Test 2-Anger, Hostility, and Aggression

*Denying or suppressing angry feelings can lead to physical or emotional problems. *Depression is sometimes described as anger turned inward. *Appropriate expression of anger involves assertive communication skills leading to problem solving or conflict resolution.

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Aggression is a behavior intended to threaten or injure the victim's security or self-esteem. It means to "go against," "to assault," or "to attack." It is a response that aims at inflicting pain or injury on objects or persons. Whether the damage is caused by words, fists, or weapons, the behavior is virtually always designed to punish. It is frequently accompanied by bitterness, meanness, and ridicule. An aggressive person is often vengeful (Warren, 1990).

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Anger is a strong, uncomfortable, emotional response to a provocation, either real or perceived. Hostility and Aggression are inappropriate expressions of anger.

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Anger is an emotional state that varies in intensity from mild irritation to intense fury and rage. It is accompanied by physiological and biological changes, such as increases in heart rate, blood pressure, and levels of the hormones epinephrine and norepinephrine (APA, 2006a).

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If the client refused PRN medication during the triggering phase, offer it again at this time If they are unwilling to take a time out, obtain assistance from several other staff members who will be within sight, but not as close as the primary staff member who is dealing directly with the patient. (Show of force)

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Inappropriate expressions of anger may result in impulsive behavior, disregarding possible negative consequences. Communicated aggressively, conflict escalates, and the problem that created the conflict goes unresolved. Anger can lead to aggression when the coping response is displacement (kick the cat)

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Offer PRN medication as ordered. Physical activity such as walking may help the client to relax and become calmer. (In the triggering phase, remember we still have the ability to communicate with the client-we are still in the talking phase)

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Restraints are removed as per protocol DO NOT lecture or chastise but instead discuss the behavior in a calm rational manner. Reintegrate the patient into the unit and unit activities as soon as they are ready to participate. DO NOT discuss the incident in detail with the other clients on the unit.

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The nurse must take control of the situation Provide directions in a calm, firm, voice Direct client to a time out or cooling off period in a quiet area or in their room Emphasize to the client that aggressive behavior is not acceptable and the nurse is there to help them regain control

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Related Disorders

About 90 percent of psychiatric patients are portrayed in the media as violent, but in reality only about 10 percent exhibit angry, hostile, or aggressive behavior. Clients with psychiatric disorders are much more likely to harm themselves than others.

Acting Out

An immature defense mechanism The person uses actions (verbal or physical aggression) rather than reflections or feelings to deal with emotional conflicts or stressors Serves to help the person feel less helpless or powerless Often used by children and adolescents

Anger

Anger is a normal human emotion. It is a positive emotion that can motivate a person to resolve conflicts, solve problems, and make decisions. Anger can also energize the body for self-defense (fight or flight response). Anger arousal is a personal signal of threat or injustice against the self. The signal elicits coping responses to deal with the stress.

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Anger is constructive when it provides a feeling of control over a situation and the individual is able to assertively take charge of a situation. Anger is constructive when it is expressed assertively, serves to increase self-esteem, and leads to mutual understanding and forgiveness

Nursing Implications

Approach in a calm, nonthreatening manner Convey empathy for their anger or frustration as appropriate Encourage the client to verbalize feelings Use clear, simple, short statements Suggest moving to a quiet area and move other clients to decrease stimulation

Attempted Interventions by the Nurse

Approaches John at a safe distance (six feet) Nurse says "John, tell me what is happening." Nurse correctly-Recognized signs of impending violence, spoke calmly with nonthreatening body language, and attempted to help John verbalize feelings

Nursing Implications

As the client regains control during the recovery phase, encourage discussion about the situation or triggers that led up to the aggressive behavior Encourage rest, relaxation, and sleep Assist the client to explore alternatives to the aggressive behavior Assess staff members for injuries, and debrief with the staff and evaluate how the situation was handled.

Postcrisis

Attempts reconciliation with others and returns to previous level of functioning before the incident Behaviors Remorse Apologies Crying Quiet, withdrawn behavior

Factors that Contribute to Aggressive Behavior

Attitudes about work Level of education Religious choices Exposure to the media Population problems, overcrowding, limited resources Unavailability of community resources

BEHAVIORAL APPROACHES Aggressive, violent clients

Avoid isolating yourself or being alone with a client who has a potential for violence. Remember that a history of violence is the best predictor of future violent episodes. If a client becomes aggressive while you are with him or her, give the client space and keep some distance away - DO NOT move closer to or touch the client.

Escalation

Behavior indicates a movement toward loss of control. The client has lost the ability to problem solve or think clearly Pale/Flushed Face Yelling/Swearing Agitated Threatening Demanding Clenched fists Hostility

BEHAVIORAL APPROACHES

Call for nursing staff assistance as soon as possible if a client becomes increasingly agitated or begins acting out in any way.

