Chapter 11 MH

normal human emotion
results when a person is frustrated, burt or afraid
handled appropriately, a positive force for resolving conflicts, solving problems, and making decisions
body physically energized for self-defense (fight-or-flight kicks in)

often perceiveed as a negative feeling
not healthy to deny or try to eliminate = can cause heart disease, HTN, and high cholesterol
inappropriate expression can lead to hostility/aggression
catharsis -> should teach peoeple assertive communication and mindfulness, supposed to provide relief but can cause more anger sometimes
cognitive-behavioral therapies
anger supression

hostility is verbal aggression
expressed through verbal abuse, lack of cooperation, violation of rules or norms, threatening behavior
may be expressed when a person feels threatened or powerless

attack on or injury to another person or destruction of property
hostility and aggression are meant to harm or punish another person or force itno compliance

people with mental illness are more at risk for being attacked or doing self harm more than anyone else
paranoid delusions -> feel like someone is out to get them
auditory hallucinations -> command voices telling them to harm someone else
dementia, delirium, head injuries -> elderly lady who has never cussed starts to and becomes aggressive
intoxication with alcohol or other drugs
antisocial, borderline personality disorders
depression -> person feels emotionally trapped and lashes out
intermitten explosive disorder (IED) -> rar diagnosis, serious assults or destruction of property
acting out -> immature self defense mechanisms, not being able to have multiple emotions, throwing tantrums `

possible role of neurotransmitters: decreased seratonin; increased doapamine and norepi
structural damage to limbic system
damage to frontal or temporal lobes

failure to develop impulse control due to
dysfunctional families with poor examples of parenting
inconsistent responses to children's behaviors -> gets corrected sometiems and one day they are doing right one day are doing wrong
interpersonal rejection

cultural views/values affect expression of anger
social determinants of health cause disparities in health outcomes -> poverty can increase risk of hostility and aggression
some culture-bound syndromes involve anger suppression or aggressive behavior

be aware of factos influencing aggression in psychiatric environment/ unit milieu
individual clients
- history of violent or aggressive behaviors in the past = single biggest risk factor for future aggression
- how client handles anger
- beliefs about anger
assess behavior to determine phase of aggresion cycle

an event or circumstances in the environment initiates the client's reponse, which is often anger or hostility
signs/symptoms: restlessness, anxiety, irratibility, pacing, muscle tension, rapid breathing, perspirations, loud voice, anger

the client's response represent escalating behaviors that indicate movement toward a loss of controls
signs/symptoms: pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly

during an emotional and physical crisis, the client loses control
signs/symptoms: loss of emotion and physical control, throwing objects, kicking, hitting, spitting, biting, scracthing, shrieking, screaming, inabiliy to communicate clearly

the client regains physical and emotional control
signs/symptoms: lowering of voice; decreased muscle tension; clearer, more rational communication; physical relaxation

client attempts reconciliation with others and returns to the level of functioning before the aggressice incident and its antecedents
signs/symptoms: remorse; apologies; crying; quiet, withdrawn behavior

common problems
- risk for violence
- ineffective coping
outcome identification, client will:
- not harm self or threaten others
- refrain from intimidating/frightening behaviors
- describe feelings and concerns without aggression
- comply with treatment

most effective and least restrictive when implemented early in the aggression cycle
managing the environment
- group and planned activities
- scheduled one-to-one interactions
- problem-solving or conflict resolution
- considering safety and security of other patients

approach in a nonthreatening, calm manner
convey empathy
encourage verbal expression of angry feelings
use clear, simple, short statements -> brief statements and questions to obtain information
allow client time for self-expression
suggest client go to a quieter area
offer PRN medications if ordered
suggest physical activity, such as walking

call for assistance
take control
provide directions in a firm, calm voice
direct client to time-out in quiet room or area
communicate that aggressive behavior is not acceptable
offer medication if redused in triggering phase
show of force = getitng 4-6 people to be around you

take charge of situation for safety
restraint or seclusion -> let patient know you "we have to put you in restraints
- only staff with trainning should participate in restraint
- four to six trained staff members are needed
- inform client that behavior is out of control and staff is taking measures for safety -> call for an order in 1 hour after restraints /seclusion

talk about situation or trigger -> let the staff know what triggered incident
help client relax or sleep
help client explore alternatives to aggressive behavior
assess and document any injuries
debrief staff
encourage other clients to talk about feelings
- do not discuss client's aggressive behavior in detail with other clients

remove patient from restraint or seclusion as soon as criteria met
calmly discuss behavior (don't lecture or chastise)
give client feedback for regaining control
reintegrate client as soon as they are able to participate

care is most effective when anger is defused in an earlier stage
goal is to teach angry, hostile potentially aggressive clients to express feelings verbally and safely wihtout threats or harm to others or destruction of property

sentinel event (bad event that causes serious injury) alert concerning intimidating and disruptive behaviors
overt actions: verbal outbursts, physical threats
passive activities: refusing to perform assigned tasks, uncooperative attitude
occurence of disruptive and intimidating behaviors
2016 JCAHO added workplace bullying

code of conduct defining acceptable and inappropriate/ unacceptable behaviors
process for managing disruptive/ unacceptable behaviors
education on expected professional behavior
zero tolerance = all are held accountable

be aware of your own management of anger
practice and gain experience in restraint/seclusion before using -> don't use if you're not trained to
be calm, nonjudgmental, and nonpunitive
learn from watching experienced nurses deal with hostile or aggressive clients