ATI Ch 24, Crisis and Anger Management Flashcards
What is a crisis?
An acute, time-limited event during which a client experiences an emotional response that cannot be managed with normal coping mechanisms.
Usually lasts up to 6 weeks.
Is experiencing a crisis pathological?
No, a crisis is not pathological but represents a struggle for equilibrium and adaptation.
What are common characteristics of a crisis?
- Experiencing a sudden event with little or no time to prepare
- Perception of the event as overwhelming or life-threatening
- Loss or decrease in communication with significant others
- Sense of displacement from the familiar
- An actual or perceived loss
What are the types of crises?
- Situational/external
- Maturational/internal
- Adventitious
What is a situational/external crisis?
An often unanticipated loss or change experienced in everyday life events, such as divorce or job change.
What is a maturational/internal crisis?
Achieving new developmental stages that require learning additional coping mechanisms, such as getting married or retiring.
What constitutes an adventitious crisis?
The occurrence of natural disasters, crimes, or national disasters.
What should the nursing history assessment include during a crisis?
- Presence of suicidal or homicidal ideation
- Client’s perception of the precipitating event
- Cultural or religious needs
- Support system
- Present coping skills
- Physical assessment
What are common risk factors for a crisis?
- Accumulation of unresolved losses
- Current life stressors
- Concurrent mental and physical health issues
- Excessive fatigue or pain
- Age and developmental stage
What are protective factors in crisis management?
- Support system
- Prior experience with stress/crisis
What are the phases of a crisis?
- Phase 1: Escalating anxiety activates increased defense responses.
- Phase 2: Anxiety escalates as defense responses fail, leading to disorganization.
- Phase 3: Trial-and-error methods fail, anxiety escalates to severe levels.
- Phase 4: Overwhelming anxiety can lead to anguish, powerlessness, depression, and possible violence.
Fill in the blank: A crisis usually lasts up to _______.
[6 weeks]
True or False: A crisis can lead to either psychological deterioration or growth.
True
What is Acting out?
Dealing with emotional conflicts or stressors through actions rather than through reflection or feelings.
Acing out can be seen as a coping mechanism for emotional distress.
What results in Anger?
Frustration, hurt, or fear.
Anger is often a response to perceived threats or injustices.
Define Catharsis.
Engaging in aggressive but safe activities that provide a release for anger.
Catharsis can involve physical activities like exercise or art to express feelings.
What happens during the Crisis Phase?
The client/patient becomes physically aggressive.
This phase indicates a significant escalation in emotional distress.
What characterizes the Escalation Phase?
The client/patient builds towards loss of control.
This phase is crucial as it signals the potential for aggressive behavior.
What is the term for dealing with emotional conflicts or stressors through actions rather than through reflection or feelings?
Impulse
Impulse behavior often leads to aggressive actions.
What does the term ‘Impulse Control’ refer to in the context of aggression?
The ability to delay gratification
Control is essential in managing aggressive impulses.
Define Physical Aggression.
Behavior in which a person attacks or injures another person or destroys property.
Physical aggression can manifest in various forms including verbal threats and physical violence.
What happens during the Postcrisis Phase?
The client/patient is removed from restraint or seclusion as soon as they meet the behavioral criteria.
This phase is crucial for recovery and reintegration.
What phase is it when a client/patient regains control?
The recovery phase - The client/patient has effectively managed their aggressive behavior.
Regaining control is a key step in the therapeutic process.
What is the Triggering Phase?
Incident or situation that initiates an aggressive response.
Identifying triggers is essential for preventing aggression.
Fill in the blank: The ability to delay _______ is an important aspect of impulse control.
gratification
Delaying gratification can help individuals manage their impulses.
True or False: Physical aggression only refers to the destruction of property.
False
Physical aggression also includes attacking or injuring another person.
What is the purpose of crisis intervention?
To provide rapid assistance for individuals or groups with an urgent need and to resolve the immediate problem causing a crisis.
What is the initial task of the nurse during a crisis intervention?
To promote a sense of safety for the client and assess the client’s potential for suicide or homicide.
