Anger, Hostility, and Aggression Flashcards
Anger
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
Physical Aggression
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
Catharsis
activities that are supposed to provide a release for strong feelings such as anger or rage
-walking, praying, talking to someone
Hostility
(Verbal Aggression)
-emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior
Impulse Control
the ability to delay gratification and to think about one’s behavior before acting
Acting Out
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
Etiology
Neurobiological Theories
- Serotonin
- Dopamine and Norepinephrine
- structural damage of limbic system and frontal and temporal lobes of brain may alter ability to modulate aggression
Serotonin
plays inhibitory role
-low serotonin levels = increased aggressive behavior
Dopamine and Norepinephrine
increased activity is associated with increased impulsively violent behavior
Applying the Nursing Process
- 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
Assessment
- 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
Assessment Checklist
- unit milieu
- history of violence
- how does the client handle anger?
- psychosis/ substance abuse
- how does the client handle disappointment?
Risk Factors
past history of violence
Treatments
- 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
Interventions
- 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
Manage the Environment
- 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
Skills a patient can practice that will be useful when returning to the community
- expressing angry feelings appropriately
- assertive communication skills; “I” statements
- negotiating a solution
Stages In Aggressive Incidents
- triggering phase
- escalation phase
- crisis phase
- recovery phase
- post-crisis phase
Interventions during what phases are key to prevent physically aggressive behavior?
-triggering phase
-escalation phase
(early phases)
Triggering Phase
an event or circumstances in the environment initiates the clients response, which is often anger or hostility
Signs/ Symptoms/ Behaviors of the Triggering Phase
- restlessness
- anxiety
- irritability
- pacing
- muscle tension
- rapid breathing
- perspiration
- loud voice
- anger
Escalation Phase
the clients responses represent escalating behaviors that indicate movement towards a loss of control
Signs/ Symptoms/ Behaviors of Escalation Phase
- pale or flushed face
- yelling/ swearing
- agitation
- threatening
- demanding
- clenched fists
- threatening gestures
- hostility
- loss of ability to solve the problem or think clearly
Crisis Phase
during an emotional and physical crisis, the client loses control
Signs/ Symptoms/ Behaviors of Crisis Phase
- loss of emotional and physical control
- throwing objects
- kicking
- hitting
- biting
- scratching
- shrieking
- screaming
- inability to communicate clearly
Recovery Phase
client regains physical and emotional control
Signs/ Symptoms/ Behaviors of Recovery Phase
- lowering of voice
- decreased muscle tension
- clearer, more rational communication
- physical relaxation
Post-Crisis Phase
client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents
Signs/ Symptoms/ Behaviors of Post-Crisis Phase
- remorse
- apologies
- crying
- quiet
- withdrawn behavior
Managing Aggressive Behavior: Triggering Phase
- 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
Managing Aggressive Behavior: Escalation Phase
- 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
Managing Aggressive Behavior: Crisis Phase
- 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
Managing Aggressive Behavior: Recovery Phase
- 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
Managing Aggressive Behavior: Post-Crisis Phase
- 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
Treatment
- 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
Atypical Anti-psychotics
more effective than conventional anti-psychotics and have less side effects
- anti-psychotic meds require careful assessment for extrapyramidal side effects
- Clozapine, Risperidone, Olanzapine
What drug treats extrapyramidal side effects?
Benzotropine
