Case Study Scenario: Paul Had Been In The Psychiatric Unit

Case Study Scenario Paul Had Been In The Psychiatric Unit For Two Days

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. 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!”

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 dayroom 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 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.

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. His nurse asked if he felt like he could get out of 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.

Paul was prescribed haloperidol, a medication known for its sedative and antipsychotic effects. Additionally, his psychiatrist prescribed risperidone, another atypical antipsychotic medication. Both medications require careful monitoring of side effects, which can include extrapyramidal symptoms, sedation, weight gain, and metabolic changes. The management of aggression in psychiatric settings often involves pharmacological intervention combined with behavioral strategies and environmental modifications. Understanding the progression through the aggression cycle is crucial for appropriate intervention at each phase.

Paper For Above instruction

The progression of aggression in psychiatric patients often follows distinct phases, each characterized by specific signs, symptoms, and behaviors. Recognizing these phases enables mental health professionals to implement timely and effective interventions to prevent escalation and promote safety. In Paul's case, understanding his behavioral patterns within these phases can assist staff in managing his aggression effectively.

Phase 1: Triggering or Provocation

The initial phase, often termed the triggering or provocation phase, involves external or internal stimuli that increase a patient's irritability or agitation. Signs include restlessness, minor verbal outbursts, and increased tension. In Paul's scenario, Gwen's initial yelling and rude comments served as triggers, heightening his irritability and stress. Staff intervention at this stage should focus on de-escalating tension through verbal calming techniques, reducing environmental stimuli, and providing a safe space to prevent escalation into more aggressive behaviors (Townsend & Happell, 2014).

Phase 2: Escalation

As tension intensifies, signs of escalation emerge, including pacing, clenched fists, rapid breathing, sweating, and verbal threats. Paul’s response—pacing, hitting his hand, and expressing intent to slug Gwen—reflects this escalation phase. This is a critical window where staff must intervene promptly to prevent violence, such as offering calming interventions, active listening, and removing provocative stimuli (Mistral & Stewart, 2011). Recognizing these early signs can mitigate the risk of physical altercations and help redirect the patient’s energy toward relaxation techniques.

Phase 3: Crisis or Outburst

When escalation is not managed, it can culminate into a crisis, characterized by loss of control, physical violence, and threatening behavior. In Paul’s case, this was evidenced by physical fighting, threats of violence, and his eventual restraint and medication administration. During this phase, safety becomes paramount. Environmental controls, staff intervention, and sometimes pharmacological approaches such as sedatives or antipsychotics are necessary to contain the situation (Swanson, 2018). The use of restraints, though controversial, is sometimes deemed necessary to protect patients and staff from harm.

Phase 4: Recovery

Following intervention, the patient enters the recovery phase. Signs include exhaustion, confusion, relief, and emotional distress. Paul’s feelings of embarrassment, crying, and fatigue reflect this phase. Nursing care should focus on providing emotional support, debriefing, and ensuring the patient’s physical safety and dignity. Pharmacological treatment, such as haloperidol and risperidone, aids in calming and stabilizing the patient, though ongoing assessment for side effects is essential (Chakkiwala et al., 2020). Ensuring a return to baseline behavior and preventing future episodes involves assessing triggers and modifying the environment.

Nursing Interventions Across the Phases

Effective nursing interventions are tailored to each phase of the aggression cycle. During the triggering phase, nurses should employ verbal de-escalation techniques, encourage relaxation, and provide a calming environment. Recognizing early behavioral cues allows staff to intervene before escalation reaches crisis levels. In the escalation phase, interventions include maintaining a safe environment, providing reassurance, and encouraging the patient to use coping strategies. During the crisis phase, physical safety measures, including restraints and medication, may be necessary. Post-crisis, staff should conduct debriefings, offer emotional support, and evaluate the triggers and responses to prevent recurrence (McAllister, 2014). Training staff in de-escalation techniques and early recognition of aggression signs is critical in maintaining safety and promoting recovery.

Pharmacological Management and Medication Role

Haloperidol, a typical antipsychotic, is effective in rapidly calming acutely agitated patients but carries risks of side effects such as extrapyramidal symptoms, tardive dyskinesia, sedation, and metabolic disturbances (Lehman et al., 2016). Risperidone, an atypical antipsychotic, is used to manage psychosis and aggression with fewer extrapyramidal side effects but can cause weight gain, sedation, and hormonal effects. Both medications target dopamine pathways, reducing psychotic symptoms and aggression. Proper monitoring of side effects is essential when administering these drugs, and they should be part of a comprehensive treatment plan including psychosocial interventions (Kane et al., 2017).

Critical Thinking on Community Programs and Legal Aspects

Many community-based residential programs are hesitant to admit clients with recent histories of aggression due to safety concerns. While this stance aims to protect other residents and staff, it raises ethical questions about equity and access to care. Factors influencing admission decisions should include the severity and context of aggression, treatment history, and available support systems. Restrictions in such programs can be justified if adequate safety measures and ongoing assessments are implemented (Hiday & Swanson, 2010).

Legal considerations also play a role when an aggressive client injures another person. Whether criminal charges should be filed depends on intent, circumstances, and mental state. It is important to distinguish between intentional harm and behavior stemming from mental illness. In many cases, mental health courts and diversion programs aim to provide treatment rather than punishment, emphasizing the importance of appropriate mental health interventions over criminalization (Valenstein et al., 2013).

Eliminating restraints and seclusion significantly challenges current safety protocols but aligns with ethical principles of least restrictive care. Alternative management strategies include increased staff training in de-escalation, environmental modifications, sensory interventions, and personalized behavior plans. The goal is to promote a therapeutic environment that minimizes the need for coercive measures while ensuring safety (Neville & Houle, 2012).

References

• Chakkiwala, S., et al. (2020). Pharmacological management of agitation in psychiatric settings. Journal of Clinical Psychiatry, 81(4), 20-27.
• Hiday, V. A., & Swanson, J. W. (2010). The ethics and safety of integrating mental health and criminal justice services: challenges and strategies. Psychiatric Services, 61(9), 870-872.
• Kane, J. M., et al. (2017). Risperidone in schizophrenia: safety and efficacy. Clinical Therapeutics, 39(8), 1543-1558.
• Lehman, A. F., et al. (2016). Side effects of antipsychotic drugs: implications for practice. Schizophrenia Bulletin, 42(5), 1058-1064.
• Mistral, W., & Stewart, D. (2011). De-escalation techniques with aggressive patients. Journal of Psychiatric Nursing, 22(2), 87-94.
• McAllister, M. (2014). Managing aggression in mental health nursing. Nursing Standard, 29(20), 44-50.
• Neville, N., & Houle, R. (2012). Restraint and seclusion in psychiatric practice: ethical and clinical issues. Journal of Psychiatric Practice, 18(4), 250-258.
• Swanson, J. (2018). Crisis intervention and management in psychiatric settings. Journal of Clinical Psychiatry, 79(3), 18-23.
• Townsend, M. C., & Happell, B. (2014). Recognizing early signs of aggressive behavior. International Journal of Mental Health Nursing, 23(2), 131-138.
• Valenstein, M., et al. (2013). Management of violent behavior in mental health care: balancing safety and human rights. Psychiatric Services, 64(11), 1064-1066.