Nursing 126 Ch. 24 - Anger, Aggression, & Violence

Assure your safety from violence by:

Avoid wearing dangling jewelry Have enough staff for backup Always know the layout of the area Do not stand directly in front of client or in front of doorway If escalating provide feedback "you seem upset." Avoid confrontation with the client either through verbal means or a show of force.

Medications for Acute Aggression

1 - Antipsychotics - Typical: Haldol - Cogentin/Benadryl used w/Haldol to prevent EPS - Atypical: Risperdal, Zyprexa 2 - Benzodiazepines - Ativan

Meds for Chronic Aggression (all take about 4-8 weeks)

1 - Beta-Blockers - Inderall - turn off SNS 2 - Lithium (mood stabilizer) 3 - Anti-Convulsants (3) Depakote, Lamictal, Tegretol

Risk factors for anger/aggression (3)

1 - history of violence 2 - paranoid ideation 3 - poor coping skills/impulsivity

Managing pre-assaultive stage: (4)

1 - listen to pt. 2 - use de-escalation techniques 3 - maintain your safety 4 - offer PRN meds

De-escalation approaches for pre-assaultive phase of angry pt. (list at least 4)

1 - maintain pt. self-esteem 2 - remain calm 3 - respond early 4 - estab. pt's. concern 5 - maintain large personal space 6 - give options 7 - non-aggressive posture

milieu conductive to violence (5)

1 - overcrowding 2 - staff inexperience 3 - staff controlling 4 - poor limit setting 5 - not enough activities

milieu that reduces violence (3)

1 - solutions w/options 2 - empathy without options 3 - Empathy w/options (BEST)

Brain abnormalities (Anger)

- such as brain tumors, Alzheimer's temporal lobe epilepsy, and traumatic injury to certain parts of the brain result in changes to personality that includes increased violence.

Which item of assessment data is the best predictor of violence for a newly admitted client? A. A recent assault on a drinking companion. B. A family history of bipolar disorder. C. The nurse's subjective feeling that client is cooperative. D. A childhood history of being quick to anger.

A recent assault on a drinking companion.

Causes of anger and aggression

Brain abnormalities Serotonin levels Genetic and environmental factors

Milieu characteristics conducive to violence:

Determine if environment is conducive to anger management Does the staff have the skills needed to handle angry aggressive clients Are staff numbers adequate

Which intervention strategy should be *avoided* by staff working with a client who is shouting and flailing his arms? A. Defusing the situation by laughing or making a joke of the challenge B. Saying "Let's go to your room to talk about this" C. Moving a few staff close together as a group to provide a show of force D. Allowing one staff person to speak to the client while others provide support

Defusing the situation by laughing or making a joke of the challenge

Environment Theory

History of childhood violence, abuse, addictions at risk for developing into violent adults; substance abuse, intoxication, or withdrawal are related to violence in hospital

How are meds for Acute Aggression given? What are 2 sites? Which preferred?

IM - Ventroglutueal and Dorsogluteal (preferred) 3 Mls (ccs) at most for each side

Which neurotransmitter imbalance has been shown to have a relation to impulsive aggression? A. Low levels of γ-aminobutyric acid B. Low levels of serotonin C. High levels of dopamine D. High levels of acetylcholine

Low levels of serotonin

Which client on the mental health unit is at *highest* risk for violence directed at others? A. Mr. A, who has a history of recurrent severe depression B. Mr. B, who is in an alcohol rehabilitation program C. Mr. C, who has delusions of persecution and has assaulted his brother D. Mr. D, who has somatic symptoms for which no organic basis is found

Mr. C, who has delusions of persecution and has assaulted his brother

When analyzing assessment data to arrive at nursing diagnoses for a nonpsychotic client who displays much anger and occasional aggression, which nursing diagnosis would receive the *least* initial consideration? A. Social isolation B. Risk for other-directed violence C. Ineffective coping: overwhelmed D. Ineffective coping: maladaptive

Social isolation

Neurobiological Theory

Some people may be biologically predisposed to anger & aggression; some disorders result in agitation. Due to: 1. Low lvls. of serotonin assoc. w/aggression >when amygdala stimulated, rage results 2. Neurobiological disorders assoc. w/anger such as tumors, Alzheimers, temporal lobe epilepsy (Both nature & nurture influence lvls. of anger/aggress)

bullying

Using physical or psychological means or force to get his or her way. esp. by intimidating or hurting others who may be smaller or weaker (occurs between persons with different levels of authority)

Which of the following would be the most appropriate response by the nurse to help a client who is demonstrating escalating anger? A. Walk the client to his room and help him practice stress-reduction techniques such as deep breathing or muscle relaxation. B. Suggest the client spend some time in the gym with a punching bag to relieve his stress. C. Suggest the client spend some time pacing rapidly in the hallway until he feels less stressed. D. Sit with the client in the day room so he can vent his anger and not isolate.

Walk the client to his room and help him practice stress-reduction techniques such as deep breathing or muscle relaxation.

An angry client has made a suicide attempt by shooting himself in the chest. He has a complicated dressing that is changed twice daily. He frequently loses patience with the nurses and shouts at them while they perform the dressing change. Which plan could they create to intervene effectively in this behavior? A. Tell him they will not change his dressing if he is going to abuse them. B. Wordlessly finish the dressing and leave when the shouting starts. Return in 20 minutes. C. Confront him with the fact that no dressing would be necessary if he had not shot himself. D. Explain that they are professionals and unused to being shouted at by people they are trying to help.

