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Anger/Aggression Management slideshare

Anger is a normal human emotion that is crucial for individual’s growth. When handled appropriately and expressed assertively, anger is a positive creative force that leads to problem solving and productive change.
When channeled inappropriately and expressed as verbal aggression or physical aggression, anger is destructive and potentially life threatening force.
it is critical that psychiatric nurses be able to assess patients at risk for violence and intervene effectively with patients before, during and after an aggressive episode.

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Anger/Aggression Management slideshare

  1. 1. ANGER/ AGGRESSION MANAGEMENT PRESENTED BY: Ms. Priyanka Kumari M.Sc. Nursing ( Mental Health Nursing)
  2. 2. SPECIFIC OBJECTIVES Define and differentiate between anger and aggression and violence. Explain theories of aggression. Enlist types of anger. Discuss the predisposing factors to the maladaptive expression of aggression. Explain the phases of aggression. Recognize the signs/symptoms of aggression/anger. Explain the nurses’ response to patient aggression. Explain about the management of anger/aggression. Apply the nursing process for the person who expressing anger or aggression.
  3. 3. ANGER Anger is a normal, healthy emotion that serves as a warning signal and alerts us to potential threat or trauma. Warren(1990) outlined some fundamental points about anger:  It Is physiological arousal.  Anger and aggression are significantly different.  Expression of anger is learned.  Expression of anger can come under personal control.
  4. 4. DEFINITION Anger is an emotional state that varies in intensity from mild irritation to intense fury and rage. It is accompanied by physiological changes, such as increase in heart rate, blood pressure and level of the hormones epinephrine and norepinephrine. – American Psychological Association, 2010
  5. 5. Aggression is behavior intended to threaten or injure the victim’s security or self-esteem. It means “to go”, “to attack”.  In Psychology, the term aggression refers to a range of behaviors that can result in both physical and psychological harm to oneself, other or objects in the environment.
  6. 6. Social psychologists define aggression as behavior that is intended to harm another individual who does not wish to be harmed. (Baron & Richardson, 1994) Violence is defined as “a physical act of force intended to cause harm to a person or an object and to convey the message that the perpetrator’s point of view is correct and not the victim’s.” (Harper-Jaques and Reimer, 1992)
  7. 7. Aggression is verbal statement that are intended to threaten. Aggression and violent behavior represent a continuum from suspicious behavior to extreme actions that threaten the safety of others or result in injury or death.
  8. 8. THEORIES ON AGGRESSION Biological theory Psychological theory Humanistic theory Social learning theory
  9. 9. BIOLOGICAL THEORY Current neurobiological research has focused on three areas of the brain believed to be involved in aggression: the limbic system, frontal lobe, hypothalamus.  Neurotransmitters also have been suggested as having a role the expression or suppression of anger or aggressive behavior.
  10. 10. LIMBIC SYSTEM (Amygdala, Frontal lobes and limbic system): Stimulation of the amygdala results in augmented aggressive behavior, while lesions of this area greatly reduce one's competitive drive and aggression.
  11. 11. FRONTAL LOBE: dysfunctions of frontal lobe will alter neurochemistry, neurometabolism.  Impaired function of the prefrontal cortex leads to aggression. Lesions in the frontal cortex are characterized by aggression, irritability and short tempers. Damage to the frontal lobes can result in impaired judgement, personality changes, problems in decision making, inappropriate conduct of aggressive outburst.
  12. 12. HYPOTHALAMUS: regulatory role. The hypothalamus causes aggressive behavior when electrically stimulated, but also has receptors that determine aggression levels through the neurotransmitters serotonin and vasopressin.
  13. 13. Stress raises the level of steroids, the hormone secreted by adrenal gland. Nerve receptors for these hormones become less sensitive in an attempt to compensate, and the hypothalamus tells the pituitary gland to release more steroids. After repeated stimulation, the system may respond more vigorously to all provocation. That may be one reason why traumatic stress in childhood may permanently enhance one’s potential for violence.
  14. 14. Testosterone has been shown to correlate with aggressive behavior in mice and in some humans. Progesterone, LH, and Prolactin increase aggression. Estrogen decreases aggression. Thyroid hormones: increase aggression. Serotonin: Low serotonin could contribute to aggressive behavior. Alcohol disinhibits an individual. Over half of all acts of rape occur while the aggressor is under the influence of alcohol.
