Editing Mental Health and Psychosocial Nursing (section)

=== De-escalation and Management of Aggression ===
Recognize the escalation continuum: anxiety, defensiveness, physical aggression, tension reduction. Intervene early.

Technique: maintain a calm low voice, keep at least two arm-lengths of personal space, position yourself between the client and the exit without blocking either party's escape, avoid sustained direct eye contact and crossed arms, remove the audience, offer choices ("Would you like to walk with me or sit in the quiet room?"), and set a clear limit with a stated consequence. Call for adequate staff before you need them.

'''Least restrictive intervention first''': verbal de-escalation, then voluntary time out and reduced stimuli, then offered PRN medication, then seclusion, then restraint. Restraint is an emergency measure, never a convenience or punishment, and never a substitute for staffing.

Restraint and seclusion requirements for violent or self-destructive behavior (Centers for Medicare and Medicaid Services standards): a provider order is required, an order may never be written PRN, a face-to-face evaluation by a qualified provider must occur '''within 1 hour''' of initiation, and orders are time-limited and renewed every 4 hours for adults 18 and older, every 2 hours for ages 9 to 17, and every 1 hour for children under 9. Nursing responsibilities include continuous or every-15-minute observation per policy, circulation and skin checks, range of motion, offering fluids and toileting, documenting behavior and less restrictive measures tried, and discontinuing at the earliest safe moment with a debriefing afterward.