module 4 (crisis, anger, aggression) lecture questions and definitions

disaster nursing

A common feature of disasters is that they overwhelm local resources and threaten the function and safety of the community. Disasters leave victims with a damaged sense of safety and well-being and varying amounts of emotional trauma.

crisis intervention

A short-term therapeutic process that focuses on the rapid resolution of an immediate crisis or emergency using available personnel, family and/or environmental resources

crisis

A sudden event in one's life, during which usual coping mechanisms cannot resolve the problem ***disturbs equilibrium

For the past three days a student has skipped classes, cried constantly, experienced panic attacks, and is now exhibiting difficulty with short-term memory. In her assessment of this student, what crucial information should the nurse initially obtain prior to planning interventions? A. The student's description of the precipitating stressor B. The student's usual ability to cope with stress C. The student's available support system D. The student's access to community resources

A. The student's description of the precipitating stressor

dispositional crisis

An acute response to an external situational stressor; help is immediately sought House Fire: Call 911 immediately Abusive relationship: Go to hospital, physical wounds treated; agency assistance

pre-assaultive stage: de-escalation

Analyze client and situation. Respond as early as possible. Remain honest. Be goal oriented. Show respect for client's personal space. Calmly interact with the client. Spend adequate time with client. Ensure quiet environment; visibility to staff. Ensure your safety When behaviors are observed, first ensure that sufficient staff is available ***universal trauma precautions (assume that every person you encounter has been traumatized)

The nursing student is developing a plan of care for a client experiencing a crisis situation. Number the following in priority order for implementation of this plan. Assess for suicidal and homicidal ideation Discuss coping skills used in the past and note if they were effective Establish a working relationship by active listening. Develop a plan of action for dealing with future stressors. Evaluate the developed plans effectiveness.

Assess for suicidal and homicidal ideation Establish a working relationship by active listening. Discuss coping skills used in the past and note if they were effective Develop a plan of action for dealing with future stressors. Evaluate the developed plans effectiveness.

A client has not received what was expected for lunch and directs an angry verbal outburst at the nurse. Which is an accurate description of this display of emotion? A. Anger is a primary emotion that is automatically experienced. B. Anger is a psychological arousal. C. The expression of anger can come under personal control. D. The expression of anger and aggression are closely related.

C. The expression of anger can come under personal control.

seclusion and restraints

Can only be used if client is a danger to self or others Can only be used when less-restrictive methods have been tried and failed Require a physician's order and assessment Order includes: reason client has been confined, how he or she should be confined, maximum time of confinement, and criteria for release Client must be directly observed by a staff member for safety during the entire confinement Licensing and accreditation agencies guide the times for assessment, hydration, toileting needs, nutrition, comfort, and documentation

risk factors: current behaviors

Certain behaviors are predictive of impending violence and have been termed the "prodromal syndrome." Rigid posture Clenched fists and jaws Grim, defiant affect Talking in a rapid, raised voice (change in tone of voice) Arguing and demanding Using profanity and threatening verbalizations Agitation and pacing Pounding and slamming

An angry client states to the nurse, "You red- headed skinny witch. You can't tell me what to do." Which appropriate intervention would the nurse implement during this outburst? A) Reprimand the client for poor judgment and derogatory remarks. B) Respond to angry expressions with matching verbalizations. C) Offer support by the use of empathy and therapeutic touch. D) Ignore initial derogatory remarks.

Correct answer: D During expressions of anger and aggression, ignoring initial derogatory remarks can be an appropriate nursing intervention. Lack of feedback often extinguishes an undesirable behavior. ***never touch a client when they are escalating

What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place on an inpatient unit? A) Reinforce unit rules with the client population. B) Create protocols for the future release of tensions associated with anger. C) Process client feelings and alleviate fears of undeserved seclusion and restraint. D) Discuss the situation that led to inappropriate expressions of anger.

D) Discuss the situation that led to inappropriate expressions of anger. Rationale: The nurse should determine that the purpose for holding a debriefing session with clients and staff after a take-down intervention is to discuss the situation that led to inappropriate behavior. It is important to determine the factors leading to the inappropriate behavior in order to develop future intervention strategies. In this situation it is also important to help clients and staff process feelings about the incident.

emergency safety interventions

Exhaust all lesser restrictive interventions Every effort must be made to resolve crisis without using physical interventions Restraints & Seclusion used only for imminent danger ---Applied only by trained staff ---Must consider individual's medical status ---Can't be applied as punishment or for staff convenience ---Applied for the briefest amount of time possible

assessment of anger

Frowning Clenched fists Low-pitched words forced through clenched teeth Yelling and shouting Intense or no eye contact Easily offended Defensive Passive-aggressive Emotional over-control and flushed face Intense discomfort Tension Broset's checklist - quick, simple, reliable checklist that can be used for a risk assessment for potential violence score ----1 point for each behavior observed ----score > 2 = begin de-escalation techniques

crisis reflecting psychopathology

Influenced or triggered by preexisting psychopathology Personality disorders; anxiety disorders; bipolar disorder; schizophrenia

