Faculty of Nursing

Psychaitric department
Limit setting

Under supervision of :
Dr/Heba. & Dr/Amira
2022-2023
‫‪Prepared by :‬‬
‫‪.‬دعاء على عبد الصمد‬
‫‪-٢‬دعاء محمد ابراهيم أحمد‬
‫‪-٣.‬دينا احمد محمود الراعي‬
‫‪-٤.‬دينا عبد الحميد محمد السيد‬
‫‪-٥.‬دينا محمد احمد مصطفى‬
‫‪-٦.‬رامي خالد علي محمد‬
‫‪-٧.‬رانيا عبدهللا أحمد الشاذلي‬
‫‪-٨.‬رانيا فريد سيد أحمد‬
‫‪-٩.‬رانيا يوسف محمد يوسف‬
‫‪-١٠.‬رجب محمد رجب محمد‬
‫‪-١١‬رحاب زكريا محمد عبد الكريم‬
‫‪-١٢‬رحاب شلبي محمد محمد‬
‫‪-١٣‬رحاب مجاهد محمد السيد‬
‫‪-١٤.‬رحاب مسعد بيومي ابو هيكل‬
‫‪-١٥.‬رحمه صالح السيد المندوه‬
‫‪-١٦.‬رحمه عبد المولى عبدربه عبد المولى‬
‫‪-١٧.‬رحمه مجدي محمد بدير احمد‬
‫‪-١٨.‬رشا جابر عبده محمد‬
‫‪-١٩.‬رضا محمد حسن عبد الغفار‬
‫‪-٢٠.‬رقيه محمود محمد السيد‬
Outlines:
1- Introduction.
2- Definition.
3- Purpose.
4- Types of behaviors need limit sitting.
5- Types of limit sitting.
6- Principles of Limit Setting.
7- Techniques.
8- Five easy steps to help you effectively and (calmly) set
Limits.
9- Nursing role.
Objectives:
After this presentation the nurse will be able to :
- Define the limit setting .
- List purpose of limit setting .
- numerate types of limit setting .
- Mention the types of behavior need limit setting.
- List steps of limit setting . 
- List the principles of limit setting .
- Discuss the technique of limit setting
- Discuss Nursing role in limit setting .
Introduction:
Sometimes a person with mental illness may display some behaviour
that is challenging To family members. When these behaviors cause
problems, it is important to develop Reasonable rules and to set
consequences for breaking those rules. This process is called
Limiting. It can be helpful to everyone involved, because it sets out
clearly what is Acceptable and what is not. The type of limits you set
would depend on your own situation And tolerance.

Definition:
- It is a process that which decrease the patient anxiety and stress ,
enabling the patient to re-
Establish himself ,control his unacceptable behaviour and find
appropriate way of behaviour.
- Is one of the most powerful tools you can use to promote positive
behavior change? For the
People in your care The art of limit setting will help you offer choices
not ultimatums and it
Will help you provide a structure for good decision making.
Purpose :

- You can provide a structure for good decision making .

Limit setting strategies are used to enhance the patient’s sense of self
and to make sure that the patient is mentally stable and able to
control their emotions .
- The nurse use limit setting as a tool to prevent disruptive behaviors
and provide quality of care for all patients .
- Limit setting also helps to defend the patient from stressful behavior
and enhance the patient’s feeling of safety and containment .
- To provide security، Trust and assurance
- To decrease the patient anxiety .
- To provide reality contact between the person and his environment .
- To learn new behavior .
- To raise his self – esteem .
- To develop ego function .
- The purpose of limits is to teach not to punish through limits.
– People begin to understand that their actions , positive or negative ,
result in predictable consequences by giving such choices and
consequences.

Types of behaviors need limit setting:

• Destructive Behavior:
An expression of hostility, anger and aggression by destroying and
Damaging property or yourself.

• Disorganized behavior:
Behavior that is self-contradictory or
inconsistent It may include.
Purposeless behavior, unpredictable agitation, or
Extreme emotional reaction (e.g., laughing after a catastrophe).
A typical example: dressing in clothing inappropriate for the weather
(e.g., wearing several layers on a warm summer day).

• Deviant behavior:
Defined as actions that violate social norms, which may include both
Informal social rules or more formal societal expectations and laws.

• Withdrawn behavior:
Avoiding or not seeking out social contact. People who withdraw
May actively avoid spending time with other people. Or, they may not
Put any effort into seeking out social interactions.

• Manipulative Behaviour:
Manipulative behavior includes actions a person uses to gain influenceor
control over someone else. These behaviors may include:
▪ Lying

▪ Denying
▪ Passive-aggressive behavior
▪ Silence
▪ Criticizing
▪ Withholding
▪ Blaming

Types of limit setting:

Types of limit sitting:
1- (Verbal ) :A client may approach the nurse and attempt to gain
personal information,
the nurse would use limit setting by saying ‘it is not acceptable for
you to ask personal
questions. If you continue, I will terminate our interaction, we need to
use this time to
work on solving your problems.
 2- Non verbal limits:  Such as indicating No with a shake of the
head.
3-Chemical : -drugs ,such as Fast acting sedating medication.
4- Mechanical Restraints : -is any method of physically restricting
person's freedom of movement physical activity normal access to the
body.
a-anklet : band around ankle 
  b-wristlet :band around wrist 
C- mitten :cloth covering 
d-helmet: head covering
5- Seclusion : -any involuntary confinement of a person alone in a
room that that the person is physically prevented from leaving it
means isolation
6 -Time out: Removal individuals from peers or reward situation
without restrain to reduce 
particular behavior.

