week 2 anger and aggression

Research has found that atypical antipsychotics were more effective than

conventional antipsychotics for aggressive, psychotic patient

anger related personality traits and social inhibition are associated with the presence and serenity of

coronary artery disease

Keen observation skills and background knowledge for accurate assessment are

critical factors in predicting potential violent behaviors.

what is required within 24 after the release from seclusion or restraint

debriefing session

what is high hostility and anger associated with

increased risk of coronary artery disease and hypertension

The nurse should be aware of factors that

influence aggression in the psychiatric environment, or unit milieu.

what dose serotonin play a role in what does low levels of serotonin lead to

inhibitory role in aggressive behavior, therefore, low serotonin levels may lead to increased aggressive behavior

➢Why is it important for other clients to share their opinions & reactions to the seclusion & restraint of another client during a debriefing session?

you can get good info from the clients it calms them down

Acting Out

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

Behaviors associated with this prodromal stage include

rigid posture, clenched fists, and jaws, defiant affect, talking in a rapid voice; arguing and demanding; using profanity and threatening verbalizations; agitation and pacing, and pounding and slamming.

when can mental health clinicians break confidentiality

to warn a third party of direct threats made by the client

the nurse can help clients express anger appropriately by serving as a model and by role playing assertive communication techniques which include

"I" statements that express feelings and are specific to the situation "I feel angry when you interrupt me" "I am angry that you changed the work schedule without talking to me " this is appropriate communication of anger

A lack of psychological space-having no privacy, being unable to get sufficient rest-may be more important in

triggering aggression than a lack of physical space.

what are the 5 stages of aggressive behavior

triggering phase escalation phase crisis recovery postcrisis

what would be an example of a nursing diagnosis for a patient with aggressive behavior

risk for other directed violence- at risk for behavior in which an individual demonstrates that he or she can be physically, emotionally and or sexually harmful to others

what are some effective methods of anger expressions

using assertive communication to express anger, should replace angry aggressive outbursts of temper such as yelling or throwing things

some cultures such as asian and Native American see expressing anger as

rude or disrespectful and avoid it all costs in these cultures, trying to help a client express anger verbally to an authority figure would be unacceptable

➢Verbal and physical aggression especially assault and battery, require

safe, immediate interventions based on the principle of the least restrictive alternative.

what diagnosis are highly correlated with assertive behavior

schizophrenia, substance abuse, mania, antisocial, borderline, neurocognitive disorders

what plays a major inhibitory role in aggressive behavior

serotonin

what are the goals of restraints or seclusion

- To give the client the opportunity to regain physical and emotional self-control

what are some interventions for an aggressive client

- build a trusting relationship with this client as soon as possible - be aware of factors that increase the likelihood of violent behavior or agitation. use verbal communication or PRN medications to intervene before the client becomes destructive - if the client tells you they are feeling hostile, try and help the client express these feelings in nondestructive ways - always maintain control of yourself and the situation, remain calm - decrease stimulation by turning off the television or lowering volume/ lights or go to quiet room - tell the client what you are going to do and again when doing it - use simple direct speech

what can the nurse suggest or do for a client that is in a triggering phase

- can encourage the client to express his or her Nauru feelings verbally suggesting that the client is in control - suggest going to a quiet room or move other clients to decrease stimulation - PRN meds should be offered if ordered -physical activity such as walking can help

what does the nurse monitor for someone on restraints/ seclusion

- clients skin condition, blood circulation in hands and feet (for clients in restraints), emotional well-being and readiness to discontinue seclusion or restraint - observe the client closely for side effects of the medications - implements and documents offer of food, fluids, and procedure

what are some interventions for a client with a weapon

- do not attempt to remove the weapon. keep something like a pillow or mattress wrapped around your arm between you and the weapon -if it is necessary to remove the weapon, try to kick it out of their hands- never reach for it - distract the client momentarily by throwing water in their face or yell suddenly - you may need to call for outside assistance- when this is done, total responsibility is delegated to he outside authorities - do no trap client

what are some immediate expected outcomes for an aggressive patient

- refrain from harming others or destroying property throughout hospitalization - be free of self inflicted harm throughout hospitalization - demonstrate decreased acting out behavior with 12-24 hours - experience decreased restlessness or agitation within 24-48 hours

Why is it important to assess a client in restraints frequently?

