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12918737 Videbeck Psychiatric Nsg Handouts

12918737 Videbeck Psychiatric Nsg Handouts

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Published by: kishor on May 19, 2009
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Anger, Hostility, and Aggression
Anger 
is a normal human emotion.
Hostility 
and
aggression 
are inappropriate expressions of anger.Anger is a strong, uncomfortable, emotional response to a provocation, either real orperceived.It results when one is frustrated, hurt, or afraid and energizes the body for defense(fight or flight).
Denying or suppressing angry feelings can lead to physical or emotional problems
Anger that is expressed inappropriately can lead to hostility and aggression
Appropriate expression of anger involves assertive communication skills that lead toproblem solving or conflict resolution
Venting angry feelings by engaging in safe but aggressive activities (punching bag, yelling) is called
catharsis 
. However, research has shown that catharsis may increaserather than alleviate angry feelings
Clients with depression may have anger attacks when they feel emotionally trapped
Hostility and Aggression
Hostile and aggressive behavior may occur suddenly without warning, but often stages orphases can be identified:
Triggering
Escalation
Crisis
Recovery
PostcrisisHostility is an emotion expressed by:
Verbal abuse
Lack of cooperation
Violation of rules or norms
Threatening behavior (verbal aggression)
Related Disorders
Most psychiatric clients are not aggressive, but some exhibit angry, hostile, or aggressivebehavior caused by:
Paranoid delusions
Auditory (command) hallucinations
Dementia, delirium
Head injury
Intoxication with alcohol or drugs
Antisocial and borderline personality disorders
Intermittent Explosive Disorder: 
 
Rare psychiatric diagnosis involving discrete episodes of aggressive impulses resultingin serious injury or property damageEpisodes are out of proportion to any provocation, and the person is remorseful andembarrassed afterward.
Acting Out 
An immature defense mechanism in which the person deals with emotional conflict orstress by actions rather than reflection or feelings; the person is trying to feel lesspowerless or helpless by acting out.
Etiology of Hostility and Aggression
Neurobiologic theories 
: decreased serotonin, increased dopamine and norepinephrine;structural damage to limbic system, damage to frontal or temporal lobes
Psychosocial theories 
: failure to develop impulse control and ability to delaygratification
Cultural Considerations
In certain cultures, expressing anger may be seen as rude or disrespectful; someculture-bound syndromes involve aggressive, agitated, or violent behavior.
Treatments and Medications
Treatment often focuses on treating the underlying or comorbid psychiatric diagnosissuch as schizophrenia or bipolar disorder.
Aggressive Clients
Lithium for bipolar disorder, conduct disorder, or mental retardation
Carbamazepine (Tegretol) or valproate (Depakote) for dementia, psychosis, orpersonality disorders
Atypical antipsychotics such as clozapine (Clozaril), risperidone (Risperdal), andolanzapine (Zyprexa) for dementia, brain injury, mental retardation, and personalitydisorders
Benzodiazepines for older adults with dementia
Haloperidol (Haldol) and lorazepam (Ativan) for clients with psychoses
Application of the Nursing Process
Assessment 
Early assessment and intervention needed when clients are angry or hostile to avoidphysically aggressive episodes
Nurse must assess both individual clients and the therapeutic milieu or environment
Assessment and intervention are based on five phases of aggression
Data Analysis 
Common nursing diagnoses:
Risk for Other-Directed Violence
 
Ineffective Coping
Outcome Identification 
The client will:
Not harm self or threaten others
Refrain from intimidating or frightening behaviors
Describe feelings and concerns without aggression
Comply with treatment
Intervention 
Interventions are most effective and least restrictive when implemented early in the cycleof aggression.
Managing the milieu includes:
Having planned activities; informal discussions
Scheduled one-to-one interactions; letting clients know what to expect
Helping clients with conflicts to solve their problems, including expression ofangry feelings
Managing aggressive behavior includes:
Triggering 
phase:
Approach in nonthreatening, calm manner
Convey empathy
Listen
Encourage verbal expression of feelings
Suggest going to a quieter area, or use of PRN medications
Physical activity such as walking
Escalation 
phase:
Take control
Provide directions in firm, calm voice
Direct client to room or quiet area for time out
Offer medication again
Let client know aggression is unacceptable and nurse or staff will helpmaintain/regain control if needed
If ineffective to that point, obtain assistance from other staff (show offorce) to get client to take time out or take medication
Crisis 
phase:
Staff must take control of situation as determined by facility or agencypolicy (trained in techniques for behavioral management)
Use restraint or seclusion only if necessary
Recovery 
phase as client regains control:
Talk about the situation or trigger
Help client relax or sleep
Explore alternatives to aggressive behavior
Provide documentation of any injuries
Staff debriefing

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