Cynthia D. Steele, RN, MPH The Copper Ridge Institute The Johns Hopkins University.
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Transcript of Cynthia D. Steele, RN, MPH The Copper Ridge Institute The Johns Hopkins University.
Cynthia D. Steele, RN, MPHThe Copper Ridge Institute
The Johns Hopkins University
Prevention and Management of AggressionComplex and difficultSupport confidence and vigilance, not fearProvide skills and coach routinelyCoaching means demonstration with the
aggressive patientIF you are not willing to “get wet”, why
should they?
Loyalty and SupportIt is unacceptable to abuse residents and it is
also inappropriate for you to be abused. We can solve the problems, but you must
report it promptly after one incident
ChallengesDementia units are the answerVictim blamingTurnoverTransferring the patientPoor discharge instructions to the receiving
staffTaking time to observe and be social firstLack of communication
Create a common language and a Routine and safe place for reporting and discussing behaviors.
The nurses “don’t ever listen”
Be a coach and “get wet” If you are asking them to change their behavior, you must be willing to try it first. They will not believe you. The aides must not be routinely blamed.
The Cynthia D. Steele, RN, MPH Caring Hands Award for Excellence in Care by Nursing Assistants, $1,000 award, recognition, status
Recognize success, usually one person who “never has a problem”
Categories of MisbehaviorsPhysicalVerbalSexualExit seekingOthers?
Significance
CommonAlienationRisk of institutionalizationRisk of dischargeIncrease in cost of care
Caregivers Perspective
Most common recipientDeliberate acts by a “bad patient”Random, unprovokedTolerance varies greatlyDemoralizationMany belief systems
A Dementia Sensitive CultureEducate everyoneUse the same languageConsistency of approachConfidence in ability to maintain safetyMinimize impact of behavior problems
Behavior Problems: Origins and Risk Factors
Cognitive impairmentPsychiatric disordersPhysical illness, DeliriumEnvironmental pressCaregiver approach
*often multi-factorial
The 5 D ProcessDescribe the behaviorDecode itDesign a planDetermine if it works
Document, document, document
Cognitive Risk Factors: The 4 A’sAmnesia: short term memory and learningAphasia: communicationApraxia: coordination Agnosia: recognition
Environmental risk factorsUnder/over stimulationNoiseActivity of peersCues and mis-cuesTemperature
Environmental AdaptationShelter from chaosStructure, routine, familiarityActivity program
Caregiver approachMiscommunicationRushingThreateningInflexibility Too many persons talking and touching
General Approaches
Adjust expectations to abilitiesIdentify and treat psychiatric conditionsGive vigilant medical careAdjust environmental pressFine-tune caregiver approachTrial and error important
Aggression
Any behavior, physical or verbal that causes or has the potential to cause harm to self, others or objects
“Handle with Care”Keenan and Steele, 1995
Cycle of escalationResponse at each levelMake a planOne person talkingSafe AttireBody positionSafe holds and releases
Cycle of Escalation
CalmAnxiousAngryHostile, threateningAggression
Micro-CuesFacial flushingPacingTension in musclesGestures
Response to Escalation
Anxious listen, comfortAngry give space,
monitorHostile make a planAggression allow to defuse if safe, if not,
use non-offensive physical control
Make a PlanCommunication essentialWorking together often more efficientWho will talk?Who will do care?
1) Relaxed posture
2) Eye level with the patient
3) “How-can-I-help” rather than “You-must-do”
4) Body language should convey choices not control
1) Far enough away so you won’t get hurt… but
2) During care, you’re never in the safety zone!
3) Constant vigilance is required.
Attire How you dress…1) Avoid dangling
hair, id tags, jewelry…
2) Wear footwear that favors movement.
3) Approaching patient? Remove glasses and watch
The Geri-Hold
Common ExamplesShowering: Mrs. X due for showerHas hx of biting and kickingYou reach across her to get the shampoo, she
bites
Exit seekingMrs. R. sees you go out the door and
attempts to follow youShe says “I have to go to the bus stop for my
kids”
DressingYou tell Mr. G. to hold up his arms so you can
pull over a sweatshirt He shoves you when you try to put the shirt
on
TransfersMrs. X has just returned from her dental
appt,She is sitting in a wheelchair and needs to be
transferred to a geri chair or reclinerShe hits and kicks
Approach to the Psychotic PatientNot usefulReality orientation
ArguingReasoningThreatening
Often usefulEmpathyReassurance
Offering to helpDistraction
“Don’t sit on my Mother!”Not useful
“There is no one here”
“Just calm down”
Often useful“What is
upsetting you?”
“May I sit down?” Remove the
chair
“I always wait for my husband to come home to eat!”Not helpful:
“You know he is dead” “I told you he isn’t coming”
“You’d better eat or I’ll have to take the food away”
Helpful:“Let’s get
started and I’ll watch for him”
“I’ll keep a plate of food warm for him”
“I am sure he is alright”
ConclusionsCaring for dementia clients is challengingAdjust expectations to abilitiesUse success of othersTrial and error is importantJoining “their world” can be fun