Principles of Limit Setting:

→ Principles of limit setting in psychiatric nursing:
1. Limits must be selected so that the staff have the best chance to
maintain the limits consistently on all shifts, remembering that staff are
not robots and unexpected contingencies will always arise.
2. Some actions have natural consequences and these can provide a
basis for the selection of limits and add strength to their rationale, eg -
 if a patient stays in bed in one position all the time then s/he will
develop pressure sores and is at risk of developing other complications.
3. Some limits can be negotiate, others cannot especially those that are
beyond the control of the staff
4. Staff must be aware that they are role models for the limits they set.
Their behavior must be consistent wit what is expected of thepatient
and visitors.
5. Limits should be clear and simple with a clear rationale have some
therapeutic and/or practical aim. Do not set unnecessary orcontrolling
rules without clear reasoning.
6. Limits must be consistent with policy and reflect the philosophy of
the hospital and the unit.
7. Limits are documented in the management plan.

Technique:
  1. identify problematic behavior at need for limit:
  Limit setting by nurse is based on knowledge & understanding of the
problem & situation which should be realistic & meaningful.
  Nurses should be able to evaluate the situation & recognize the need so
  that effective limits could be established
  2. Communicate expected behavior:
Always communicate with the patient wither based on good
communicational skills or nonverbal motion to make the patients realize
their expected behavior limit. limits should not presented as a
punishment and should be clarified to him before negative consequences
  are applied.
  3. Guidelines for effectively using limits: State limit: Clearly, directly
and simply statements are told to the
  patient. The limit is stated clearly as a statement of fact and is not
presented as advice or punishment.
  The consequences should be: Simple and direct as the limit, it
  should immediately follow the client exceeding the limit and
  should be used consistently each time and should be matched to  the
interests and desires of the patient.
4. Help the patient understand the reason for limit:
  Tells Clear simple & concrete understanding to the patients of the
situation needs & the ability. patient will be less likely to misinterpret
the nurses motives & understanding.
..5. Enforce the limit:
Realistically the limit must be enforced on put into practice feeling to
follow the limit another action to be initiated.
6. Help the patient verbalize his feeling about the limit.
Patients must be allowed to express his/her feelings about the limit so
that the patient will better evaluate reality & judge rational control.
7. Evaluate the limit:
o The Effectiveness of the limit should be evaluated by the nurse.
• Effective limit should be in place for better & secure behavior.
communication and rational thinking.
8. Consistency:
This consistency must be present in the individual authority figure. If the
nurse has put a limit on a particular behavior, she must enforce it each
time, not overlook it because she is tired. All the staff should be
informed with the limits.
if there is not consistency on the part of all staff members, the patient
will usually respond with increased anxiety.

Five easy steps to help you effectively

(and calmly) set Limits :
1)Begin with empathy and trust.
2) Next, observe or notice what is happening, and simply narrate or
State what you see or hear.
3) Briefly explain why you want the behavior to stop.
4) Set the limit, while demonstrating the desired behavior or offering An
alternative, if possible.
5) Follow through with the limits each and every time (consistence).

Nursing role :
- Limits need to be set in inpatient mental health units to ensure the
safety and well-being of patients and staff.
There are many ways to set limits:
- Crises prevention institute had made general approach for limit
setting. It helps to change the behavior positively.
- Apply limits in consistent manner through: Patient should be
constantly and continuously exposed to an atmosphere of quiet
acceptance.
- Consistency must to be maintained from nurse to nurse and shev
which must be planned properly.
- Permissiveness to be limited e.g. with patients who are homicidal
suicidal, hyperactive and suspicious.
- Patient is allowed to feel as he does but limitation are put on his
behavior.
- Limit and it's reinforcement requires a great deal of fact and
understanding, and should be done in a quiet and matter of fact
way.
- The attempt to win patient's liki”g (favoritism) is most disastrous
for the patient.
- Engaging patients in an empathic manner: If they understood
where we are coming from, instead of just saying ‘this is the rule’,
say ‘this is what you have to do . this is why uthis is the rule, this
is why we are pulling you up, this is why we are having a chat to
you, how do you feel about this?
- If limit sitting process applied in this way, patients can experience
this as the nurse caring for them within the therapeutic
relationship.
- Treat patient respectfully during the process of limit setting. Use
An authoritative,
rather to enhance positive outcomes, limit-setting style the nurse
should explain to the patient which behavior is inappropriate and
why it is disturbing for others.
- give choices and allow time to change his/her behavior. Limit
should be clear and have therapeutic aim.
- Nurse should not disclose personal information and should
maintain therapeutic relationship.

References:
1 ) Maguire , T , Effective Limit Setting Strategies , unpublished
presentation 2011 .
2 ) Varcarolis , E , Halter , M , Foundations of Psychiatric Mental
Health Nursing : A Clinical Approach / Edition 6 Chapter 10
Developing Therapeutic Relationships , Elsevier Health Sciences ,
2009 .
3 ) Crisis Prevention Institute , The Art of Setting Limit , 2009 . 4 )
Exploring nurses ‘ and patients ‘ perspectives of limit setting in a
forensic mental health setting.July 2013 , International Journal of
Mental Health Nursing , Tessa Maguire , Michael Daffern , Trish
Martin .