How to De-escalate Your Agitated Patient: Tips From a Psychiatric Nurse

Kimika Medina, BSN

It is inevitable, at some point, that as a nurse, you are going to be assigned a patient that is or has become agitated. Most of us nurses are great communicators, but an angry patient who may also be experiencing psychosis can be difficult to manage. Whether you work in a psychiatric ward, ER, or a medical surgical floor, a patient may become upset or even aggressive. Intervening quickly can prevent the situation from becoming out of control. Therefore, it is important to recognize the early signs of agitation so that you can act promptly to avoid further escalation. Remember verbal de-escalation should always be attempted before medication or restraints are used, as long as the patient or others are not in immediate danger. So, what are signs your patient is escalating and what can you do about it?

Subtle (and Not So Subtle) Signs Your Patient is Becoming Agitated

Usually, there are warning signs from patients that they are becoming irritated. Subtle clues can cue you in that your patient is slowly becoming upset, and you may need to intervene. Here are a few signs to look out for:

Pacing
Fidgeting
Clinched fist
Rapid speech
Raising voice/shouting
Verbal aggression
Difficulty focusing

So, you recognize your patient is agitated and you need to step in.

What Can You Do?

1- Think safety

Safety always comes first. Stand where you can get to the nearest doorway quickly if you need to. If your patient is upset, you always want to keep physical distance, about two arms lengths away. This can also make the patient feel safe as well when they are severely agitated.

2- Keep cool

It is easy to allow the moment to make you flustered or upset. Have you noticed that the person who is able to control situations the best is also the calmest person in the room? This applies here, so try to watch your tone. Even if the patient is shouting, keep cool and do not raise your voice. Keep your tone low and speak slowly. If the patient appears to be overly anxious, give short, concise directives as they may not be able to process long instructions at that time.

3- Decrease stimulation

Look around your environment and decrease stimulation in whatever ways possible. Simple changes like turning down the volume of the television, dimming the lights, or removing the patient to a quieter place may help decrease their agitation and stress levels.

4- Be respectful

When is the last time you calmed down when you felt you were being disrespected? Giving the patient respect even when they are being difficult is always important and helps not to escalate matters further.

5- Set boundaries

Be assertive and make it clear what behavior will be accepted. When giving choices, make sure you can deliver. I also suggest limiting the choices to 2-3; less is better to prevent decision overload, especially if they are in a heightened state of stress. Allow time for them to reflect and answer.

6- Listen

Don't assume you know what they are upset about or that they are just acting out. Finding out from the patient what is bothering them will help you arrive at a solution that you both can agree on and diffuse the situation.

Keep in mind the patient that is delusional, or hallucinating may feel paranoid or in danger. Do not agree with what is not real, rather focus on the emotions they are feeling. For instance, if the patient is convinced they are being followed by a rouge FBI spy who wants to kidnap them, instead of simply dismissing the notion try saying something like this: "Wow, I do not see anyone in the hallway but that must make you terrified! This is a safe, secure place, and no one can walk in and take you here.”

7- Be empathetic

Showing empathy during a perceived crisis will make the patient feel heard and help them become calmer and open to a solution. This goes hand in hand with listening. For instance, the patient may be "acting out" due to a personal issue that is bothering them. A lot of time, we can relate to the issue, and showing the patient you hear them and empathize can go a long way.

Conclusion

No matter what field of nursing you are in, you are bound to have a patient that becomes angry or "wound up,” but the faster you become involved, the quicker you can nip it in the bud! Try these basic steps the next time your patient is agitated and bring calm back to your patient and your shift.

References

Steps for Working With Delusions

How Do Psychiatric Nurses / NPs Stay Safe on the Job?

CPI's Top 10 De-Escalation Tips

All you need to know about agitated depression