Nur 225
01/10/2024
Anger, Aggression, and Crisis Interventions
Introduction
- Anger: an emotional state that varies in intensity from mild irritation to intense fury and rage.
o Not a bad thing and can be positive. It prompts us to action
o Anger is normal, it is the reaction to or lack of reaction anger that can become an issue
o Assault is just the threat
o Battery is the acting out or physically lying hands on someone
- Aggression: the outcome of reacting to anger
o Intended to threaten or injure the victims security or self-esteem
o Always designed to punish
- Modeling: strongest form of learning
o Role models can be both positive and negative
o The earliest models are typically the primary care giver
o As the child matures, role models can be celebrities or any other influential individual in the child’s life.
Predisposing Factors to Anger and Aggression
- Operant conditioning
o When specific behavior is positively or negatively reinforced
A positive reinforcement is a response to the specific behavior that is pleasurable or produces the desired results.
A negative reinforcement is a response to the specific behavior that prevents an undesirable result from occurring.
o Anger and aggression can be learned through operant conditioning
- Neurophysiological Disorders
o Several disorders of, or conditions within, the brain have been implicated in episodic aggression and violent behavior. They
include:
Temporal or frontal lobe epilepsy
Brain tumors
Brain trauma
Encephalitis
- Biochemical Factors
o Aggressive behavior may have some correlation to alterations in brain chemicals. These include:
Hormonal dysfunction associated with hyperthyroidism or Cushing’s disease
Alterations in the neurotransmitters epinephrine, norepinephrine, dopamine, acetylcholine, and serotonin may play a
role in facilitation or inhibition of aggression
- Socioeconomic Factors
o High rates of violence exist within the subculture of poverty in the United States.
o Poverty is thought to encourage aggression because of the associated deprivation, disruption of families, and unemployment.
- Environmental Factors
o Several environmental factors have been associated with an increase in aggressive behavior. They include:
Physical crowding of people
Discomfort associated with a moderate increase in environmental temperature
Extremely hot temperatures actually decreases agitation
Use of alcohol and some other drugs, particularly cocaine, amphetamines, hallucinogens, and anabolic steroids
Availability of firearms
The Nursing Process: Assessment
- Prevention is the key!
- Anger can be identified by a cluster of characteristics that include:
o Frowning
o Clenched fists
o Low-pitched words forced through clenched teeth
o Yelling and shouting
o Intense or no eye contact
o Easily offended
o Defensive response to criticism
o Passive-aggressive
o Emotional over control and flushed face
o Intense discomfort
o Tension
- Aggression can be identified by a cluster of characteristics that include:
o Pacing
o Restlessness
o Tense face and body
o Verbal or physical threats
o Threats of homicide or suicide
o Loud voice, shouting, use of obscenities
o Argumentative
o Increased agitation
o Overreaction to environmental stimuli
o Panic anxiety leading to misinterpretation of the environment
o Disturbed thought processes
o Suspiciousness
o Disproportionate anger
, - Assessing Risk Factors
o Prevention is the key issue in the management of aggressive or violent behavior.
o Three factors are important considerations in identifying extent of risks:
Past history of violence (widely recognized as a major risk factor in the treatment setting)
Client diagnosis (schizophrenia, bipolar mood disorder, substance abuse, antisocial PD, Borderline PD, neurocognitive
disorders)
Current behavior
o Certain behaviors are predictive of impending violence and have been termed the “prodromal syndrome.” These include:
Rigid posture
Clenched fists and jaws
Grim, defiant affect
Talking in a rapid, raised voice
Arguing and demanding
Using profanity and threatening verbalizations
Agitation and pacing
Pounding and slamming
The Nursing Role
- Remain calm. Be assertive (not aggressive) when needed
- Set verbal limits on behavior.
- Keep a diary of anger, triggers and how the situation was handled.
- Avoid touching the client.
- Help determine source of anger and recognize triggers, do not accuse or threaten
- Ignore derogatory remarks (initially).
- Help find alternative ways of releasing tension.
- Role model and offer support
- Observe for escalation of anger. Look for prodromal
- When behaviors are observed, first ensure that sufficient staff is available.
- Consistently focus on the clients needs, experiences, and feelings.
- Describe options clearly and offer choices
- REASSURE…of safety of prevention of loss of control
- Identify and explore the clients needs and problems
- Discuss problem-solving alternatives with the client
- Portray genuineness, empathy, non-judgmental attitude towards the client
- Avoid the word “why”
- Techniques for dealing with aggression include:
o Try to find out what is upsetting the client:
o Talking down
o Physical outlets
o Medication(s)
o Call for assistance
o Observation and documentation
o Ongoing assessment
o Staff debriefing
Therapeutic Environment (Milieu)
- Creates a supportive, safe, and therapeutic environment.
- Management of the total environment in order to provide the least amount of stress, while promoting the greatest benefit.
- The goal of the environment is to allow the patients to learn positive coping skills.
- Comfortable, open, friendly setting,
- Appropriate décor, color scheme for the correct age
- Promote independence within the client
- Maintain boundaries
- Work cohesively as a team
- Maintain professionalism
- Apply rules fairly
- Promote feelings of value, self-worth, and hope for the future.
