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When ED staff at University of California at Irvine Medical Center in Orange were about to search an agitated patient, he pulled a knife out and began cutting his wrist. "He said that voices were telling him to do it," recalls Sherlene Shepp, RN, MICN, clinical nurse supervisor, who ordered the patient to close the knife and throw it on the ground. "He waited a second, looked at me and asked, If I do it, will you sit down and talk to me?’ she recalls. Shepp agreed, and just as the police arrived, he closed the knife and threw it on the floor. She then went into the room and sat and talked to the patient.
The patient continued to cooperate throughout his stay in the ED. "I think he did so because we were honest, direct, and followed through with what we said," says Shepp. "Luckily, the knife was dull and did little damage."
When a patient is in a crisis, it might help to give them options, recommends Shepp. "If you approach them and say, I am going to do this,’ they get defensive," she says. "Instead, say, I don’t want you to hurt yourself or the team,’ then give them options."
Here are ways to give choices to agitated patients:
• Determine what is upsetting the patient. Patients in crisis are scared from being out of control and possibly bad past experiences, she says. "Ask patients if they feel they need medication, if they are hungry, or if they want to talk," Shepp suggests.
When one patient was lashing out because he was afraid to get medicated, Shepp informed the patient that he decides whether he gets medicated. "By being violent, of course they would medicate him. But if he was cooperative, we would not force him to take something he did not want," she says. " He asked, I really have a choice?’ I told him, Yes.’" The man agreed to talk to the doctor calmly and then take a nap, says Shepp. "He was transferred to an inpatient bed without incident," she reports. "Just remember that these patients are as scared as you are. If you respect the patient, it goes a long way."
• Be direct. An agitated patient has conflicting feelings and ideas, notes Shepp. "This is a time when they need structure," she advises. In addition to giving patient options, you need to be direct, Shepp says. "For example, I will tell a patient, I will not allow you to hurt yourself or the staff. Would you like medication to help relax you?’" You have to set limits and stick to what you say, Shepp adds. "If this patient was to escalate, I would ask him to remain in one area, and tell him if he cannot do that or won’t take medications, physical restraints may be needed," she explains.
• Be honest about what will occur if the patient is violent. Shepp never tells patients they won’t be restrained. "I always let them know that we will protect them no matter what," she says. "I am very honest that their behavior is what decides what measures we have to take."
• Take the patient seriously. Shepp recalls seeing nurses and physicians walk out of patients’ rooms laughing over the situation. "I feel that if everyone remembered that this patient could be his or her loved one, it would really help," she says. "Also remember that some of your patients may be hearing voices already or paranoid, and this would only escalate them." Give an agitated patient the same respect, dignity, and confidentiality that you’d provide any ED patient with, Shepp stresses.
• Avoid physical harm if a patient does become violent. "You need to know where the exits are and have a clear path to get away from someone if you need to," says Diane Presley, RN, MSN, director of nursing for emergency services/critical care at Seton Medical Center in Austin, TX. Determine if there are any potential weapons in the room, Presley advises. "If the patient is in restraint, know which limbs are restrained," she suggests. Keep a safe distance from a potentially violent patient or visitor and know how to summon help, recommends Presley. "Predefined codes can alert the team to situations where immediate assistance is required," she says.
Many violent individuals decompress at this point, says Presley. "The team leader should speak in a organized manner with a calm voice," she notes. "Be sure that staff have removed jewelry, stethoscopes, scissors, and pens that could be used as weapons against them."
For more information on management of potentially violent patients, contact:
• Diane Presley, RN, MSN, Director of Nursing, Emergency Services/Critical Care, Seton Medical Center, 1201 W. 38th St., Austin, TX 78705. Telephone: (512) 324-1031. Fax: (512) 324-1401. E-mail: DPresley@seton.org.
• Sherlene Stepp, RN, MICN, Clinical Nurse Supervisor III, UCI Medical Center, 101 The City Drive, Route 128, Orange, CA 92868. Telephone: (714) 456-6549. Fax: (714) 456-5390. E-mail: firstname.lastname@example.org.