Nursing Field Notes / Mental Health · Psychiatric Care Course
Crisis Management 🚨
Phases of Crisis · De-escalation · Restraints & Seclusion
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A crisis moves through predictable phases — recognizing which phase a client is in tells you whether to talk, redirect, or physically intervene. The core rule: always use the least restrictive intervention that keeps everyone safe, and escalate toward restraints/seclusion only when verbal and environmental measures fail.
🎯 First moveEliminate the trigger using nursing measures before anything else.
🪜 Least restrictive firstVerbal de-escalation → meds → seclusion → restraints, in that order.
📝 Restraints clockHCP assess within 1 hr · document q15 min · renew q4 hr (adult).
🌡️
PHASES
STEP 1 · WHERE ARE THEY IN THE CRISIS
A crisis is not a single event — it's a rising and falling curve, and each phase calls for a different response.
🌡️ The 4 phases of crisis
🧠 "TECP" — Trigger · Escalation · Crisis · Post-crisis. A client saying "I feel like I can barely get out of bed in the morning" a day after an outburst = phase 4, post-crisis disorganization & depression, not a new problem.
🎯 First-line intervention: eliminate the trigger
A client becomes agitated and threatens to punch another client. Priority action:
Eliminate the trigger using nursing measures and interventions
🧠 Stopping the trigger stops the climb up the curve — act at phase 1–2, before the crisis peak, whenever possible.
🔎 Determine the true source of anger
A client is yelling and screaming at staff. Action to take:
Determine the true source of the client's anger
🧠 The visible target (a staff member, a roommate) is often not the real trigger — assess before assuming.
🗣️
DE-ESCALATE
STEP 2 · CALM COMMUNICATION & SAFE APPROACH
Words and environment first — most crises never need to reach restraints.
🗣️ Core de-escalation communication
1
💬 Explain all activities of care clearly & calmly
2
🎯 Eliminate the trigger
3
🔇 Low-stimulation environment — NOT near the nurses' station
4
🔎 Determine the source of the anger
5
🤲 Acknowledge the client's emotions
🧠 Sample scripting:"I'm Lily and I'm here to help" (identify yourself, calm tone) → "I see you are upset" (acknowledge the emotion, don't argue with it).
🪑 First action when a client throws a chair
A client becomes angry and throws a chair in the dayroom. First intervention:
Acknowledge the client's emotions
🧠 Validate before you redirect — arguing or issuing commands first tends to escalate further.
🚷 Poor impulse control + verbal tirade
A client with a history of poor impulse control bursts into a verbal tirade in the dayroom. Priority action:
Remove other clients from the day room
🧠 Milieu safety first — protect bystanders before continuing to work with the escalated client.
🛡️ Personal safety when approaching an angry client
🧠 4 safety rules: have other staff as backup · stand far enough away to avoid injury · identify yourself & remain calm · give simple directions in a calming voice. Never let yourself be positioned between the client and the exit.
🔒
SAFETY
STEP 3 · LEAST RESTRICTIVE → MOST RESTRICTIVE
Medication and seclusion come before restraints — and restraints carry strict legal timelines once used.
🪜 Least-restrictive-intervention principle
🗣️ Verbal de-escalation & environmental changes
▼
💊 PRN medication (anxiolytic/antipsychotic)
▼
🚪 Seclusion (alone in a safe room)
▼
⛓️ Physical restraints — last resort
🧠 Always try the least restrictive option that keeps the client and others safe before moving to the next step. Restraints/seclusion require a provider's order — they are never a first response or a punishment.
💊 Pharmacology used in acute agitation/violence
Class
Example drug (brand)
Anxiolytic — benzodiazepine "-pam" / "-lam"
Lorazepam (Ativan)
Typical antipsychotic
Haloperidol (Haldol)
Atypical antipsychotic
Ziprasidone (Geodon)
For a client displaying violent behavior, the provider may prescribe lorazepam, haloperidol, and/or ziprasidone — select-all-that-apply pattern.
🧠 "-pam/-lam" = benzo family (lorazepam, diazepam) — fast-acting anxiolytic for acute agitation, distinct from the antipsychotics used for the same scenario.
⛓️ Restraints — the legal timeline
1
📄 Get a provider's order for restraints — renewed every 4 hours for adults
2
🩺 Client must be assessed by the HCP within 1 hour of the order
3
📝 Document every 15 minutes
4
🤲 Monitor & meet physical needs continuously
🧠 Within the first hour after restraints + seclusion are applied, the nurse must: meet the client's physical needs, obtain a prescription for the restraints, and objectively document the client's behavior.
🩺 Intervening with a violent client
When intervening with a violent client, the nurse should: identify themselves to the client and remain calm. When a client threatens to harm a staff member, the appropriate intervention is: address the patient with simple directions and a calming voice.
🧠 Never argue, raise your voice to match theirs, or make sudden movements — calm, simple, predictable communication is itself a de-escalation tool.