Nursing Process for Client with Anger

    A. The Concept of Anger


    Anger is an emotion that stretched from irritability to aggresivitasexperienced by all people (Iyus Yosep,2009: 113). Usually, anger is a reaction to an unpleasant stimulus or threatening (Widjaya kusuma, 1992:423). Anger by stuart and sunden (1987: 363) is a nagging feeling that arises as a response to the anxiety that is felt as a threat (mind keliat ana, 1996: 5).

    Anger is an experiential state consisting of emotional, cognitive and physiological components that co-occur, rapidly interacting with and influencing each other in such a way that they tend to be experienced as a singular phenomenon. The individual also behaves in reaction to precipitating events and to experienced anger.

    Anger, a normal human emotional, is a strong, uncomfortable, emotional response to a real or perceived provocation(Thomas, 1998). Anger results when a person is frustrated, hurt , or afraid. Handled appropiately and expresseed assertively, anger can be positive force that helps a person to resolve conflicts, solve problems and make decisions. Anger energizes the body physically for self- defense, when needed, by activating the “fight-or- fligth” response mechanisms of the sympathetic nervous system.

    Disclosure of anger directly and constructively at the time there will be a relief to individuals and helping others to understand her true feelings. However, cultural factors should be considered so that the benefit of both parties can be achieved.

    Repressed anger, or pretended not to upset the client himself would complicate and interfere with interpersonal relationships. Many situations in life that lead to anger, such as a disturbed body functions and should be in the hospital, self-control which was taken over by others, suffering from illness, a role that can not be done because in the hospital, nursing services late and many other things can improve client emotions.

    The physiologic responses to the emotion depend on the type of anger being experienced. There are two predominant patterns of anger : active organized anger and helpless anger. Active anger is a physical and mental state in which the individual feels energized to use the angry feeling to correct the “wrong” or to retrieve what was lost. The person experiences the loss as a challenge that he or she has the power or strength to address. During the state of active or organized anger a person feel in mental control, there is heightening of skin color, respiration become fuller and the blood pressure and pulse are decreased.

    The physiological chages associated with anger expression are significant because are reflect cardiar reactivity in men that is associated with coronary heart disease. In other research, the opposite approach to anger—  repression — has been associated with essential hipertension and cardiac reactivity in woman ( Sigman et al.,2000). These chages are strongest in African Americans, who show longer- lasting cardiac reactivity to anger white research subject (Fredrickson et al., 2000)

    Clearly, the venting of anger management techniques are beneficial to many who struggle with anger control. These techniques are derived from two theoretical  bases.

    B.  Etiology

    1. Neurobiologic  theories

    Researchers have examined role of neurotransmiters in aggression in human , but they have ben unable to identify a single cause. Findings reveal that serotonin plays a major inhibitory role in aggressive behavior. This finding may be related to the anger attacks seen in some client with depression. In addition, increased activity of dopami and norepinephrin in the brain is assosiated with impulsively violent behavior ( Kavoussi et al., 1997)

    1. Psychosocial Theories

    Positive relationship with parent, teachers, and peers; success in school ; and the ability to be responsible for one’s self foster development of these qualities. Children in dysfunctional families wit a poor parenting , inconsistent responses to the child’s behavior and lower socioeconomic status are at increased risk of failing to development can result in a person wo is impulsive easily frustrated and prone to aggressive behavior.

    C.  Five Phase Aggression Cycle

    Phase Definition Sign, symptoms, and behaviors
    Triggering An event or cicumstances inthe enviroment initiates the client’s response, which is often anger or hostility Reslestsness, anxiety, irritability, pacing, rapid breathing, perspiration, loud voice, anger
    Escalation Client’s responses respresent escalating behaviors that indicate movement toward a loss of control Pale or flushesd face, yelling. Swearing, demanding, clencled fist,threatening gesture, hostility, loss of ability to solve the problem or think clearly.
    Crisis During a period of emotional and physical crisis, the cllient loses control Loss of emotional and physical control, throwing objects, kicking, hitting, spitting, bitting, scratching, shrieking, screaming, inability to communicated clearly.
    Recovery Client regains physical and emotional control Lowering of voice,decreased muscle tension, clearer, more rational communication, physical relaxation.
    Postricrisis Client attempts reconcliationwith others and returns to the level of functioning before the aggressive incident and its antecedents. Remorse , apologies, crying, quiet withdrawn behavior.