  15. 15. PSYCHOANALYTICAL THEORIES Sigmund Freud is well known as the father of psychoanalysis. In his early theory, Freud asserts that human behaviors are motivated by sexual and instinctive drives known as the libido, which is energy derived from the Eros, or life instinct. Thus, the repression of such libidinal urges is displayed as aggression.
  16. 16. Later, Freud added the concept of Thanatos, or death force, to his Eros theory of human behavior. Contrary to the libido energy emitted from the Eros, Thanatos energy encourages destruction and death. In this conflict between Eros and Thanatos, some of the negative energy of the Thanatos is directed toward others, to prevent the self-destruction of the individual. Thus, Freud claimed that the displacement of negative energy of the Thanatos onto others is the basis of aggression.
  17. 17. According to Freud: Aggression may be due to impaired mother-child relationship (children of punitive parents are more aggressive) Aggression is developed during the oral stage when the pleasure of biting is added to that of sucking. Fixation on the oral stage of psychosexual development may lead to sadistic personality.
  18. 18. Aggression may be due to impaired development of superego. Aggression may be due to defense mechanisms:  Projection  Narcissism  Repression
  19. 19. LORENZ THEORY- THE EVOLUTIONARY THEORY OFAGGRESSION Lorenz looked at instinctual aggressiveness as a product of evolution. Aggressiveness is beneficial and allows for the survival, territory protection and success of populations of aggressive species since the strongest animals would eliminate weaker ones and over the course of evolution, the result would be a stronger, healthier population.
  20. 20. Adler’s view: Aggression is due to the striving for superiority and perfection. Mc Dougall’s view: Aggression is an instinct. A civilized man modifies and replaces physical aggression and destruction with sarcastic smiles, polished insulting words. Only when these methods fail, may the individual regress to the primitive and childish way of behavior.
  21. 21. HUMANISTIC THEORY Aggression is a drive (basic concept). It arises from deprivation of basic needs (Abraham Maslow) The drive theory attributes aggression to an impulse created by an innate need. In this theory, frustration and aggression are linked in a cause and effect relationship. Frustration is the cause of aggression and aggression is the result of frustration. Frustration may cause apathy, depression, anxiety, etc…
  22. 22. SOCIAL LEARNING THEORY Albert Bandura and his colleagues were able to demonstrate one of the ways in which children learn aggression. Bandura's theory proposes that learning occurs through observation and interaction with other people The experiment involved exposing children to two different adult models, an aggressive model and a non-aggressive one.
  23. 23. He predicted that children who observed an adult acting aggressively would be likely to act aggressively. Aggression is initially learned from social behavior and maintained by reward, which encourages the further display of aggression. Aggressive responses are acquired so they are evitable (optimistic).
  24. 24. Media violence: Although most young people who are exposed to violence in TV and movies and playing violent video games do not become violent criminals, they can become more open to acts of violence. However, media violence is explicitly not considered a causal influence of aggression, but in a combination with genetic and early social influences could have an influence.
  25. 25. TYPES: Instrumental Aggression Hostile Aggression Relational Aggression
  26. 26. Instrumental aggression: Aggression aimed at obtaining an object, privilege or space with no deliberate intent to harm another person. Typically of toddlers.
  27. 27. Hostile aggression: Aggression intended to harm another person such as hitting, kicking or threating to beat up someone.
  28. 28. Relational aggression: It is intended to harm others through deliberate manipulation of their social standing and relationships. According to Daniel Olweus it is a type of bullying.
  29. 29. Is harming others through purposeful manipulation and damage of their peer relationships or social status. It can be proactive (planned and goal oriented) and reactive (in response to perceived threats, hostility or anger).
  30. 30. OTHER TYPES: Verbal aggression. Physical aggression against others. Physical aggression against property or objects. Physical aggression against self.
  31. 31. PREDISPOSING FACTORS OF ANGER/AGGRESSION: Modeling Operant conditioning Neurophysiological disorders Biochemical factors Socioeconomic factors Environmental factors
  32. 32. MODELING Children model their behavior at a very early age after their primary caregivers, usually parents. How parents or significant others express anger becomes the child’s method of anger expression. Whether role modeling is positive or negative depends on the behavior of the models.
