Questions based on the case study of Paul
ANSWER
Let’s address each question using Paul’s case study:
What stage of the aggressiveness cycle is Paul in?
Paul is at the escalation stage of the hostility cycle.
What are the symptoms and behaviors associated with this cycle?
Signs, symptoms, and behaviors of the escalation phase include increasing stress, pacing, clenched fists, fast breathing, perspiration, vocal agitation, and physical signs such as punching things or yourself.
Describe the nursing interventions for a client in this phase.
Nursing actions in the escalation phase are intended to de-escalate the situation and avoid further escalation. Strategies include:
Keeping a cool disposition.
Recognizing emotions and refocusing attention through therapeutic conversation.
Providing personal space while providing safety.
Offering PRN drugs as indicated for agitation.
Implementing environmental changes to decrease stimulation.
Which phase of hostility is Paul currently in?
Paul has reached the crisis phase of the aggressiveness cycle.
What are the symptoms and behaviors associated with this cycle?
Signs of the crisis phase include loss of control, aggressive physical behaviors (such as fighting), threats of damage, screaming, and efforts to injure oneself or others.
Describe the nursing interventions for a client in this phase.
Nursing interventions during the crisis period are centered on immediate safety and containment:
To manage a crisis, initiate a code or call for assistance.
If required, use physical restraint tactics to ensure safety.
To calm the client, administer rapid-acting medicines (such as haloperidol).
Creating a safe setting (for example, a seclusion chamber) to avoid harm.
Watch for indicators of de-escalation or escalation.
Which phase of hostility is Paul currently in?
Paul is in the post-crisis or recovery stage of the aggressiveness cycle.
What are the symptoms and behaviors associated with this cycle?
Signs of the post-crisis phase include reduced agitation, physical tiredness, guilt, melancholy, and possible acceptance of intervention.
Describe the nursing interventions for a client in this phase.
Nursing interventions in the post-crisis phase aim to help both mental and physical rehabilitation.
Allowing for rest and healing in a tranquil setting.
Offering reassurance and emotional support.
Encourages the expression of feelings and thoughts.
Monitor for indicators of ongoing distress or the need for additional assistance.
Debriefing or counseling should be initiated if needed.
Which phase of the aggressiveness cycle is Paul currently in?
Paul is still in the post-crisis phase, working for stabilization.
What are the symptoms and behaviors associated with this cycle?
Reflection, emotional processing, and a willingness to participate in therapeutic therapies are all signs of the post-crisis/stabilization period.
Describe the nursing interventions for a client in this phase.
Nursing interventions in the post-crisis/stabilization period emphasize long-term maintenance and prevention:
Working with the client to create a crisis prevention plan.
Educating the client and family on coping methods and medication adherence.
Referring to outpatient services and follow-up treatment.
Watch for indicators of relapse or recurrence of aggressive behavior.
Documenting the incident thoroughly to ensure continuity of care.
Which phase of the aggressiveness cycle is Paul currently in?
Paul is still in the post-crisis/stabilization period, reflecting on the occurrence and its ramifications.
What are the symptoms and behaviors associated with this cycle?
Emotional sensitivity, introspection, tiredness, and probable anguish about the occurrence are all warning signs.
Describe the nursing interventions for a client in this phase.
The nursing interventions in this phase aim to assist emotional stability and recovery.
Provide ongoing emotional support and validation of feelings.
Watch for signs of distress or depressive symptoms.
Providing opportunity for rehabilitative activities and counseling.
Encouraging self-care and good coping strategies.
Assessing discharge readiness and developing community reintegration plans.
Haloperidol belongs to what drug class? What are the potential adverse effects of this drug. What are the names of additional medications in this class?
Haloperidol is a typical antipsychotic drug from the butyrophenone class. Extrapyramidal symptoms (dystonia, akathisia, parkinsonism), sedation, anticholinergic effects (dry mouth, impaired vision), and neuroleptic malignant syndrome are all possible side effects. Fluphenazine and trifluoperazine are two other medicines in this class.
Risperidone belongs to what drug class? What are the potential adverse effects of this drug. What are the names of additional medications in this class?
Risperidone is an atypical antipsychotic drug in the benzisoxazole class. Weight gain, drowsiness, hyperprolactinemia, extrapyramidal symptoms (less severe than with normal antipsychotics), and metabolic impacts are all possible side effects. Other drugs in this category include olanzapine and quetiapine.
Many community-based residential programs will not accept clients with a recent history of aggressiveness. Is this fair to the client? What considerations should affect these decisions?
It might be argued that banning clients with a recent history of aggressiveness from community-based programs is not always fair because it limits them access to critical support and therapy. Factors that influence decisions should include:
Assessment of the client’s existing stability and the likelihood of future aggressiveness.
The residential program provides necessary support services and safety precautions.
Collaboration with mental health providers to create personalized care programs.
Consider the client’s right to treatment and the least restrictive environment.
If an aggressive client injures another client or a staff member, should criminal charges be pursued against them? Why, or why not?
The decision to seek criminal charges is based on the circumstances and severity of the incident. Legal concerns, including purpose and capacity at the time of the incident, should be considered. Mental health doctors, legal consultants, and institutional policies all play important roles in identifying the proper actions to promote safety and justice.
