Anger, Hostility, and Aggression

Question 1

Anger

Answer 1

normal human emotion, is a strong, uncomfortable, emotional response to a real or perceived provocation
-anger results when a person is frustrated, hurt, or afraid

Question 2

Physical Aggression

Answer 2

behavior in which a person attacks or injures another person or destroys property
-both verbal and physical aggression are meant to harm or punish another person or to force someone into compliance

Question 3

Catharsis

Answer 3

activities that are supposed to provide a release for strong feelings such as anger or rage
-walking, praying, talking to someone

Question 4

Hostility

Answer 4

(Verbal Aggression)

-emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior

Question 5

Impulse Control

Answer 5

the ability to delay gratification and to think about one’s behavior before acting

Question 6

Acting Out

Answer 6

an immature defense mechanism in which the person deals with emotional conflict or stress by actions rather than reflections or feelings
-person is trying to feel less powerless or helpless by acting out

Question 7

Etiology

Answer 7

Neurobiological Theories

• Serotonin
• Dopamine and Norepinephrine
• structural damage of limbic system and frontal and temporal lobes of brain may alter ability to modulate aggression

Question 8

Serotonin

Answer 8

plays inhibitory role

-low serotonin levels = increased aggressive behavior

Question 9

Dopamine and Norepinephrine

Answer 9

increased activity is associated with increased impulsively violent behavior

Question 10

Applying the Nursing Process

Answer 10

• Assessment and effective intervention with angry, hostile patients can often prevent aggressive episodes
• Early assessment, judicious use of medications, and verbal intervention with angry patients can often prevent anger from escalating into physical aggression

Question 11

Assessment

Answer 11

• aware of factors that influence aggression in the environment
• aggression is less common on units with a strong psychiatric leadership; clear staff roles, planned, adequate events such as staff-patient interaction, group interaction, and activities
• lack of psychological space– having no privacy, unable to get sufficient rest– may be more important in triggering aggression than lack of physical space

Question 12

Assessment Checklist

Answer 12

• unit milieu
• history of violence
• how does the client handle anger?
• psychosis/ substance abuse
• how does the client handle disappointment?

Question 13

Risk Factors

Answer 13

past history of violence

Question 14

Treatments

Answer 14

• focuses on treating the underlying or comorbid psychiatric diagnosis
• atypical anti-psychotics were more effective than conventional anti-psychotics for aggressive, psychotic patients
• anti-psychotics require careful assessment for extrapyramidal side effects
• short-term use of seclusion or restraint during crisis phase of aggression cycle

Question 15

Interventions

Answer 15

• Hostile patient in Social Setting–> get far away as possible
• In Psychiatric Setting—> engage in dialogue (talk therapy); less restrictive
• interventions are most effective and least restrictive when implementing early in the cycle of aggression (triggering phase)
• manage the environment
• manage aggressive behavior

Question 16

Manage the Environment

Answer 16

• group and planned activities such as card playing, watching and discussing movies, or participating in informal discussions give patients opportunity to talk about events or issues when they are calm
• schedule 1:1 interactions
• if patients have a conflict or dispute with one another, offer opportunity for problem-solving or conflict resolution
• talking with other patients is helpful
• close supervision of client

Question 17

Skills a patient can practice that will be useful when returning to the community

Answer 17

• expressing angry feelings appropriately
• assertive communication skills; “I” statements
• negotiating a solution

Question 18

Stages In Aggressive Incidents

Answer 18

• triggering phase
• escalation phase
• crisis phase
• recovery phase
• post-crisis phase

Question 19

Interventions during what phases are key to prevent physically aggressive behavior?

