Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Tool to Assist in the Assessment of Client Preferences for Dealing with Agitation: Coping Agreement Questionnaire

Treatment Plan

Coping Agreement

Patient Name: 

Sex: 

Date of Birth: 

"CNO": 

Unit / Ward No.: 

Hospitalization can be a stressful time. Therefore, the nurse interviewer would like to find out the best ways to care for you in case you become upset and you need help dealing with your emotions. We are asking you to answer a few questions to help us assist you. Please keep the staff informed about how you are feeling at all times.

  1. What upsets you and/or causes you to lose control?
    •    Being tired
    •    Being hungry
    •    Having visitors
    •    Being touched
    •    Not being able to go home
    •    Too much noise
    •    Feeling lonely
    •    Not having visitors
    •    Feeling rejected
    •    Other
  2. What have you done when you were upset or lost control?
    •    Cry
    •    Withdraw
    •    Slam doors
    •    Hurt myself
    •    Throw things
    •    Hit people
    •    Strike out
    •    Yell
    • Other.
  3. If I am about to lose control, please try the following things to help me calm down.
    •    Talk with me
    •    Allow me to sit quietly by myself in a room
    •    Have me deep breathe
    •    Help me get involved in another activity
    •    Give me medicine
    •    Other
  4. Family recommendations:
     
     
    If at any time, your emotional state puts you or others in an unsafe situation, and the information you have given us has not helped you gain control of yourself so that you are safe, staff will intervene by using an alternative intervention. A physical intervention will only be used as a protective method to help keep you or others safe. Once you have gained control, staff will once again review your treatment plan and coping agreement with you. Together we will make any necessary changes in your treatment.
  5. The following questions will be asked if clinically indicated:  Not clinically indicated
    1. As a last resort, in a crisis situation which treatment would you prefer?
      •    Seclusion
      •    Restraint
      •    No preference
    2. If either seclusion of restraint is used, do you wish to have your family/significant other notified?
      •    Yes
      •    No

Patient's Signature: 

Date: 

Nurse's Signature: 

Date: 

Treating Physician's Signature: 

Date: 

Revision History: Place (X) if the revision is after seclusion/restraint; also document debriefing meeting in the progress notes.

Date: 

Revision ( ): 

Staff Signature: 

Date: 

Revision ( ): 

Staff Signature: 

Date: 

Revision ( ): 

Staff Signature: 

(If necessary continue revision history on a UCR Continuation Sheet)

Reprinted with Permission from David J. Hellerstein, MD.

New York State Psychiatric Institute