What is the best approach to managing an agitated hospital patient on the night shift?

Management of Agitated Hospital Patients on Night Shift

The most effective approach to managing an agitated hospital patient on the night shift involves implementing a structured de-escalation protocol first, followed by appropriate pharmacological intervention only when necessary, and using physical restraints as a last resort. 1

Initial Assessment and Safety Measures

• Ensure safety of patient, staff, and others in the area 1
• Quickly assess for underlying reversible causes of agitation:
  • Metabolic disturbances
  • Infections (UTI, pneumonia, sepsis)
  • Neurological causes
  • Medication-related causes
  • Hypoxia (check oxygen saturation)
  • Pain, constipation, or urinary retention 1
• Create a calming physical environment:
  • Decrease sensory stimulation
  • Remove potential weapons
  • Ensure staff have unobstructed exit path 2
  • Remove neckties, stethoscopes, or secure long hair 2

Verbal De-escalation Techniques

1. Respect personal space - Maintain two arms' length distance from patient 2
2. Minimize provocative behavior - Avoid threatening postures or direct confrontation 2
3. Establish verbal contact - Designate one staff member to interact with patient 2
4. Be concise - Use simple language and concise sentences 2
5. Identify patient's goals - "What helps you at times like this?" 2
6. Use active listening - "Tell me if I have this right..." 2
7. Agree or agree to disagree - Build empathy without unnecessary argument 2
8. Set clear limits and expectations - "We're here to help, but safety comes first" 2
9. Offer choices and optimism - Provide realistic choices to empower patient 2
10. Debrief patient and staff - Explain interventions and review alternatives 2

Pharmacological Management

If verbal de-escalation fails, proceed to medication based on suspected etiology:

For Unknown or Psychiatric Causes:

• First-line: Haloperidol 5-10 mg IM (2-5 mg for elderly/debilitated patients) 1
• Alternative: Olanzapine 5-10 mg PO/IM 3

For Medical/Intoxication-Related Agitation:

• First-line: Lorazepam 2-4 mg IM/IV 1
• For severe cases: Consider adding haloperidol after benzodiazepine 2

For More Rapid Sedation:

• Consider combination of haloperidol and lorazepam 1

Special Populations

Elderly Patients:

• Use lower doses of haloperidol (0.5-1 mg bid) 1
• Consider atypical antipsychotics (risperidone, olanzapine, quetiapine) 1

Children and Adolescents:

• Haloperidol 0.5-1 mg, repeating as needed 1
• For adolescents with bipolar disorder, consider olanzapine with caution regarding weight gain 3

Physical Restraint (Last Resort)

Physical restraint should only be used when:

• Less restrictive options have failed
• Patient poses immediate danger to self or others
• To prevent serious disruption of treatment program 2

When implementing restraint:

• Preserve patient autonomy and dignity
• Monitor nutrition, hydration, elimination needs
• Ensure airway is unobstructed at all times
• Inform family of restraint use 2
• Terminate restraint once patient regains self-control 2

Monitoring and Documentation

• Continuously monitor vital signs and mental status 1
• Watch for adverse effects:
  • Extrapyramidal symptoms with antipsychotics
  • QT prolongation with haloperidol
  • Respiratory depression with benzodiazepines 1
• Document triggers, warning signs, and response to interventions 2

Common Pitfalls to Avoid

• Mistaking agitation for pain 1
• Overlooking delirium as cause of agitation 1
• Using excessive sedation 1
• Implementing physical restraint prematurely 1
• Using restraint for staff convenience rather than patient need 2
• Failing to consider cultural factors that may influence triggers and expression of aggression 2

By following this structured approach, night shift staff can effectively manage agitated patients while maintaining dignity, safety, and therapeutic relationships.