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Chapter 21
Anger
and
Aggression
Anger and aggression
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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
Prevalence and community
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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
Theory
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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
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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
Cultural considerations
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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)
Application of nursing process
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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
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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)
Application of nursing process
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Implementation
 Ensure
safety
 Stages of Violence Cycle
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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
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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
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Implementation
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Pharmacological, Biological & Integrative Therapies
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Medications for acute aggression
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Medications for chronic aggression
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Atypical antipsychotics/ Typical antipsychotics
Benzodiazepines
Carbamazepine (Tegretol)
Beta-blockers
Buspar
Lithium
Anticonvulsants (Lamictal)
Evaluation
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Care plan with specific outcome criteria and review essential
 Provides info about the extent to which interventions have achieved
the outcomes