote)
◆ Carbamazepine (Tegretol)

Question 24

Psychopharmacology: Antidepressants

Answer 24

Selective Serotonin Reuptake inhibitors (SSRI)

Question 25

Acute Aggression Control Techniques

Answer 25

■ Team assistance

■ Seclusion and Restraint (a 1998 report of 142 deaths related to S and R changed how this is done nationally)

Question 26

Seclusion/Restraint

Answer 26

Use as a LAST resort; if de-escalation does not work
◆ Can cause psychological harm to patients with previous significant physical or emotional trauma
◆ Not to be used as punitive measure
◆ Protective measure for patient and others
◆ Informed consent obtained at time of admission
◆ Physician’s order can be obtained after emergency

Question 27

Nursing Care for Restrained Patient

Answer 27

■ Explain reason for restraint, reassure & support: confused, delirious, frightened
■ SR requires constant observation (audio/video or face to face)
■ Check VS every hour unless sleeping
■ Check extremities, Range of motion q 2 hours
–>Remove only one restraint at a time
–>Never leave patient in only one restraint
■ Offer fluids, bathroom or bedpan q hour
■ Remove restraints or unlock door when calm and able to control behavior gradual integration back into the unit
***Document thoroughly

Question 28

What to document on restraints:

Answer 28

1. Other interventions used before restraint
2. Behaviors observed, mental status, mood, signs of decreased aggression
3. Safety measures-check pockets
4. PRN medication

Question 29

How long to doctors orders last for restraints on adults? Adolescents? Children under 9 y/o? How often must physician see patient in restraints?

Answer 29

• -> Lasts 4 hours for adults, 2 hours for adolescents, and 1 hour for children under age 9
• -> Physician must see patient within 1 hour and every 24 hours

Question 30

What are the differences in restraints?

Answer 30

• 2-point (both wrists)
• 3-point (both wrists and one leg)
• 4-point (both wrists, both legs)
• 6- point (both wrists, both legs, waist, upper torso)

Question 31

Terminating Seclusion/Restraints

Answer 31

■ Talk to patient, assess readiness to move to less restrictive measures
■ Remove restraints gradually as self control returns - one extremity at a time (if 4-point)
■ Monitor patient’s response to removal
■ Debrief:
1. patient - talk about concerns regarding S and R
2. staff - what led up to event, future prevention
3. other patients

Question 32

Responding to Assault on Nurses

Answer 32

■ Nurses must be provided with training programs in the prevention and management of aggressive behavior
■ Assaults tend to occur in situations in which the patient perceives the nurse’s actions as restricting, controlling, or aggressive
■ Reported assaults range from verbal threats and minor altercations to severe injuries, rape, and murder
■ Nurses may suppress the normal range of feelings after an assault
■ Support groups for nurses to express anger, blame, and anxiety