anger and aggression

anger is a

priminal, not always logical human emotion

anger may arise as a response to

feelings of vulnerability and uneasiness because of a frustration of desire, a threat to one's needs (emotional or physical), or a challenge

anger is an ____ reaction to a stressor and sometimes its a reaction that

unplanned, may not always think would happen (kind of a surprise to the person)

constructive anger

(assertive communication) meets needs and safety

destructive anger

(aggression) causes emotional or physical harm to others

aggression

harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness

aggression can be directed at

others or oneself

agression is a ____ reaction when

hostile, control over anger is loss

violence

is a term unique to human beings and refers specifically to physical aggression

control of violence in the healthcare setting becomes a

top priority to maintain the milieu

How does the patient usually communicate before it escalates to anger, aggression, or violence?

the patient usually communicates increasing anxiety before

nurses can hopefully recognize

early recognize escalation of anger and intervene

warning signs of escalating anger

pacing, hitting fists together, ringing fingers together, slamming doors, verbal (active threatening)

Although most people who have a psychiatric disorder (esp. on medication) are not violent, those who have a psychiatric disorder are

5x more violent than those who do not

anger is common in which condtions

ADHD, ODD, impulsivity in children, dementia, depression, attempted suicide, PTSD, mania, psychosis (paranoia), personality disorders

ODD

oppositional deviance disorder

impulsivity is common in ___

boys

why is anger common in demntia

they mourn their loss of independence and reject help

medical and neurological causes of violence

brain lesions, alzheimer's, traumatic brain injuries, infections, hematomas, intoxication, UTIs

anger biologically stimulates the ____, causing the body to

hypothalamus, react to the anticipation of harm

socially: anger reactions are learned and reinforced through the

family and societal norms ex. if you were raised in a household with anger/hitting you are more likely to enter a relationship like that

what does freud say about anger?

anger cannot be suppressed and will eventually express itself in some form (somatic illness, defense mechanisms, maladaptive behaviors, etc)

Freud thought one of the most important contributions to violent behaviors is the

early and ongoing physical, sexual, or emotional abuse

catecholamines (____ and ___) act as both

adrenaline and noradrenaline, stress hormones and neurotransmitters, flooding the brain and body to create a rapid surge of energy, increased heart rate, and raised blood pressure to prepare for physical action

serotonin is often called the ___ ____

mood stablizer

lower levels of serotonin in the prefrontal cortex does what?

weakens the brain's ability to control emotional impulses coming from the amygdala, making aggressive reactions more likely

dopamine is tied to the brain's

reward system

dopamine can reinforce aggressive behavior by

making the initial release of venting feel temporarily satisfying, which cna train the brain to seek that same feeling again

GABA is the primary

calming/inhibitory neurotransmitter

lower or dysregulated GABA activity is tied to

reduced impulse control and heightened stress responses

blood draws may show

homocysteine and DHEA

too much DHEA shows

Adrenal glands are in overreaction

what is important to prevent escalation to anger/aggression

accurate and early assessment to identify patient anxiety

what are some signs of anxiety before escalation?

increased demands, irritability, frowning, red face, pacing, clenching/unclenching fists, twisting hands, splotchy red spots on neck/chest, not smiling, chnaged in mood and behavior

examples of changes in mood and behavior

talkative and loud to calm and angry

if the patient is hyperverbal and loud then the nurses voice

should not get loud, be soft and get down on their level and stay closest to exit

nursing assessment for anger/aggression

take an accurate history, identify coping skills, and patients perception of the issues

the nurse should not assume

how the patient feels and always ask

predictive factors of violent outcomes

1. s/s that may precede violence

2. Recent acts of violence, including property violence

3. Silence

4. Suspiciousness or paranoid thinking

5. alcohol or drug intoxication

6. possession of a weapon or weapon object (fork, knife, rock)

signs and symptoms that may preceed violence

angry, irritable affect

hyperactivity (pacing, slamming doors)

