Agitation Nursing Care Plans Diagnosis and Interventions
Agitation NCLEX Review and Nursing Care Plans
Agitation and anxiety are frequently correlated; the difference between the two is that agitation is triggered by feelings of tension and irritation, which can likely cause a high level of stress and hyperactivity.
The most common cause of agitation in patients is the presence of a risk factor or a psychiatric disorder.
Clinical presentation of hostility and destructive behaviors are commonly suggestive of poor health outcomes and may endanger the patient or those in his or her vicinity.
Institutionalization may be necessary to address the societal implications and risk of injury in cases involving combative or fear-inducing behavior.
Signs and Symptoms of Agitation
- Alterations in the level of consciousness
- Verbalized or non-verbalized hostility
- Repetitive behaviors
- Damage to property
- Aggression (e.g., cursing, screaming)
Risk Factors to Agitation
- Prolonged use of psychoactive medications
- Presence of psychiatric disorder/s
- Poor sleep pattern
- Prolonged or involuntary hospitalization
- History of aggression
Causes of Agitation
Agitation is more prevalent in patients with comorbidities, functional disability, or neurodegenerative conditions.
- Bipolar Disorder (BD). BD patients suffer manic episodes, resulting in substantial activity and energy fluctuations. Psychomotor agitation (PMA) is a complication of this disorder marked by an uncontrollable increase in psychomotor activity. The presence of PMA may be indicated by restlessness and hostility. Unpredictable escalation to aggression may necessitate early intervention due to the increased risk of harm to the patient and those in close vicinity. PMA is a multifactorial condition that can culminate in a series of changes in cognitive, behavioral, and physiological domains, and these manifestations can be attributed to a number of causative factors: Drug-induced, genetics, neuroanatomy, defective neurotransmitters, hormone imbalance, neuronal alterations, stressors, and coexisting personality disorders
- Autism. Patients with autism spectrum disorder (ASD) are prone to encounter communication and social interaction difficulties. Due to the decreased serotonin transmission and other etiological factors (e.g., heredity, infection), this disorder can affect auditory and visual perception in a subtly disruptive manner. There is also an increase in anxiety-like and repetitive behaviors. Other clinical symptoms of ASD that can aid the diagnosis are PMA, aggression, mood swings, and seizures.
- Alzheimer’s Disease (AD) and dementia. As a result of cognitive loss, those with AD and its associated dementias are likely to exhibit behavioral and psychological changes as evidenced by aggression and depression. Along with memory impairment is neurodegeneration, as the loss of neurons, hypofunction of serotonergic systems, and decrease in neurotransmission can impact the functioning of the central nervous system (CNS). These disturbances can increase the risk of hallucinations and dementia-related symptoms such as agitation, memory loss, disorientation, and delirium. AD-related aggression may also suggest an increase in undirected motor activity, thereby causing disabling behavioral changes which decrease the quality of life and affects the person’s ability to perform activities of daily living (ADLs)
- Schizophrenia. Neurochemical alterations and abnormal neuroanatomical structure are causal factors of delirium in schizophrenia patients. Eccentric and paranoid behaviors indicate the onset of deterioration. And due to an impaired sense of reality, patients with this disorder experience hallucinations and delusions. It is also widely recognized to reflect psychosis which may progress and lead to feelings of nervousness, uneasiness, and restlessness. Antipsychotic medications that elicit drug-induced agitation are further complicating factors to consider.
- Hypothyroidism. This condition affects cognitive function and may lead to mental retardation. Its psychiatric symptoms include irritability, psychosis, hyperactivity, lethargy, and excitability. PMA is usually expected in hyperthyroidism, but it may also manifest in hypothyroidism due to a lack of impulse, anxiety, and memory deficits that affects everyday activities. Although these symptoms can be mitigated by medications, drug-induced side effects may also make a patient become agitated and distressed.
- Menstrual cycle. Hormonal changes such as estrogen influence can cause sensations of tension and make women feel overwhelmed and agitated. Irritability and anxiety are also effects of premenstrual syndrome and premenstrual dysphoric disorder.
Other causes of agitation may include:
- Peer pressure
Complications of Agitation
- Risk of Injury (e.g., falls, hostility)
- Removal of indwelling medical devices (e.g., catheters)
Diagnosis of Agitation
As a healthcare provider, it is common to make inaccuracies in determining the cause of agitation and diagnosing a pre-existing condition; therefore, extra caution is advised. A thorough and accurate diagnosis is necessary for selecting the most effective pharmacological treatment and selecting the most appropriate management strategy.