aggression

Is one way that individuals express anger Is a behavior that is intended to threaten or injure the victim's security or self-esteem Can cause damage withwords, fists, or weapons, but it is virtually always designed to punish

crisis of anticipated life events

Normal life-cycle transitions that may be anticipated but over which the person may feel lack of control Job transfer; getting married; becoming a parent; onset of chronic or terminal illness

characteristics of a crisis

Occurs in all individuals at one time or another and is not necessarily equated with psychopathology. crises are: 1. precipitated by specific identifiable events 2. personal by nature 3. acute, not chronic, and are resolved in one way or another within a brief period

maturational/developmental crisis

Occurs in response to failed attempts to master developmental tasks associated with life cycle transitions Leaving home during late adolescence

assessment of aggression

Pacing Restlessness Tense face and body Verbal or physical threats Threats of homicide or suicide Loud voice, shouting, use of obscenities Argumentative Increased agitation Overreaction to environmental stimuli Panic anxiety leading to misinterpretation of the environment Disturbed thought processes Suspiciousness Disproportionate anger *** distance x 2 (2 arm lengths away when escalation begins)

assaultive stage: medications

Per physician's order, medications can be given (chemical restraint) Benzodiazepines Antipsychotics Antihistamines Mood stabilizers (children)

crisis resulting from traumatic stress

Precipitated by an unexpected external stressor over which person has little or no control and from which s/he feels emotionally overwhelmed & defeated; not a part of everyday life Nature) Flood; fire; earthquake; (National Disaster) Acts of terrorism, war, riots, airplane disaster; (Crime of violence): rape, spousal, child or elder abuse; assault/murder;

psychiatric emergencies

Situations in which general functioning has been severely impaired and the person is rendered incompetent or unable to assume personal responsibility for their behavior Suicide risk; drug overdose; acute psychoses; alcohol intoxication

A patient requires an as-needed sedation. What would the nurse keep in mind when choosing a PRN sedative for an agitated patient? a. Intramuscular injection can be traumatic, so oral meds should be used where possible. b. Benzodiazepines are less sedating but have the advantage of no side effects. c. Lithium carbonate works well but only for those already taking regular daily dosages. d. Diazepam/Valium is the preferred benzodiazepine because it is a short-acting sedative

a. Intramuscular injection can be traumatic, so oral meds should be used where possible. The intramuscular route can be traumatic for patients, particularly for trauma survivors, and can itself be perceived as an aggressive or punitive intervention. Benzodiazepines in sufficient dosage can be as sedating as antipsychotics and are not free of side effects; they are central nervous system depressants and can cause paradoxical excitement or aggression in some persons. Lithium carbonate reduces aggression in select situations involving chronic aggression but is not effective or appropriate for PRN use. Diazepam is a long-acting sedative and as a result would not be appropriate for PRN use

anger

an emotional state that varies in intensity from mild irritation to intense fury and rage. Anger causes physiological changes (e.g., increased heart rate, blood pressure, and levels of biogenic amines). Not a primary emotion; learned Typically experienced as an automatic inner response to hurt, frustration, or fear A physiological arousal, instilling feelings of power and generating preparedness Significantly different from aggression Capable of being under personal control

A patient who has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, "Back off, (expletive)!" and then goes into the day room. Which intervention would be most important to undertake before the nurse follows the patient into the day room? a. Contact the patient's physician to obtain an order for seclusion. b. Review the patient's history for clues about his risk of violence. c. Assure that adequate staff are available and nearby for backup. d. Check for orders for PRN medication and prepare for a sedative.

c. Assure that adequate staff are available and nearby for backup. Before responding to a potentially dangerous situation, it is essential that other staff be notified of the situation and that adequate numbers of staff are prepared to come to one's assistance immediately if needed. All other actions are of lower priority or would unduly delay the nurse's response to a situation requiring a prompt response. Having a peer complete the lower priority activities would enable the responding nurse to intervene more quickly.

grief responses - preschool children

commonly experience separation anxiety, regressive behaviors, nightmares, stomach aches, and hyperactive or withdrawn behaviors.

At an out-patient obstetric clinic, a pregnant client on welfare exhibits extreme anxiety when discussing a failure in school. This is an example of which type of crisis? A) dispositional crisis B) crisis of anticipated life transition C) maturational/developmental crisis D) crisis reflecting psychopathology

crisis of anticipated life transition

A patient on a medical unit has a history of hostile and menacing behavior toward staff and sometimes even strikes them. Which plan would be best for forestalling such incidents? a. Give the patient Lorazepam/Ativan every 4 hours to reduce anxiety. b. Explain that the response to any violence will be to use restraints. c. Arrange for security personnel to stand by during all nursing care. d. Point out the problem and help the patient identify things that are causing frustration.

d. Point out the problem and help the patient identify things that are causing frustration. Identification of triggers to violent acting-out incidents allows the patient and nurse to plan interventions to avert such triggers and reduce frustration. This also provides practice in coping more adaptively in general. Benzodiazepines can reduce anxiety but would not give him skills that might also benefit him in other situations; benzodiazepines can also sometimes increase impulsiveness by disinhibiting the patient. Setting limits and indicating what consequences to expect can be a helpful adjunct, but as a primary intervention, it does not teach new skills to use to avoid problem behaviors in the first place; expecting the patient to behave differently without giving him the skills to do so is setting him up for failure and further frustration. Using security personnel would be expensive and disruptive to their work, but it would be a possible intervention if all other options prove unsuccessful.

