Access Training Materials – Cengage



Your Role in Assisting with Specific Behavior Problems

Making generalizations about behavior management is difficult, because each patient is a unique individual. However, the general care you provide to patients with these conditions is similar. Always follow the care plan for specific information, goals, and approaches. Use common sense.

Guidelines for . . . Assisting with Behavior Problems

• Follow the approaches listed on the care plan.

• If the care plan calls for you to respond when a patient demonstrates a specific behavior, implement the approaches as soon as the behavior starts. Do not wait for the patient to lose control.

• Watch the patient’s response to your approaches. Adjust your approach, equipment, routine, and other care, if necessary.

• Communicate effective approaches to other team members.

• Modify your own behavior in response to the patient’s behavior.

• Control your own responses and reactions.

• Be patient. Make sure your body language does not send the wrong message.

• Use good communication and listening skills.

• Avoid lying to the patient.

• Avoid making promises you cannot keep.

• Avoid discussing facility or staff problems with the patient. If the patient complains, inform the nurse or other appropriate person.

• Discuss family, friends, or other pleasant information with patients. This provides a source of strength, comfort, and support.

• Protect the safety of the patient and others.

• Practice empathy.

• Remove the irritant, or cause of the behavior, if known.

• Attempt to learn the cause of the behavior, and communicate this information to other team members.

• Make certain the patient’s physical needs are met.

• Give alert patients as much control as possible. Offer choices in care and routines. Encourage them to direct their own care.

• Be happy. Smile to communicate caring. Make sure your body language does not send a negative message. Positive behavior is contagious.

Yelling and Screaming

Yelling and screaming may be the only way some patients can communicate or express displeasure. Most screaming behavior is seen in confused patients, but occasionally alert patients also yell and scream. Ways to deal with this type of behavior are usually discovered by trial and error.

Guidelines for . . . Assisting the Patient Who Is Yelling/Calling Out

• Look for the cause of the behavior. If you can identify it, correct it.

• If the patient is alert, ask what the problem is. Use active listening skills and provide comfort.

• Realize that people from some cultures scream with pain and grief. This is socially acceptable in the person’s culture.

• Offer the patient something to eat or drink.

• Monitor body language to see if the patient grimaces or shows other signs of pain.

• Try to distract the patient. Redirecting the behavior with a positive activity, such as a walk or looking at a picture album, may be helpful.

• Eliminate or minimize environmental stimulation. Try moving the patient to a quiet area.

• Provide physical comfort measures, such as turning, positioning, or a backrub.

• Take the patient to the bathroom. Some confused patients scream from the discomfort of a full bladder.

Physical or Verbal Aggression

Physical aggression is hitting, scratching, kicking, biting, or fighting. This is called combative behavior. Verbal aggression is arguing, accusing, threatening, or swearing.

Guidelines for . . . Assisting the Aggressive Patient

• Attempt to identify the cause of the behavior and eliminate it, if possible.

• Respect the patient’s need for personal space.

• Take physical threats seriously and keep your distance.

• Watch the patient’s eyes. They will usually focus on the part of the body to be attacked.

• Remain calm.

• Speak in a soft, low, calm voice.

• Do not make the person feel trapped or cornered.

• Do not turn your back on an aggressive patient.

• Avoid touching the patient, as this may cause further agitation.

• Show that you are interested in what the patient is saying.

• Show empathy and acknowledge that you understand how the patient feels.

• Reassure the patient.

• Praise efforts at self-control.

• Do not argue or try to reason with the patient.

• Make sure your body language is not threatening.

• If aggressive behavior occurs in a public area, move the patient if it is safe to do so. If not, move others out of the way.

• Call for assistance from others, if necessary.

Sleeping Problems

Measures to Promote Sleep

Basic nursing comfort measures are effective in helping patients sleep. Measures that promote comfort, rest, and sleep are:

• Helping the patient into loose-fitting, comfortable nightwear.

• Assisting with toileting and personal hygiene needs before bedtime.

• Providing a warm bath or shower, if permitted.

• Avoiding caffeinated beverages after the evening meal.

• Providing a snack, if desired.