- Physical Assessment. Identifying the signs and symptoms of agitation is a crucial aspect of establishing diagnostic criteria. There are several standardized diagnostic scales that can assess agitation and social interaction. Typically, monitoring peak behavioral symptoms during hospitalization involves days of clinical observation. Agitated individuals often have trouble interacting with their surroundings and are completely incapable of participating in any type of activity.
- Cognitive Assessment. Cognitive decline and memory impairment are sufficient indicators of psychological illnesses (e.g., AD, BD, dementia) that can induce agitation in individuals. Identified hallucinations and delusions are clinical manifestations of disease progression and severity. However, these predictors may fluctuate based on the current stage of the disease. For instance, apathy is the earliest neuropsychological symptom in the pre-dementia stage, whereas its severe form can induce hyperactivity and agitation.
- Medical History. Existing medical conditions (metabolic, infectious, or endocrine disorders), structural abnormalities, or predisposition to chronic illnesses might assist in identifying and excluding diseases or factors as the potential source of agitation.
- Neurological examination. Patients with a history of trauma and those with psychiatric disorders may require neurological examination. Atypical symptoms, such as delirium and fever, may necessitate more specialized and focused investigations, such as brain computed tomography (CT), endocrine tests, blood and chemical analyses, and lumbar puncture.
Treatment of Agitation
- Medications. Antipsychotic drugs and tranquilizers are usually first in line when it comes to the management of an agitated patient. However, the side effect profile should be thoroughly considered and evaluated as these agents can sometimes cause respiratory depression and hypotension.
- Muscle relaxation exercises. Relaxation training includes deep breathing exercises, progressive muscle relaxation, guided imagery, and autogenic training. These techniques remain effective in promoting increasing relaxation and self-regulation competencies. They are known to elicit relaxation responses by gradually releasing tension in the muscles via proprioceptive stimulation, increasing blood oxygen levels, conjuring sensory experiences, reducing anxiety and cortisol levels, and cranial nerve X stimulation.
- Hormone replacement therapy. During perimenopause and premenstrual syndrome, hormonal fluctuations can cause frequent mood swings, agitation, and manic episodes. Therapeutic hormone replacement with effects on serotonin neurotransmission in the brain can be used to reduce the impact of these hormones.
- Therapeutic communication. In order to effectively address the patient’s concerns and feelings, it is essential to de-escalate and take control of the situation. The healthcare providers should ask open-ended questions to initiate a conversation and assist in identifying problems or probable triggers that may influence irrational/volatile behaviors. The purpose is to prevent instigating fear and anxiety, and instead, the patient should feel supported and validated for their concerns. Another goal is to establish a cooperative relationship and relieve stress before employing more intrusive and appropriate strategies.
Other management strategies may include the following:
- Ensuring safety. Since psychiatric patients are prone to be agitated, the major responsibility of caregivers and personnel is to ensure the safety of the environment. In some cases, physical restraints may be warranted, but they should be limited to situations in which the patient or staff are threatened by agitated behavior. Patients that pose an urgent risk and necessitate stringent intervention include those who are violent or suicidal.
- Sleep. The induction of sleep can be a desirable therapeutic approach for the control of agitation in patients with psychotic disorders. This focuses on the improvement of psychiatric symptoms due to its calming effect, but it also permits the staff to evaluate the efficacy of the intervention and involve the patient in care planning.
- Minimizing disturbances and stimuli
Nursing Diagnosis For Agitation
Nursing Care Plan for Agitation 1
Risk for Violence: Self-Directed or Other Directed
Nursing Diagnosis: Risk for Violence: Self-Directed or Other Directed related to agitation secondary to bipolar disorder.
- The patient will verbalize emotional control and refrain from harming themselves or others.
- The patient will seek medical attention or assistance when prompted with hostile thoughts.
|Agitation Nursing Interventions||Rationale|
|Routinely assess the patient’s behavior and be alert for signs of increased agitation and extreme hyperactivity.||In extreme cases of hyperactivity, patients may be unable to make appropriate choices and may engage in risky activities. Early de-escalation or treatment of mania decreases the likelihood of causing harm to oneself or others.|
|Approach the patient with calmness and discuss procedures and guidelines in a clear and concise manner.||BD patients are more likely to resort to tantrums, verbal hostility, and physical violence due to hypersensitivity or altered sensory perception. A proactive approach will aid in managing moderate agitation and anger; however, if verbal consolation and de-escalation techniques fail, healthcare personnel may employ other alternatives to prevent injury to themselves or others. In addition to calming the patient, this intervention offers them reassurance and helps them meet their needs.|
|Maintain a passive stance and refrain from disputing with the patient.||In patients with BD, inconsistencies serve as reasons for anger outbursts. Avoid argumentation with belligerent patients, as it can exacerbate their mania and aggression. Due to hyperactivity and elation, judgment may also be affected, resulting in a feeling of invincibility (being right or rational).|
|Ensure that expectations, routine care, and assistance are consistently met. Provide the patient with a safe and structured environment.||Maladaptive responses to anxiety or agitation include withdrawal, violence, and vague and unrealistic expectations. The presence of these responses may contribute to manipulation and inadequate coping. Consistency and the establishment of reasonable expectations will facilitate better adaptation to the situation and a trusting relationship.|
|Redirect the patient’s energy, attention, or agitation to low stimulating and calming activities.||Helps relieve aggression or hostility. It may also reduce restlessness and muscle tension.|
Nursing Care Plan for Agitation 2
Nursing Diagnosis: Risk for Injury related to agitation secondary to mood disorder.