- safety - legality

treatment of an aggressive patient

- use of antipsychotic medications requires careful assessment for the development of extrapyramidal side effects - Although not a treatment per se, the short-term use of seclusion or restraint may be required during the crisis phase of the aggression cycle to protect the patient and others from injury. Many legal and ethical safeguards govern the use of seclusion and restraints. - Follow agency protocols.

what can the nurse do during the recovery phase

-help the client relax, perhaps sleep, and return to a calmer state -it is important to help the client explore alternatives to aggressive behavior by asking what the client or staff can do next time to prevent an aggressive episode

how many trained staff are needed to retain an aggressive patient

4-6

➢How many staff members are needed legally when placing an acting out client in restraints or seclusion? Check Textbook~~~~~Why?

4-6

Catharsis

Activities that are supposed to provide a release for strong feelings such a anger, rage etc. talking to someone, walking, praying etc.

Hostility

Also called verbal aggression, is an emotion, expressed through verbal abuse, lack of cooperation, violation of rules or norms or threatening behavior. Hostile behavior is intended to intimidate or cause emotional harm to another, and it can lead to physical aggression.

psychosocial theories

As a child matures he or she is expected to develop impulse control (the ability to delay gratification) and socially appropriate behavior. This lack of development due to dysfunctional families can result in a person who is impulsive, easily frustrated, and prone to aggressive behavior.

what is essential with a patient that is potentially aggressive what is helpful

Close supervision of the patient who is potentially aggressive is essential Talking with other patients about their feelings is helpful

When planning the care of clients experiencing aggression the nurse incorporates the principle of the "least restrictive alternative," meaning that less restrictive interventions must be tried before more restrictive measures are employed. Which would the nurse consider to be the most restrictive intervention? a. Tension reduction strategies. b. Haloperidol (Haldol) given orally. c. Voluntary quiet room or "time-out." d. Haloperidol (Haldol) given intramuscularly.

D

what happens in the recovery phase

Debriefing to discussing the episode Post-crisis, the patient is removed from restraint or seclusion as soon as he or she meets the behavior criteria.

what are some important skills the patient can practice

Expressing angry feelings appropriately, using assertive communication statements, and negotiating a solution are important skills patient's can practice. These skills will be useful for the patient when he or she returns to the community.

If a patient is psychotic, hyperactive, or intoxicated, the nurse must consider

the safety and security of other patients, who may need protection from intrusive or threating demeanor of that patient.

what is a common combination treatments for aggressive patients

Haloperidol and lorazepam are commonly used in combination to decrease agitation or aggression and psychotic symptoms.

what risk factors would you assess for

Past history of violence (major risk factor)

the etiology of serotonin, dopamine, norepinephrine are known as what theory

Neurobiologic Theories

Prodromal Syndrome is characterized by

Novisky and associates describe a prodromal syndrome that is characterized by anxiety, and tension, verbal abuse, and profanity, and increasing hyperactivity. These escalating behaviors usually do not occur in stages but most often overlap and sometimes occur simultaneously.

how should a nurse respond to a client that says Client: "There is no way you people are going to treat me like that ! Who do you think you are?

Nurse: "Tell me what is going on. Nurse: "How can I help you?""

Restraint

Physical/chemical /mechanical control of a client to prevent injury to self or others

Seclusion

Process of placing a client alone in a specially designed room for protection and close observation

staff must take charge for

the safety of the patient, staff, and other patients

➢What are some contradictions to seclusion /restraint?

cardiac disorders pulmonary disorders

Impulse control

The ability to delay gratification and to think about one's behavior

outcomes

The client will: - not harm or threaten others. - refrain from behaviors that are intimidating or frightening to others. - describe his or her feelings and concerns without aggression - comply with treatment - Take responsibility for his or her feelings of anger - use steps of the problem solving process to diffuse anger - seek out staff to talk about feelings

what is the criteria for removal of restraint or seclusion

To have decreased muscle tension To demonstrate self control To make no verbal threats

what is included in the assessment

Unit milieu History of violence How does the client handle anger Psychosis/Substance Abuse How does the client handle disappointment

The treatment of aggressive patients often focuses on treating

the underlying or comorbid psychiatric diagnosis

for adult clients the use of restrain and seclusions require

a face to face evaluation by a licensed independent practitioner within 1 hour of restraints or seclusion and every 8 hours after that

