10 ANGER, HOSTILITY, ANDAGGRESSION 205
continued from page 204The client’s ability to understand what is happen-
ing to him or her may be impaired.Being placed in seclusion or restraints can be
terrifying to a client. Your assurances may help
alleviate the client’s fears.The client has a right to the least restrictions pos-
sible within the limits of safety and prevention of
destructive behavior.The client is a worthwhile person regardless of
his or her unacceptable behavior.Accurate recording of information is essential in
situations that may later be reviewed in court.
Restraint, seclusion, assault, and so forth are sit-
uations that may result in legal action.When the client is agitated, you are in a stressful
situation and under pressure to move quickly.
This increases the possibility of making an error
in dosage or administration of medication.Human immunodeficiency virus (HIV) and other
diseases are transmitted by exposure to blood or
body fluids.Psychoactive drugs can have adverse effects such
as allergic reactions, hypotension, and
pseudoparkinsonian symptoms.The other clients have their own needs and prob-
lems. Be careful not to give attention only to the
client who is acting out.When placing the client in restraints or seclusion,
tell the client what you are doing and the reason
for this (to regain control or to protect the client
from injuring himself, herself, or others). Use
simple, concise language in a nonjudgmental,
matter-of-fact manner. (See Nursing Diagnosis:
Risk for Injury in this care plan for restraint
safety interventions and rationale.)Tell the client where he or she is and that he or
she will be safe. Assure the client that staff mem-
bers will check on him or her, and if possible, tell
the client how to summon the staff.Reassess the client’s need for continued seclusion
or restraint as you observe him or her. Reorient
the client or remind him or her of the reason for
restraint if necessary. Release the client or de-
crease restraint as soon as it is safe and therapeu-
tic to do so. Base your decisions and actions on
the client’s, not the staffs, needs.Remain aware of the client’s feelings (including
fear), dignity, and rights.Carefully observe the client, and promptly com-
plete charting and reports in keeping with hospi-
tal or unit policy. Bear in mind possible legal
implications.Administer medications safely: take care to pre-
pare correct dosage, identify correct sites for
intramuscular administration, withdraw plunger
to aspirate for blood, and so forth.Take care to avoid needlestick injury and other
injuries that may involve exposure to the client’s
blood or body fluids.Monitor the client for effects of medications, and
intervene as appropriate.Talk with other clients, especially after the situa-
tion is resolved; allow them to ventilate their feel-
ings related to the situation.Adapted from Schultz JM & Videbeck SL (2002). Lippincott’s Manual of Psychiatric Nursing Care Plans(6th ed). Philadelphia,
Lippincott, Williams & Wilkins.
*denotes collaborative interventions