How should a nurse respond to agitation in a psychiatric emergency?

• A. Restrain the patient immediately to prevent harm.
• B. Focus only on calming the patient without assessment or help.
• C. Use de-escalation techniques, assess for medical causes, and seek assistance if needed.
• D. Administer benzodiazepines regardless of medical status.

Answer: (C)

Managing agitation in a psychiatric emergency hinges on calming the situation while quickly checking for medical contributors. Start by using de-escalation techniques to reduce arousal and build trust. Speak in a calm, steady voice, adopt an open and nonthreatening posture, and acknowledge the patient’s distress without arguing. Offer choices, set clear boundaries, and give the patient a sense of control. Create a safe, quieter environment and remove objects that could be used to harm either the patient or staff.

At the same time, perform a focused medical assessment because many causes of agitation are medical or substance-related. Check vital signs, assess airway and breathing, and look for signs of delirium, hypoxia, infection, pain, dehydration, electrolyte disturbances, or metabolic problems. Consider conditions such as intoxication, withdrawal, new-onset medical illness, or medication interactions. Gather collateral information when possible (history, medications, last intake, and substances used) to guide the assessment.

Seek help from colleagues, physicians, psychiatry, and security if needed. If agitation cannot be safely managed with de-escalation and medical treatment, implement the least restrictive intervention necessary, with continuous monitoring and a plan to reassess as soon as possible. In all steps, document the assessment, intervention, and patient response, and adjust the plan as the situation evolves.