Option 2: Restless but no imminent signs of violence

Last updated: May 1, 2025

Reading the signs

From the doorway, you see the patient sitting in bed, fidgeting with her hospital gown and blanket. When she sees you, she pulls the blanket up to her neck and asks you angrily why you are there. When you explain that you came because she has a fever and she seems uncomfortable, she pulls the blanket down and stares at you.

The nurse tells you:

The patient is listless and confused, though she reorients and redirects easily.
The nurse is worried the patient will pull out her IV and urinary catheter—that is why she called you.
The patient has been hospitalized for moderate diverticulitis for 3 days. She has needed a urinary catheter the whole time because of frequent incontinence.
The patient has had a low-grade fever all day.
The patient has a history concerning for mild dementia but still lives independently and performs basic ADLs.
The patient's alcohol intake is unknown, but one of her daughters has voiced mild concern, saying she's seen the patient have “a glass or two too many” of wine on occasion.

Question: What is your next step?

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Order restraints to avoid having the IV pulled out. She looks like a tough stick.
Order broader antibiotic coverage. She probably has a resistant organism.
Order a benzodiazepine for alcohol withdrawal.
Assess the patient further.

Avoid assumptions that can lead to quick, and often incorrect, decisions (e.g., fever means infection, or a relative's concern means alcohol dependence). Always perform a thorough examination and remain objective.

Prioritize and triage

Question: What is your rapid assessment of this patient's level of agitation?

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Mild
Moderate
Severe

Question: What is the best next step for addressing this patient's agitation?

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Wrist restraints
Parenteral calming medications (while you still have IV access)
Oral calming agents
De-escalation techniques

In cooperative patients with mild agitation, proceed with medical evaluation and diagnostic testing using de-escalation techniques. Use calming medications only if necessary.

Do not assess a patient with agitation only once. If possible, personally reexamine the patient frequently, looking for any evidence of progression.

Order diagnostics

More information...

You are able to complete your examination with occasional gentle redirection of the patient.

Vital signs: heart rate 90 beats/minute, blood pressure 136/89 mm Hg, respiratory rate 18 breaths/minute, SpO₂ 95% on room air
Cardiovascular: regular rate, no murmurs, strong bilateral radial pulses
Breath sounds: clear and equal bilaterally
Abdomen: not distended, bowel sounds are present, mild suprapubic and LLQ tenderness
Neurological: no gross cranial nerve abnormalities, purposeful movement of all 4 extremities
Skin: hot and dry

Question: Which of these diagnostic studies would you order for this patient?

Make your choices, then click on the explanation bubbles to reveal the answers.

CBC
BMP
Urinalysis
Blood cultures
Blood gases
Head CT
Abdominal CT

Routine laboratory studies are not recommended in patients with agitation. Diagnostic testing is tailored based on clinical features, history, and examination findings.

Practice

De-escalation techniques are integral to the management of agitation, and learning how to effectively use them will make your clinical life easier! Review the table below to brush up on the techniques that you'll want to have at the ready.

De-escalation techniques

Principles and techniques for de-escalation ^[1]
Principles		Techniques
Avoid escalation	Be mindful of personal space.	Keep a distance of at least two arms' length. Ensure a clear exit path for both the clinician and patient.
Avoid escalation	Maintain a nonconfrontational demeanor and body language.	Keep your hands visible and relaxed. Do not stand directly in front of the patient. Avoid prolonged eye contact and staring. Maintain an open and calm manner and expression. Avoid threatening, condescending, or insulting language and anything that might cause the patient to feel humiliated.
Engage the patient verbally	Provide structure and reassurance.	Introduce yourself and explain your role and intention to help. Ask how the patient prefers to be addressed. Explain what to expect.
Engage the patient verbally	Use concise, simple, and repetitive language.	Keep your sentences short and use simple words. Give the patient time to process information and respond. Repeat your message until it is heard and understood.
Build cooperation and trust	Identify feelings and desires.	Ask what the patient wants. Use targeted questions based on information provided by the patient and/or the medical record.
	Listen actively.	Restate and verbally acknowledge the information provided by the patient. Try to understand the patient's subjective experience.
	Validate perceptions and emotions.	Acknowledge the patient's feelings. Seek out points on which you can agree, like specific facts or general truths and principles. On points of disagreement, be honest but understanding.
Defuse the situation	Clarify rules and limits.	Set working conditions. Tell the patient when their behavior is causing you or other staff members to feel threatened or upset. Inform the patient that violent or abusive behavior will not be accepted.
	Help the patient stay in control.	Tell the patient what you need them to do to enable their care. Explain how to get attention and communicate needs. Indicate how to deal with contingencies.
	Offer choices and optimism.	Allow the patient to choose between different acceptable options. Offer comforting measures (e.g., food, drink, or phone access). If medication is necessary, involve the patient in decisions (e.g., the type of medication or route of administration). Provide an honest and realistic but hopeful outlook.
After involuntary intervention	Debrief.	Attempt to restore the clinician-patient relationship. Allow the patient to explain their view. Explain why the intervention was necessary. Engage the patient in planning for future contingencies. Debrief others who witnessed the event, including family members and staff.

