Activate the duress alarm or call for assistance if there is risk of harm. Ensure other patients or staff are safe. Maintain my own safety: keep distance, avoid blocking exits, stay at eye level but not too close. Remove or secure objects that could be used as weapons.

Safety is always the first priority.

Use De‑escalation Communication

Approach with a calm, non‑threatening tone: “I can see you’re in a lot of pain and frustrated.” “I want to help you feel more comfortable.” “Let’s work together to sort this out.”

Key strategies: Keep voice low and slow, avoid arguing or correcting, use short, simple sentences, validate feelings without agreeing to unsafe behavior and maintain open body language.

Address Pain and Nicotine Withdrawal

Two major triggers for agitation here are likely: uncontrolled pain and nicotine cravings

As the RN i can: Assess pain using an appropriate scale, Administer prescribed analgesia, offer nicotine replacement therapy (NRT) (patch, gum, lozenge) if ordered or obtain a prompt medical order and explain that NRT can help reduce the urge to leave the ward. Which shows that you are addressing her needs, not just restricting her.

Set Clear, Safe Boundaries

You must be firm but respectful: “For your safety, you can’t leave the ward right now.” “I can help you with nicotine replacement, so you don’t feel like you need a cigarette.” and “We can talk about going outside once you’re medically stable.”

Boundaries should be: Clear, consistent, non‑punitive and focused on safety

Assess Contributing Factors

Once she is calmer, complete a focused assessment: Pain level, withdrawal symptoms, anxiety or fear, delirium risk, medication side effects and any other unmet needs (food, toileting, sleep)

Engage the Multidisciplinary Team

Depending on severity: Notify the medical officer, request security if behavior escalates, involve mental health liaison if needed and consider clinical review if behavior suggests delirium or acute deterioration.

Document all actions clearly and objectively.

Documentation

Record: Behavior observed, triggers, interventions used, patient response, team members involved and safety measures implemented

The use objective language (e.g., “raised voice”, “threw chair”, “pacing rapidly”).

Reflective, Person‑Centred Approach

Even in crisis, maintain dignity: Avoid shaming language, offer choices where possible, reassure him that your goal is to help and debrief with her once calm.

Two men in the room was intimidating to her. Not sure if it was necessary for both to be there. They also did not introduce themselves or what their intent was.

The first response here is very comprehensive!

Once there is some calm in the room, i would address her pain. Using PQRST, and how it makes her feel. Get HX on how she normally deals with the pain, and talk about my concerns. And come up with some strategies etc.

-Ensuring a safe distance and easy way out if needed. Definitely I wouldn't follow the patient around the room as this can be intimindating.

-Non-threatening posture; open posture, appropriate eye contact.

-Introducing myself and my intention.

-Repeating and rephrasing what I am saying to ensure understanding.

-Active listening and empathic responses; "It sounds like you are in a lot of pain, I would like to help you". Repeating what the patient is saying to show my understanding.

-Asking them what they want and what strategies that help them to calm down; food, tv etc, and providing these things to them.

-Offering positive solutions; 'the patient wanting a smoke', instead of offering patches when they are agitated, redirect saying things like "let's get your pain sorted first as you seem to be in a lot of pain". Then once calm explaining why they cannot smoke in the ward, and now offering alternatives like the patches.

-Not announcing security is coming as this would escalate them further.

-Not making promises you cannot keep; keep everything reasonable and true.

I would then ask how I can help and address the pain that she is experiencing.

Lots of active listening would be used as well as non-threatening posture. The woman clearly needs to be heard and the health care team in the scenario continually spoke over the top of her which only lead to more frustration.

In these scenarios you need to remain calm and collected and continue to de-escalate the situation rather than escalate it.

Knocking and asking the patient if for permission to come in and introducing self.

Remaining a safe distance from the patient

Acknowledge the patient and their concern

Reassuring the patient I want to help and suggest addressing the pain first and then address other needs.

Ask for informed consent before approaching or touching the patient.

If the patient is still escalated I would leave the room to allow the patient to calm down or ask if they would prefer another nurse to help

Inform security discreetly for assistance

I may then sit on the ajusect chair in a non threatening manner and in a calm voce try to build a repour with the patinet. To do this I would acknowledge her pain her need for a ciggaret and empathise with her. In this way I could grtadualy move the situatin away from the immediate tention and assess her needs , Offer a plan that would address both her pain (possably attributing to the agitaion) and her need for a ciggette. I wopuld include her is these discussions and ask for her input after we have estabilished that I can not immedatly let her leave for a ciggartee but we can work together to move forward and that I understand her axiusness. In this way I could offer anagesigs and review the ssmoking polocy of the hospital and offer supported evidejce of what can be offered. Addsionaly I would offer to contact family memeber or do this on her bealf to help deescolate the situation.

I may then sit on the adjacent chair in a non-threatening manner and, in a calm voice, try to build rapport with the patient. To do this, I would acknowledge her pain and her need for a cigarette and empathise with her. In this way, I could gradually move the situation away from the immediate tension and assess her needs.

I would offer a plan that addresses both her pain, which may be contributing to her agitation, and her need for a cigarette. I would include her in these discussions and ask for her input after establishing that I cannot immediately let her leave for a cigarette, but that we can work together to move forward and that I understand her anxiety.

In this way, I could offer analgesia, review the hospital’s smoking policy, and provide evidence-based information about what alternatives or support can be offered. Additionally, I would offer to contact a family member, or do this on her behalf, to help de-escalate the situation.

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