- The patient will maintain optimal health, respond to drugs at recommended doses, and be free of harmful levels of hyperactivity.
- The patient will voluntarily take frequent rest periods and will not be physically agitated.
|Agitation Nursing Interventions||Rationale|
|Assess the degree of agitation and orientation.||Impulsiveness, paranoia, violent outbursts, frustrations, and aggression may lead to destructive outcomes, including harm to oneself and others. Arguing is likely to make the patient more upset, whereas verbal orientation can make the patient feel more at ease and secure.|
|Prescribe planned, non-competitive, solitary activities and diversions with the assistance of a nurse or assistant||Patients with mood disorders are easily distracted, irritated, and agitated; hence they need a structured regimen or routine activities that could restore focus and executive function.|
|Communicate in short, straightforward sentences using terms the average person can understand. Avoid complex medical jargon when relaying step-by-step directions.||Patients will find it easier to organize their thoughts and convert feedback and response to the activity or intervention if there are clear and easy directions.|
|Incorporate regular rest periods in the patient’s schedule.||The common signs and symptoms of agitation include distress, restlessness, and pacing, which may deplete energy levels. Promoting rest conserves energy and improves coping mechanisms by reducing physical and psychological stress over time.|
|Keep the care environment devoid of stimulation, such as background noise, low-temperature ventilation, and bright lighting.||Reduces anxiety, agitation, and the likelihood of precipitating seizures.|
|Offer a urinal bowl or bedpan if the patient has short-term memory and paranoia.||Due to cognitive shifts, memory impairment and paranoid delusions are likely to occur. Dysregulation of sensory processing can lead to movement, sensing, and visual difficulties, potentially resulting in injuries. Moreover, transient or short-term memory loss can lead to environmental safety concerns, as patients may become disoriented when leaving their care setting or wander while searching for a commode or toilet in the middle of the night.|
Nursing Care Plan for Agitation 3
Compromised Family Coping
Nursing Diagnosis: Compromised Family Coping related to agitation secondary to Alzheimer’s Disease, as evidenced by stress, fatigue, anxiety, social isolation, withdrawal from caring for the patient, feelings of insufficiency in crisis management, and lack of comprehension of the patient’s responses to health complications.
Desired Outcome: The family will demonstrate improved coping skills concerning the patient’s condition and need.
|Agitation Nursing Interventions||Rationale|
|Assess the family’s knowledge and comprehension of the patient’s condition and behavior.||Lack of knowledge might result in negative interaction patterns and cause family members to experience dread, affective liability, or agitation. On the contrary, knowledge enhances the family’s tolerance and understanding of the person with dementia. This intervention will also enable the nurse to respond to inquiries and concerns and dispel misconceptions and myths concerning AD.|
|Help the family recognize erratic behaviors and impending signs of aggression.||Recognizing changing or negative behaviors (e.g., acting out) helps minimize the risk of violent behavior.|
|Assess the level of agitation among family members. Note for fatigue and reduced social exposure.||The stress and strain of caring for a loved one with a serious disorder can lead to disorganization and disinhibition in the family, making them more prone to depression and psychological distress.|
|Provide avenues for family members to voice their worries and feelings. Allow sufficient time for questioning and identifying feelings around role reversal and meeting the expectations of care provision.||The family’s economic status may be affected due to hospital costs and hinder their own goals in life. Meeting the patient’s long-term needs may physically and psychologically drain and exhaust them. In addition, becoming involved in the treatment process and restraining agitated patients to de-escalate situations can cause a great deal of mental strain.|
|Assist the family in identifying issues and providing knowledge regarding the effectiveness of stress management. Inform them of behavioral management techniques (e.g., time-out, positive reinforcement, token rewards) that can be used to address and manage the patient’s volatile behavior or agitation.||Increases the ability to meet the patient’s needs by fostering an environment of mutual understanding and support for resolving problems and managing restlessness and stress.|
|Encourage the family to preserve healthy and intimate social contacts.||Isolation, restlessness, and stress impact the health and capabilities of the caregiver. Not only does the presence of a social support system benefit the patient, but it also aids the caregiver in coping and functioning more successfully.|
Nursing Care Plan for Agitation 4
Impaired Social Interaction
Nursing Diagnosis: Impaired Social Interaction related to agitation secondary to schizophrenia, as evidenced by social anxiety, inadvertent emotional responses, inability to make eye contact, and verbalized social discomfort.