    Anger is not synonymous with aggression. Certainly, when angry, some individuals respond with physical and/or verbal assault. Others may engage in passive, indirect aggression. Aggression is common, but other possibilities abound. Some individuals, especially when anger is moderate, engage in adaptive behavior such as assertiveness, confiict management, problem-solving, limit setting, and appropriate disengagement such as the taking of a time out. Still others behave dysfunctionally, but not aggressively (for example, drive recklessly or become intoxicated).

    How one behaves when angry varies with many things, such as the situational context, cultural norms, intensity of anger, prior history in such situations, pre-anger state, and the like. How the person behaves, the consequences of behavior, and the variability of adaptive and maladaptive behavior across anger episodes should be assessed and integrated into treatment planning.

    D. Application of The Nursing Process

    • Assessment

    –               Overal assessment

    Client expression of anxiety and of anger generally look simillar.both may involve increased demands, iritability, frowning, redness, of the face, pacing, and twisting of the hand or clenching and unclenching of the fists. Speech either may be increased in rate and volume or may be slowed, pointed, and quiet.

    Some predictive factor of violence

    1. Signs and symptoms that usually (but not always) predictor of imminent violence (e.g.,pacing, restlessnes)
    2. Hyperactivity : most important predictor of imminent violence ( e.g., pacing , restlessness)
    3. Increasing anxietynandtension: clenched jaw orfist, rigid posture, fixed or tense facial expresion, mumbling to self (client may have sortness of breath, swating and rapid pulse)
    4. Verbal abuse: profanity, argumentatyveness
    5. Loud voice, change of pitch, or fery soft voice for cing others to strain to hear intence eye contact or avoidance of eye contact
      1. Recent acts of violence, including property violence
      2. Stone silence
      3. Alcohol or drug intoxication
      4. possession of a weapon or object that may be used as a weapon (e.g.,fork, knife, rock)
      5. milieu caracteristics conducife to violence:
        1. overcrouding
        2. staff inexperience
        3. provocative or controlling staff
        4. poor limit setting
        5. arbitrary revocation of privileges

    –       Self Assessment

    The nurse’s ability to intervence safely in situations of anger and potential violence depends on the nurse’s self-awarness. Without this awarness, nursing interventions are marked by impulsive or emotion-based responses, which are generally nontherapeutic and my be harmful. Self awarness includes knowledge of personal responses to anger and aggression, including choice of words and tone of voice, as well as nonverbal communication via body posture and facial expression awarness of the norms brought from the nurse’s own family and of norms brought from the larger society is also essencial.Finally, the nurse must assess situational factors (e.g., fatigue, insufficient staff) that may decrease normal competence in the management of complex client problems.

    Self – assessment promotes calm responses to client anger and potential aggression. These responses are further supported by use the following techniques :

    • Deep breathing
    • Relaxation of muscles that are not in use
    • Emphatetic interpretation of the client’s disstress
    • Review of intervention strategies
    • Review of prevention strategies
    Assessment guidelliness of anger and aggression

    1. A history of violence is the single best predictor of future violence.
    2. Client who are hyperactive, impulsive or predispose to irritability are at higher risk for violence.
    3. Assess client for violence
    • Does the client have a wish or intent to harm?
    • Does the client have a plan?
    • Does the client have means available to carry out the plan?
    • Does the client have demographic risk faktor : male gender, age 14 to 24 years, low socioeconomic status, low support system?
    1. Aggression by client occur most often inthe context o fthe limmit setting by the nurse.
    2. Client with a history of limited coping skills, including lack of assertivenes or use of intimidation, are at higher risk of using violence.
    3. Assess self for personal triggers and responses likely to escalate client violence, including client characteristic or situation that trigger impatience, irritation, or defensiveness.
    4. Asses personal sense of competence when in any situation of potential conflict ; consider asking for the assistance of another sraff member.

