Ch 27: Anger, Aggression, and Violence

what is anger?

en emotional response to frustration, threat to one’s needs, or a challenge. It is a normal and sometimes positive emotion when expressed in a healthy way

how can anger be expressed in a healthy way?

by channeling it into productive activities like exercise, art, or organizing; it can also motivate or aid survival

what is aggression?

an action or behavior that results in a verbal or physical attack

is aggression always inappropriate?

no, aggression can sometimes be necessary, such as for self-protection

how does aggression differ from violence?

Violence is always objectionable and involves intentional force that results in, or may result in, injury to another person

why is coping with a patient’s anger challenging for nurses?

It becomes more difficult when the anger is personal and directed at the nurse or the student

when should nursing interventions for anger ideally begin?

before anger and aggression escalate into a problem

what psychiatric disorders are often associated with violence?

Psychosis, boderline personality disorder, PTSD, and intermittent explosive disorder

What emotional state often precedes negative feelings and behaviors like anger and aggression?

anxiety

Why is assessing and responding to anxiety important in preventing aggression?

it can yield extremely positive outcomes by preventing escalation into anger or violence

Which neurotransmitters influence aggression?

serotonin, dopamine, GABA, and glutamate

What role does media play in learning aggressive behavior?

Television often portrays violence as an acceptable way to resolve conflict and rarely shows consequences, reinforcing aggression in viewers

What is bullying, and how is it related to aggression?

a form of violence involving negative acts like teasing, kicking, or spitting, intended to harm or bother another person

what behavioral signs may indicate a patient experiencing anger?

irritability, increased demands, frowning, facial redness, pacing, twisting hands, clenching/unclenching fists

how might speech change in an angry patient?

it may become loud and rapid or slow, pointed, and quiet

what should nurses assess when they notice behavior changes in a patient

Whether the behavior differs from the patient’s baseline, and if there is a history of aggression or violence.

Why is identifying patient triggers important?

Most reactions stem from past experiences; recognizing triggers helps prevent escalation.

what can initial and ongoing assessment hep prevent?

escalation to anger and aggression by identifying problems early

What is the most important predictor of imminent violence?

Hyperactivity (e.g., pacing, restlessness).

What physical signs may indicate increasing anxiety or tension?

clenched jaw/fist, rigid posture, tense facial expression, mumbling, SOB, sweating, rapid pulse

What vocal signs may precede violence?

profanity, argumentativeness, sudden increase or decrease in voice, volume, or stone silence

what eye contact behaviors may signal potential violence?

intense staring or complete avoidance of eye contact

What recent behaviors may indicate higher risk of violence?

acts of violence or property destruction

What substances can increase risk of aggression?

alcohol or dug intoxication

why is possession of certain objects concerning?

items like a fork, knife, or rock may be used as weapons

What environmental (milieu) factors contribute to violence risk?

Overcrowding, inexperienced staff, provocative or controlling staff, poor limit setting, and arbitrary loss of privileges.

what is trauma-informed care based on?

The understanding that disruptive patients often have histories of violence and victimization, which can affect their ability to cope and respond to interventions

How can trauma histories affect patient behavior?

they may impair self-soothing, lead to negative coping, and increase vulnerability to coercive interventions like restraints

What is the focus of trauma-informed care?

recognizing and addressing the impact of a patient’s past trauma or violence on their current behavior and treatment

What is the single best predictor of future violence?

a history of violence

which patient characteristics indicate higher risk for violence?

being delusional, hyperactive, impulsive, or irritable

what key questions help assess risk for violence?

• Does the patient have a wish or intent to harm?

• Do they have a plan?

• Do they have the means to carry out the plan?

• Do they have demographic risk factors?

What are demographic risk factors for violence?

Male, age 14–24, low socioeconomic status, lack of support, and history of prison time

in what context does patient aggression most often occur?

During limit-setting by the nurse

What coping patterns suggest a higher risk for violence?