What should be prioritized when assisting a client with suicidal or homicidal thoughts?
Prioritize interventions to address the client’s physical needs first.
List some initial interventions in crisis intervention.
- Identifying the current problem and directing interventions for resolution
- Taking an active, directive role with the client
- Encouraging active participation by the client in planning solutions and goal setting
- Helping the client to set realistic, attainable goals
- Using strategies to decrease anxiety
- Developing a therapeutic nurse-client relationship
- Teach coping skills (assertiveness and parenting skills)
- Develop action plan
- Join critical incident stress debriefing group
What are some techniques to communicate effectively with a client in crisis?
- Remain with the client
- Listen and observe
- Make eye contact
- Ask questions related to the client’s feelings and the event
- Demonstrate genuineness and caring
- Communicate clearly and with clear directives
True or False: It is important to avoid false reassurance and other nontherapeutic responses during crisis intervention.
True
What types of action plans should be developed for a client in crisis?
- Short-term
- Focused on the crisis
- Realistic and manageable
What is Critical Incident Stress Debriefing?
A group approach used with people exposed to a crisis situation.
What types of medications may be administered during crisis intervention?
- Antianxiety medications (e.g., alprazolam, diazepam, oxazepam)
- Antidepressants (e.g., paroxetine, bupropion, fluoxetine)
Define primary care in the context of psychotherapy.
Collaborate with the client to identify potential triggers, instruct on coping mechanisms, and assist in lifestyle changes.
What is the focus of secondary care in crisis intervention?
Collaborate with the client to identify interventions during an acute crisis that promote safety.
What does tertiary care involve in the context of crisis intervention?
Collaboration for recovery from crises, including rehabilitation centers, short-term residential services, and workshops.
What community services can assist during a crisis?
- Crisis stabilization
- Hotlines and warm lines
- Mobile and peer crisis services
What is the nature of anger as described in the text?
Anger is a normal emotional response to perceived frustration and can be positive or negative depending on how it is expressed.
What can denied or suppressed anger manifest as?
Physical or psychological findings.
List some disorders that can be comorbid with anger issues.
- Depressive disorders
- Substance use disorders
- Bipolar disorders
- Posttraumatic stress disorder
- Alzheimer’s disease
- Personality and psychotic disorders
What is the relationship between mental illness and aggression?
Clients with mental illness are more likely to hurt themselves than to express aggression against others.
Fill in the blank: Anger can be referred to as a _______ emotion related to another disorder.
[secondary]
What underlying feelings can contribute to aggression in clients?
- Inadequacy
- Insecurity
- Guilt
- Fear
- Rejection
What challenges do individuals with limited coping skills face?
They are easily overwhelmed.
What is the definition of seclusion and restraint in a mental health setting?
Seclusion and restraint must be used only according to legal guidelines and should be the interventions of last resort after other less restrictive options have been tried and there is a risk of harm to the client or others.
What must a provider’s prescription for seclusion or restraint include?
The prescription must include the reason for the seclusion or restraint, length of time, type of restraints, and criteria needed for removal from the secluded area or release of restraints.
What is the importance of evaluating the client face to face after restraint application?
The client is evaluated (face to face) by a health care provider, RN, or physician’s assistant (PA) within 1 hour.
True or False: Restrained clients can be left alone.
False
How often should restrained clients be monitored?
Continuous monitoring every 15 minutes and documentation by prepared staff.
What are some expected findings of a client exhibiting aggression?
Expected findings include:
* Hyperactivity such as pacing, restlessness
* Hypersensitivity, easily offended
* Intense or no eye contact
* Facial expressions like frowning or grimacing
* Body language such as clenching fists
* Rapid breathing
* Aggressive postures
* Verbal clues like yelling or shouting
* Drug or alcohol intoxication
List some risk factors associated with aggression in clients.
- Past history of aggression
- Poor impulse control
- Poor coping skills
- Comorbidity leading to violence
- Living in a violent environment
What is contingency management in the context of nursing care?
Contingency management involves rewarding desired behavior, like maintaining a calm demeanor, with quantifiable rewards.