    Nursing diagnosis

    When potential aggression is identified, ineffective coping ( overwhelmed or maladaptive), risk for self directed violence and risk for other –directed violence are important nursing diagnoses.

    Client may have coping skills that are adequate for day-to-day events in thier lives but are overwhelmed by the stresses of illness or hospitalization. Other client may have a pattern of a set of coping that have been developed to meet unusual or extraordinary situation (e.g. abusive families).

    Ideally, intervention occurs at the point of inefective coping. Nurses work with client to support or teach ways of coping that will decrease anxiety and distress. However, client behavior may escalate quickly, or the client may mask early signs of distress. Nurses may be distracted and may miss those early signs, even when they are visible. Other cleint may be acutely intoxicated and not amenable to early nursing intervention. In these situation, the problem with anger may not be resolved before the risk for violence arises.

    Several possible nursing diagnoses :
    1. Difficulty expressing anger without hurting others, in connection with not knowing how to phrase that can be accepted, manifested in anger with a loud voice to people around.
    2. Communication disorders in relation to the feelings of anger toward the situation and the services received is manifested by insulting or blaming the nurse, such as “You should be here 1 hour ago”
    3. Adjustments are not effective in relation to the mengkonfrontrasi incapable of anger, manifested by saying rude words and excessive.
    4. Adjustments are not effective in relation to the rejection anger manifested by the words “I was never angry”
    5. Has the potential to rage at other people in connection with desire as opposed to hospital treatment, manifested by refusing to follow hospital rules and want to hit someone else.
    6. Has the potential to rage at other people in connection with the control functions of the brain affected by neurological disorders of the brain that is manifested by confusion and interpersonal hypersensitivity to stimuli.
    7. The prolonged strength angry with respect to new diagnostics, new situations and a lack of information.

    Outcome criteria

    The nursing outcomes classification outlines specific outcome criteria for use with angry and aggressive client(  Moorhead, Johnson & Maas, 2004). See table for selected potential outcomes for aggresive behavior.

    Aggression Self-Control ( NOC)
    Nursing outcome and definition Intermediate indicators Short- term indicator
    Aggression Self Control : Self – restraint of assaultive, combative, or destructive, behavior toward other Maintains self control without supervision

    Upholds contract to restrain aggressive behaviors.

    Identifies when angry

    Identifies when frustrated

    Communicates need appropriately

    Vents negative feelings appropriately

    Refrains from striking others

    Refrains from destroying property

    Uses specific techniques to kontrol anger


    Planning interventions necessitates having a sound assessment; for example, past history (previous actof violence, comorbid disorders), present coping skills and willingness and capacity of the client to learn alternative and nonviolent ways of handling angry feelings.

    Does the client have

    • Good coping skills but is presently overwhelmed?
    • Marginal coping skills and uses anger or violence as away to cover other feeling and gain a sense of mastery or control?
    • A neuropsikoticor chronic psychotic disorder and is prone to violence?
    • Cognitive deficits that predispose to anger in the form of misinterpretation of enviromental stimuli?

    Does the situation cal for

    • Psychotherapeutic approahes to teach the client new skills for handling anger?.
    • Immediate intervention to prevent overt violence( deescalation techniques, restraints or seclusion, and/ or medications)?

    Does the environment provide

    • Privacy for the client?
    • Enough space for client or is there overcrowding?
    • A healthy balance between structured time and quiet time?

    Do the skills of the staff call for

    • Additional education for staff in verbal deescalation techniques ?
    • Conseling of staff regarding use of punitive and arbitrary approaches to client?
    • Additional training in restraint techniques?


    Nursing intervention Rationale
    –       Build a trust relationship with this client as soon as possible, ideally well in advance of aggressive episodes –       Familiarity with and trust inthe staff members can decrease the client’s fears and facilitate communication
    –       Be aware of factors that increase the likelihood of violent behavior or that signify a build-up of agitation. Use verbal communication or PRN medication to intervene before the client’s behavior reaches a destructive or violent point and physical restraint becomes necessary. –       A period of building tension often precedes acting out or violent behavior; however, a client who is intoxicated or psychotic may become violent with out warning.

