Heart rate: 103 bpm 

Provide wound care and assess the severity of injuries.

Administer ordered medications (IM lorazepam) for acute anxiety and distress.

Offer therapeutic presence and emotional reassurance.

Secure the environment by removing harmful objects and placing the patient on 1:1 observation.

Notify the provider and behavioral health team about the incident.

Prioritize life-saving safety interventions to prevent further self-harm.

Initiate an emergency involuntary psychiatric hold.

Arrange transfer to an inpatient psych facility.

Complete documentation and ensure a warm, safe handoff.

Encourage slow deep breathing for the patient.

• This will allow for the patient to breathe out excess carbon dioxide and reduce their chances of respiratory alkalosis.

Calm the patient and reduce anxiety.

• It is imperative to attempt to calm the patient and reduce their external stimuli for the patient to be safe.

Assess and treat the underlying cause.

• Although initially it is important to calm the patient for their safety; to prevent a state like this again it is important for the nurse to assess and treat the underlying cause of this panic.

Establish trust with the patient through therapeutic communication.

• Therapeutic communication is key in deescalating a patient. This trust and ease that the nurse develops may prevent the patient from becoming aggressive as well.

Ensure a safe environment for all.

• If the patient seems to be becoming violent, it is important to place them in a safe environment. This can include placing them close to the nurse's station, having one-to-one precautions, and removing items that may be used as a weapon to others or self.

Involve interprofessional help early.

• The patient is experiencing a panic attack that has underlying causes. It is important to gain other healthcare professionals on this patient's team quickly to prevent him from escalating to forms of aggression.

Encourage the patient to regularly bathe and inform them of the importance of hand hygiene

• The patient will likely remain in the hospital for a prolonged period of time following this crisis. Due to this, they are at a higher risk of infection. To decrease the chances of acquiring these, it is important to encourage regular bathing and hand hygiene.

Obtain regular lab testing and monitoring

• Regular lab testing allows for the nurse to monitor the patients' WBC count to prevent an infection. This is important because stress can weaken the immune system.

Maintain skin integrity

• The nurse should regularly check the patient's skin integrity and educate about nail-biting leading to infection.

Benzodiazepines such as lorazepam and diazepam for anxiety. This medication works by enhancing GABA activity which inhibits the CNS, leading to a lower respiratory rate and restoring breathing patterns.