acting out is an immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings.

The person engages in acting-out behavior, such as verbal or physical aggression, to feel temporarily less helpless or powerless.

anger when a person is frustrated, hurt, or afraid Anger, expressed appropriately, can be a positive force that helps a person solve problems and make decisions.

Although anger is normal, it is often perceived as a negative feeling.

hostility also called verbal aggression, is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior. can rise from anger

. A person may express hostility when they feel threatened or powerless. Hostile behavior is intended to intimidate or cause emotional harm to another, and it can lead to physical aggression.

physical aggression behavior in which a person attacks or injures another person or destroys property.

physical or verbal behavior is intended to harm

postcrisis phase the client is removed from restraint or seclusion as soon as they meet the behavioral criteria.

The nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner.

recovery phase the client regains control they are encouraged to talk about the situation or triggers that led to the aggressive behavior.

The nurse should help the client relax, perhaps sleep, and return to a calmer state

In the escalation phase, interventions include using a directive approach; taking control of the situation;

using a calm, firm voice for giving directions; directing the client to take a time-out in a quiet place; offering PRN medication; and making a “show of force.”

Expected outcomes for aggressive clients may include The client will not harm or threaten others. The client will refrain from behaviors that are intimidating or frightening to others.

The client will describe their feelings and concerns without aggression. The client will comply with treatment.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

issued a sentinel event alert concerning “intimidating and disruptive behaviors

Assertive Communication is use with "I" statements such as "I feel frustrated when you interrupted"