    –       Decrease environmental stimulation by turning stereo or television off or lowering the volume; lowering the light; asking other clients,visitors, or other to leave the area ( or you can go with the client to another room).

    –    If the client is feeling threathened, he or she can perceive any stimulus as a threat. The client is unable to deal with excess stimuli when agitated.

    –       If the client tells you(vernally or nonverbally) thet he or she is beginning to feel hostile, aggresive, or destructive,try to help the client express these feelings, verballly or physically, in nondestructive ways. –    The client may need to learn nondestructive ways to express feelings. The client can try out new behaviors with you in a non threathening environment and learn to focus on expressing emotions rather than acting out.
    –       Calmly and respectfully assure the client that you ( the staff) will provide control if he or she cannot control himself or herself, but do not threaten the client. –    The client may fear loss of control and will be reassured that control will be provide. The client may be afraid of what he or she may do if he or she begins to express anger.
    –       Always maintain control of your self and the situation ; reamin calm. If you do not feel competent in dealing the situation, obtain assistance as soon as posible. –    Your behavior provides a role model for the client and communicates that you can and will provide control.
    –       If you are not properly or skilled in dealing safely with a client who has a weapon, do  not attempt to remove the weapon. keep something ( like a pillow,mattress, or a blanket wrapped around your arm) between you and the weapon. –    Avoding personal injury, summoning help, leaving inthe area, or protecting other client may be the only things you can realistically do. You may risk further danger by attempting to remove a weapon or subdue an armed client.
    –       Do not use physical restraints or techniques with out sufficient reason. –    The client has a right to the fewest restrictions possible within the limits of safety and prevention of the destructive behavior.
    –       Remain aware of the client’s body space or territory ; do not trap the client. –    Potentially violent people have a body space zone much larger than that of the other people (up to four times as large)
    –       Talk with the client in a low, calm voice. You may ned to reorient the client; call the client by name ; tell the client your name and where you are, and so forth. –    Using a low voice may help to calm the client or prevent increasing agitation. The client may be disoriented or unaware of what is happening.
    –       Do not strike the client. –    Physical safety of the client is a priority
    –       Tell the client  where he or she is and that he or she will be safe. –    Being placed in seclusion or restraints can be terrifying to a client.
    –       Reassess the client’s need for continued seclusion or restraint as you observe him or her. Reorient the client or remind him or her of the reason for restraint if necessary. –    The client has a right to the least restrictions posible within the limits of safety and prevention of destructive behavior.
    –       Carefully observe the client and promptly complete charting and reports in keeping with hospital or unit policy. –    Acurate recording of information is essential in situations that may later be reviewed in court. Restraint , seclusion , assault, and so forth are situations that may result in legal action.
    –       Administer medications safely : take to prepare correct dosage. Identify correct sites for intramuscular administrations, withdraw plunger to aspirate for blood, and so forth –    When the client is agitated, you are in a stressful situation and under presure to move quickly.
    –       Monitor the client for effect of medications, and intervene as appropriate. –    Psychoactive drugs can have adverse effects such as allergic reactions, hypotension, and pseudoparkinsonian symptoms.


    Evaluation of the client should be based on the observation angry behavior and changes in subjective response to the client. Maynard and vhitty, 1979 (quoted from Stuart and Sundeen, 1987: 582) recommends a few questions on the evaluation:
    1. how do you feel about the experience?
    2. how other people respond to it?
    3. whether there is a chance for her confrontation?

    Focus of evaluation is how the expression of anger, rage accuracy, suitability of the object, an expression of equality with trigger anger and client awareness of the natural process, so that if the phase has been completed angry client can be through if the next phase until the disease can accept the situation and can use the adjustment effective.

