While monitoring the communal recreation room on an inpatient psychiatric unit, a practical nurse (PN) notes that a client diagnosed with schizophrenia is rapidly pacing, breathing heavily, and aggressively throwing playing cards at the walls. Arrange the following nursing de-escalation actions in the correct chronological order of priority, from first to last.
- 1Ensure personal safety by maintaining distance and securing a clear path to the room's exit.
- 2Instruct other individuals in the recreation room to calmly relocate to a safe, quiet area.
- 3Verbally engage the client from a safe distance using a calm, non-confrontational tone.
- 4Offer a prescribed PRN oral antianxiety medication or the choice of moving to a low-stimulation room.
- 5Activate the facility's behavioral emergency response team if the client's agitation continues to escalate.
Answer
The correct priority sequence is to ensure personal safety, protect bystanders, attempt verbal de-escalation, offer voluntary alternatives (medication/environment), and finally activate the emergency response team if needed.
Crisis intervention in psychiatric nursing strictly follows the hierarchy of safety and least restrictive measures. The practical nurse must first secure personal safety, then protect bystanders (which concurrently reduces environmental stimulation). Once the environment is secure, the nurse attempts verbal de-escalation. If basic communication is insufficient, offering voluntary choices (like prescribed PRN medication or a quiet room) is the next appropriate step. Calling a behavioral emergency response team is a restrictive, high-level intervention reserved for when these initial, less restrictive measures fail to prevent imminent harm.
Step-by-Step Solution
Key Concept
Crisis De-escalation Sequence and Least Restrictive Interventions