What steps should be taken to handle aggressive behavior in a mental health setting?
- Responding quickly
- Remaining calm and in control
- Encouraging verbal expression of feelings
- Allowing personal space
- Maintaining eye contact
- Communicating with honesty and nonaggression
- Avoiding accusatory statements
- Describing options clearly
- Reassuring the client of staff support
What clinical screening tools are used for assessing anger reactions?
- Dimensions of Anger Reactions
- Patient-Reported Outcome Measurement Information System (PROMIS)
- State-Trait Anger Scale (STAS)
- Clinical Anger Scale (CAS)
Fill in the blank: The client should not be left alone when _______ are applied.
restraints
What assessments should be conducted hourly for restrained clients?
- Physiological and mental status
- Vital signs (including pulse oximetry)
- Review of circulatory status and skin integrity
- Offering fluids
What actions should be taken if restraints have been applied?
Range of motion exercises are executed every 2 hours.
What is the role of self-assessment in managing aggressive behavior?
Self-assessment involves self-awareness to understand personal triggers and responses.
What are some nursing care responsibilities when dealing with aggressive clients?
- Provide a safe environment
- Follow policies of the mental health setting
- Assess for triggers that escalate emotions
What should you tell the client to do in a particular situation?
Tell the client calmly and directly what they must do, such as, ‘I need you to stop yelling and walk with me to the day room where we can talk.’
What physical activity can be used to deescalate anger and behaviors?
Walking
What should be informed to the client regarding their behavior?
Inform the client of the consequences of their behavior, such as loss of privileges.
What should be done if the client does not respond to calm limit-setting?
Use pharmacological interventions.
How many staff members should be available as a ‘show of force’ if appropriate?
Four to six staff members
What should be discussed with the client following an aggressive or violent episode?
Discuss ways for the client to keep control during the aggression cycle.
What should be reassessed following an aggressive episode?
Reassess the milieu and identify potential and actual stressors.
What should be encouraged after an aggressive incident?
Encourage the client to talk about the incident and what triggered the aggression.
What should staff do after an incident to evaluate their actions?
Debrief the staff to evaluate the effectiveness of actions.
What should be documented after a critical incident?
Document the entire incident completely including:
* Behaviors leading up to the incident
* Nursing interventions implemented
* Client’s response
When should debriefing be completed for clients in seclusion or restraints?
As soon as possible following the discontinuation of the seclusion and/or removal of restraints.
What should be discussed during client debriefing?
Discussion of any misperceptions
What should be displayed to support the client’s return to the unit milieu?
Display of support
What should be identified to prevent subsequent seclusion/restraint?
Identification of different approaches
What is important to do regarding the client’s point of view during debriefing?
Listening to the client’s point of view
What should be provided to the client if they believe their rights have been violated?
Provide guidance
What should be recognized during the debriefing process?
Recognition of any trauma that occurred
What should be adapted as needed following a critical incident?
Adapt plan of care
What are the medications mentioned for controlling aggressive and impulsive behaviors?
Olanzapine, ziprasidone
What is the classification of Olanzapine and Ziprasidone?
Atypical antipsychotics
What is the therapeutic intent of Olanzapine and Ziprasidone?
Used to control aggressive and impulsive behaviors.
Why are Olanzapine and Ziprasidone used more commonly than Haloperidol?
Due to the severity of adverse effects of Haloperidol.
What disorder is characterized by anger as a symptom and is commonly associated with trauma?
Post-Traumatic Stress Disorder
This disorder often arises after experiencing or witnessing a traumatic event.
Which type of disorders may include anger as a symptom and involves mood disturbances?
Depressive Disorders
These disorders can lead to feelings of sadness, irritability, and anger.
What type of disorders may manifest anger and involve enduring patterns of behavior and inner experience?
Personality Disorders
These disorders can significantly affect an individual’s social functioning.
Which disorder is characterized by recurrent episodes of impulsive aggression?
Intermittent Explosive Disorder
It involves sudden episodes of unwarranted anger.
What can cause anger as a symptom due to chemical imbalances?