    Other interventions that can be used as a therapy in an angry client

    –          Cognitive-behavioral interventions

    Cognitive-behavioral interventions target different elements in this working model. For instance, strategies that enhance self-awareness of anger can target the whole sequence. Clients may experience increased efficacy in lowering anger as they become able to initiate other coping strategies when they are aware of themselves and the triggers of their anger. Other strategies intervene between anger engendering events and responses to them. For example, an individual might appropriately (i) avoid anger-provoking events, (ii) distance one’s self in time from provocative cues, and (iii) take a time out.

    Relaxation interventions focus on emotional and physiological arousal, thus training clients to lower arousal and increase a sense of calmness and control, thereby increasing overall coping capacity. Cognitive therapy focuses on dysfunctional cognitive and cultural components of the pre-anger state, biased appraisal processes, and the cognitive component of experienced anger, and helps the individual identify and alter anger-engendering cognitive and schema themes. Self-instructional training and problem-solving address cognitive elements of

    anger, providing assistance in changing angry self-dialogue and guiding one’s self through angry events in a calmer, more task-focused manner.

    Communication, assertion, and confiict management skills are linked to changing the individuals’ appraisals of their ability to cope and dysfunctional ways of responding to inevitable interpersonal confiict. Finally, interventions combining various treatments target multiple sites in anger arousal. For example, cognitive, relaxation, assertion, and communication skills have been put together in effective combinations.

    Although these are but a few of the strategies that might be employed, they suggest how cognitive-behavior therapy can be adapted to anger reduction and target different elements thereof.  Interventions such as those described above are action- or change-oriented interventions. They assume that the client recognizes and accepts anger as a personal problem and is actively invested in anger reduction. This, however, is often not the case with angry clients, necessitating that cognitive-behavior therapy address two other important issue— stage of readiness and the therapeutic alliance.

    –          Insomatic Intervention

    Anger control assisstance

    Control of anger and escalating violence are an important part of psychiatric care. Anger control assistance is defined as a nursing intervention aimed at facilitation of the expression of anger in an adaptive and nonviolent manner ( Mc Closkey & Bulechek, 2000). For the psychiatric nurse, anger control includes establishing a basic level of trust and rapport with the client and using a calm and reassuring manne. The nurse should use every means possible to learn from the client ( or this family and friends) that situations are likely to bring on anger. Further, the nurse should encourage the client to let the nursing staff know when he is feeling tension. Although the nurse has a responsibility to help the client learn to deal with his anger, she also has a clear duty  to assess for inappropriate aggression and intervene before it is expressed.

    Some of the techniques used in anger control include limiting access to frustrating situations, providing physical outlets for expression of anger or tension( such us punching bags, large motors activities and use of anger journals), and ensuring that a client for whom anger is a problem is given enough personal space that he does not have to feel ancroachedon by others when he is unable to tolerate environmental stimuli. However, even when all of the techniques available are used to assist the client to remain in  control, there are times when the clients must be physically stopped from harming himself or others. there are two commonly used interventions for situations where the client is out of control : use of physical restraints and use of seclusion. These external controls may be used only when there its other option for protecting the client and others.


    Varcolis,Elizabeth M., Verna B. C.,&Nancy, C.S.(2006). Foundation of Psychiatric Mental Health Nursing: A Clinical Approach fifth edition .2006. Missouri : Saunders elsevier

    Yosep, Iyus. 2009. Keperawatan Jiwa. Bandung : PT Refika Aditama

    Barry, Patricia.D. (1998). Mental Health & Mental Illness: six edition. Philadelphia : Lippincot

    Antai Otong, Deborah.(1995). Psychiatric Nursing : Biological and Behavioral Concepts. Philadelphia: W.B Saunders Company

    Frisch, Noreen Cavan& lawrence E. Frisch. 2005. Psychiatric Mental Health Nursing,3rd edition 5. maxwell drive , clifton  park , NY : Thomson delmar learning

    Videbeck, Sheila L.(2004). Psychiatric Mental Health Nursing 2nd Edition. Philadelphia : Lippincot Williams & Wilkin.

    Deffenbacher ,Jerry L . (1999). Cognitive- Behavioral Conceptualization and Treatment of Anger . Journal of clinical psychology. Accessed from on the 16th December 2009


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