Anger

a 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

further structural damage in the limbic system and the frontal and temporal lobes of the brain may alter the person's

ability to modulate aggression this can lead to aggressive behavior

what is some of the criteria the client would have to meet tin order to come our of seclusion or restraints

ability to verbalize feelings and concerns rationally, to make no verbal threats, to have decreased muscle tensions and demonstrate self control

catharsis

activities that are supposed to provide a release for anger this can increase rather than alleviate anger, therefore, it may be contradicted for angry clients

what are some risk factors for aggressive behavior

actual or potential physical acting out of violence destruction of property homicidal or suicidal indeation physical danger to self or others history of assaultive behavior or arrests neurologic illness disordered thoughts agitation or restlessness lack of impulse control delusions, hallucinations, or other psychotic symptoms personality disorder manic behavior conduct disorder PTSD substance abuse

simply suppressing or attempting to ignore angry feelings may

adversely affect control of hypertension

Assessment and effective intervention with angry or hostile patients can often prevent

aggressive episodes

triggering phase definition and signs/ symptoms/ behaviors

an event or circumstances in the environment initiates the clients response which is often anger or hostility restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, anger

If PRN medication has not been taken earlier, the nurse may obtain

an order for intramuscular (IM) medication in this type of emergency situation the follow up with a face-to-face evaluation with a psychiatric health care provider.

if the client has refused all PRN meds, the nurse may obtain

an order for intramuscular medication in this type of emergency situation

when should the nurse get a doctors order after deciding to use restraints

as soon as possible

Remember to offer support to the patients family, who may

be angry or embarrassed when the patient is restrained or secluded.

if a client remains in retrains for 1-2 hours, 2 staff members

can free one limb at a time for movement and exercise

what is an unhealthy way of dealing with anger

denying or trying to eliminate anger. it is essential for good health to recognize, press, and manage angry feelings in a positive manner it. becomes negative when the person denies it, surprises it, for expresses it inappropriately

in social settings, the most frequent response to hostile people is to get as far away from them as possible. In the psychiatric setting, however, engaging the hostile person in...

dialogue (talk therapy) is most effective to prevent the behavior from escalating to physical aggression and is less restrictive.

crisis phase definition and signs/ symptoms/ behaviors

during an emotional and physical crisis, the client loses control loss of emotional and physical control, throwing objects, kicking, hitting, setting, biting, scratching, shrieking, screaming, inability to communicate clearly

where are interventions key when trying to prevent physically aggressive behavior

during the triggering and escalation phase

Behaviors associated with the prodromal syndrome should be considered

emergent and demand immediate attention.

what is the most effective way to prevent physical aggression

engaging the hostile person in dialogue

patients with dark skin, regardless of race, are sometimes perceived as more dangerous than light skinned patients and therefore are more likely to

experience compulsory hospitalization, increased use of restraints, higher doses of medication

what are some important skills a client can practice

expressing angry feelings appropriately, using assertive communication statements and negotiating a solution

Conversely, when predictability of meetings or groups and staff-patient interactions are lacking, patients often feel

frustrated and bored, and aggression was more common and intense.

Scheduling 1:1 interactions with patients indicates the nurse's

genuine interest in the patient and a willingness to listen to the patients concerns, thoughts, and feelings. Knowing what to expect enhances the patient's feelings of security.

scheduling one to one interactions with he client indicates that the nurse

has a genuine interest in the client and a willingness to listen to the client's concerns, thoughts, and feelings

The best predicator of future violence is a

history of violent behavior.

some people can express their anger by engaging in aggressive but safe activities such as

hitting or punching a bag yelling

short-term use of restraint or seclusion is permitted only when the client is

imminently aggressive and dangerous to himself or herself or to others and all other means of calming the client have been unsuccessful

intervention are most effective and least restrictive when

implemented early in the cycle of aggression

Interventions are most effective and least restrictive when

implemented early in the cycle of aggression (Triggering phase).

