Anger, Aggression, and violence

Question 1

what is anger

Answer 1

emotional response to frustration, a threat to ones needs, or a challenge
when handled appropriately can provide individual with positive force to solve problems and make decisions
varies in emotional state from mild irritation to intense fury and rage
capable of being under personal control
can be channeled into something positvie

Question 2

aggression

Answer 2

an action or behavior that results in a verbal or physical attack
used synonymously with violence
intended to threaten or injure the victims security or self esteem
can cause damage with words, fists, or weapons, always designed to punish
no always inappropriate and is sometimes necessary for self-protection

Question 3

violence

Answer 3

always an objectionable act that involves intentional use of force that results in or has potential to result in injury to another individual

Question 4

crisis= Danger + opportunity

Answer 4

crisis can be dangerous but can be used for both you and individual in crisis to grow and to strengthen your relationship with one another

Question 5

etiology of anger

Answer 5

biological factors - areas of the brain, neurotransmitters, predisposition
psychological factors, behavioral therapy, learned response, social learning theory, imitate others

Question 6

predisposing factors to anger and aggression

Answer 6

modeling
neurophysiological disorders
operant conditioning
biochemical factors
medical factors
*always look for potential medical causes
socioeconomic factors
environmental factors

Question 7

modeling

Answer 7

role-modeling is the strongest form of learning
can be positive or negative
significant others or celebrities

Question 8

neurophysiological disorders

Answer 8

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

Question 9

operant conditioning

Answer 9

specific behavior positively or negatively reinforced
Pavlov’s dog

Question 10

biochemical factors affecting aggression

Answer 10

hormone dysfunction: Hyperthyroidism
low serotonin
thiamine and niacin
medical factors: UTI, electrolyte dysfunction

Question 11

comorbidities of agression/anger

Answer 11

PTSD
SUD
coexist with depression, anxiety, psychosis, personality disorders
cardiovascular disease
strokes

Question 12

what does anger look like?

Answer 12

increased demands
irritability
frowning
redness in face
pacing
twisting hands
clenching and unclenching of fists
speech increased in rate and volume or may be slowed

Question 13

assessment of anger and aggression

Answer 13

a history of violence is the single best indicator of future violence
individuals are delusional, hyperactive, impulsive, predisposed to irritability, non-adherent to meds are at higher risk of violence
aggression by individuals occurs most often in the context of limit setting by nurse
hx of limited coping skills, including lack of assertiveness or use of intimidation, indicates higher risk of violence

Question 14

questions to assess major factors associated with violence

Answer 14

does individual wish or intend to harm
do they have a plan
does the individual have the mean available to carry out plan
does the individual have demographic risk factors (male, 14-24, low socioeconomic status, inadequate support system, prison time)

Question 15

risk assessment identifies for aggression

Answer 15

agitation, restlessness, escalating anxiety
resistance to suggested treatment
history of assaultive or threatening behavior esp. last 12m/12h
known history of drug or alcohol misuse
cognitive changes causing misinterpretation of environments and staff care activities (delirium, delusions, psychosis, hallucinations)

Question 16

predictors of violence

Answer 16

hyperactivity (pacing, restless)
increasing anxiety, tension (clenched jaw or fists, rigid posture, fixes or tensed facial expression, mumbling to self)
verbal abuse (profanities, argumentativeness)
loud voice, change of pitch, very soft voice
intense eye contact or avoidance of eye contact
recent acts of violence
possession of a weapon or object that can be used as one
isolation that is uncharacteristic

Question 17

psychosocial interventions

Answer 17

interventions begin prior to any signs of escalation
approach patient in a controlled, nonthreatening and caring manner
allow pt enough space to be perceived as less of a threat ( stand 1 foot farther than arm length from pt)
make sure you have escape route
do not take anything personal, respond in kind manner.