De-escalation Techniques
- Calm voice
- Fresh air
- Identify consequences
- Group participation
- Open Hands
- Nonthreatening posture
- Relaxation techniques
- Allow a phone call
- Express concern
- Reduce stimulation
- Helpful attitude
- Reduction in demands
- Decrease waiting times and request refusals
- Offer PRN medication
- Therapeutic communication
- Time out/Quiet time
- Distract with a more positive activity
PRN Medications
01/10/2024
Anger, Aggression, and Crisis Interventions
Introduction
- Anger: an emotional state that varies in intensity from mild irritation to intense fury and rage.
o Not a bad thing and can be positive. It prompts us to action
o Anger is normal, it is the reaction to or lack of reaction anger that can become an issue
o Assault is just the threat
o Battery is the acting out or physically lying hands on someone
- Aggression: the outcome of reacting to anger
o Intended to threaten or injure the victims security or self-esteem
o Always designed to punish
- Modeling: strongest form of learning
o Role models can be both positive and negative
o The earliest models are typically the primary care giver
o As the child matures, role models can be celebrities or any other influential individual in the child’s life.
Predisposing Factors to Anger and Aggression
- Operant conditioning
o When specific behavior is positively or negatively reinforced
A positive reinforcement is a response to the specific behavior that is pleasurable or produces the desired results.
A negative reinforcement is a response to the specific behavior that prevents an undesirable result from occurring.
o Anger and aggression can be learned through operant conditioning
- Neurophysiological Disorders
o Several disorders of, or conditions within, the brain have been implicated in episodic aggression and violent behavior. They
include:
Temporal or frontal lobe epilepsy
Brain tumors
Brain trauma
Encephalitis
- Biochemical Factors
o Aggressive behavior may have some correlation to alterations in brain chemicals. These include:
Hormonal dysfunction associated with hyperthyroidism or Cushing’s disease
Alterations in the neurotransmitters epinephrine, norepinephrine, dopamine, acetylcholine, and serotonin may play a
role in facilitation or inhibition of aggression
- Socioeconomic Factors
o High rates of violence exist within the subculture of poverty in the United States.
o Poverty is thought to encourage aggression because of the associated deprivation, disruption of families, and unemployment.
- Environmental Factors
o Several environmental factors have been associated with an increase in aggressive behavior. They include:
Physical crowding of people
Discomfort associated with a moderate increase in environmental temperature
Extremely hot temperatures actually decreases agitation
Use of alcohol and some other drugs, particularly cocaine, amphetamines, hallucinogens, and anabolic steroids
Availability of firearms
The Nursing Process: Assessment
- Prevention is the key!
- Anger can be identified by a cluster of characteristics that include:
o Frowning
o Clenched fists
o Low-pitched words forced through clenched teeth
o Yelling and shouting
o Intense or no eye contact
o Easily offended
o Defensive response to criticism
o Passive-aggressive
o Emotional over control and flushed face
o Intense discomfort
o Tension
- Aggression can be identified by a cluster of characteristics that include:
o Pacing
o Restlessness
o Tense face and body
o Verbal or physical threats
o Threats of homicide or suicide
o Loud voice, shouting, use of obscenities
o Argumentative
o Increased agitation
o Overreaction to environmental stimuli
o Panic anxiety leading to misinterpretation of the environment
o Disturbed thought processes
o Suspiciousness
o Disproportionate anger
, - Assessing Risk Factors
o Prevention is the key issue in the management of aggressive or violent behavior.
o Three factors are important considerations in identifying extent of risks:
Past history of violence (widely recognized as a major risk factor in the treatment setting)
Client diagnosis (schizophrenia, bipolar mood disorder, substance abuse, antisocial PD, Borderline PD, neurocognitive
disorders)
Current behavior
o Certain behaviors are predictive of impending violence and have been termed the “prodromal syndrome.” These include:
Rigid posture
Clenched fists and jaws
Grim, defiant affect
Talking in a rapid, raised voice
Arguing and demanding
Using profanity and threatening verbalizations
Agitation and pacing
Pounding and slamming
The Nursing Role
- Remain calm. Be assertive (not aggressive) when needed
- Set verbal limits on behavior.
- Keep a diary of anger, triggers and how the situation was handled.
- Avoid touching the client.
- Help determine source of anger and recognize triggers, do not accuse or threaten
- Ignore derogatory remarks (initially).
- Help find alternative ways of releasing tension.
- Role model and offer support
- Observe for escalation of anger. Look for prodromal
- When behaviors are observed, first ensure that sufficient staff is available.
- Consistently focus on the clients needs, experiences, and feelings.
- Describe options clearly and offer choices
- REASSURE…of safety of prevention of loss of control
- Identify and explore the clients needs and problems
- Discuss problem-solving alternatives with the client
- Portray genuineness, empathy, non-judgmental attitude towards the client
- Avoid the word “why”
- Techniques for dealing with aggression include:
o Try to find out what is upsetting the client:
o Talking down
o Physical outlets
o Medication(s)
o Call for assistance
o Observation and documentation
o Ongoing assessment
o Staff debriefing
Therapeutic Environment (Milieu)
- Creates a supportive, safe, and therapeutic environment.
- Management of the total environment in order to provide the least amount of stress, while promoting the greatest benefit.
- The goal of the environment is to allow the patients to learn positive coping skills.
- Comfortable, open, friendly setting,
- Appropriate décor, color scheme for the correct age
- Promote independence within the client
- Maintain boundaries
- Work cohesively as a team
- Maintain professionalism
- Apply rules fairly
- Promote feelings of value, self-worth, and hope for the future.
De-escalation Techniques
- Calm voice
- Fresh air
- Identify consequences
- Group participation
- Open Hands
- Nonthreatening posture
- Relaxation techniques
- Allow a phone call
- Express concern
- Reduce stimulation
- Helpful attitude
- Reduction in demands
- Decrease waiting times and request refusals
- Offer PRN medication
- Therapeutic communication
- Time out/Quiet time
- Distract with a more positive activity
PRN Medications