Wordlessly finish the dressing and leave when the shouting starts. Return in 20 minutes.

Anger can be defined as A. an unhealthy way of releasing anxiety. B. perpetrating intentional harm on others. C. an expression of conflict with others. D. a normal response to a perceived threat.

a normal response to a perceived threat.

Clients with cognitive deficits

are particularly at risk for acting aggressively. Can be from Alzheimer's or other dementia or brain injury.

Cognitive theory

cognitions drive anger

The clinic waiting room is crowded and hot. The doctor seeing clients was late because of an emergency surgery and is quite behind schedule. A client is pacing and looking tense. The nurse estimates that he has at least a 45-minute wait. The nurse should A. tell the client that pacing will not help the rate at which clients are seen. B. adjust the appointment schedule to allow the client to be seen next. C. empathize with the long wait and ask the client if he would mind sitting down until his turn comes. D. explain to the client what caused the back-up and suggest that he has time to go to the coffee shop.

explain to the client what caused the back-up and suggest that he has time to go to the coffee shop.

A client is experiencing manic hyperactivity. In the dining room she stands up and shouts "This food is garbage! I'll fight anyone who says it's not! I can fight all of you at one time and win with one hand tied behind my back!" She is flushed, her fists are clenched, and she glares challengingly at clients and staff. The nurse's most relevant assessment is that the client A. is upset with the quality of the food. B. is getting rid of tension in a harmless way. C. is frustrated by limits imposed by hospitalization. D. has a high potential for other-directed violence.

has a high potential for other-directed violence.

When working with an angry client it is best to A. encourage the client to fully explore and express his anger. B. help the client deny and repress the feelings of anger. C. help the client reframe the anger-producing situation. D. ignore the client's anger and change the subject.

help the client reframe the anger-producing situation.

What is the single best predictor of future violence?

history of violence

Anger and hostility are also risk factors for:

hypertension and cardiovascular disease. Hostility has been shown to increase adrenocorticotropin and cardiovascular responses to stress and to increase illness.

A short-term goal for a client who has demonstrated aggression while an inpatient would be that the client will A. strike objects rather than people. B. limit aggression to verbal outbursts. C. isolate in lieu of striking people. D. identify situations that precipitate hostility.

identify situations that precipitate hostility.

Aggression

is a harsh physical or verbal action that reflecting rage

An adolescent male is swearing and shouting at his physician, who refused to give him a pass to leave the unit. This behavior A. is acceptable if directed at staff but not when directed at other clients. B. may reduce tension and prevent the client from physically acting out. C. is a major indicator that the client may become physically aggressive. D. can be attributed to lack of parental controls applied at an early age.

is a major indicator that the client may become physically aggressive.

Anger

is the emotional response to perception or frustration of desires, threat, or challenge

One site known to be associated with aggression

is the limbic system which mediates primitive emotion and behaviors that are necessary for survival. The amygdala mediates anger experiences. The temporal lobe is associated with high violence.

The more a nurse's intervention is prompted by emotion, the A. less likely it is to be therapeutic. B. less likely it is to be aggressive. C. more likely it is to be effective. D. more likely it is to be empathetic.

less likely it is to be therapeutic.

A nurse attempts to intervene verbally when an angry client threatens to throw a chair. The client turns his wrath from the original unmet need to the nurse and begins to shout at her. Several staff members gather behind the nurse. In response to the direction to try to calm down, the client shouts "I will calm down when that bitch isn't in my face." The nurse should A. stand her ground. B. leave the room. C. move to the rear of the staff group. D. apologize for upsetting the client.

move to the rear of the staff group.

Postassaultive stage-

once seclusion is no longer needed the staff should review the incident with the client and with staff members. It can be a learning moment for all concerned. For the client their out of control behavior.

A client has been placed in seclusion to control aggressive behavior. Care while the client is secluded should include A. observation every 30 minutes. B. releasing the client every 8 hours. C. increasing sensory stimulation. D. providing for nutrition and hydration.

providing for nutrition and hydration.

The most restrictive method for dealing with an aggressive client who is out of control is A. seclusion. B. a show of force. C. verbal intervention. D. antipsychotic medication.

seclusion.

An intervention of priority importance when a client with cognitive deficit is experiencing a catastrophic reaction is to A. decrease sensory stimuli. B. smile and call the client by name. C. take the client to the bathroom. D. calming asking the client what's wrong.

smile and call the client by name.

The factor most likely to contribute to a client's escalating anger is A. watching violence on television. B. another client's depressed mood. C. staff telling him he is "inappropriate." D. staff asking how to be helpful.

staff telling him he is "inappropriate."

Serotonin levels- (Anger)

studies have shown a relationship between impulsive aggression and low levels of serotonin.

Assaultive stage:

use of restraints, seclusion and medications. Throughout this time, the team leader continues to relate to the client in a calm, steady voice, communicating decisiveness, consistency, and control.

Nurses coping with angry clients may find it helpful to remember that anger and aggression begin as feelings of A. isolation. B. confidence. C. competence. D. vulnerability.

vulnerability.

s/s risk of escalating anger leading to aggressive behavior.

•Hyperactivity: most important predictor of imminent violence (e.g., pacing, restlessness) •Increasing anxiety and tension: clenched jaw or fist, rigid posture, fixed or tense facial expression, mumbling to self (patient may have shortness of breath, sweating, and rapid pulse) •Verbal abuse: profanity, argumentativeness •Loud voice, change of pitch; or very soft voice, forcing others to strain to hear •Intense eye contact or avoidance of eye contact