assertive communication is healthy

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Med Surg I Chapt 11

Mental Health

Question	Answer
acting out is an immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings.	The person engages in acting-out behavior, such as verbal or physical aggression, to feel temporarily less helpless or powerless.
anger when a person is frustrated, hurt, or afraid Anger, expressed appropriately, can be a positive force that helps a person solve problems and make decisions.	Although anger is normal, it is often perceived as a negative feeling.
catharsis engaging in aggressive but safe activities such as hitting a punching bag or yelling.
crisis phase When the client becomes physically aggressive the staff must take charge of the situation for the safety of the client, staff, and other clients.
escalation phase the period when the client builds toward loss of control
hostility also called verbal aggression, is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior. can rise from anger	. A person may express hostility when they feel threatened or powerless. Hostile behavior is intended to intimidate or cause emotional harm to another, and it can lead to physical aggression.
impulse control (the ability to delay gratification
physical aggression behavior in which a person attacks or injures another person or destroys property.	physical or verbal behavior is intended to harm
postcrisis phase the client is removed from restraint or seclusion as soon as they meet the behavioral criteria.	The nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner.
recovery phase the client regains control they are encouraged to talk about the situation or triggers that led to the aggressive behavior.	The nurse should help the client relax, perhaps sleep, and return to a calmer state
triggering phase incident or situation that initiates an aggressive response
Both verbal and physical aggression are meant to harm or punish another person or to force someone into compliance.
Some clients with psychiatric disorders display hostile or physically aggressive behavior that represents a challenge to nurses and other staff members.
Anger or angry feelings are not bad or wrong. It is not healthy to deny or try to eliminate ever feeling angry. It is essential for good health to recognize, express, and manage angry feelings in a positive manner.
A person may deny or suppress (i.e., hold in) angry feelings if they are uncomfortable expressing anger
Possible consequences are physical problems such as migraine headaches, ulcers, or coronary artery disease and emotional problems such as depression and low self-esteem.
Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately.
Anger energizes the body physically for self-defense when needed by activating the “fight-or-flight” response mechanisms of the sympathetic nervous system.
High hostility and anger are associated with increased risk of coronary artery disease, hypertension, increased stroke risk, and early heart attacks
catharsis, are supposed to provide a release for anger. However, catharsis can increase rather than alleviate angry feelings.
cathartic activities may be contraindicated for clients who are angry.
Activities that are not aggressive, such as walking or talking with another person, are more likely to be effective in decreasing angry feelings
Cognitive behavioral therapy techniques, such as distraction, communication skills, problem-solving, and changing one’s perspective or reframing, can be effective in managing situations or problems that provoke angry feelings
Hostility, also called verbal aggression, is behavior meant to intimidate or cause emotional harm to another and can lead to physical aggression.
Physical aggression is behavior meant to harm, punish, or force another person into compliance.
Most clients with psychiatric disorders are not aggressive.
Clients with schizophrenia, bipolar disorder, dementia, head injury, antisocial or borderline personality disorders, or conduct disorder and those intoxicated with alcohol or other drugs may be aggressive.
Rarely, clients may be diagnosed with IED.
treatment of aggressive clients often involves treating the comorbid psychiatric disorder with mood stabilizers or antipsychotic medications.
Assessment and effective action with clients who are angry or hostile can often prevent aggressive episodes.
Aggressive behavior is less common and less intense on units with strong psychiatric leadership, clear staff roles, and planned and adequate events such as staff–client interaction, group interaction, and activities.
The nurse must be familiar with the signs, symptoms, and behaviors associated with the triggering, escalation, crisis, recovery, and postcrisis phases of the aggression cycle.
In the triggering phase, nursing interventions include speaking calmly and nonthreateningly, conveying empathy, listening, offering PRN medication, and suggesting retreat to a quiet area.
In the escalation phase, interventions include using a directive approach; taking control of the situation;	using a calm, firm voice for giving directions; directing the client to take a time-out in a quiet place; offering PRN medication; and making a “show of force.”
In the crisis phase, experienced, trained staff can use the techniques of seclusion or restraint to deal quickly with the client’s aggression.
During the recovery phase, interventions include helping clients relax, assisting them to regain self-control, and discussing the aggressive event rationally.
In the postcrisis phase, the client is reintegrated into the milieu.
Important self-awareness issues include examining how one handles angry feelings and deals with one’s own reactions to angry clients.
Which is an example of assertive communication?
Which statement about anger is true?
Which type of drugs requires cautious use with potentially aggressive clients?
A client is pacing in the hallway with clenched fists and a flushed face. They are yelling and swearing. In which phase of the aggression cycle is this client?
Behaviors observed during the recovery phase of the aggression cycle include
Which statements are examples of unacceptable behaviors under the JCAHO standards for a culture of safety?
Children and adolescents often “act out” when they cannot handle intense feelings or deal with emotional conflict verbally.
Researchers have examined the role of neurotransmitters in aggression in animals and humans but have been unable to identify a single cause
Hwa-Byung or hwabyeong is a cultural syndrome that literally translates as anger syndrome or fire illness, attributed to the suppression of anger
Bouffée délirante, a condition observed in West Africa and Haiti, is characterized by sudden outbursts of agitated and aggressive behavior, marked confusion, and psychomotor excitement
These episodes may include visual and auditory hallucinations and paranoid ideation that resemble brief psychotic episodes (
Amok is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects
This behavior is precipitated by a perceived slight or insult and is seen only in males
Lithium has been effective in treating aggressive clients with bipolar disorder, conduct disorders (in children), and intellectual developmental disorder.
Carbamazepine (Tegretol) and valproate (Depakote) are used to treat aggression associated with dementia, psychosis, and personality disorders.
Atypical antipsychotic agents such as clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa) have been effective in treating aggressive clients with dementia, brain injury, intellectual developmental disorder, and personality disorders.
Benzodiazepines can reduce irritability and agitation in older adults with dementia, but they can result in the loss of social inhibition for other aggressive clients, thereby increasing rather than reducing their aggression.
Haloperidol (Haldol) and lorazepam (Ativan) are commonly used in combination to decrease agitation or aggression and psychotic symptoms.
Atypical antipsychotics are more effective than conventional antipsychotics for clients demonstrating aggressive behavior and experiencing psychosis
the short-term use of seclusion or restraint may be required during the crisis phase of the aggression cycle to protect the client and others from injury.
Common problems when working with aggressive clients include Risk for violence Ineffective coping
If the client is intoxicated, depressed, or psychotic, additional problems may be identified
Practice drills for working with aggressive patients help ensure staff safety by preparing staff members.
t may be prudent for two staff members to approach the client together as a team, and techniques to de-escalate aggression should be learned.
Expected outcomes for aggressive clients may include The client will not harm or threaten others. The client will refrain from behaviors that are intimidating or frightening to others.	The client will describe their feelings and concerns without aggression. The client will comply with treatment.
. Bullying is defined as abusive conduct, such as verbal abuse, threatening, intimidating or humiliating behaviors, and work interference (sabotage), which prevents work from getting done
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	issued a sentinel event alert concerning “intimidating and disruptive behaviors
” that undermine a culture of safety and lead to errors, decreased patient satisfaction, preventable adverse outcomes, increased health care costs, and loss of qualified personnel
The Assaulted Staff Action Program (ASAP) was established in Massachusetts to help staff victims cope with the psychological sequelae of assaults by clients in community-based residential programs.
Raymond B. Flannery, Jr. studied assaults by clients in community residences, including physical or sexual assaults, nonverbal intimidation, and verbal threats
healthy anger can motivate change, assist with problem solving, and protect self
Assertive Communication is use with "I" statements such as "I feel frustrated when you interrupted"	assertive communication is healthy
Passive or aggressive communication is maladaptive
5 stages of Aggression Triggering=Anxiety Escalation=Yelling Crisis=Loss of Control Recovery=Regaining Control Postcrisis=Reconciliation
Nurses should use a calm voice, encourage feelings, and offer a quiet space with the Triggering phase
Nurses should set limits, reduce stimuli, and offer PRN medication with Escalation phase
Nurse should ensure safety and possible seclusion/restraints with the Crisis phase. (when someone is hurting themselves or others)
De-escalation steps before restraints
Haloperidol is for acute agitation (used for aggression)
Lorazepam (Ativan) is for severe anxiety/agitation (used for aggression)
Olanzapine is for psychosis/aggression (antipsychotic, used for aggression)
Lithium is bipolar aggression (for maintenance, used for aggression)
Signs of escalating violence are STAMP! Staring Tone/volume increased Anxiety Mumbling Pacing

Created by: Daarina Jones

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