Answer 19

-triggering phase
-escalation phase
(early phases)

Question 20

Triggering Phase

Answer 20

an event or circumstances in the environment initiates the clients response, which is often anger or hostility

Question 21

Signs/ Symptoms/ Behaviors of the Triggering Phase

Answer 21

• restlessness
• anxiety
• irritability
• pacing
• muscle tension
• rapid breathing
• perspiration
• loud voice
• anger

Question 22

Escalation Phase

Answer 22

the clients responses represent escalating behaviors that indicate movement towards a loss of control

Question 23

Signs/ Symptoms/ Behaviors of Escalation Phase

Answer 23

• pale or flushed face
• yelling/ swearing
• agitation
• threatening
• demanding
• clenched fists
• threatening gestures
• hostility
• loss of ability to solve the problem or think clearly

Question 24

Crisis Phase

Answer 24

during an emotional and physical crisis, the client loses control

Question 25

Signs/ Symptoms/ Behaviors of Crisis Phase

Answer 25

• loss of emotional and physical control
• throwing objects
• kicking
• hitting
• biting
• scratching
• shrieking
• screaming
• inability to communicate clearly

Question 26

Recovery Phase

Answer 26

client regains physical and emotional control

Question 27

Signs/ Symptoms/ Behaviors of Recovery Phase

Answer 27

• lowering of voice
• decreased muscle tension
• clearer, more rational communication
• physical relaxation

Question 28

Post-Crisis Phase

Answer 28

client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents

Question 29

Signs/ Symptoms/ Behaviors of Post-Crisis Phase

Answer 29

• remorse
• apologies
• crying
• quiet
• withdrawn behavior

Question 30

Managing Aggressive Behavior: Triggering Phase

Answer 30

• approach in a non-threatening calm manner
• convey empathy
• encourage expression of angry feelings verbally
• use clear, simple, short statements
• allow client time to express themselves
• suggest client to got to a quiet area or may get assistance to move other clients to decrease stimulation
• offer PRN meds
• use relaxation techniques and look at ways to solve problems

Question 31

Managing Aggressive Behavior: Escalation Phase

Answer 31

• nurse must take control
• provide direction in a calm, firm voice
• client should be directed to take a time-out for cooling off in a quiet area or in their own room
• tell client aggressive behavior is not acceptable and the nurse is there to hep the client regain control
• offer PRN meds if it was declined in the triggering phase
• if continues to escalate, obtain assistance from other staff

Question 32

Managing Aggressive Behavior: Crisis Phase

Answer 32

• staff must take charge
• 4 to 6 trained staff are needed to restrain an aggressive patient; 4 each limb, 1 head, 1 torso
• if PRN med has not been take earlier, nurse may obtain an order for intramuscular (IM) med in this type of emergency situation
• follow-up with a face- to- face evaluation with s psychiatric healthcare provider
• nurse performs close assessment and documents action

Question 33

Managing Aggressive Behavior: Recovery Phase

Answer 33

• debriefing to discussing episode, how it was handled, what worked well or needed improvement, and how the situation could have been defused more effectively
• encourage other clients to talk about their feelings regarding the incident

Question 34

Managing Aggressive Behavior: Post-Crisis Phase

Answer 34

• removed from restraint or seclusion when meets behavioral criteria
• do not lecture or chastise for aggressive behavior but discuss in a calm, rational manner
• can be given feedback for regaining control with expectation that they will be able to handle feelings or events in a non-aggressive manner in the future
• re-integrate in the milieu and activities as soon as can participate

Question 35

Treatment

Answer 35

• Haloperidol (Conventional Anti-psychotic)
• Lorazepam (Anxiolytic: Benzodiazepine)
• used in combination to decrease agitation or aggression and psychotic symptoms
• patients who are agitated and aggressive but not psychotic benefit from Lorazepam; given 2mg doses every 45 to 60 minutes

Question 36

Atypical Anti-psychotics

Answer 36

more effective than conventional anti-psychotics and have less side effects

• anti-psychotic meds require careful assessment for extrapyramidal side effects
• Clozapine, Risperidone, Olanzapine

Question 37

What drug treats extrapyramidal side effects?

Answer 37

Benzotropine