Limited coping skills, lack of assertiveness, or use of intimidation

Why is self-awareness important for nurses when managing patient anger or aggression?

It helps ensure interventions are thoughtful and effective, not impulsive or emotion-based.

What aspects of communication should nurses be aware of during interactions?

Choice of words, tone of voice, body posture, and facial expressions.

What personal factors should nurses reflect on for effective intervention?

Their own strengths, needs, concerns, and vulnerabilities.

what may result from a lack of self-awareness in nurses during interventions?

responses that are emotionally driven rather than professional and therapeutic

what may overwhelm a patient’s otherwise adequate coping skills

the stress of illness or hospitalization

How might maladaptive coping contribute to patient behavior?

it may increase the likelihood of anger and aggression

what is a logical nursing diagnosis when anger or aggression is identified?

risk for violence

what diagnosis should be considered if the patient turns anger inward?

risk for suicide

which nursing diagnosis is used when poor coping methods contribute to anger and aggression?

impaired coping

what other nursing diagnoses are relevant for patients at risk for anger and aggression?

stress overload, and impaired impulse control

when should intervention ideally begin in managing anger?

before any sign of escalation-through building trust with brief, nonthreatening, non directive interactions

what is an example of a nonthreatening, non directive interaction?

talking about weather, sports, or the patient’s interests

what is one of the first steps in intervening with an angry patient?

express concern and a desire to listen, helping identify what the patient is feeling

why is acknowledging a patient’s needs important, even if the needs are irrational or impossible?

it helps de-escalate the situation by showing validation and empathy

what is a clear expectation nurses can state to a patient showing early signs of anger?

“I expect that you will stay in control”

what interventions may be necessary if early signs of aggression are missed or ineffective?

pharmacologic intervention, seclusion, or restraint to ensure safety

How should a nurse approach an angry or escalating patient?

In a controlled, nonthreatening, and caring manner while maintaining a calm exterior.

How much personal space should be given to a potentially violent patient?

At least 1 foot more than the patient’s reach with arms or legs.

What spatial safety precaution should nurses always take during escalation?

Ensure the patient is not between you and the door—maintain an escape route.

How should nurses speak to an escalating patient?

With short, slow sentences in a low, calm voice—never yell.

Why avoid ending de-escalation statements with “Okay?”

It may imply choices exist when they don’t, potentially confusing or agitating the patient.

What communication strategy helps patients regain a sense of control?

Offering two structured options, like: “Do you want to go to your room or the quiet room?”

Why is the environment important during de-escalation?

A quiet, visible space helps calm the patient while keeping staff nearby for support.

What is the nurse’s role regarding PRN medications for aggression?

Assess appropriateness, educate the patient on purpose, effects, and side effects—even if the patient is escalated.

What signs and symptoms indicate a Risk for Violence?

Rigid posture, clenched fists/jaw, hyperactivity, pacing, history of violence, family violence, or substance use.

What are the desired outcomes for the nursing diagnosis Risk for Violence?

• No violence

• Identifies angry feelings

• Identifies alternatives to aggression

• Refrains from verbal outbursts

• Avoids violating others' space

• Maintains self-control

What signs and symptoms indicate a Risk for Suicide?

Impulsivity, suicidal ideation, overt/covert suicidal statements, feelings of worthlessness, hopelessness, or helplessness.

What are the desired outcomes for the nursing diagnosis Risk for Suicide?

• No suicide

• Expresses feelings

• Verbalizes suicidal ideas

• Refrains from suicide attempts

• Plans for the future

What signs and symptoms indicate Impaired Coping?

Difficulty with tasks, inability to function at previous level, poor problem-solving or cognition, verbalizing inability to cope.

What are the desired outcomes for Impaired Coping?

• Identifies current coping methods

• Uses support system

• Uses new coping strategies

• Takes personal action to manage stressors

What signs and symptoms indicate Stress Overload?

Feelings of anger, impatience, pressure, tension, problems with functioning or decision making.

What are the desired outcomes for the diagnosis Stress Overload?