- The patient will seek supportive social relationships and enhance interactions with family, significant others, and colleagues.
- The patient will exhibit interest in acquiring effective coping strategies and engaging in activities.
|Agitation Nursing Interventions||Rationale|
|Identify signs and symptoms of the patient becoming agitated and anxious in a certain situation.||Typically, the symptoms of schizophrenia (hallucinations, delirium) impede social interaction. Increased anxiety may also exacerbate agitation and aggression.|
|Establish realistic goals and determine the risk for social isolation.||Avoids pressure and a sense of failure, both of which may inhibit communication due to dissociation. Setting realistic goals increases the patient’s sense of control and delivers gratification upon goal achievement.|
|Ensure that the care environment is free of stimuli (e.g., loud noises, bright lights) and avoid crowding as much as possible.||Anxiety, tension, and aggravation can all be worsened by an unsettling care environment. Moreover, a distracting and stimulating environment can lead to manic episodes and an inability to concentrate.|
|Limit or avoid touching the patient. If touching is necessary, ensure that it is done in a gentle and steady manner.||Touching patients without their knowledge and understanding can be misconstrued as a coercive or sexual gesture. The idea of any physical contact may be considered inappropriate for schizophrenic patients.|
|Provide information about maladaptive behaviors and support the patient in learning positive or adaptive behaviors (e.g., social adaptation) instead.||To help patients adapt and function at a higher level in society. This intervention will also mitigate aggressive responses and resistance to care, thereby increasing the patient’s quality of life.|
|Offer social skills training and consider the patient’s previous hobbies and interests.||Increase the likelihood of patient participation in activities and prevents aggravation of restlessness.|
Nursing Care Plan for Agitation 5
Nursing Diagnosis: Ineffective Coping related to agitation secondary to panic disorder, as evidenced by ritualistic behavior, decreased social interaction, poor problem-solving skills, incapacity to meet fundamental needs, and incapacity to fulfill role expectations
- The patient will demonstrate adept coping with absent ritualistic activities/behaviors.
- The patient will make some effort to stop compulsive thoughts and behavior.
|Agitation Nursing Interventions||Rationale|
|Assess the patient’s level of restlessness or agitation. Investigate sources of increasing anxiety and identify the type of situations causing ritualistic, aggressive, and nonaggressive behaviors.||Recognizing emotional and physical responses to triggering circumstances can aid in patient education and facilitate the development of interventions that can prevent the course of verbal aggression to violence.|
|Ensure that the patient’s initial dependency requirements are addressed.||Although dependency is a dysfunctional coping strategy, eliminating sources of dependency or enforcing independence may cause anxiety and agitation. It is important to explain and gradually minimize maladaptive behaviors so that the patient does not feel overwhelmed.|
|Establish independence slowly in the course of the therapeutic process and provide a system of reward and positive reinforcement for independent behaviors.||Recognizing the patient’s positive coping practices and healthier efforts will increase their self-esteem and encourage them to continue engaging in these activities.|
|Initially, allow the patient time for their usual rituals or routines. Always adopt a nonjudgmental and welcoming approach when communicating.||Depriving the patient of their usual routine may cause them to get agitated, which may result in verbal or nonverbal outbursts of anger. Additionally, it might trigger panic-level anxiety and insomnia.|
|Take note of severe stress reactions (e.g., statements of suicidal thoughts, extreme restlessness, depression)||These are often emotional responses to the situation and condition. It elicits fear and aggravation of death and prognosis.|
|Assist the patient in comprehending their behavior and assessing their lifestyle risk factors, which may cause a myriad of conditions and stress. Encourage preventative measures against anxiety and agitation and recognize their efforts.||The patient may be unaware that unmanaged and unresolved emotional issues may contribute to the progression of agitation to a sequence of maladaptive and destructive behaviors. Before any significant progress can be made toward a solution, problems must be acknowledged and accepted.|
|Gradually reduce the time spent engaging in ritualistic activities as participation in care activities increases.||The patient may benefit and regain functioning when ritualistic behaviors (compulsive urges) are replaced with adaptive ones.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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