Acute Agitation Management for Nurses with Dee Henderson, RN, MSN

Hostility, uncooperativeness and impulsivity: acute agitation can be one of the most stressful aspects of a nurses job. With forty years of nursing experience, Dee Henderson, RN, MSN, joins us to discuss how both pharmacologic and non-pharmacologic interventions can be used to de-escalate the crisis cycle.

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Let’s Define Our Terms

Acute agitation: A feeling of irritability or severe restlessness with mental distress, excessive motor activity associated with a feeling of inner tension.  This “tension” can manifest as self-injury or aggression towards others, which can be verbal and/or physical.

The Crisis Cycle is a pattern of behaviors individuals go through when they are experiencing immediate emotional and behavior crisis. This behavior pattern has been described as phases of acting out behavior (Colvin, 1992; Kaufman, Mostert, Trent, & Hallan, 1998; Sprague & Golly, 2004).


Metabolic Causes of Acute Agitation

May include (but are not limited to)

  • Drug intoxication or withdrawal
  • Acute alcohol intoxication or withdrawal
  • High fevers related to systemic infections such as encephalitis
  • Delirium from infections such as an acute UTI (especially in older females)
  • Electrolyte imbalances
  • Endocrine abnormalities such as thyroid disorders
  • Head trauma
  • A post-ictal state

Psychiatric Causes

May include (but are not limited to)

  • Psychosis
  • Unstable Bipolar (particularly in the manic state)
  • Paranoia
  • Delusional disorders
  • Psychogenic substance abuse such as hallucinogens

All of these involve imbalances in neurotransmitters. Dysregulation of the pathways and levels of dopamine, serotonin, GABA, norepinephrine, and androgen are the main culprits in affecting mental status.




  • Try lowering the temperature of the room combined with offering a blanket (this is conducive to having a patient want to sit or lie down)
  • Turn down the lighting can also decrease the stimuli that may be triggering
  • Meet basic Maslow’s Hierarchy needs for food, drinks, or other comfort measures not only help resolve those needs but builds a foundation of trust essential for therapeutic communication and cooperation.


  • Patients often just want to be heard, seen, and their feelings validated.
    • “You sound really angry. Can you tell me more about that?”
    • “You mentioned seeing spiders on the walls and that has you scared. I can’t see what you are seeing so you will have to tell me what is happening.”

Dee’s 4 c’s when interacting with acute agitation

  1. Composure: Maintain a calm exterior will help the patient to calm down or at least not escalate their condition. 
  2. Compassion: We become nurses because we feel called to help others, and these patients come to us in their most vulnerable state.
  3. Consistency: A patient can be become agitated when they perceive confusing variations in their care. Also, on a unit, a nurse doesn’t want to be seen as providing special treatment to some patients. 
  4. Caring: Out of our compassion comes caring. We are there to meet our  patients’ needs, whether physical or mental, and to support their spiritual needs.


  • B52: The classic “cocktail” which usually includes the “10-2-50” which consists of 10mg of Haldol, 2mg of Ativan, and 50mg of Benadryl
    • This is modified, of course, if the patient is elderly or otherwise needs lower doses
  • Zyprexa Zydis or Risperdal M tabs, both of which are oral dissolvable tabs
  • Seroquel is useful in helping break a manic episode in a bipolar patient
  • Olanzapine (Zyprexa): atypical antipsychotic, mood stabilizer
  • Haloperidol/Haldol: typical antipsychotic