  33. 33. OPERANT CONDITIONING: A positive reinforcement is a response to the specific behavior that is pleasurable or produces the desired results. A negative reinforcement is a response to the specific behavior that prevents an undesirable result from occurring. Anger responses can be learned through operant conditioning.
  34. 34. NEUROPHYSIOLOGICAL DISORDERS Tumors in the brain, particularly in the areas of the limbic system and the temporal lobes; trauma to the brain, resulting in cerebral changes; and diseases, such as encephalitis, have all been implicated in the predisposition to aggression and violent behavior.
  35. 35. BIOCHEMICAL FACTORS Violent behavior may be associated with hormonal dysfunction caused by Cushing’s disease or hyperthyroidism Some research indicates that various neurotransmitters (e.g., epinephrine, norepinephrine, dopamine, acetylcholine, and serotonin) may play a role in the stimulation and inhibition of aggressive impulses.
  36. 36. SOCIOECONOMIC FACTORS An ongoing controversy exists as to whether economic inequality or absolute poverty is most responsible for violent behavior within this subculture.
  37. 37. ENVIRONMENTAL FACTORS Moderately uncomfortable temperature appears to be associated with an increase in aggression, while extremely hot temperatures seem to decrease aggression. A number of epidemiological studies have found a strong link between use of alcohol and violent behavior. Other substances, including cocaine, amphetamines, hallucinogens, and anabolic steroids, have also been associated with violent behavior.
  38. 38. PHASES OF AGGRESSION Triggering phase Escalation phase Crisis phase Recovery phase Post crisis phase Phases Of Aggression
  39. 39. Triggering phase: An event or circumstances in the environment initiates the client’s response, which is often anger or hostility. This is a circumstances where a person is still on a non- threatening manner. Which can be managed easily and without any hostile or aggressive behavior.
  40. 40. Escalation phase: The client’s responses represent escalating behaviors that indicate movement toward a loss of control. Here a man with a very high anger level will result to a pale or flushed face, yelling, agitated, showing threatening gestures such as clenching fist and even the ability to think clearly is loss.
  41. 41. Crisis phase: During this stage the man will loss his control and will react to the environment by: Kicking, Punching, Screaming, Throwing objects and he will have loss the ability to communicate clearly.
  42. 42. Recovery phase: As the person regains physical and emotional control the man is showing a more relaxed state by lowering his voice, has a decreased muscle tension and has more rational communication with others.
  43. 43. Post crisis phase: The man will attempt reconciliation for everything he has done. He will be very emotional that they apologize in a quiet yet crying behavior. In here the man can now be reintegrated to the environment to be more relaxed and emotionally stable.
  44. 44. SIGN AND SYMPTOMS OF AGGRESSION: IN TRIGGERING PHASE- Restlessness Anxiety Irritability Muscle tension Rapid breathing Perspiration Loud voice.
  45. 45. IN ESCALATION PHASE- Pale or flushed face Yelling Agitated Threatening Demanding Clenched fists Hostility, loss of ability to solve problems.
  46. 46. IN CRISIS PHASE- Loss of emotional and physical control Throwing objects Kicking, Hitting Spitting Biting, scratching Screaming Inability to communicate clearly.
  47. 47. IN RECOVERY PHASE- Lowering of voice Decreased muscle tension Clearer More rational communication and Physical relaxation.
  48. 48. IN POST CRISIS PHASE- Remorse Apologies Crying Quiet Withdrawn behavior.
  49. 49. NURSES’ RESPONSE TO ASSAULT: Response types are:  Affective  Cognitive and behavioral  Physiologic
  50. 50. Affective: Personal –  Irritability  Depression  Anger  Anxiety  Apathy
  51. 51. Professional-  Erosion of feelings of complete, leading increase anxiety and fear.  Feelings of guilt or self-harm.  Fear of potentially violent patient.
  52. 52. Cognitive and behavioral: Personal-  Suppressed thoughts of assault  Social withdrawal. Professional-  Reduced confidence in judgement.  Consideration of job change.
  53. 53.  Possible hesitation in responding to other violent situation.  Possible over-controlling.  Possible hesitation to report future assault.  Possible withdrawal from colleagues.  Questioning of capabilities by coworker.