Toxicities
Exposure to certain toxins can affect brain function and lead to irritability.
Which medical conditions can lead to anger due to physical injury to the brain?
Head Injuries
Traumatic brain injuries can alter emotional regulation.
What type of deficits can result in anger issues, particularly in childhood?
Developmental Deficits
These deficits may affect emotional and social skills.
What nutritional deficiency can lead to irritability and anger?
Malnutrition
Lack of essential nutrients can impact mood and behavior.
What physical condition may cause anger as a symptom due to abnormal growths in the body?
Tumors
Tumors affecting the brain can alter mood and behavior.
Which mood disorder is characterized by extreme mood swings including anger?
Bipolar Disorder
This disorder includes episodes of mania and depression.
What degenerative disease can lead to changes in mood, including increased anger?
Alzheimer’s Disease
This disease affects memory and can lead to behavioral changes.
What type of disorders can involve anger as a symptom due to withdrawal or intoxication?
Substance Use Disorders
These disorders are characterized by the harmful use of psychoactive substances.
What is a risk factor associated with aggressive behavior?
History of violence/rage or aggressive behavior
This indicates a past tendency towards aggression which can predict future violent actions.
Name a psychological factor that can increase the risk of aggression.
Poor coping skills
Individuals lacking effective coping strategies may resort to aggression when faced with stress.
What can limit the effectiveness of support in managing aggression?
Limited support systems
A lack of social or emotional support can lead to increased feelings of isolation and aggression.
What is comorbidity in the context of aggression?
The presence of one or more additional disorders accompanying aggression
Comorbidity can complicate treatment and management of aggressive behaviors.
What type of delusion can be a risk factor for aggression?
Psychotic delusions
These delusions can distort reality and lead to unpredictable behaviors.
What are command hallucinations?
Hallucinations that instruct individuals to perform certain actions
These can lead to violent behavior if the commands are aggressive in nature.
What type of reactions may occur in individuals with cognitive disorders?
Violent angry reactions
Cognitive impairments can lead to misunderstandings and frustration, resulting in aggression.
What environmental factor can contribute to aggressive behavior?
Living in a violent environment
Exposure to violence can normalize aggressive behaviors and increase the likelihood of acting out.
What role does limit setting play in aggression management?
It is a technique used by nurses within the therapeutic milieu
Effective limit setting helps to establish boundaries and reduce aggressive incidents.
Which vitamin deficiencies are mentioned as risk factors for aggression?
Thiamine & niacin deficiencies
These deficiencies can affect brain function and behavior, potentially leading to aggression.
How can caffeine intake affect aggression?
It can increase anxiety and agitation
High caffeine consumption may lead to heightened states of irritability and aggression.
What types of troubles can contribute to aggressive behavior?
Financial or legal troubles
Stress from these issues can lead to frustration and aggressive responses.
What are the characteristics of units that are predictive of violence?
- Busy, noisy, crowded
- Rigid unit rules
- Lack of patient privacy and space
- Lack of patient autonomy
- Strict hierarchy of authority
- Lack of meaningful, planned, and predictable ward activities
- Lack of patient control over the treatment plan
- Boundary violations
These characteristics can create an environment that fosters aggression and violence among patients.
What unit characteristic involves the absence of personal space for patients?
Lack of patient privacy and space
This can be both psychological and physical, contributing to feelings of vulnerability or frustration.
Fill in the blank: A unit with _______ rules can be predictive of violence.
Rigid unit
Rigid rules may limit patient autonomy and contribute to feelings of oppression.
What staff behavior can contribute to a predictive environment for violence?
- Insufficient staff assistance with ADLs
- Denial of patient requests or privileges
- Rude or patronizing staff behavior
- Unclear staff roles
- Power struggles related to medications
- Failure of staff to listen or to convey empathy
These behaviors can exacerbate patient frustration and feelings of helplessness.
True or False: Lack of meaningful ward activities can predict violence in a unit.
True
Meaningful activities are essential for patient engagement and can reduce feelings of agitation.
What does the term ‘boundary violations’ refer to in the context of units predictive of violence?
