Crisis, Aggression, Abuse and Legal Issues

Safety, patient rights and reporting

Mental Health

Preventing and managing aggression

Early signs: pacing, clenched fists, loud voice, staring, threats.
De-escalate: calm low voice, respect personal space, open posture, offer choices, listen, reduce stimuli.
Your safety: keep a clear path to the door; don't turn your back; get help early.
PRN medication offered voluntarily first.
Seclusion or restraint only for imminent danger when other steps fail: order required; violent-behavior orders last up to 4 h (adults), 2 h (ages 9–17), 1 h (under 9); face-to-face evaluation within 1 h; continuous monitoring.

Admission and patient rights

Voluntary: may request discharge (may be held briefly for evaluation, per state law).
Involuntary: danger to self or others, or gravely disabled; time limits and court review per state law.
Patients keep their rights: to communicate, to have visitors, privacy, the least restrictive care, and to refuse treatment (except in emergencies or by court order). Commitment doesn't mean legal incompetence.
Duty to warn (Tarasoff): credible threats against an identifiable person must be reported per policy.

Abuse and violence

Intimate partner violence

Ask privately, without the partner present; use a professional interpreter, not family.
Cycle: tension building → violent incident → "honeymoon" (apology, calm).
Safety planning; document injuries with photos, body maps and the patient's own words; give resources. Reporting rules for adults vary by state.

Sexual assault

Ideally, don't shower, change, or urinate before the exam (evidence).
Forensic nurse (SANE) exam; emergency contraception; STI prophylaxis; HIV PEP within 72 h; emotional support.

Child abuse: red flags (mandatory report)

Injuries that don't match the story or developmental stage; delay in seeking care.
Bruises on a baby who isn't yet cruising; patterned bruises; bruises on ears, neck, torso.
Spiral fractures, multiple fractures at different stages; immersion burns (glove or stocking pattern).

Older adult abuse (mandatory report)

Unexplained injuries, poor hygiene, missing money or possessions, fear of a caregiver, untreated problems.

Human trafficking signs: someone else speaks for the patient, holds their ID, inconsistent stories.

Crisis intervention

A crisis is short-term (usually resolves within 4–6 weeks). Be directive, focus on the immediate problem and safety, mobilize supports and coping skills, then plan follow-up.

Grief

Kübler-Ross stages (denial, anger, bargaining, depression, acceptance) don't happen in a fixed order. Prolonged grief disorder (new diagnosis): intense grief lasting ≥12 months (≥6 months in children) that disrupts life.