Recovery

Client regains physical and emotional control Behaviors Lowering of voice Decreased muscle tension Clearer, more rational communication Physical relaxation

Causes

Clients with paranoid delusions are attempting to protect themselves from self-perceived threats. Clients with auditory or command hallucinations telling them to hurt someone or someone is going to hurt them Clients with dementia, delirium, head injury, and intoxication with ETOH/drugs Antisocial and borderline personality disorder patients Younger males Clients with depression may have outbursts of anger due to feelings of being emotionally trapped. These outbursts are verbal only-no threats of physical aggression. The outburst is uncharacteristic of the client's personality, inappropriate to the situation, and followed by remorse. Often related to irritable mood, overreaction to minor annoyances, and decreased coping skills

Violent Aggressive Behavior

Contract with the client to use nonviolent methods to control anger Be prepared to use seclusion if escalation with potential for violence exists

1. Triggering

Definition-An event or circumstances in the environment initiates the client's response which is often either anger or hostility. Behavior Restlessness Anxiety Irritability Pacing Muscle Tension Rapid Breathing Perspiration Loud Voice Anger

Interventions

Different for each phase of the aggression cycle as we discussed earlier when we defined them individually.

BEHAVIORAL APPROACHES for Increased Agitation/Anxiety

Do not turn your back on the client. Use a calm, quiet tone of voice, and encourage the client to verbalize feelings instead of acting them out. Avoid threatening or expressing a judgmental, punitive attitude

Crisis Phase

During a period of emotional and physical crisis, the client loses control. Signs, symptoms, and behaviors include loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching shrieking, screaming, and/or inability to communicate clearly

Self-Awareness Issues

How nurse handles own angry feelings Level of comfort with expression of anger from others Ability to be calm, nonjudgmental Nurse must have assertive communication skills, conflict resolution skills, ability to see that client's behavior/anger is not a personal attack or a sign of nurse's failure, and ability to deal with own fear when clients are aggressive or threatening

Cultural Considerations

In certain cultures, expressing anger may be seen as rude or disrespectful (certain Asian cultures/Native Americans); some culture-bound syndromes (West Africa/Haiti) involve aggressive, agitated, or violent behavior Some cultures view cause of physical illness to be unexpressed anger

Behavioral Approaches Escalation to Violence

Intercede early to diffuse the situation as quickly as possible Continue nonthreatening behavior If restraint or seclusion is warranted enlist the assistance of at least four qualified staff members. (Follow policy) Move in organized, calm manner, stating you wish to help the client and you will not permit him/her to harm self or others

(IED)

Intermittent explosive disorder is characterized by repeated episodes of aggressive, violent behavior in which you react grossly out of proportion to the situation. Road rage, domestic abuse, and angry outbursts or temper tantrums that involve throwing or breaking objects may be signs of intermittent explosive disorder Client is nonviolent between episodes

Signs Indicating Client has Moved to Crisis Phase

John runs to the end of the hall and will no longer talk to the nurse (Loss of emotional and physical control) Note-the nurse once again tries to get John to agree to take prn meds and a time-out. John refuses but now John picks up objects from a nearby table (nurse recognizes that violence is imminent.

Pharmacology for Aggressive Clients

Lithium for bipolar disorder, conduct disorder, or mental retardation Carbamazepine (Tegretol) or Valproate (Depakote) for dementia, psychosis, or personality disorders Atypical antipsychotics such as Clozapine (Clozaril), Risperidone (Risperdal), and Olanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personality disorders Benzodiazepines e.g. Xanax for dementia Ziprasidone (Geodon), Haloperidol (Haldol) and lorazepam (Ativan) for clients with psychoses

Etiology of Hostility and Aggression

Neurobiological theories: decreased serotonin, increased dopamine and norepinephrine; structural damage to limbic system, damage to frontal or temporal lobes Hormonal (testosterone) Psychosocial theories: failure to develop impulse control and ability to delay gratification, Monkey See Monkey Do General lack of social and personal accountability

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ONLY STAFF WITH SPECIALIZED TRAINING SHOULD PARTICIPATE IN THE RESTRAINT OF A PHYSICALLY AGGRESSIVE CLIENT The students' role is to remove the "audience" i.e. escort other patients to their rooms or community room and close the door until the situation is under control.

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PRN Medication should be given (if not already administered) as soon as the patient is safely restrained. The patient is closely observed in seclusion and the nurse documents the patients behavior

Behaviors-Verbal and Nonverbal

Pacing in the hall (Triggering Phase) Muttering to himself (Triggering Phase) Avoiding close contact with anyone else (Trig) Yells "I can't take it" "I can't stay here" (Esc.) Fists are "clenched" (Esc.) Appears very "agitated" (Esc.) (The above behaviors indicate we are still in the talking phase and the nurse can attempt to diffuse the situation)

Important to Note

Psychiatric patients who tend to be more aggressive are those whose illness is more symptomatic and possess a marked lack of insight (the ability to understand the true nature of one's situation and accept some responsibility for that situation) and judgment (the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. The highest rates of aggression and hostility among psychiatric patients tend to be older males with schizophrenia and younger males and females with personality disorders. All patients and visitors throughout the hospital have the potential to become hostile and aggressive. It is a response when one feels powerless

Intermittent Explosive Disorder

Rare psychiatric diagnosis involving discrete episodes of aggressive impulses resulting in serious injury or property damage Episodes are out of proportion to any provocation, and the person is remorseful and embarrassed afterward.