how should the nurse approach a client in the triggering phase

in a nonthreatening, calm manner in order to de-estcalate the clients's emotion and behavior

when is the client removed from restraints

in the post crisis phase as soon as he or she meets the behvairoal criteria

low serotonin level may lead to

increased aggressive behavior

increased activity of dopamine and norepinephrine in the brain is associated with

increased impulsively violent behavior

what is dopamine and norepinephrine in the brain associated with

increased impulsively violent behavior

Hostility or verbally aggressive behavior can be

intimidating, or frightening even for experienced nurses

Physical aggression

is behavior in which a person attacks or injures another person or that involves destruction of property. Both verbal and physical aggression are meant to harm or punish another person or to force someone into compliance such as rape.

what does anger do for the body

it energizes the body physically for self-defense, when needed, by activating the fight or flight response mechanisms of the sympathetic nervous system.

clients have the right to treatment in the

least restrictive environment appropriate to meet their needs

Patients who are agitated and aggressive but not psychotic benefit most from

lorazepam which can be given in 2-mg doses every 45 to 60 minutes.

possible consequences to dealing with anger in the wrong way are physical problems which include

migraine headaches ulcers coronary artery disease emotional problems such as depression and low self esteem

should a patient be hospitalized if their treatment can be done in an outpatient setting

no

if the client's behavior continues to escalate and he or she is unwilling to accept direction to a quiet area, the nurse should

obtain assistance from other staff members

Early assessment, judicious use of medications, and verbal intervention with an angry patient can

often prevent anger from escalating into physical aggression.

Patients exhibiting these behaviors are also threatening to

other patients, staff, and visitors. Safety!!!

what does seclusion do

provides decreased stimulation, protects other from the client, prevents property destruction, and provides privacy for the client

It is important to consider the environment for all patients when trying to

reduce or eliminate aggressive behavior.

as the clients anger subsides, the nurse can help the client by using

relaxation techniques and look at ways to solve any problem or conflict that may exist

what happens to the client as their behaviors towards the crisis phase, he or she loses the ability

to perceive events accurately, solve problems, express feelings appropriately, or control his or her behavior

what are some stabilization/ community expected outcomes for an aggressive patients

stabilization - demonstrate the ability to exercise internal control over his or her behavior - be free of psychotic behavior - identify ways to deal with tension and aggressive feelings in a nondestructive way community - participate in therapy for underlying associated psychiatric problems - demonstrate internal control of behaviors confronted with stress.

Aggressive behavior is less common on psychiatric units with

strong psychiatric leadership, clear staff roles, and planned and adequate events such as staff-patient interaction, group interaction, and activities.

when the client enters the escalation phase, the nurse should provide directions to the client in a calm, firm voice. The client should be directed to the nurse should tell the client that

take a time-out for cooling off in a quiet area their behavior is not acceptable and that the nurse is there to help the client regain control *meds should be offered again if they were refused earlier*

Group and planned activities such as playing card games, watching and discussing movies, or participating in informal discussions give patients the opportunity to

talk about events or issues when they are calm.

as the client regains control he or she is encouraged to

talk about the situation or triggers that led to the aggressive behavior

what must you tell the client before restraining

that their behavior is out of control and the staff is taking control to provide safety and prevent injuries

postcrisis phase definition and signs/ symptoms/ behaviors

the client attempts reconciliation with others and returns to the level of function before and the aggressive incidnet and its antecedents remove, apologies, crying, quiet, withdrawn behavior

short term use of seclusion or restraint is permitted only if

the client is imminently aggressive and dangerous to himself or herself or to others

Short-term use of restraint or seclusion is permitted only when

the client is imminently aggressive and dangerous to himself or herself or to others.

recovery phase definition and signs/ symptoms/ behaviors

the client regains physical and emotional control lowering of voice, decreased muscle tension, clearer more retinal communication, physical relaxation

escalation phase definition and signs/ symptoms/ behaviors

the clients responses represent escalating behaviors that indicate movement towards a loss of control pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think Cleary

staff must monitor a client in restraints continuously on a 1:1 basis for A client in seclusion is monitored 1:1 for

the duration of the restraint period the first hour and then may be monitored by audio and video equipment

what a culture considers acceptable strongly influences

the expression of anger

If patients have a conflict or dispute with one another, the nurse can offer

the opportunity for problem-solving or conflict resolution.

what should the nurse do post-crisis

➢The nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner. ➢The client can be given feedback for regaining control, with the expectation that he or she will be able to handle feelings or events in a non-aggressive manner in the future. ➢The client should be reintegrated into the milieu and its activities as soon as he or she can participate.