Question

Scenario

You are the nurse working triage in the emergency department (ED). This afternoon a woman brings in her father, ALI, a 72-year-old who is a retired doctor. The daughter reports that over the past several months she has noticed her father has progressively had problems with his mental capacity. These changes have developed gradually but seem to be getting worse. At times he is alert, and at other times he seems disoriented, depressed, and tearful. He is forgetting things and doing things out of the ordinary, such as placing the milk in the cupboard and sugar in the refrigerator. He had difficulty finding objects in the kitchen and at times forgets where his room is.

This morning he thought it was nighttime and wondered what his daughter was doing at his house. He could not pour his coffee, and he seems to be getting more agitated. ALI reports that he has been having memory problems for the past year and at times has difficulty remembering the names of family members and friends.

A review of his past medical history (PMH) is significant for hypercholesterolemia and coronary artery disease (CAD). He had a myocardial infarction (MI) 5 years ago. ALI’s vital signs (VS) today are all within normal limits (WNL).

Q:How do you manage a patient who is showing some signs of agitation and aggression? Discuss two skills.     

Answer 1

Agitation is a condition where the person is worried or restless and agitation may cause pacing, sleeplessness or aggression and the person may verbally or physically hurt someone.

How to manage a patient showing agitation and aggression ( following the LOWLINE Model)

1. Listen : Saying nothing can be powerful at the beginning of the de-escalation process. Active listening uses non- directive, non- intrusive verbal feedback to let agitated patients know they are being paid attention to.

2.offer : offer reflective comments, which should be brief and use the words spoken by the angry patient. When a patient seems angry or agitated, it is important for nurses to notice it and to state what they see or hear, so the patient will be sure that their feelings are being taken seriously. At this stage it is wise to avoid comments that could be seen as devaluing.  

3. Wait : Resist the temptation to fill the void with words. It can worsen the situation.

4.Look : Eye contact should be maintained, but it should be appropriate at the moment too. Unnecessary facial expressions should be avoided.

5. Incline: Inclining the head is useful to affirm interest. A slightly inclined head often serves to present a non- threatening posture.

6. Nod: A occasional and appropriate nod will ensure and demonstrate attention and a willingness to listen.

7. Express: It is advised to express a desire to understand or to express empathy. It is also important to keep it brief . This shows to the patient that their concerns are being taken seriously.

Other interventions

Remain calm when dealing with a agitated patient. Set verbal limits on behaviour. Avoid touching the patient when he or she is becomes angry. Observe the patient for escalation of anger . When these behaviours are observed, ensure that sufficient staff are available to help with a potentially violent situation. Techniques for dealing with aggression include talking down and physical outlets.

If agitation continues to escalate, offer medications such as haloperidol, risperidone, lorazepam.