Dive deeper

Agitation is one of the toughest management challenges you will face. The differential is broad, and further management will depend on the diagnosis. The following table covers management for critical causes of agitation. You can also find it in “Approach to the agitated or violent patient,” along with a comprehensive review of management.

Management of critical causes of agitation
	Suggestive findings	Immediate intervention
Hypoxia	↓ SpO₂ Dyspnea	Start oxygen therapy. Manage underlying cause of hypoxemic respiratory failure (e.g., pneumonia, acute asthma exacerbation, acute exacerbation of COPD, acute heart failure, CO poisoning).
Hypercarbia	PaCO₂ > 45 mm Hg Dyspnea or hypopnea	Manage underlying cause: e.g., hypercapnic respiratory failure of any cause, substance-related respiratory depression (due to opioid intoxication, severe salicylate toxicity). Consider mechanical ventilation.
Hypoglycemia	Serum or fingerstick glucose ≤ 70 mg/dL (≤ 3.9 mmol/L)	Give PO dextrose or IV dextrose . Evidence of chronic alcohol use and/or poor nutritional status Consider concurrent prophylactic IV thiamine. ^[2]^[3]^[4]^[5] Higher doses of thiamine are indicated if there is a concern for active Wernicke encephalopathy. See also “Alcoholic ketoacidosis.” See “Treatment of hypoglycemia” for further management details.
Hypothermia	Core body temperature < 35.0°C (95.0°F)	Initiate active and/or passive rewarming, as indicated. See “Treatment” in “Hypothermia.”
Hyperthermia	Elevated body temperature History of heat exposure and/or excessive physical activity Clinical features of drug-induced hyperthermia	Initiate cooling measures. Discontinue potentially causal drugs. See “Treatment” in “Heatstroke” and in “Drug-induced hyperthermia.”
Shock	Clinical features of shock History of trauma, bleeding, diarrhea, vomiting, and/or reduced oral intake Clinical features of underlying cause (e.g., bleeding, clinical signs of hypovolemia, signs of sepsis, symptoms of heart failure, or clinical features of pulmonary embolism)	Consider IV fluid resuscitation and/or vasopressors. Provide immediate hemodynamic support as needed.
Pain	High score on subjective and/or objective pain assessment. See “Pain intensity scale,” “Behavioral pain scale,” and “Critical care pain observation tool.”	Initiate treatment for pain.
Sepsis	History of infectious symptoms ≥ 2 positive SIRS or qSOFA criteria	Check serum lactate and obtain 2 sets of blood cultures. Initiate fluid resuscitation and start antibiotic therapy for sepsis. See “Sepsis management.”
Seizure	History of seizure disorder Ictal or postictal signs of generalized seizures or complex partial seizures	Initiate pharmacological interruption of ongoing active seizures. See “Management of acute seizures and status epilepticus.” If alcohol withdrawal seizures are suspected, consider treatment for alcohol withdrawal.
Wernicke encephalopathy	Evidence of chronic alcohol use and/or poor nutritional status Confusion, oculomotor dysfunction, and/or gait ataxia ^[6]	Start treatment with full-dose IV thiamine . Consider treatment for alcohol withdrawal.
Acute urinary retention	History of BPH, pelvic surgery, pelvic cancer, urinary stones, or spinal disease/injury Suprapubic pain/discomfort Palpable bladder	Perform urgent bladder catheterization. See “Treatment” in “Urinary retention.”

Related resources

Continue the adventure!

If you haven't explored the other scenario yet, jump over to “Option 1: Severe agitation with signs of potential violence.” You can also return to the main module; see “Restless state wrap-up.”

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