  54. 54. Physiologic: Personal-  Disturbed sleep  Headache  Stomach aches  Tension Professional-  Increase absenteeism.
  55. 55. MANAGEMENT  The goal of anger management is to reduce both the emotional feelings and the physiological arousal that anger engenders.
  56. 56. General Principles of Management The safety of patient, clinician, staff, other patients and potential intended victims. The doors should be open outwards and not be lockable from inside or capable of being blocked from inside. One must take care to reduce accessibility to patients of movable objects, earrings, eyeglasses, lamps and pens. Adequate caregiver training.
  57. 57. Availability of appropriate supervision. Constant Observation in a calm and firm but respectful manner. Putting space between self and patient. Avoiding physical or verbal threats, false promises and build rapport with client. Training in basic self-defense techniques and physical restraint techniques are useful.
  58. 58. Environmental management: violence prevention Remove potential weapons from the environment. Search environment routinely to maintain it as hazard free. Search patient and belongings for weapons or potential weapons during admission. Monitor the safety of items.
  59. 59. Assign single room to patient. Place the patient in a room near a nursing station. Place patient in least restrictive environment. Provide plastic, rather than metal, clothes hanger as appropriate.
  60. 60. NURSING PROCESS: Assessment Anger Anger can be associated with a number of typical behaviors, including (but not limited to) the following:  Frowning facial expression.  Clenched fists.  Low-pitched verbalizations forced through clenched teeth.  Yelling and shouting.
  61. 61.  Intense eye contact or avoidance of eye contact.  Easily offended.  Defensive response to criticism.  Passive–aggressive behaviors.  Emotional over-control with flushing of the face.  Intense discomfort; continuous state of tension.
  62. 62. Anger has been identified as a stage in the grieving process. Individuals who become fixed in this stage may become depressed. Because of the negative connotation to the word anger, some clients will not acknowledge that what they are feeling is anger. These individuals need assistance to recognize their true feelings and to understand that anger is a perfectly acceptable emotion when it is expressed appropriately.
  63. 63. Aggression Aggression can arise from a number of feeling states, including anger, anxiety, guilt, frustration, or suspiciousness. Aggressive behaviors can be classified as:  Mild (e.g., sarcasm)  Moderate (e.g., slamming doors)  Severe. (e.g., threats of physical violence against others)  Extreme (e.g., physical acts of violence against others).
  64. 64. Aggression may be associated with (but not limited to) the following defining characteristics:  Pacing, restlessness.  Tense facial expression and body language.  Verbal or physical threats.  Loud voice, shouting, argumentative.  Threats of homicide or suicide.
  65. 65.  Increase in agitation, with over-reaction to environmental stimuli.  Panic anxiety, leading to misinterpretation of the environment.  Disturbed thought processes; suspiciousness.  Angry mood, often disproportionate to the situation.
  66. 66. Assessing Risk Factors Past history of violence. Client diagnosis. Current behavior.
  67. 67. DIAGNOSIS Ineffective coping related to negative role modeling and dysfunctional family system evidenced by yelling, name calling, hitting others, and temper tantrums as expressions of anger. Risk for self-directed or other-directed violence related to having been nurtured in an atmosphere of violence; history of violence
  68. 68. OUTCOME IDENTIFICATION The client: Is able to recognize when he or she is angry, and seeks out staff/support person to talk about his or her feelings. Is able to take responsibility for own feelings of anger. Demonstrates the ability to exert internal control over feelings of anger. Is able to diffuse anger before losing control.
  69. 69. Uses the tension generated by the anger in a constructive manner. Does not cause harm to self or others. Is able to use steps of the problem-solving process rather than becoming violent as a means of seeking solutions.
  70. 70. NURSING INTERVENTION Remain calm when dealing with an angry client. Set verbal limits on behavior. Clearly delineate the consequences of inappropriate expression of anger and always follow through:  Have the client keep a diary of angry feelings, what triggered them, and how they were handled.  Avoid touching the client when he or she becomes angry.  Help the client determine the true source of the anger.  It may be constructive to ignore initial derogatory remarks by the client.
  71. 71.  Help the client find alternate ways of releasing tension, such as physical outlets, and more appropriate ways of expressing anger, such as seeking out staff when feelings emerge.  Role model appropriate ways of expressing anger assertively.
