PROTECTIVE FUNCTIONS

Common Behavioral Problems

1. Anger
1. Definition: feelings of resentment in response to anxiety when threat is perceived; need to discharge tension of anger.
2. Assessment:
1. Degree of anger and frequency: scope of anger ranges on a continuum from everyday mild annoyance —> frustration from interference with goal accomplishment —> assertiveness (behavior used to deal with anger effectively) —> anger related to helplessness and powerlessness that may interfere with functioning —> rage and fury, when coping means are depleted or not developed.
2. Mode of expression of anger
1. Covert, passive expression of anger: being overly nice; body language with little or no eye contact, arms close to body, soft voice, little gesturing; sarcasm through humor; sublimation through art and music; projection onto others; denying and pushing anger out of awareness; psychosomatic illness in response to internalized anger, e.g., headache.
2. Overt, active expression of anger: physical activity to work off excess physical energy associated with biological response (e.g., hitting a punching bag, taking a walk); aggression, assertiveness.
3. 3 Physiological behaviors - result of secretion of epinephrine and sympathetic nervous system stimulation preparing for fight-flight.
1. Cardiovascular response: increased blood pressure and pulse, increased free fatty acid in blood.
2. Gastrointestinal response: increased nausea, salivation, decreased peristalsis.
3. Genitourinary response: urinary frequency.
4. Neuromuscular response: increased alertness, increased muscle tension and deeptendon reflexes, ECG changes.
4. Positive functions of anger
1. Energizes behavior.
2. Protects positive image.
3. Provides ego defense during high anxiety.
4. Gives greater control over situation.
5. Alerts to need for coping.
6. A sign of a healthy relationship.
3. Analysis/nursing diagnosis: defensive coping related to source of stress (stressors):
1. Biological stressors - instinctual drives (Lorenz, on aggressive instincts, and Freud), endocrine imbalances, seizures, tumors, hunger, fatigue.
2. Psychological stressors - inability to resolve frustration that leads to aggression; real or imagined threatened loss of self-esteem; conflict, lack of control; anger as a learned expression and a reinforced response. Prolonged stress; an attempt to protect self; a desire for retaliation; a normal part of grief process.
3. Sociocultural stressors - lack of early training in self-discipline and social skills; crowding, personal space intrusion; role modeling of abusive behavior by significant others and by media personalities.
4. Nursing care plan/implementation long-term goals: constructive use of angry energy to accomplish tasks and motivate growth.
1. Prevent and control violence.
1. Approach unhurriedly.
2. Provide atmosphere of acceptance; listen attentively, refrain from arguing and criticizing.
3. Encourage expression of feelings.
4. Offer feedback of client’s expressed feelings.
5. Encourage mutual problem solving.
6. Encourage realistic perception of others and situation and respect for the rights of others.
2. Limit setting:
1. Clearly state expectations and consequences of acts.
2. Enforce consequences.
3. Encourage client to assume responsibility for behavior.
4. Explore reasons and meaning of negative behavior.
3. Promote self-awareness and problem-solvmg abilities. Encourage and assist client to:
1. Accept self as a person with a right to experience angry feelings.
2. Explore reasons for anger.
3. Describe situations where anger was experienced.
4. Discuss appropriate alternatives for expressing anger (including assertiveness training).
5. Decide on one feasible solution.
6. Act on solution.
7. Evaluate effectiveness.
4. Health teaching:
1. Explore other ways to express feelings, and provide activities that allow appropriate expression of anger.
2. Recommend that behavioral limits be set (by the family).
3. Explain how to set behavioral limits.
4. Advise against causing defensive patterns in others.
5. Evaluation/outcome criteria:
1. Demonstrates insight (awareness of factors that precipitate anger; identifies disturbing topics, events, and inappropriate use of coping mechanisms).
2. Uses appropriate coping mechanisms.
3. Reaches out for emotional support before stress level becomes excessive.
4. Evidence of increased reality perception and problem-solving ability.


2. Combative-aggressive behavior
1. Definition:acting out feelings of frustration, anger, anxiety, etc. through physical or verbal behavior.
2. Assessment: recognize precombative behavior:
1. Demanding, fist clenching.
2. Boisterous, loud.
3. Vulgar, profane.
4. Limited attention span.
5. Sarcastic, taunting, verbal threats.
6. Restless, agitated, elated.
7. Frowning.
3. Analysis/nursing diagnosis: risk for self-injury and violence directed at others related to:
1. Frustration as response to breakdown of selfcontrol coping mechanisms.
2. Acting out as customary response to anger (defensive coping).
3. Confusion (sensory/perceptual alterations).
4. Physical restraints, such as when postoperative patient discovers wrist restraints.
5. Fear of intimacy, intrusion on emotional and physical space (altered thought processes).
6. Feelings of helplessness, inadequacy (situational or chronic low self-esteem).
4. Nursing care plan/implementation:
1. Long-term goal: channel aggression - help person express feelings rather than act them out.
2. Immediate goal: prevent injury to self and others.
1. Calmly call for assistance; do not try to handle alone.
2. Approach cautiously. Keep client within eye contact, observing client’s personal space.
3. Protect against self-injury and injury to others; be aware of your position in relation to the weapon, door, escape route.
4. Minimize stimuli, to control the environment - clear the area, close doors, turn off TV so person can hear you.
5. Divert attention from the act; engage in talk and lead away from others.
6. Assess triggering cause.
7. Identify immediate problem.
8. Focus on remedy for immediate problem.
9. Choose one calm, quieting individual to interact with person; nonauthoritarian, nonthreatening.
10. Maintain verbal contact to keep communication open; offer empathetic ear, but be firm and consistent in setting limits on dangerous behavior.
11. Negotiate, but do not make false promises or argue.
12. Restraints may be necessary as a last resort.
13. Place person in quiet room so he or she can calm down.
3. Health teaching:
1. Explain how to obtain release from stress and how to rechannel emotional energy into acceptable activity.
2. Advise against causing defensive responses in others.
3. Explain what is justifiable aggression.
4. Emphasize importance of how to recognize tension in self.
5. Explain why self-control is important.
6. Explain to family, staff, how to set behavioral limits.
7. Explain causes of maladaptive coping related to anger.
8. Teach how to use problem-solving method.
5. Evaluation/outcome criteria:
1. Is aware of causes of anger; can recognize the feeling of anger and use alternative methods of expressing anger.
2. Expression of anger is appropriate, congruent with the situation.
3. Replaces aggression and acting out with assertiveness.