198 Unit 3 CURRENTSOCIAL ANDEMOTIONALCONCERNS
empathy for the client’s anger or frustration is impor-
tant. The nurse can encourage the client to express his
or her angry feelings verbally, suggesting that the
client is still in control and can maintain that control.
Use of clear, simple, short statements is helpful. The
nurse should allow the client time to express himself
or herself. The nurse can suggest that the client go to
a quiet area or may get assistance to move other clients
to decrease stimulation. Medications (PRN) should be
offered, if ordered. As the client’s anger subsides, the
nurse can help the client to use relaxation techniques
and look at ways to solve any problem or conflict that
may exist (Maier, 1996). Physical activity, such as
walking, also may help the client relax and become
calmer.
If these techniques are unsuccessful and the
client progresses to the escalation phase,the nurse
must take control of the situation. The nurse should
provide directions to the client in a calm, firm voice.
The client should be directed to take a time out for
cooling off in a quiet area or his or her room. The nurse
should tell the client that aggressive behavior is not
acceptable and that the nurse is there to help the
client regain control. If the client refused medications
during the triggering phase, the nurse should offer
them again.
If the client’s behavior continues to escalate and
he or she is unwilling to accept direction to a quiet
area, the nurse should obtain assistance from other
staff members. Initially four to six staff members
should remain ready within sight of the client but not
as close as the primary nurse talking with the client.
This technique, sometimes called a “show of force,” in-
dicates to the client that the staff will control the sit-
uation if the client cannot do so. Sometimes the pres-
ence of additional staff convinces the client to accept
medication and take the time out necessary to regain
control.
When the client becomes physically aggressive
(crisis phase), the staff must take charge of the situa-
tion for the safety of the client, staff, and other clients.
Psychiatric facilities offer training and practice in safe
techniques for managing behavioral emergencies, and
only staff with such training should participate in the
restraint of a physically aggressive client. The nurse’s
decision to use seclusion or restraint should be based
on the facility’s protocols and standards for restraint
and seclusion. The nurse should obtain a physician’s
order as soon as possible after deciding to use restraint
or seclusion.
Four to six trained staff members are needed to
restrain an aggressive client safely. Children, ado-
lescents, and female clients can be just as aggressive
as adult male clients. The client is informed that his
or her behavior is out of control and that the staff are
taking control to provide safety and prevent injury.
Four staff members each take a limb; another staff
member protects the client’s head; yet another helps
control the client’s torso if needed. The client is trans-
ported by gurney or carried to a seclusion room, and
restraints are applied to each limb and fastened to
the bed frame. If PRN medication has not been taken
earlier, the nurse may obtain an order for intra-
muscular medication in this type of emergency situ-
ation. As noted above, the nurse performs close as-
sessment of the client in seclusion or restraint and
documents the actions.
As the client regains control (recovery phase),
he or she is encouraged to talk about the situation
or triggers that led to the aggressive behavior. The
nurse should help the client relax, perhaps sleep, and
return to a calmer state. It is important to help the
client explore alternatives to aggressive behavior by
asking what the client or staff can do next time to avoid
an aggressive episode. The nurse also should assess
staff members for any injuries and complete the re-
quired documentation such as incident reports and
flow sheets. The staff usually has a debriefing session
to discuss the aggressive episode, how it was handled,
what worked well or needed improvement, and howJohn, 35 years of age, was admitted to the hospital for
schizophrenia. John has a history of aggressive behav-
ior, usually precipitated by voices telling him he will be
harmed by staff and must kill them to protect himself.
John had not been taking his prescribed medication for
2 weeks before hospitalization. The nurse observes
John pacing in the hall, muttering to himself, and avoid-
ing close contact with anyone else.
Suddenly, John begins to yell, “I can’t take it. I can’t
stay here!” His fists are clenched, and he is very agitated.CLINICALVIGNETTE: ESCALATIONPHASE
The nurse approaches John, remaining 6 feet away from
him, and says, “John, tell me what is happening.” John
runs to the end of the hall and will not talk to the nurse.
The nurse asks John to take a PRN medication and go to
his room. He refuses both. As he begins to pick up ob-
jects from a nearby table, the nurse summons other staff
to assist.