Chapter 21

1. Chapter 21 Anger and Aggression

2. Anger and aggression • Anger • Primal, not always logical-human emotion • Varies in intensity from mild irritation to rage and fury • Aggression • Hostile reaction that occurs when control over anger is lost • Used in attempt to regain control over stressor or flee situation • Violence: refers to physical aggression • Patients communicate increase anxiety before it escalates to anger, aggression, or violence: Remember-LISTEN TO THE PTS

3. Prevalence and community • Anger and violence common aspects of social interaction • Of the 1.6 million violent deaths in US, ½ were suicides and 1/3 were homicides and 1/5 were casualties of war • Persons with psych disorder 5x more violent • Medical & neurological causes of organic brain syndrome can result in agitated, aggressive or violent behavior

4. Theory • Anger stimulates hypothalamus causing body to react to anticipation of harm • Heredity is a factor (males with XYY chromosome more prone) • Selyes General Adaptation Syndrome • Fight or Flight • Freud’s Ego Defense Mechanisms • Suggest mind can channel anger into socially acceptable ways • Lewis • Most important contributor is early & ongoing physical, sexual or emotional abuse

5. Theory • Neurobiological factors • Brain structure: Limbic system-mediates primitive emotion & behaviors necessary for survival • Neurotransmitters: cholinergic & catecholaminergic mechanisms involved in predatory aggression. Serotonergic and GABA modulate aggression • Genetic Factors: twin studies proved genetic component to violence in addition to childhood violence

6. Cultural considerations • Violence is complex issue • Socioeconomic, medical and psychiatric issues are contributing factors • Substantial correlations between environment and aggression (poverty, unemployment, poor) • Males are more violent than females • Subculture supports intimidation & aggression as means of problem solving and achieving social status reinforces the use of violence (gangs)

7. Application of nursing process • Assessment • Accurate, early can identify pt anxiety before it escalates to anger and aggression • Leads directly to appropriate nursing diagnosis and intervention • Expressions of anxiety and anger are similar (increased demands, pacing, irritability, frowning, red face, clenching of fists) • On admission, obtain comprehensive history of pt gathered from variety of sources if possible • Remember: patient history is a good predictor of risk for violence • Assessment guidelines review

8. Application of nursing process • Diagnosis • Patient safety is 1st priority • Risk for self directed violence and risk for other directed violence are primary nursing diagnosis • If pt is escalating and not amenable to early nursing interventions or deescalating techniques then medication and/or restraints may be necessary • Outcome Identification • Inclusion of short, intermediate and long term goals • Planning • Necessitate sound assessment, including history (previous acts of violence, comorbid, disorders, present coping skills, alternative and nonviolent ways to handle anger (de-escalation techniques)

9. Application of nursing process • Implementation • Ensure safety • Stages of Violence Cycle • Pre-assaultive phase: de-escalation techniques • Assaultive phase: Medication, Seclusions (involuntary confinement of pt alone in room), Restraint (refers to any manual method or mechanical device, material, or equipment attached or adjacent to patients body, restricts movement • Post-assaultive phase: post seclusion/restraints staff should review the incident with pt and others

10. Application of nursing process • Implementation • Critical Incident Debriefing; staff analysis of violent episode • Documentation of violent episode • Anticipated increased anxiety and anger in hospital settings • Anxiety reduction techniques • Interventions for patient with cognitive deficits • Catastrophic reaction; severe agitation and aggression including scream, cry or strike out due to fear • Psychotherapy • Manage chronic aggression • Behavioral interventions • Cognitive behavioral approaches

11. Application of nursing process • Implementation • Pharmacological, Biological & Integrative Therapies • Medications for acute aggression • Atypical antipsychotics/ Typical antipsychotics • Benzodiazepines • Medications for chronic aggression • Carbamazepine (Tegretol) • Beta-blockers • Buspar • Lithium • Anticonvulsants (Lamictal) • Evaluation • Care plan with specific outcome criteria and review essential • Provides info about the extent to which interventions have achieved the outcomes