• Expresses feelings constructively

• Reports calmness and acceptance

• Reduced or absent physical symptoms of stress

• Optimal decision making

What is the primary goal of de-escalation techniques in nursing?

To maintain the patient’s self-esteem and dignity while reducing agitation and ensuring safety.

What should a nurse maintain in themselves and the patient during de-escalation?

calmness

When should the nurse respond to signs of escalation?

As early as possible to prevent progression to violence.

What kind of tone of voice should be used in de-escalation?

A calm, clear tone of voice.

Why is it important to avoid invading personal space during high anxiety?

Because personal space increases in times of high anxiety, and invading it may escalate aggression

What is the nurse’s role in identifying patient needs during de-escalation?

Determine what the patient considers to be needed and identify shared goals.

What communication techniques are essential for de-escalation?

Use of genuineness, empathy, and assertiveness (not aggression).

What should the nurse avoid during de-escalation to prevent escalation?

Arguing and dishonesty.

How can a nurse help a patient feel more in control during de-escalation?

By giving several clear options for action or response.

What safety guideline must the nurse follow during a de-escalation situation?

Do not take chances; always maintain personal safety.

what are key nursing roles in helping manage anger and aggression?

role modeling and educating patients on healthy expression of anger, coping skills, de-escalation techniques, and self-soothing

what is the purpose of the “do over” technique in anger management?

To allow the patient to practice a more appropriate response with coaching from the nurse.

What emerging strategy may nurses introduce to support healthy emotion regulation?

Mindful living, such as mindfulness practices and stress reduction techniques.

What is a nurse’s role in identifying triggers for aggressive behavior?

Helping patients identify and understand their triggers so they can learn to manage them.

Why is a multidisciplinary approach important for patients with behavioral issues?

It ensures consistent implementation of the plan of care and promotes team-based intervention and safe discharge planning.

What is a Snoezelen room and how does it help in aggression management?

A multisensory timeout room with soft lighting, music, and pillows that promotes security and relaxation.

What should staff be alert for when managing aggression in antisocial patients?

Manipulation or disruptive behavior disguised as another patient’s actions; staff must remain aware of environmental dynamics.

Why should nurses avoid wearing dangling accessories in acute psychiatric settings?

They could be grabbed by patients, leading to injury.

What is the benefit of having enough staff present during an escalating situation?

To provide backup support while allowing only one staff member to talk, preventing overstimulation.

How should nurses position themselves physically when speaking to an agitated patient?

Stand to the side, not directly in front or blocking exits, to avoid appearing confrontational.

How can feedback be used to de-escalate behavior?

By reflecting observations like “You seem upset,” the nurse allows emotional processing and calming

Why should verbal confrontation and security involvement be minimized during escalation?

It may escalate aggression; confrontation should be delayed until the patient is calm, and security kept in the background.

What is the nursing diagnosis when a patient is overwhelmed by stress and has poor decision-making ability?

stress overload

What are early physical signs of aggression?

Rigid posture, clenched fists/jaw, pacing, hyperactivity

What should the nurse do first when noticing signs of patient aggression?

Respond early using calm, clear communication and de-escalation

What is the difference between seclusion and restraint?

Seclusion is involuntary confinement alone in a locked room; restraint limits physical movement.

what is the priority before using restraints?

try less restrictive interventions like verbal de-escalation or PRN meds

what patients should not be placed in restraints or seclusion?

those with COPD, spinal injuries, pregnancy, seizures, delirium, or active suicidal intent

what is an important legal requirement when restraints are used?

A provider’s order must be obtained as soon as possible.

What is the outcome goal for a patient with the diagnosis of ‘Impaired Coping’?

The patient uses support systems and engages in stress management actions.

Which de-escalation principle addresses verbal style?

Use a calm, clear tone of voice.

What should the team leader do during a restraint event?

Be the only one communicating to reduce external stimuli.

What are two primary indications for using mechanical restraint?

• To protect the patient from self-harm

• To prevent assault on others