1. Anger and Aggression Chapter 21

2. 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 Anger and aggression

3. 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 Prevalence and community

4. 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 Theory

5. 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 Theory

6. 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) Cultural considerations

7. 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 Application of nursing process

8. Diagnosis  Patient safety is 1 st 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) Application of nursing process

9. 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 Application of nursing process

10. 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 Application of nursing process

11. 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 Application of nursing process