196 Unit 3 CURRENTSOCIAL ANDEMOTIONALCONCERNSFor aggressive clients with psychoses, the cocktail
or chaser approach may be used to produce rapid se-
dation. The cocktail method involves giving two med-
ications, usually haloperidol (Haldol) and lorazepam
(Ativan), in successive doses until the client is se-
dated. The first dose is given at the time of the ag-
gressive behavior, a second dose is given 30 minutes to
1 hour after the behavior, and a third dose is given 1 to
2 hours after the behavior. The chaser approach in-
volves giving only lorazepam at the specified time in-
tervals, followed by an antipsychotic medication after
the client is sedated with the lorazepam (Hughes,
1999) (Table 10-1). Both methods require careful as-
sessment for the development of extrapyramidal side
effects, which can be quickly treated with benztropine
(Cogentin). Chapter 2 provides a full discussion of
these medications and side effects.
Although not a treatment per se, 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. Many legal and ethical
safeguards govern the use of seclusion and restraint
(see Chap. 9).
APPLICATION OF THE
NURSING PROCESS
Assessment and effective intervention with angry or
hostile clients can often prevent aggressive episodes.
Early assessment, judicious use of medications, and
verbal interaction with an angry client can often pre-
vent anger from escalating into physical aggression.Assessment
The nurse should be aware of factors that influence
aggression in the psychiatric environment (unit mi-
lieu). Shepherd and Lavender (1999) found that ag-
gressive behavior was less common on psychiatric
units with strong psychiatric leadership, clear staff
roles, and planned and adequate events such asstaff–client interaction, group interaction, and activ-
ities. Conversely, when predictability of meetings or
groups and staff–client interactions were lacking,
clients often felt frustrated and bored and aggression
was more common and intense. Lepage, et al. (2000)
found an association between increased numbers of
young adults (18 to 20 years of age) on inpatient psy-
chiatric units and higher rates of violence. Nijman
and Rector (1999) discovered that lack of psychologi-
cal space—having no privacy, being unable to get suf-
ficient rest—may be more important in triggering ag-
gression than a lack of physical space.
In addition to assessing the unit milieu, the nurse
needs to assess individual clients carefully. A history
of violent or aggressive behavior is one of the best pre-
dictors of future aggression. Determining how the
client with a history of aggression handles anger and
what the client thinks is helpful is important in as-
sisting him or her to control or nonaggressively man-
age angry feelings. Clients who are angry and frus-
trated and believe that no one is listening to them
are more prone to behave in a hostile or aggressive
manner.
The nurse should assess the client’s behavior to
determine which phase of the aggression cycle he or
she is in so that appropriate interventions can be im-
plemented. The five phases of aggression and their
signs, symptoms, and behaviors are presented in Table
10-2. Assessment of clients must take place at a safe
distance. The nurse can approach the client while
maintaining an adequate distance so the client does
not feel trapped or threatened. To ensure staff safety
and exhibit teamwork, it may be prudent for two
staff members to approach the client.Data Analysis
Nursing diagnoses commonly used when working
with aggressive clients include the following:- Risk for Other-Directed Violence
- Ineffective Coping
Table 10-1
RAPIDTRANQUILIZATION OF THEACUTELYAGGRESSIVEPSYCHOTICCLIENT
30 Minutes to 1 Hour 1 to 2 Hours
At the Time of the Behavior After the Behavior After the BehaviorCocktailChaser*Lorazepam 1–2 mg PO or IMHaloperidol 5–10 mg PO or IMLorazepam 1–2 mg PO or IMLorazepam 1–2 mg PO or IM;
total dose of 3–6 mg
Haloperidol 5–10 mg PO or
IM; total dose of 15–30 mg
Lorazepam 1–2 mg PO or IM;
total dose of 3–6 mgLorazepam 1–2 mg PO or IM;
total dose of 2–4 mg
Haloperidol 5–10 mg PO or IM;
total dose of 10–20 mg
Lorazepam 1–2 mg PO or IM;
total dose of 2–4 mg
*Redosing is for clients who have not achieved sedation from the previous dose of medication. When the client
becomes sedated, then antipsychotic medication is offered. (Hughes, D. H. [1999]. Acute psychopharmacologi-
cal management of the aggressive psychotic patient. Psychiatric Services, 50[9], 1135–1137.) © 1999, American
Psychiatric Association. Reprinted with permission.