Anger, Hostility and Aggression

  1. A normal human emotion that is strong, uncomfortable, emotional reponse to a provocation.
  2. The provocation of anger can be real or imagined.
    Hurt, frustration or fear during anger energizes the body for "fight or flight"
  3. Denying or suppressing anger may cause physical or emotional problems
    Inappropriate expression of anger can result in hostility or aggression

    Appropriately expressed anger acn solve problems or resolve conflicts
  4. Venting angry feelings by engaging in safe activities that are aggressive such as hitting a punching bag, yelling.
  5. Research shows that catharsis can increase rather than alleviate angry feelings.
    Cathartic activities are contraindicated for angry persons.
  6. What should a client do instead of catharsis?
    • Non-aggressive activities such as walking and talking with someone.
    • Primary interventions include teaching the clinent to use assertive communcation - "I"
    • Role modeling or role playing
    • Problem solving tactics
    • Constructive discussions about their anger

  7. Men with a history of angry outbursts were twice as likely not experience a stroke.
  8. Hostility or aggressiveness may occur suddenly - the following phases may be identified:
    • Triggering
    • Escalation
    • Crisis
    • Recovery
  9. Most psychiatric patients are not aggressive, but some exhibit angry or hostile behavior.
    Most psychiatric patients are more likely to hurt themselves not someone else.
  10. Disorders associated with "anger":
    • Paranoid delusions
    • Auditory hallucinations
    • Dementia
    • Delirium
    • Head injury
    • Antisocial and borderline personality disorders
    • Intoxication with drugs or alcohol
  11. Rare psychiatric disorder

    Discrete episodes of aggressive impulses resulting in serious injury or property damage.
    Intermittent explosive disorder
  12. Out of proportion to provocation - client does feel remorse.

    Often develops late adolescence to "30's"

    Large men with dependent personality
    Intermittent explosive disorder
  13. Immature defense mechanism
    Uses actions - not reflection
    Acting out
  14. Verbal or physical aggression
    Common among children and adolescents
    Acting out
  15. Violent clients tend to be lower functioning and their mental illness symptoms are more severe.
  16. Benzodiazepines for treatment?
    Can provide sedation and reduce agitation and aggression in older adults with dementia.
  17. In younger or aggressive client's
    this class of drugs (benzodiazepines) are not helpful as they reduce social inhibitions
    and may increase aggression.
  18. Nursing assessment:
    • Early assessment or identification is critical
    • Nurses must assess both individual clients as well as the therapeutic milieu.
  19. What is the ideal therapeutic milieu?
    • Strong evidence of leadership from staff members
    • Clear staff rules
    • Planned activities
  20. Nursing diagnoses for the angry client:
    • Risk for other directed violence
    • Ineffective coping
  21. General interventions to reduce violence:
    • Behavioral contracts
    • Behavior modifications such as biofeedback training
    • Decrease stimuli
    • Physical activities or distractions such as exercise, music, games, or hobbies
    • Prevent conflicts with other clients
    • Group activities and discussions
    • Planned one on one time with nurse/client.
  22. In the psychiatric setting, dialogue is the most effective intervention to halt the progression or aggressive or violent behavior.
  23. Past history of predisposing factors of violence:
    History of violence is the biggest prdictor if a person will be violet.

    • Suicidal
    • Homicidal
    • Self mutilation
    • Substance abuse
    • Paranoia
    • Victims of violence
  24. Predisposing symptoms:
    • Intense distress
    • Pacing
    • Clenching fists
    • Change in tone of voice
    • Change in body language
    • Threatening behavior
  25. Restraints and/or seclusion should be measures of last resort!
  26. Restlessness
    Loud voice
    Anger is apparent

    symptoms of which phase?
  27. Nursing interventions during triggering phase:
    • Approach client in non threatening calm matter.
    • Convey empathy
    • Use short, simple statements
    • Suggest that the client go to a quiet place
    • Consider moving other clients
    • Decrease stimuli
    • Offer PRN medications to client
  28. PRN medications for violent client:
    • Haloperiodol (Haldol) - last longer
    • Lorazepam (Ativan) - faster working
    • Atypical antipsychotic
  29. Client's behavior is moving toward a loss of control.
    Pale or flushed face
    Yelling, swearing, agitated
    Threatening and demanding
    Clenched fists, threatening gestures
    Loss of ability to think clearly or solve problems

    symptoms of which phase?
    Escalation phase
  30. Nurses interventions during escalation phase:
    • Take control
    • Provide directions in a calm, firm voice
    • Direct the client to their room or a quiet area for "time out" being careful that you are nearer to the door
    • Advise them the behavior is unacceptable
    • Offer medications
    • Enlist 4-6 staff members to remain within sight this is a show of force.
  31. Client loses control

    May throw things
    Kick, scream, hit, bite, scratch
    Cannot communicate clearly
    May resort to screaming or shrieking

    symptoms of which phase?
    Crisis phase
  32. Nurse's interventions during crisis phase:
    • Staff must take and regain control
    • Staff should have been trained in effective ways to "take down" or subdue clients (PMAB)
    • Use of restraint or seclusion is often necessary and "standing orders" should be in place for these situations
    • PRN medications (IM) may also be needed
  33. Medical legal aspects:
    • The client is informed that they are out of control and have forced the staff to take control
    • Staff is required to observe and document clients while they are in seclusion
    • Know agency's policies and be up to date on training
  34. Client regains physical and emotional control

    Lowering of voice
    Decreased muscle tension
    Clearer and more rational communication
    Physical relaxation

    symptoms of which phase?
    Recovery phase
  35. Nurse's interventions during recovery phase:
    • Was there a "trigger"
    • Promote relaxation - sleep for the client
    • Provide documentation of any injuries
    • Staff may hold a debriefing session
  36. Client attempts reconciliation with others and returns to former level of functioning.

    May be tearful or quiet

    symptoms of which phase?
    Post-crisis phase
  37. Nurse's interventions during post-crisis phase:
    • Client is removed from seclusion and/or restraints
    • Rejoins the therapeutic milieu
    • Calm discussions of behavior
    • Avoid lecturing or chastising
    • Return to groups or other activities
    • Focus on how to handle future problems in a calm, rational matter.
  38. Educational issues for the family:
    • Discuss how to avoid or identify "triggers"
    • Self monitoring and problem solving traits for the client
    • Non violent coping techniques
    • Stress management
    • Groups family and individual therapy
Card Set
Anger, Hostility and Aggression
Anger, Hostility and Aggression