Post Discharge/Community Based Care

Regular follow-up appointments, individual and group psychotherapy, compliance with prescribed medication, and participation in community support programs help the client to achieve stability Anger management groups are available to help clients express their feelings and learn problem-solving and conflict-resolution techniques

Common nursing diagnoses:

Risk for Other-Directed Violence Ineffective Coping

Risk Factors for Violence

Schizophrenic Hearing voices that the staff are trying to kill him. (Self preservation/survival is one of our most basic instincts). Off meds for two weeks (altered thought processes) Schizophrenia is a disorder of thought. Younger males (hormone-testosterone) are more prone to aggression

Hostile Behavior

Several studies have demonstrated that significant immune mediated changes occur in people who displayed hostile or negative behaviors. Blood Pressure changes occur in people who display hostile or negative behaviors during periods of conflict.

Tips for Controlling Anger

Take a 'timeout.' Although it may seem cliché, counting to 10 before reacting really can defuse your temper. Get some space. Take a break from the person you're angry with until your frustrations subside a bit. Once you're calm, express your anger. It's healthy to express your frustration in a nonconfrontational way. Stewing about it can make the situation worse. Get some exercise. Physical activity can provide an outlet for your emotions, especially if you're about to erupt. Go for a brisk walk or a run, swim, lift weights or shoot baskets. Think carefully before you say anything. Otherwise, you're likely to say something you'll regret. It can be helpful to write down what you want to say so that you can stick to the issues. When you're angry, it's easy to get sidetracked. Identify solutions to the situation. Instead of focusing on what made you mad, work with the person who angered you to resolve the issue at hand. Use 'I' statements when describing the problem. This will help you to avoid criticizing or placing blame, which can make the other person angry or resentful — and increase tension. For instance, say, "I'm upset you didn't help with the housework this evening," instead of, "You should have helped with the housework." Don't hold a grudge. If you can forgive the other person, it will help you both. It's unrealistic to expect everyone to behave exactly as you want. Use humor to release tensions. Lightening up can help diffuse tension. Don't use sarcasm, though — it's can hurt feelings and make things worse. Practice relaxation skills. Learning skills to relax and de-stress can also help control your temper when it may flare up. Practice deep-breathing exercises, visualize a relaxing scene, or repeat a calming word or phrase to yourself, such as "Take it easy." Other proven ways to ease anger include listening to music, writing in a journal and doing yoga.

Crisis

The client completely loses physical and emotional control We have passed the talking stage Behaviors Throwing Kicking Screaming Biting Scratching Spitting Inability to communicate clearly

Expected Goals/Outcomes

The client will: Not harm self or harm/threaten others Refrain from intimidating or frightening behaviors Describe feelings and concerns without aggression Comply with treatment

Hostility and Aggression

The hostile aggressive behavior may occur suddenly without warning, but often times stages or phases can be identified.

Predictors for Violent Behavior

The strongest risk factor for violent behavior is a previous history of violent behavior It is sometimes helpful to ask the client to assess his/or her own potential for violence-some clients on the unit will verbalize to you that they feel angry enough to hit someone

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This is known as a "show of force" and sometimes (hopefully) the client will take meds and a timeout. This also reinforces to the client that the staff is in control and will control the situation if the client is unable to do so.

Treatments and Medications

Treatment often focuses on treating the underlying or comorbid psychiatric diagnosis such as schizophrenia or bipolar disorder. If the individual is having angry outburst due to low serotonin for example, use of SSRIs such as Prozac or Paxil will often assist the patient controlling inappropriate behavior in social situations.

Behavioral Approaches Increased Agitation/Anxiety

Use nonthreatening body language -Arms visible at sides-palms outward -Keep distance-arms length or greater -Avoid body contact-do not touch client at this time

Evaluation

Was the client's anger defused in an early stage? Did the angry, hostile, and potentially aggressive client learn to express feelings verbally and safely without threats or harm to others or destruction of property?

Nsg. Interventions during the Crisis Phase

When John began to pick up objects to obviously throw at the nurse, the nurse then summoned assistance from other staff members. Four to six staff should remain ready and in sight, but not as close as the primary nurse. This technique is known as a "show of force" and indicates to the client that if he is unable to control himself, then there are those who will assist him in regaining control

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When restraint or seclusion is used, the nurse must then phone the physician and obtain the order. Requirements can vary from state to state and facility to facility as to the time frame in which the physician must evaluate the patient. Aggressive children, females, and elderly clients can be just as difficult to restrain as adult males can be.