Many consumer and family support groups advocate for the total removal of constraints and seclusion. Is that realistic? How should aggressive/assaultive clients be managed without the use of restraints or seclusion?
While the goal of eliminating restraints and seclusion is desired, it may not be possible in all instances due to safety issues for both clients and personnel. Alternative approaches to controlling aggressive or assaultive individuals include:
Putting crisis prevention measures and de-escalation techniques into action.
Providing extensive staff training in trauma-informed care and behavioral management.
Using therapeutic communication and contextual changes to lessen triggers.
Providing other methods of intervention, such as sensory modification or relaxation techniques.
Advocating for structural improvements that will improve mental health care delivery while reducing the need for restrictive measures.
These comments provide a thorough explanation of the stages of the aggressiveness cycle, appropriate nurse actions, pharmaceutical information, and critical thinking concerns for treating violent conduct in a psychiatric context.
QUESTION
Case Study Scenario Paul had been in the psychiatric unit for two days. He has a history of anger since his traumatic brain injury (TBI) a few years ago. On the morning of Paul’s second day there, a new client was admitted. Her name was Gwen, and he heard the nurse say that she had psychosis with delusions. As soon as she saw Paul standing near her in the hallway, Gwen stared at him and began to yell. Paul felt instantly on edge. He tried to remain calm but could not understand why she had specifically targeted him. The staff calmed Gwen and distracted her attention. Paul voluntarily went to his room for some quiet time. Throughout the day every time Gwen saw Paul, she would say something hurtful. The nurse said, “She is confused, don’t let her upset you.” Paul tried not to let her comments bother him, but Gwen would not stop. He tried avoiding her, but she seemed to find him and would interrupt whatever he was doing to say rude comments. Even though the words didn’t always make sense, her intent was obvious. Paul became more irritated until he felt he might say something he shouldn’t. His goal was to be discharged soon, and he realized that out-of-control behavior would keep him in the hospital longer. He tried to ignore Gwen even when she kept insisting, he answered her questions and comments. 1. Which phase of the aggression cycle is Paul in? 2. What are the signs, symptoms, and behaviors of this cycle? 3. Explain the nursing interventions for a client in this phase? Paul started answering Gwen’s accusations. He tried telling her to stop. He tried reasoning with her, but that made no difference. He paced in the hallway, hitting his fist on his hand. He was breathing fast and perspiring. The nurse asked Paul what was going on. She said, “You seem tense, please tell me about it.” Paul replied, “If that woman doesn’t stop being rude, I’m going to slug her!” 4. Which phase of aggression is Paul in? 5. What are the signs, symptoms, and behaviors of this cycle? 6. Explain the nursing interventions for a client in this phase? That evening Paul felt weary with enduring Gwen’s taunts. She had threatened to “beat him up” which he didn’t think she could actually do. He was sitting at a table in the day room reading when Gwen came into the room. She went directly to him and made offensive comments. When he ignored her and wouldn’t look up, Gwen shoved him, hard. Paul jumped to a standing position from his chair. “Knock it off,” he said. Gwen punched him in the chest and then Paul lost control. He and Gwen were on the floor Mental Health Case Study #4 – Instructor’s version / answer sheet fighting. Other peers and staff pulled them apart. Paul felt so angry. He yelled at Gwen and threatened to kill her. He kept trying to get away from staff to attack her again. 7. Which phase of the aggression cycle in Paul in? 8. What are the signs, symptoms, and behaviors of this cycle? 9. Explain the nursing interventions for a client in this phase? Paul was put in the seclusion room with four-point restraints. Staff forced him to receive an injection. The nurse said, “This will help you calm down.” As the medication took effect, Paul did feel calmer. His tense muscles relaxed and he started to fall asleep. He no longer wanted to kill Gwen. 10. Which phase of the aggression cycle in Paul in? 11. What are the signs, symptoms, and behaviors of this cycle? 12. Explain the nursing interventions for a client in this phase? The nurse asked Paul if he felt like he could get out of the restraints and go to his room to rest on his bed. He nodded and went with staff to lie down. He was worrying about how this incident was going to stop him from getting discharged soon. He needed to get home so he could return to work as soon as possible. He apologized to the nurse; he realized he was crying. He thought maybe it was due to all the stress. He was embarrassed and felt so tired. He just stayed in his room the rest of the night. 13. Which phase of the aggression cycle is Paul in? 14. What are the signs, symptoms, and behaviors of this cycle? 15. Explain the nursing interventions for a client in this phase? Paul’s Medications The injection the RN gave to calm Paul down contained haloperidol. 16. What type of medication is this and which drug class? What are the side effects of this medication? What are the names of some other meds in this drug class? The new medication Paul’s psychiatrist in the hospital prescribed and started him on is risperidone. 17. What type of medication is this and which drug class? What are the side effects of this medication? What are the names of some other meds in this drug class? Answer the following from “Critical Thinking Questions” on p. 183 18. Many community-based residential programs will not admit a client with a recent history of aggression. Is this fair to the client? What factors should influence such decisions? 19. If an aggressive client injures another client or a staff person, should criminal charges be filed against the client? Why or why not? 20. Many consumer and family support groups support the total abolition of restraints and seclusion. Is that realistic? Without restraint or seclusion options, how should aggressive/assaultive clients be managed?