  72. 72. Observe client for escalation of anger (called the prodromal syndrome):  Increased motor activity.  Pounding.  Slamming.  Tense posture, defiant affect.  Clenched teeth and fists, arguing,  Demanding, and challenging or threatening staff.
  73. 73. When these behaviors are observed, first ensure that sufficient staff are available to help with a potentially violent situation. Attempt to defuse the anger beginning with the least restrictive means. Techniques for dealing with aggression include:  Talking down. (Ensure that client does not position self between door and nurse.)  Physical outlets.
  74. 74. Medication: If agitation continues to escalate, offer client choice of taking medication voluntarily. If he or she refuses, reassess the situation to determine if harm to self or others is imminend.  Acute agitation and aggression:  Antipsychotics Eg. Ziprasidone IM.  Haloperidol- 0.5 to 10 mg IM.  Risperidone 0.5mg-1mg- In dementia and schizophrenia.
  75. 75.  Trazodone – 50-100mg . In older clients with sun downing syndrome and aggression.  Benzodiazepines Most commonly lorazepam, oral or injection.  Other sedating agents used include Valproate, chloral hydrate and diphenhydramine.
  76. 76.  Chronic aggression: When client continues to exhibit aggression more than several weeks’ choice of medication is based on underlying condition. I.e., if related to:  Antipsychotic- schizophrenia.  Anxiolytics- Buspirone  Carbamazepine and valproate to treat bipolar associated aggressive behaviour.  Antidepressants –trazodone in aggression associated with organic mental disorder.  Anti-hypersensitive medication – Propanolol to treat aggression related to organic brain syndrome.
  77. 77. Restraints: If client is not calmed by “talking down” or by medication, use of mechanical restraints and/or seclusion may be necessary. Be sure to have sufficient staff available to assist.  Physical restraints are any manual methods or physical or mechanical device attached to or adjacent to the patient’s body that she/he cannot easily remove and that restricts freedom of movement or normal access to one’s body, material or equipment.
  78. 78.  Chemical restraints are medications used to restrict patient’s freedom of movement or for emergency control of behaviour, but it is not a standard treatment for the patient’s medical or psychiatric condition.
  79. 79. Guidelines for use of restraints:  Restraints should be applied with care that not to injure a patient.  Adequate personnel must be assembled before the patient is approached.  Each staff member should be assigned responsibility for controlling specific body parts.  Restraints should be available and in working order.  Padding of cuff restraints helps to prevent skin breakdown. For the same the patient should be positioned in anatomical alignment.
  80. 80.  Restraints must not be used to punish a patient or solely following the convenience of staff or other patients.  Staff must take into consideration the medical/psychiatric status of patient.  Written policy must be followed.  Physical restraints should be used very sparingly and only after careful and comprehensive review.
  81. 81.  All mechanical restraints must be padded; proper size and type must be used.  Both the patient and restraining device must be checked frequently.  A restrained limb should be periodically exercised and, if possible the patient should be ambulated at reasonable intervals.  Attention to need for hydration, elimination, comfort, and social interaction must be assured.
  82. 82. Observation and documentation: Observe the client in restraints every 15 minutes (or according to institutional policy). Ensure that circulation to extremities is not compromised (check temperature, color, pulses). Assist client with needs related to nutrition, hydration, and elimination. Position client so that comfort is facilitated and aspiration can be prevented. Document all observations.
  83. 83. Ongoing assessment: As agitation decreases, assess client’s readiness for restraint removal or reduction. With assistance from other staff members, remove one restraint at a time, while assessing client’s response. This minimizes the risk of injury to client and staff.
  84. 84. Staff debriefing: It is important when a client loses control for staff to follow-up with a discussion about the situation. Debriefing is an important part of terminating the use of seclusion or restraints. Debriefing is a therapeutic intervention that includes reviewing the facts related to an event and processing the response to them. It provides the staff and patient with an opportunity to clarify the rational for seclusion, offer mutual feedback. Identify alternative, methods of coping that might help the patient avoid seclusion in the future.