Inappropriate interactions or lack of respect for personal space and rights
Boundary violations can lead to distrust and increased tension between staff and patients.
Fill in the blank: A strict _______ of authority can lead to an environment predictive of violence.
Hierarchy
A strict hierarchy may limit open communication and exacerbate power imbalances.
What is a common staff behavior that may lead to power struggles related to medications?
Unclear staff roles
Unclear roles can cause confusion and conflict over medication management.
What is the triggering phase in the Five-Phase Aggression Cycle?
An event or circumstances in the environment initiates the client’s response, which is often anger or hostility.
What characterizes the escalation phase of the Five-Phase Aggression Cycle?
The client’s responses represent escalating behaviors that indicate movement toward a loss of control.
Describe the crisis phase in the Five-Phase Aggression Cycle.
During an emotional and physical crisis, the client loses control.
What occurs during the recovery phase of the Five-Phase Aggression Cycle?
The client regains physical and emotional control.
What is the postcrisis phase in the Five-Phase Aggression Cycle?
The client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents.
List some signs and symptoms during the triggering phase.
- Restlessness
- Anxiety
- Irritability
- Pacing
- Muscle tension
- Rapid breathing
- Perspiration
- Loud voice
- Anger
What behaviors are exhibited during the 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
What are the characteristics of the crisis phase?
- Loss of emotional and physical control
- Throwing objects
- Kicking
- Hitting
- Spitting
- Biting
- Scratching
- Shrieking
- Screaming
- Inability to communicate clearly
What signs indicate recovery from a crisis?
- Lowering of voice
- Decreased muscle tension
- Clearer, more rational communication
- Physical relaxation
What behaviors are indicative of the postcrisis phase?
- Remorse
- Apologies
- Crying
- Quiet, withdrawn behavior
What is the first category of anger/aggression?
Pre-assaultive
Begins to become angry, exhibits increasing anxiety, tension, hyperactivity, and verbal abuse.
What characterizes the assaultive category of anger/aggression?
Commits an act of violence
This stage involves a direct act of aggression towards others.
What happens during the post-assaultive category of anger/aggression?
Is encouraged by staff to talk about what triggered and escalated the aggression
This stage focuses on understanding the incident and preventing future occurrences.
What is one example of a nurse’s response during the pre-assaultive stage?
Use therapeutic de-escalation
This involves calming techniques to reduce anxiety and aggression.
Name a strategy a nurse can use to engage with an angry patient.
Engage in dialogue; convey empathy
This helps build trust and understanding between the patient and the nurse.
What technique can be used to help manage stress in patients showing aggression?
Physical activity and relaxation techniques
These methods can help reduce tension and aggression.
How can a nurse help decrease stimulation in the environment during a pre-assaultive situation?
Decrease stimulation in environment
This can involve reducing noise, distractions, or other stressors.
What is PRN medication?
Medication offered as ordered
PRN stands for ‘pro re nata’, meaning as needed.
When should a ‘show of force’ be used?
As appropriate
This refers to the careful display of authority to deter aggression.
What should be considered a last resort in managing aggressive behavior?
Seclusion or physical or chemical restraints
These measures should only be implemented when all other options have failed.
What is an important step after an assaultive incident?
Review incident with the patient
Discussing the incident helps the patient understand their behavior and control.
What should be reassessed following an incident of aggression?
Reassess milieu
This involves evaluating the environment and conditions that may have contributed to the aggression.
What is a key component of staff involvement after an incident?
Debrief involved staff
This allows staff to process the event and improve future responses.
Why is it important to talk to other clients after an incident?
To provide support and address any concerns
This helps maintain a safe and supportive environment for all clients.
What is the primary guideline for the use of seclusion and restraint?
Seclusion and restraint must be used only according to legal guidelines and should be the interventions of last resort.
List less restrictive interventions prior to the use of restraints.
- Verbal interventions
- Offering an as needed medication
- Decreasing stimulation
- Close observation and one to one supervision
True or False: Restraints can be dangerous.
True
When can intramuscular medication be administered?