A patient is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend, who had refused to see him. His history reveals abuse as a child by a punitive father, torturing family pets, and one arrest for disorderly conduct. The priority nursing diagnosis that should be considered is: a. Stress overload b. Ineffective coping c. Risk for self-directed violence d. Risk for other-directed violence

d. Risk for other-directed violence The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in the scenario.

socioeconomic factors

high rates of violence within subculture of poverty in the US poverty thought to encourage aggression due to associated deprivation, disruption of families, unemployment

biochemical factors

hormonal dysfunction associated with hyperthyroidism alterations in neurotransmitters (epinephrine, NE, dopamine, acetylcholine, serotonin)

seclusion

involuntary confinement alone in a room that the client is prevented from leaving

grief responses: older children

may have difficulty concentrating/making decisions, somatic complaints (aches and pains, in body), sleep disturbances, and concerns about safety.

crisis intervention goal

minimum - psychological resolution of the individual's immediate crisis and restoration to at least the level of functioning that existed before the crisis period. maximum - improvement in functioning above the pre-crisis level.

predisposing factors to anger and aggression

modeling operant conditioning - specific behavior is reinforced neurophysiological disorders - any factors which increase the activity or reactivity of the brainstem biochemical factors

After repeated requests for a client to unpack and get settled on the psychiatric unit, the client states, "I have no intention of unpacking and staying on this unit." To avoid a confrontation, the nurse unpacks the client's belongings. Which nursing behavior is exemplified? 1. positive role modeling 2. negative operant conditioning 3. assertiveness 4. aggressiveness

negative operant conditioning This situation illustrates negative operant conditioning. The client's negative behavior has been reinforced and rewarded by the nurse's action of unpacking for the client.

operant conditioning

occurs when a specific behavior is positively or negatively reinforced

role modeling

one of the strongest forms of learning role models can be positive or negative earliest role model = primary caregivers

NO SUCH THING AS A CHRONIC CRISIS

people who live in constant turmoil are NOT in crisis but instead in CHAOS

whether an individual experiences a crisis in response to a stressful event depends on 3 factors

perception of event (realistic) availability of situational supports (friends, family, housing, food, money, etc.) adequate coping mechanisms

4 phases of crises

phase 1: Person is exposed to a precipitating stressor; crisis occurs; anxiety increases; previous problem solving methods used phase 2: When previous problem-solving methods do not relieve the stressor, anxiety increases. Discomfort level rises; past coping techniques don't work and feelings of helplessness occur; feelings of confusion & disorganization prevail phase 3: New problem-solving methods may be used and if effective, resolution may occur with the individual returning to a higher, lower, or previous level of premorbid function. phase 4: If resolution does not occur in previous phases, the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the person with drastic results often occur preference = crisis does NOT end in phase 4 + hospitalization

4 phases of crisis intervention

phase 1: assessment phase 2: planning of therapeutic intervention phase 3: intervention phase 4: evaluation of crisis resolution and anticipatory planning

environmental factors

physical crowding of people discomfort associated with moderate increase in environmental temperature use of alcohol and other drugs (i.e. cocaine, amphetamines, hallucinogens, anabolic steroids) availability of firearms

grief responses

physical: Stunned, weight gain/loss, insomnia, anorexia, exhausted, restless, aching arms, headaches, feels ill, palpitations, breathlessness, sighing, lack of strength, blurred vision emotional: Crying, sobbing, sadness, guilt, anger, sense of failure, irritability, resentment, bitterness, denial, frustration, shame, fear of own death, oversensitivity to environment, senses the presence of the deceased social: Forgetful, difficulty in making decisions, disorganized, concentration is difficult, preoccupation with thoughts of the deceased, time confusion, short attention span, think they are going crazy. cognitive: Forgetful, difficulty in making decisions, disorganized, concentration is difficult, preoccupation with thoughts of the deceased, time confusion, short attention span, think they are going crazy.

assessing risk factors

prevention = key issue in management of aggressive or violent behavior 3 factors important in indentifying extent of risks: 1. past history of violence (considered most widely recognized risk factor for violence in treatment setting) 2. client diagnosis (schizophrenia, major depression, bipolar, substance use disorder, neurocognitive disorders, antisocial/BPD/intermittent explosive personality disorders) 3. current behavior

restraints

restriction of movement of client's body by manual or mechanical methods

neurophysiological disorders

several disorders of, or conditions within, the brain have been implicated in episodic aggression and violent behavior temporal or frontal lobe epilepsy, brain tumors, brain trauma, encephalitis