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?
