Aggressive patients?

[NanikRN]

Had a pt last week that was admitted with aggressive behavior. He came to out acute care med-surg unit after an escalated situation at the nursing home He is not allowed back there

I spent a significant part of my day hovering around his room so I could caution dietary, lab, transport , our chaplain , etc to be careful with body positioning and avoid placing them self in a vulnerable position.

In general I think everyone is careful but you really wouldn't guess by conversing with this guy that he might be a potential threat.

Finally for my questions i just thought the above would put them more in context

Do any of you use some type of identifier on pt doors (or otherwise ) that would alert any staff to be cautious? If so, what kind of patient criteria do you use? How do you explain the identifier to the patient and family?

I'd appreciate hearing how other facilities handle this issue--thanks

[NanikRN]

Anyone?

[classicdame, MSN, EdD]

we tried that once - having a colored magnet on the door frame. Of course the family/patient asked what did it mean and then they were insulted.

[Wile E Coyote, ASN, RN]

we tried that once - having a colored magnet on the door frame. Of course the family/patient asked what did it mean and then they were insulted.

Yep, whatever indicator that's used will eventually ruffle some feathers, so it'll only work with your leadership's backing.

[Esme12, ASN, BSN, RN]

what was the incident? what made him escalate? Try not to repeat the incident...find the root cause.

We will place notice on the door for visitors/staff etc to check with nursing station before entering room. We try to limit people in the room and explain to the family it is to prevent from people/strangers from upsetting them. We try to limit the assignment with these patients to allow the CNA more time to watch them.

[Wile E Coyote, ASN, RN]

We use the generic "check with nurse before entering" as well.

[jadelpn, LPN, EMT-B]

Hopefully, the patient would be assessed and have medication changes that could help with aggressive behaviors. Perhaps the patient has a UTI or other infectious process when brought under control, the behavior is as well. Any patient at any time has the ability to lash out. We should all be mindful of personal space.

If the patient is that much of a threat, why not a sitter? That way, you won't have to hover. As far as signs or other indicators, I agree that most families have a fit if they find out why it is so. Some facilities make use of a plastic bracelet, much like fall risk and allergy--this one is orange.

[SL2014]

We get a little gray triangle thing on the top of the EMR, which indicated past violent behavior with medical staff.

Honestly though its not a huge help. VERY rarely will a person just be chilling in their room then freak out and punch someone for no reason. Usually there's some kind of preceding agitation... that's your identifier. I've had totally "normal" people become aggressive many times and people with paranoid schizophrenia be cool as a cucumber. You never know, just be ready for it with everyone.

[Overland1, RN]

Yep, whatever indicator that's used will eventually ruffle some feathers, so it'll only work with your leadership's backing.

Where I work (and probably in many other places), in due time, a visitor will likely remove the magnet to take home for the refrigerator magnet collection.

I wish I were totally kidding...

More seriously, staff in general should be notified via report if the person is really that unstable and likely to act out with aggression. In some cases, a rather benign trigger brings out this behavior, like being startled by a staff member who enters the room and speaks to the patient at close range.

Staying out of reach of the patients hands, and never standing within "kick range" are important considerations. I also teach staff to "never allow such a patient get between you and the door", and to never turn your back on such patients (aka, "watch your six")

Many hospitals teach TCI (Therapeutic Crisis Intervention), which includes many ways of remaining safe, as well as maneuvers for 'takedowns' and safely releasing a patient's tight hand grip. Much of the class teaches effective ways to de-escalate a tense situation.

[amoLucia]

Hospitals seem to have more leeway than LTC with some issues. Our surveyors tend to STRONGLY frown on anything that could be considered as an 'identifier' r/t the pt. We've had trouble with flag-coded charts, doorway signs, overbed signs and bracelets coded for "DNR", falls, diabetics, elopement risk, vision/hearing impairment, etc etc.

All considered privacy & dignity issues.

And as PPs point out, families (and pts) may feel stigmatized and become angry.

The only things I've seen are the pink "no BP/venipuncture" bands for mastectomy/dialysis pts and "allergy" bands. "Falling stars/leaves" have been OK for door frames also, as well as colored magnets (that staff are supposed to remember all the different colors).