Psychiatric Mental Health Nursing by Videbeck

10 ANGER, HOSTILITY, ANDAGGRESSION 197

If the client is intoxicated, depressed, or psychotic,

additional nursing diagnoses may be indicated.

Outcome Identification

Expected outcomes for aggressive clients may include

the following:

1. The client will not harm or threaten others.


2. The client will refrain from behaviors that
   are intimidating or frightening to others.


3. The client will describe his or her feelings
   and concerns without aggression.


4. The client will comply with treatment.

Intervention

Hostility or verbally aggressive behavior can be in-

timidating or frightening even for experienced nurses.

Clients exhibiting these behaviors are also threaten-

ing to other clients, staff, and visitors. In social set-

tings, the most frequent response to hostile people is to

get as far away from them as possible. In the psychi-

atric setting, however, engaging the hostile person in

dialogue is most effective to prevent the behavior from

escalating to physical aggression.

Interventions are most effective and least restric-

tive when implemented early in the cycle of aggression.

This section presents interventions for the manage-

ment of the milieu (which benefit all clients regardless

of setting) and specific interventions for each phase of

the aggression cycle.

MANAGING THE ENVIRONMENT

It is important to consider the environment for all

clients when trying to reduce or eliminate aggressive

behavior. Planned activities or groups such as card

games, watching and discussing a movie, or informal

discussions give clients the opportunity to talk about

events or issues when they are calm. Activities also

engage clients in the therapeutic process and min-

imize boredom. Scheduling one-to-one interactions

with clients indicates the nurse’s genuine interest

in the client and a willingness to listen to the client’s

concerns, thoughts, and feelings. Knowing what to

expect enhances the client’s feelings of security.

If clients have a conflict or dispute with one an-

other, the nurse can offer the opportunity for prob-

lem solving or conflict resolution. Expressing angry

feelings appropriately, using assertive communication

statements, and negotiating a solution are important

skills clients can practice. These skills will be useful for

the client when he or she returns to the community.

If a client is psychotic, hyperactive, or intoxi-

cated, the nurse must consider the safety and security

of other clients, who may need protection from the in-

trusive or threatening demeanor of that client. Talk-

ing with other clients about their feelings is helpful,

and close supervision of the client who is potentially

aggressive is essential.

MANAGING AGGRESSIVE BEHAVIOR

In the triggering phase,the nurse should approach the

client in a nonthreatening, calm manner. Conveying

Table 10-2

FIVE-PHASEAGGRESSIONCYCLE

Phase Definition Signs, Symptoms, and Behaviors

Triggering

Escalation

Crisis

Recovery

Postcrisis

Restlessness, anxiety, irritability, pacing, muscle

tension, rapid breathing, perspiration, loud

voice, anger

Pale or flushed face, yelling, swearing, agitated,

threatening, demanding, clenched fists, threat-

ening gestures, hostility, loss of ability to solve

the problem or think clearly

Loss of emotional and physical control, throwing

objects, kicking, hitting, spitting, biting, scratch-

ing, shrieking, screaming, inability to communi-

cate clearly

Lowering of voice, decreased muscle tension,

clearer, more rational communication, physical

relaxation

Remorse, apologies, crying, quiet withdrawn

behavior

An event or circumstances in the environment

initiates the client’s response, which is

often anger or hostility.

Client’s responses represent escalating

behaviors that indicate movement toward a

loss of control.

During a period of emotional and physical

crisis, the client loses control.

Client regains physical and emotional control.

Client attempts reconciliation with others and
returns to the level of functioning before
the aggressive incident and its antecedents.
Adapted from Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (1999). Psychiatric nursing(3d ed.). St. Louis:
Mosby, Inc.