Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Personal De-escalation Plan Example

Patient Name:   
Date:   

Problem Behaviours:

What type of behaviours are problems for you?

  •    Losing control
  •    Feeling unsafe
  •    Injuring yourself
  •    Assaultive behaviour
  •    Running away
  •    Suicide attempts
  •    Restraints/Seclusion
  •    Feeling suicidal
  •    Drug or alcohol abuse
  •    Other

Triggers:

What type of things (triggers) make you feel unsafe or upset?

  •    Not being listened to
  •    Lack of privacy
  •    Feeling lonely
  •    Darkness
  •    Being teased or picked on
  •    Feeling pessured
  •    People yelling
  •    Arguments
  •    Being isolated
  •    Contact with family
  •    Being touched
  •    Loud noises
  •    Not having control
  •    Particular time of day / night    
  •    Particular time of year    
  •    Other    

Warning Signs:

Please describe your warning signs, for Example what other people may notice when you begin to lose control?

  •    Sweating
  •    Clenching teeth
  •    Wringing hands
  •    Bouncing legs
  •    Squatting
  •    Crying
  •    Not taking care of self
  •    Singing inappropriately
  •    Eating more
  •    Breathing hard
  •    Loud voice
  •    Rocking
  •    Can't sit still
  •    Isolating/ avoiding
  •    Hurting myself
  •    Sleeping less
  •    Being rude
  •    Racing heart
  •    Red faced
  •    Sleeping a lot
  •    Pacing
  •    Swearing
  •    Hyper
  •    Hurting others or things
  •    Eating less
  •    Laughing loudly / giddy
  •    Other    

Interventions:

What are some things that help to calm you down or keep you safe?

  •    Time out in your room
  •    Reading a book
  •    Pacing
  •    Colouring
  •    Hugging a stuffed animal
  •    Taking a hot shower
  •    Blanket wraps
  •    Lying down
  •    Using cold face cloth
  •    Deep breathing exercises
  •    Getting a hug
  •    Time out in the Quiet room
  •    Sitting with staff
  •    Talking with peers
  •    Exercising
  •    Writing in a journal
  •    Taking a cold shower
  •    Running cold water on hands
  •    Ripping paper
  •    Using ice
  •    Having your hand held
  •    Going for a walk
  •    Listening to music
  •    Watching TV
  •    Talking with staff
  •    Calling a friend (who?)
  •    Calling family (who?)
  •    Molding clay
  •    Humour
  •    Screaming into a pillow
  •    Punching a pillow
  •    Crying
  •    Speaking with a therapist
  •    Drawing
  •    Making a collage
  •    Playing cards
  •    Video games
  •    Snapping bubble wrap
  •    Bouncing ball in QR
  •    Being read a story
  •    Being around other people
  •    Male staff support
  •    Female staff support
  •    Using the gym
  •    Doing chores / special jobs
  •    Other    

What are some things that do not help you calm down or stay safe?

  •    Being alone
  •    Not being listened to
  •    Being disrespected
  •    Loud tone of voice
  •    Having people around me
  •    Peer teasing
  •    Humour
  •    Being ignored
  •    Other    

Strengths:

What are your strengths when feeling out of control?

 

Skills:

What skills do you have/ what are you good at?

 

Other:

Are you able to communicate to staff when you are having a hard time? If not, what can staff do at these moments to help??

 

What kinds of incentives work for you??

 

Special Plans:

List any special plans that help you (things you have used in the past or would like to try).

 

Patient Signature: 

Date: 

Staff Signature: 

Date: 

Reprinted with Permission from The Massachusetts Department of Mental Health.

Boston Medical Center
Intensive Residential Treatment Program
85 E. Newton St.
Boston, Ma. 02118