Agitation is a state of excessive psychomotor activity often associated with mental health conditions, physical discomfort, or emotional distress. This nursing diagnosis focuses on identifying triggers, managing symptoms, and ensuring patient and staff safety while providing compassionate care.
Causes (Related to)
Agitation can manifest due to various factors that affect a patient’s mental and physical state:
- Psychological factors such as:
- Anxiety disorders
- Depression
- Bipolar disorder
- Schizophrenia
- Post-traumatic stress disorder
- Physical conditions including:
- Pain
- Infection
- Metabolic imbalances
- Drug interactions
- Withdrawal syndromes
- Environmental factors such as:
- Unfamiliar surroundings
- Overstimulation
- Lack of privacy
- Changes in routine
- Sleep deprivation
Signs and Symptoms (As evidenced by)
Agitation presents various behavioral and physical manifestations that nurses must recognize for proper assessment and intervention.
Subjective: (Patient reports)
- Feeling restless or “on edge”
- Internal tension
- Racing thoughts
- Difficulty concentrating
- Irritability
- Emotional distress
- Sleep disturbances
- Feeling overwhelmed
Objective: (Nurse assesses)
- Increased motor activity
- Pacing
- Hand wringing
- Inability to sit still
- Rapid or pressured speech
- Hostile or aggressive behavior
- Increased vital signs
- Dilated pupils
- Defensive posturing
Expected Outcomes
The following outcomes indicate successful management of agitation:
- The patient will demonstrate decreased psychomotor activity
- The patient will express feelings appropriately
- The patient will maintain personal and environmental safety
- The patient will utilize effective coping mechanisms
- The patient will participate in therapeutic activities
- The patient will report improved emotional control
- The patient will maintain stable vital signs
Nursing Assessment
Monitor Behavioral Status
- Assess the level of agitation
- Document behavioral changes
- Note triggers and patterns
- Evaluate risk for violence
- Monitor response to interventions
Evaluate Physical Status
- Check vital signs
- Assess pain levels
- Monitor medication effects
- Document sleep patterns
- Check for physical causes
Assess Safety Needs
- Evaluate environment
- Check for potential weapons
- Monitor fall risk
- Assess the need for restraints
- Document safety concerns
Review Mental Status
- Assess orientation
- Check thought processes
- Evaluate judgment
- Monitor attention span
- Document mood changes
Evaluate Support Systems
- Assess family involvement
- Document social support
- Review coping mechanisms
- Check spiritual needs
- Note cultural factors
Nursing Care Plans
Nursing Care Plan 1: Risk for Violence
Nursing Diagnosis Statement:
Risk for Violence related to increased agitation and emotional lability as evidenced by threatening gestures, hostile verbalization, and increased psychomotor activity.
Related Factors:
- Impaired impulse control
- History of aggressive behavior
- Environmental stressors
- Poor coping mechanisms
Nursing Interventions and Rationales:
- Maintain a safe distance while interacting
Rationale: Ensures staff safety while maintaining a therapeutic presence - Remove potential weapons from the environment
Rationale: Reduces risk of injury to patient and others - Implement de-escalation techniques
Rationale: Helps prevent violent behavior
Desired Outcomes:
- The patient will demonstrate self-control
- The patient will use appropriate communication
- The patient will maintain safe behavior
Nursing Care Plan 2: Anxiety
Nursing Diagnosis Statement:
Anxiety related to psychological stressors as evidenced by increased psychomotor activity, restlessness, and expressed feelings of unease.
Related Factors:
- Environmental changes
- Perceived threats
- Unmet needs
- Biochemical changes
Nursing Interventions and Rationales:
- Provide calm environment
Rationale: Reduces external stimuli that may increase anxiety - Teach relaxation techniques
Rationale: Helps patient manage anxiety symptoms - Maintain consistent approach
Rationale: Provides a sense of security and predictability
Desired Outcomes:
- The patient will report decreased anxiety
- The patient will demonstrate relaxation techniques
- The patient will maintain stable behavior
Nursing Care Plan 3: Disturbed Sleep Pattern
Nursing Diagnosis Statement:
Disturbed Sleep Pattern related to psychological and environmental factors as evidenced by difficulty falling asleep, frequent awakening, and daytime fatigue.
Related Factors:
- Anxiety and agitation
- Environmental disruptions
- Altered circadian rhythm
- Physical discomfort
Nursing Interventions and Rationales:
- Establish sleep routine
Rationale: Promotes normal sleep-wake cycle - Reduce environmental stimuli
Rationale: Creates a conducive environment for sleep - Monitor sleep patterns
Rationale: Helps evaluate the effectiveness of interventions
Desired Outcomes:
- The patient will maintain a regular sleep pattern
- The patient will report improved sleep quality
- The patient will demonstrate decreased fatigue
Nursing Care Plan 4: Impaired Social Interaction
Nursing Diagnosis Statement:
Impaired Social Interaction related to altered thought processes and behavior as evidenced by difficulty in maintaining appropriate social relationships and inappropriate social behavior.
Related Factors:
- Altered mental status
- Communication barriers
- Self-concept disturbance
- Environmental stressors
Nursing Interventions and Rationales:
- Set clear behavioral limits
Rationale: Establishes appropriate social boundaries - Encourage appropriate social interaction
Rationale: Promotes social skills development - Provide structured activities
Rationale: Facilitates appropriate social engagement
Desired Outcomes:
- The patient will demonstrate appropriate social behavior.
- The patient will participate in group activities
- The patient will maintain beneficial relationships
Nursing Care Plan 5: Ineffective Coping
Nursing Diagnosis Statement:
Ineffective Coping related to inadequate coping mechanisms as evidenced by increased agitation, poor problem-solving, and maladaptive behaviors.
Related Factors:
- Limited coping skills
- Overwhelming stressors
- Poor support system
- Previous trauma
Nursing Interventions and Rationales:
- Teach coping strategies
Rationale: Provides tools for stress management - Encourage the expression of feelings
Rationale: Promotes emotional awareness and regulation - Support positive coping mechanisms
Rationale: Reinforces adaptive behaviors
Desired Outcomes:
- The patient will demonstrate effective coping strategies.
- The patient will express feelings appropriately
- The patient will show improved problem-solving skills
References
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- Raveesh BN, Munoli RN, Gowda GS. Assessment and Management of Agitation in Consultation-Liaison Psychiatry. Indian J Psychiatry. 2022 Mar;64(Suppl 2):S484-S498. doi: 10.4103/indianjpsychiatry.indianjpsychiatry_22_22. Epub 2022 Mar 23. PMID: 35602364; PMCID: PMC9122159.
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