Question 18

deescalating techniques

Answer 18

maintain patients self-esteem and dignity
calmness
assess the patient and situation
identify stressors and stress indicators
respond early
use calm tone of voice
invest time
remain honest
avoid invading personal space in times of high anxiety, personal space increases
avoid arguing
give several clear options
use genuineness and empathy
be assertive not aggressive
maintain personal safety at all times

Question 19

considerations for staff safety

Answer 19

avoid wearing dangling earrings, scarves
ensure enough back up staff
always know layout of area and where exits are
do not stand in front of patient or block exits
if behavior escalates provide feedback allowing for patient to explore feelings and hopefully deescalate
maintain appropriate eye contact
keep facial expression even, caring, confident, engaged
try to get pt to talk to you

Question 20

supportive stance

Answer 20

confident posture not confrontational
stand at an angle not toe to toe
hands visible
always stay about 1 foot further than arm/leg length away

Question 21

youth violence risk factors

Answer 21

environmental- peer influence and gang related behavior
biological- impulse control or self-regulation problems
family- attachment problems, family stress, autocratic parenting, disengaged parenting, lack of supervision

Question 22

level 1 anger/aggression/violence

Answer 22

the patient is asking simple, normal questions
expressions of anxiety, frustration, impatience, irritability
raised voice, highly animated, reddened face, clenched fist, restlessness, repetitive movements
change in behavior- calm to loud; loud to calm

Question 23

level 1 staff intervention/responses

Answer 23

answer the question
avoid institutional/systems language/jargon
avoid coming off as cold and uncaring
come across as a real human being
avoid talking about how you feel about it/the situation
do: stay calm and in control, try to understand concern, listen for truth, reflect their emotion appear as personable as possible, comfort measures
dont: take the bait
get defensive
counterattack
be easily offended

Question 24

level 2

Answer 24

defensiveness
beginning loss of rationality
pt asks challenging questions
person is standing in your personal space; staring; glaring
refusing; refusing your requests; loudly and adamantly refusing to go along with treatment, becoming very angry and defensive
releasing- table pounding, loud sighing, throwing things, but not at you, not meant to cause harm

Question 25

nurses response in level 2

Answer 25

redirect
simply, calmly, and confidently state your request
maintain self control
manage your emotions
dont take it out on the person
dont be intimidated
be assertive not aggressive
refocus on the problem and solving it
give choices; positive choice first
reflect
make it safe for person to speak
ignore verbal put downs
talk in tones and content that allow for the person to save face
ask yourself: have i listened
isolate the interaction, move away from others, and allow yourself an exit
reduce stimulation, speak clearly and slowly, be firm but empathetic
allow loud, verbal expression of anger as ling as not threatening
not a win-lose situation
what how you say things

Question 26

level 3

Answer 26

intimidation/acting out
angry expression turns to hostility, abuse, aggression. Activity is intended to cause harm
may begin with accusations, comments about competence, irrelevant personal remarks
danger signs: persistent swearing, sexist or racist comments, personal or specific threats or harm, intimidating comments, terroristic types of threats, any physical behavior directed at the person

Question 27

nurses response to level 3

Answer 27

call for help/assistance/security/ law enforcement/ coworker/ assistance please
protect yourself
be aware of non verbal communication don’t sigh, roll eyes, show frustration that may further provoke
limit words and actions
avoid agreeing just to agree
if person can hear you explain that aggression will not achieve desired goal

Question 28

seclusion and restraint

Answer 28

last resort
use when less restrictive interventions have been determined ineffective
used in conjunction with a written modification to patients plan of care
only in accordance with safe and appropriate techniques as determined by hospital policy and state law

Question 29

seclusion

Answer 29

involuntary confinement of a patient alone in room or area
goal: safety for patient and others
may only be used in management of violent or self-destructive behavior that jeopardizes immediate physical safety of patient, staff and others

Question 30

restraint

Answer 30

manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body, or head freely

Question 31

contraindications for seclusion and restraint

Answer 31

patients who have extremely unstable medical and psychiatric conditions
COPD
spinal injury
seizure disorders
pregnancy
delirium or dementia make make seclusion and restraint intolerable due to the absence of stimulation

Question 32

emergency medical management

Answer 32

combination IM cocktail (Ativan, Haldol, Benadryl)
Haldol and Ativan can be combined in same syringe, Benadryl must be in separate syringe
geodon 20mg IM
when situation allows offer PO first; IM if indicated

Question 33

level 4

Answer 33

decrease in energy, rationality returns, reachable teachable moments
staff intervention/response: revise plan of care to include behaviors that may result in repeat subsequent interventions using restraint or seclusion
re-establish therapeutic rapport with pt
use coping model with pt

Question 34

COPING- level 4

Answer 34

c- control
o-orient
p-patterns
i-investigate
n-negotiate
g- give control and responsibility for behavior back to the patient

Question 35

debriefing with staff involved

Answer 35

mandatory debriefing for staff and clients who took part and witnesses the seclusion and restrain episode within 24 hours