Violent Patients

Foundational Approach to Violent Patient Management

Violent patients present a critical challenge in the emergency department (ED). The Certified Emergency Nurse (CEN) exam emphasizes rapid recognition, de‑escalation, and safe management of aggressive or psychotic behavior to protect the patient, staff, and others. Understanding the underlying psychiatric and medical causes, along with evidence‑based intervention protocols, is essential for safe practice and exam success.^[1]

Core Terminology for Aggression and De‑escalation

• Agitation: A state of excessive motor or verbal activity, often a precursor to violence.
• De‑escalation: A communication and behavioral technique used to calm a potentially violent person and reduce the risk of physical aggression.^[2]
• Physical Restraint: The use of mechanical devices to limit a patient’s movement; considered a last resort.
• Chemical Restraint: Administration of medications (e.g., benzodiazepines, antipsychotics) to control agitation or violent behavior.
• Seclusion: Involuntary confinement of a patient alone in a room; requires continuous monitoring.
• Medical Clearance: The process of ruling out organic causes (e.g., hypoglycemia, hypoxia, TBI) before attributing violence to a psychiatric condition.^[3]

Systematic Strategies for Agitation Control

Risk Assessment and Triage

The ED nurse must quickly assess risk factors for violence. Use a structured approach such as the “STAMP” mnemonic: Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling, Pacing. A positive STAMP suggests escalating agitation.^[1]

De‑escalation: A Step‑by‑Step Process

1. Maintain a calm demeanor: Speak in a low, slow, and clear voice. Avoid sudden movements.
2. Provide personal space: Stand at least two arm’s lengths away, with an unobstructed exit.
3. Use active listening: Acknowledge the patient’s feelings (“I can see you’re frustrated.”).
4. Set clear, simple limits: “I need you to sit down so we can talk safely.”
5. Offer choices: “Would you like to take medication now or talk with a counselor first?”
6. Call for help early: Summon security or the behavioral response team if de‑escalation fails.^[2]

Use of Restraints

Restraints are used only when all other interventions have failed and the patient poses an imminent threat. The ENA and CMS require:

• A physician’s order within 1 hour (or verbal order if immediately necessary).
• Continuous 1:1 monitoring.
• Documentation of less‑restrictive measures attempted.
• Frequent reassessment and removal as soon as safe.^[4]

Clinical Cues of Rising Patient Aggression

• Clenched fists, jaw tightness, or “boxer” stance.
• Verbal threats, profanity, or delusional content.
• Hypervigilance – scanning the room for threats.
• Pacing, sudden intrusions into personal space.
• Increased muscle tone, agitated movements.
• Poor impulse control – hitting, throwing objects.

Medical Clearance and Organic Cause Identification

A thorough evaluation must rule out organic causes. The “AEIOU TIPS” mnemonic helps recall: Alcohol, Epilepsy, Insulin (hypoglycemia), Overdose, Uremia, Trauma, Infection, Psychiatric, Stroke. A rapid focused assessment includes vital signs, oxygen saturation, blood glucose, and a brief neurologic exam.^[3]

If the patient is stable, assess for history of violence, substance use, medication non‑adherence, and suicidal or homicidal ideation. Use validated tools like the Broset Violence Checklist.^[5]

Pharmacologic and Restraint‑Based Interventions

Chemical Restraint

^[4][6]

Nursing Care During Restraints

• Maintain airway, breathing, and circulation.
• Provide hydration, toileting, and nutrition.
• Monitor for aspiration, skin breakdown, and neurovascular compromise.
• Document behavior, medication administration, and reassessment every 15 minutes (constant observation) and every 1–2 hours (if less acute).

Risk Reduction and Complication Avoidance in Restraints

• Staff safety: Avoid wearing dangling jewelry; remove glasses if at risk; position yourself between the patient and an exit.
• Environmental safety: Remove sharps, heavy objects, and electrical cords from the patient’s area.
• Physical restraint complications: Asphyxia (due to prone positioning), aspiration, rhabdomyolysis, venous thromboembolism – never restrain in prone position.^[4]
• Medication side effects: Dystonia, neuroleptic malignant syndrome (rare but deadly), respiratory depression.

CEN Test Focus Areas in Behavioral Emergencies

• First step in any behavioral emergency: safety assessment of patient, staff, and environment.
• De‑escalation is always preferred – restraints are a last resort and must be documented meticulously.
• Medical clearance is paramount – many exam questions test your ability to identify organic causes (e.g., hypoglycemia, hypoxia, head injury).
• Know the mnemonic “STAMP” for early warning signs.
• Legal issues: Restraint orders must be renewed every 4 hours for adults (18+) and every 2 hours for children 9–17; 1 hour for children under 9 (CMS guidelines).
• Remember chemical restraint options: lorazepam, haloperidol, olanzapine – and any contraindications.
• Never use a “prone restraint” – it is associated with positional asphyxia and sudden death.

References

1. Emergency Nurses Association. Sheehy’s Emergency Nursing: Principles and Practice. 7th ed. St. Louis, MO: Mosby; 2019. https://www.ena.org/publications/books/sheehys-emergency-nursing
2. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de‑escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De‑escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. https://doi.org/10.5811/westjem.2011.9.6864
3. Marco CA, Vaughan J. Medical clearance of the psychiatric patient. Emerg Med Clin North Am. 2005;23(3):779-793. https://doi.org/10.1016/j.emc.2005.03.006
4. Centers for Medicare & Medicaid Services. Hospital Conditions of Participation: Patients’ Rights. 42 CFR §482.13(e). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.13
5. Abderhalden C, Needham I, Miserez B, et al. Structure and content of the Brøset Violence Checklist. J Psychiatr Ment Health Nurs. 2004;11(6):686-692. https://doi.org/10.1111/j.1365-2850.2004.00788.x
6. Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med. 2012;13(1):26-34. https://doi.org/10.5811/westjem.2011.9.6866