Limit setting PDF

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MENTAL HEALTH NURSING: Limit Setting* I.

Definitions: 1. 2. 3. 4.

II.

Concepts of Limit Setting: 1. 2. 3. 4. 5. 6.

III.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Limits should be considered in the context in which the need for them arises (appropriate to the situation). Best of limits are team decision and approach. Limits are to be clearly defined and discussed with person. Limits need to be clarified before negative consequences are applied. Limits are to be defined before client is out of control. Limits lead to growth for the person. A person participates in his or her limit-setting insofar as possible. Consistency in the broad framework of limit setting contributes to a person’s security. Once a limit has been defined, consequences must be consistent. Enforcement of limits should be firm, not hostile. On the other hand, positive behavior is to be reinforced. Flexibility within the broad framework of limit-setting is necessary to provide for the functioning of different persons and different situations.

Techniques of Limit Setting: 1. 2. 3. 4. 5. 6. 7. 8.

*

Limits reduce anxiety and enable a person to function more adequately. Limits aid in the clarification of a person’s self-concept. Limits form a framework within which a person can learn to frame his or her requests. A limit is gradually internalized and used by a person in the management of his or her own behavior. Limits can be reassuring, decrease anxiety, convey to the person that they are important enough to care about. Attitudes of staff and methods of setting limits make the difference.

Principles of Limit Setting: 1.

IV.

Therapeutic limit setting involves a need to understand client and self. Limit setting is not a punitive response to behavior. Rather, limit setting is informing a client what behavior is acceptable (or expected), what is not acceptable, and the consequences attached to behaving unacceptably. Can be long-term or short-term limits.

Give advance warning of a limit. State expectations to client in a positive way. Be sure you can follow through with a limit before you set it. Provide an element of choice whenever possible. Present the limit in such a way that it does not lower a person’s self-esteem. Remain with a person for a while after a limit has been set. Help client explore the reason for and meaning of his or her behavior. Consider with client alternative ways to express his or her feelings.

Developed by Mary Ann Hoefler, RN, PhD, College of Saint Mary, Omaha, Nebraska. H8 – 1

9. 10. V.

Types of Limits: 1. 2. 3. 4.

5. 6. VI.

Verbal limits Written contracts Written ward rules Physical limits  holding  mechanical restraints QR (quiet room, timeout room, seclusion, isolation) Medication

Examples of Types of Clients Where You May Use Limits: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

VII.

Avoid rejecting client and convey to client he/she has right to feelings and ability to express them appropriately. NEVER SET LIMITS UNLESS YOU CAN ENFORCE THEM.

Manipulative clients Children (physical limit of holding may be effective with small children) Adolescents Suicidal clients Violent client (poor impulse control) Angry client Manic client Passive-aggressive individual Demanding client Emergency rooms

Out-of-Control Client (client who is severely disturbed or with poor impulse control): 1. 2. 3. 4. 5. 6.

7.

Referring to behavior that is physically assertive and risks injury to self, others, and environment (serious destruction of property). Goal: minimize danger to all. Best approach is prevention. Violent feelings often associated with intense anxiety. It is not therapeutic to allow a client to lose control or do something that later they will be embarrassed by (e.g., disrobing in dining room). Observe behavior, anticipate, and intervene early to prevent ways:  Separate disturbed client from rest of client group.  Talk with client if receptive — allow to verbalize feelings.  Give medications.  Sometimes physical activity helps (however, this sometimes can cause loss of control).  Avoid unnecessary touching (if necessary, inform client ahead of time). If violence occurs (client loses control) immediate intervention is necessary. a. Assessment  Need enough personnel available to ensure safety of client and staff (but not 20!).  Staff need to have been taught body mechanics and methods of holding struggling client without injury. b. Plan-plan approach  One person should direct group. H8 – 2

c.

d.

Intervention  Should use least restrictive limit first — try verbal before physical.  Give client choice (choice may be, “Do you want to walk to QR by yourself or should we assist you?”).  One person should talk with client, explaining what is happening and why.  Medication or QR as necessary.  Most violent clients are reassured if they see they can be controlled.  On the other hand, if staff is extremely anxious, it increases client anxiety. Evaluation  Review situation with client after regaining control — review with staff to see if it could have been prevented.

VIII. Use of Physical Restraints: 1. 2. 3.

4.

5.

6. 7. 8. 9.

One of earliest means used to try to control behavior (chains). Physical restraint should be used as last resort for protection of client or others from harm. Mechanical restraint such as — waist restraints — wrist restraints — ankle restraints — sheet packs  should be used only with medical order.  should be released as soon as possible (can frighten client and cause increased struggling). Seclusion or isolation — may range from confinement in room with closed, but unlocked door to a locked room with mattress with linens on floor, limited communication, and client in hospital gown.  Use latter only when absolutely necessary.  Nursing personnel always close by — available for verbal interaction if the client is able. Nursing Care  Consider client’s basic needs.  Must observe client.  Must be opportunity for communication.  Careful records.  Assess continued need. Effect of decreased stimuli in Quiet Room (QR) in some clients. Always review situation to see how it could have been prevented. Intervene before client loses control. Again, physical restraint is a last resort.

H8 – 3...