  85. 85. Communication strategies The nurse should have to:  Present a calm appearance  Speak softly  Speak in a non proactive and non judgmental manner  Speak in a neutral and concrete way  Put space between yourself and patient  Show respect to the patient  Avoid intense direct eye contact
  86. 86.  Demonstrate control over the situation without assuming an overly authoritarian stance.  Facilitate the patient’s stance.  Listen to the patient  Avoid early interpretations  Do not make promises that cannot keep.
  87. 87. EVALUATION The following type of information may be gathered to determine the success of working with a client exhibiting inappropriate expression of anger:  Is the client able to recognize when he or she is angry now?  Can the client take responsibility for these feelings and keep them in check without losing control?
  88. 88.  Does the client seek out staff/support person to talk about feelings when they occur?  Is the client able to transfer tension generated by the anger into constructive activities?  Has harm to client and others been avoided?  Is the client able to solve problems adaptively without undue frustration and without becoming violent?
  89. 89. RESEARCH ARTICLE Anger Management among Medical Undergraduate Students and Its Impact on Their Mental Health and Curricular Activities by: Gayathri S. Prabhu, Department of Anatomy, Melaka Manipal Medical College, Manipal University, 12 July 2016
  90. 90. ABSTRACT Background: This study was intended to determine the practice of students in good anger management skills and to what extent their anger can affect their studies, work, and social interactions. Variable: In this study the relationship between anger management and the effects on the mental health of medical students was evaluated. Sampling technique: A survey was also done to determine duration of the feeling of anger which lasts among medical students and its consequences. Materials and Methods: A newly developed questionnaire was utilized which included a simplified version of the Novaco Anger Scale and Provocation Inventory and the modified Patient Health Questionnaire 9 (to measure the mental health).
  91. 91. Results: The data suggests that although students with high anger tendencies display poor mental health, there is no lowering of the mental health/PHQ-9 score as the anger management technique’s effectiveness rises. “Friends” was cited as the major triggering factor for anger, whereby the feelings can last for up to a day and somewhat affect their concentration on normal activities. Conclusion: When anger is suppressed and not let out, it can be an underlying factor for anxiety and depression. Therefore, more emphasis needs to be placed on educating students on how to manage their anger especially in a stressful environment away from home.
  92. 92. SUMMARY Today we had discussed about anger and aggression, its’s predisposing factors, various stages, sign and symptoms, nurse’s response toward aggression and management.
  93. 93. CONCLUSION Anger is a normal human emotion that is crucial for individual’s growth. When handled appropriately and expressed assertively, anger is a positive creative force that leads to problem solving and productive change. When channeled inappropriately and expressed as verbal aggression or physical aggression, anger is destructive and potentially life threatening force.
  94. 94. Patients admitted to an inpatient psychiatric unit are usually in crisis, so their coping skills are even less effective. During these times of stress acts of physical aggression or violence can occur. Nurses spends more time in the inpatient unit than any other disciplines, so they are more at risk of being victims of acts of violence by patients. For these reasons, it is critical that psychiatric nurses be able to assess patients at risk for violence and intervene effectively with patients before, during and after an aggressive episode.
  95. 95. BIBLIOGRAPHY  R Sreevani A Guide to Mental Health and Psychiatry Nursing JAYPEE Publications 2nd edition page no- 242-243  Psychiatric Nursing Contemporary Practice Mary Ann Boyd Lippincott Publications 2nd edition Page no: 950-970  Psychiatric mental health nursing concepts of care in Evidence-Based practice Mary C. Townsend JAYPEE Publications 8th edition Page no: 262-271  Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry .9th ed. Hong Kong :William and Wilkinson Publishers;1998.  Stuart GW, Laria MT. Principles and Practices of Psychiatric Nursing. Ist ed. Philadelphia: Mosby Publishers; 2005. Page no- 630-651.  https://www.hindawi.com/journals/edri/2016/7461570/  https://www.slideshare.net/MenanRabie/psychology-of-aggression  https://www.slideshare.net/ > sunilkumar3828/theories-of-aggression-141218680
  96. 96. THANK YOU
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Anger is a normal human emotion that is crucial for individual’s growth. When handled appropriately and expressed assertively, anger is a positive creative force that leads to problem solving and productive change. When channeled inappropriately and expressed as verbal aggression or physical aggression, anger is destructive and potentially life threatening force. it is critical that psychiatric nurses be able to assess patients at risk for violence and intervene effectively with patients before, during and after an aggressive episode.


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