Exam 1 ATI ch29

●Anger, a normal feeling, is an emotional response to frustration as perceived by the individual. It can be positive if there is truly an unfair or wrong situation that needs to be righted.
Anger becomes negative when it is denied, suppressed, or expressed inappropriately, such as by using aggressive behavior.
Denied or suppressed anger can manifest as physical or psychological findings, such as headaches, coronary artery disease, hypertension, gastric ulcers, depression, or low self-esteem.
Aggression, unlike anger, is typically goal-directed with the intent of harming a specific person or object.
◯Inappropriately expressed anger can become hostility or aggression.
◯Aggression includes physical or verbal responses that indicate rage and potential harm to self, others, or property.
◯A client who is often angry and aggressive may have underlying feelings of inadequacy, insecurity, guilt, fear, and rejection.
Comorbidities include depressive disorders, posttraumatic stress disorder (PTSD), Alzheimer’s disease, and personality and psychotic disorders.
Categories/Taxonomies of Disorder
◯Preassaultive – The client begins to become angry and exhibits increasing anxiety, hyperactivity, and verbal abuse.
◯Assaultive – The client commits an act of violence. Seclusion and physical restraints may be required.
◯Postassaultive – Staff reviews the incident with the client during this stage.
Despite the potential for anger and aggression among individuals who have mental illness, it is important to know that individuals who have mentally illness are more likely to hurt themselves than to express aggression against others.
●Seclusion and restraint must be used only according to legal guidelines and should be the interventions of last resort after other less restrictive options have been tried.
New initiatives are being proposed to reduce or eliminate the use of mechanical restraints. National, state, and local initiatives advocate for restraint elimination. There is also heightened awareness of the damaging effects restraints may have on clients, clinicians, and caretakers alike.
◯Seclusion and restraint do not usually lead to positive behavior change. Seclusion and restraint may keep individuals safe during a violent outburst, but the use of restraint itself can be dangerous and has, on rare occasions, led to the death of clients due to reasons such as suffocation and strangulation.
◯Intramuscular medication may need to be given if aggression is threatening and if no medications were previously given.
◯When deemed essential to use restraints, remove the client from seclusion or restraint as soon as the crisis is over and when the client attempts reconciliation and is no longer aggressive.
Risk Factors
◯Past history of aggression, poor impulse control, and violence
◯Poor coping skills, limited support systems
◯Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders)
◯Living in a violent environment
◯Limit setting by the nurse within the therapeutic milieu
Subjective and Objective Data
◯Hyperactivity such as pacing, restlessness
◯Defensive response when criticized, easily offended
◯Eye contact that is intense, or no eye contact at all
◯Facial expressions, such as frowning or grimacing
◯Body language, such as clenching fists, waving arms
◯Rapid breathing
◯Aggressive postures, such as leaning forward, appearing tense
◯Verbal clues, such as loud, rapid talking
◯Drug or alcohol intoxication
*patient centered care*
Nursing Care
◯Provide a safe environment for the client who is aggressive, as well as for the other clients and staff on the unit.
◯Follow policies of the mental health setting when working with clients who demonstrate aggression.
◯Assess for triggers or preconditions that escalate client emotion.
Steps to handle aggressive and/or escalating behavior in a mental health setting include the following:
■Responding quickly
■Remaining calm and in control
■Encouraging the client to express feelings verbally, using therapeutic communication techniques (reflective techniques, silence, active listening)
■Allowing the client as much personal space as possible
■Maintaining eye contact and sitting or standing at the same level as the client
■Communicating with honesty, sincerity, and nonaggressive stance
■Avoiding accusatory or threatening statements
■Describing options clearly and offering the client choices
■Reassuring the client that staff are present to help prevent loss of control
Setting limits for the client:
☐Tell the client calmly and directly what he must do in a particular situation, such as, “I need you to stop yelling and walk with me to the day room where we can talk.”
☐Use physical activity, such as walking, to deescalate anger and behaviors.
☐Inform the client of the consequences of his behavior, such as loss of privileges.
■Use pharmacological interventions if the client does not respond to calm limit setting.
■Plan for four to six staff members to be available and in sight of the client as a “show of force” if appropriate.
Following an aggressive/violent episode:
■Discuss ways for the client to keep control during the aggression cycle.
■Encourage the client to talk about the incident, and what triggered and escalated the aggression from the client’s perspective.
■Debrief the staff to evaluate the effectiveness of actions.
■Document the entire incident completely by including:
☐Behaviors leading up to, as well as those observed throughout the critical incident
☐Nursing interventions implemented, and the client’s response
◯Olanzapine (Zyprexa)
◯Ziprasidone (Geodon)
■Classification and therapeutic intent
☐Olanzapine and Ziprasidone are atypical antipsychotics used to control aggressive and impulsive behaviors. These are used more commonly than haloperidol because of the
severity of side effects of haloperidol.
◯Haloperidol (Haldol)
■Classification and therapeutic intent
☐Haloperidol is an antipsychotic agent used to control aggressive and impulsive behavior.
■Nursing considerations
☐Monitor for clinical findings of parkinsonian and anticholinergic side effects.
☐Keep client hydrated, check vital signs, and test for muscle rigidity due to the risk of neuroleptic malignant syndrome (NMS).
◯Other medications may be used to prevent violent behavior by treating the underlying disorder. These include antidepressants, such as SSRIs; mood stabilizers, such as lithium; and sedative/hypnotic medications, such as benzodiazepines.
●Care After Discharge
◯Nursing Actions
■Teach clients how to manage medications.
■Assist the clients to develop problem-solving skills.
◯Client Education
■Encourage clients to return for follow up.
■Encourage clients to attend a support group.
Expected Pharmacological Action
●Haloperidol is an antipsychotic agent used to control aggressive and impulsive behavior.
Side/Adverse Effects
●Parkinsonian and anticholinergic side effects
●Shuffling gait
●Dry mouth
●Blurred vision
●Orthostatic hypotension
●Extrapyramidal symptoms
Nursing Interventions/Client Education
●Encourage client to drink frequent sips of water.
●Instruct client to increase fiber intake and that a stool softener may be needed.
●Instruct client to limit sunlight exposure, and encourage client to wear sunscreen and sunglasses.

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