Intramuscular medication can/need to be given if aggression is threatening and if no medications were previously administered.
What should be done after the crisis is over when restraints are used?
Remove the client from seclusion or restraint as soon as the crisis is over and when the client attempts reconciliation and is no longer aggressive.
Fill in the blank: Restraints should be used only as a ____________.
[intervention of last resort]
What is the first key point in promoting safety?
Provide a Safe Environment
What is essential for establishing trust in healthcare?
Establish Therapeutic Nurse-Patient Relationships
What should nurses offer to empower patients?
Offer Concrete Choices
What is a valuable opportunity for patient education?
Provide ‘Teachable Moment’
What should be made clear to patients regarding behaviors?
Make Behavioral Limits and Consequences Clear
What quality should nurses exhibit to foster safety?
Exhibit Self Awareness
What is important for nurses to do when patients express anger?
Remain with Patients When They are Angry
What is the first step in care after discharge?
Treat Underlying or Comorbid Diagnoses
What should be addressed to respect patient diversity in care after discharge?
Address Cultural Concerns
What is important to manage in patients after discharge?
Address Substance Use/Misuse
What type of appointments should be scheduled regularly after discharge?
Regular Follow-Ups
What type of interventions can help patients adjust post-discharge?
Cognitive and Behavioral Interventions
What techniques can be taught to assist with stress management after discharge?
Stress Management/Relaxation Techniques
What type of programs can provide ongoing support to patients after discharge?
Community Support Programs
What type of group can help patients manage anger after discharge?
Anger Management Groups
What type of counseling can be beneficial for couples after discharge?
Couples Counseling
What support group model can assist in recovery after discharge?
12-Step Groups
What are risk factors in the context of crisis?
Accumulation of unresolved losses, current life stressors, concurrent mental and physical health issues, excessive fatigue or pain, age and developmental stage
These factors can increase vulnerability to a crisis.
What are protective factors that can help during a crisis?
Support system, prior experience with stress/crisis
These factors can provide resilience and coping mechanisms.
What happens in Phase 1 of a crisis?
Escalating Anxiety from a threat
This phase marks the initial response to perceived danger.
What characterizes Phase 2 of a crisis?
Anxiety continues escalating as defense responses fail; functioning becomes disorganized; resorts to trial and error attempts to resolve anxiety
Individuals may struggle to cope effectively.
What occurs in Phase 3 of a crisis?
Anxiety escalates to severe or panic levels; trial and error methods of resolution fail; flight or withdrawal behavior
This phase indicates a critical point where coping mechanisms break down.
Describe the features of Phase 4 in a crisis.
Overwhelming anxiety that can lead to anguish and apprehension; feelings of powerlessness and being overwhelmed; dissociative findings, depression, confusion, and or violence against others or self
This phase represents the peak of crisis where individuals may experience severe psychological distress.
What is a crisis?
A turning point in an individual’s life that produces an overwhelming emotional response.
What triggers a crisis in an individual?
Confronting a life circumstance or stressor that cannot be managed through customary coping skills.
What are the four stages of crisis identified by Caplan (1964)?
- Exposure to a stressor and anxiety
- Increased anxiety due to ineffective coping
- Efforts to deal with the stressor using new methods
- Disequilibrium and significant distress when coping attempts fail
What are the three categories of crises?
- Maturational crises
- Situational crises
- Adventitious crises
What are maturational crises?
Predictable events in the normal course of life, such as leaving home, getting married, having a baby, and beginning a career.
What defines situational crises?
Unanticipated or sudden events that threaten the individual’s integrity, such as death of a loved one, loss of a job, or illness.
What are adventitious crises?
Social crises including natural disasters, war, terrorist attacks, riots, and violent crimes.
True or False: All events causing a crisis are negative.
False
Fill in the blank: Maturational crises are also called _______.
[developmental crises]
Give examples of situational crises.
- Death of a loved one
- Loss of a job
- Physical or emotional illness
What can be considered adventitious crises?
- Natural disasters
- War
- Terrorist attacks
- Riots
- Violent crimes