increasing anxiety and tension (jaw, fist, tense, sweating)

verbal abuse (profanity, argumentative)

loud voice, change of pitch or very soft voice forcing others to strain to hear

intense eye contact or avoidance of eye contact

Charcateristics conductive to violemce

loud, overcrowded, staff inexperience, provocative or controlling staff, poor limit setting, staff inconsistency (privileges inconsistent)

patient goals for anger and aggression

- display nonviolent behaviors to self or others

- recognize when anger and aggression tendencies tend to escalate and use at least one tension-reducing behavior

- make plans to continue long-term therapy to work on violence prevention and increased coping skills

- patient will remain free of injury

- no hostile or abusive behaviors

- healthy anxiety reducing techniques

tension-reducing behaviors

time out, deep breaths, talk to the "go to" person, excercise

how to properly do a deep breath and the goal of it

take a deep breath, hold it for 3-4 seconds, let it out over 7 seconds , lowers HR

does the environment provide

A safe, therapeutic milieu?

Privacy for the patient?

Enough space for the patient, or is it overcrowded?

healthy balance between quiet and structured time?

Why do the patients participate in activities?

so their minds aren't going all day

specific interventions

- all patients are searched for contraband and dangerous objects on admission and after visit

- some cases: supervised visits

- give patients space- one arm's length away

- trust your instincts

- ensure easy withdrawal from any situation

- know panic button and alarms location (body alarm)

To ensure easy withdrawal from the situation, where should the nurse be in the room?

between the patient and door but not directly in front of the door way

if a nurse were to be directly in front of the door way, this could make the patient feel

trapped and confrontational

the nurse should also ensure they don't have an __ ___ within reach

big items

set limits: direct

violence is unacceptable and describe consequences (restraints, seclusion)

set limits: indirect

Give options, " you can take this medication and go into the interview room and talk or you can sit in the seclusion room until you feel less anxious"

share observations

"you seem very upset" or "it sounds like you have the weight of the world on your shoulders" allows exploration of feelings and may de-escalate

how does having enough staff help in confrontational settings?

it allows a show of strength and often stops a confrontational setting

show of strength

only one person talks and the rest have an unobtrusive presence

the nurse should give the patient the opportunity to voluntarliy

walk to the quiet room and only intervene when appropriate

seclusion

involuntary confinement of a patient in a room

restraint

any manual method or mechanical device, material, or equipment attached to the patient's body that they cannot easily remove

least restrctive restraint

The shortest duration is used after alternative interventions have been attempted

alternative interventions

meds, verbal interventions, decrease in sensory stimulation, removal of problematic stimulus

After something big happens with a patient, there always needs to be a

critical incident debriefing (this is crucial)

Questions to ask during a critical event debriefing

Could we have done anything that would have prevented the violence?

Did we respond as a team? if not why

Is there a need for additional staff education?

how do staff members feel about this patient? about the situation?

if the answer is yes to "Could we have done anything that would have prevented the violence?" what do we follow up with

what and why wasn't it done in this situation

after the event nurses may..

internalize or externalize emotional feelings

nurses internalizing feelings

depression, withdrawal, avoidance

nurses externalizing feelings

anger, outburst, mood swings

documentation for viloence/assault

Assessment of behaviors prior to assault

Nursing interventions used

Detailed description of behaviors. during asaaltive phase

Patient response to interventions

who was called to assess the patient, order meds, seclusion, restraint

time of restraint or seclusion

observation and interventions during restraints or seclusion

any injury to staff or patient

the way the patient was reintegrated into the unit milieu (time, behavior)

why is documentation of the restraint or seclusion needed

for protocol reasons because restraints have to be released every so often, usually 1 limb at a time and exercises with each limb

observation and interventions during restraints or seclusion

foot, toilet, VS, statements, behaviors- 145 to 30 minutes depending on state laws