• Straightening the bed.

• Assisting the patient into a comfortable position and providing pillows and props as needed for comfort.

• Providing a comfortable environmental temperature and ventilation.

• Providing an extra blanket, if desired.

• Eliminating unpleasant odors.

• Eliminating noise and closing the door.

• Darkening the room as much as possible for sleep, and providing a nightlight if desired.

• Providing nursing comfort measures, such as a backrub, or repositioning the patient into a more comfortable position.

• Reporting pain to the nurse.

• If the patient is having pain, waiting at least 30 minutes after pain medication is administered before performing procedures.

• Entering the room quietly to avoid startling the patient.

• Avoiding turning on the ceiling lights during the night.

• Handling the patient gently during care.

• Avoiding physical activity or activities that may upset the patient before bedtime.

• Assisting with personal bedtime rituals, if any.

• Allowing the patient to select his or her own bedtime.

• Using music to replace noise with pleasant sounds. This helps improve relaxation and promotes rest and sleep. Ask patients if they would like you to help them find an enjoyable radio or television program with pleasant music. Some facilities have closed-circuit television that plays calming music and shows a series of beautiful nature scenes.

• Allowing the patient to read, watch television, or listen to the radio, if desired.

• If the patient receives a sleeping medication, making sure the patient is ready for sleep before the nurse administers the medication.

Patient Rooms

• Closing doors quietly

• Keeping patient doors closed

• Furnishing headphones or pillow speakers to patients for watching television

• Changing television to closed caption for patients who are hearing impaired and for patients who are watching television late at night

• Turning off incoming patient phone calls between 2000 and 0700

• Allowing patients to select a pillow that is comfortable

Hour of Sleep Interventions

• Coordinating and limiting nursing interventions between 2300 and 0500, and refraining from using direct light, telephones, intercoms, televisions, and radios during those hours. If in the room for one purpose, complete other tasks. For example, when assisting with a bedpan at 0330, also take the 0400 vital signs to avoid having to wake the patient again.

• Avoiding lengthy conversations with patients when giving care during the night. (The patient will be wide awake when you leave.)

• Using the facility’s personnel locator system for relaying messages. (Each staff member wears a badge that has a transmitter the locator system can track; this information can be displayed on terminals placed throughout the nursing unit.)

• Rescheduling restocking, noisy cleaning procedures, and supply deliveries to an hour when patients would be expected to be awake; don’t do it in the middle of the night.

• Not using hallway phones between 2200 and 0600; instead, use telephones at the nursing stations.

Controlling Sources of Noise on the Nursing Unit

• Being aware that most noise occurs at shift change. Use this knowledge to plan ways of controlling unnecessary noise.

• Identifying sources of noise. Analyze the problem to find ways of reducing and eliminating noise.

• Wearing soft-soled shoes.

• Reporting and helping investigate all patient complaints about noise.

• Limiting unnecessary staff conversation. Avoid shouting and loud talking. Avoid congregating in groups unnecessarily. Avoid mini-conferences with others in hallways as much as possible.

• Using equipment and supplies correctly. Many equipment items generate excess noise when used in a manner other than intended.

• Using curtains, doors, and other barriers to reduce or muffle sounds.

Intercoms, Ringers, and Equipment Alarms

• Limiting overhead paging to essential situations and emergencies only

• Turning ringers on phones down

• Using phones with headsets instead of receivers

• Turning the volume on intercoms and overhead pages down

• Using personal communication devices (cell phones, pagers, and beepers) in vibrate mode

• Not using the intercom to answer call lights when a patient is hearing impaired, aphasic, cognitively impaired, or not able to ask staff to respond in person

• Not using room intercoms (at all) to answer call signals at night (9:00 pm to 7:00 am) if there is more than one patient in the room or the door to the room is open

• Lowering volumes on warning devices in patient rooms so they can be heard, but are not excessively loud and do not startle the patient

• Informing the nurse before the bag on a tube feeding or IV infusion is empty so it can be changed before the pump alarm sounds

Hallways

• Closing external doors to the unit, if possible. If the unit has multiple entrances, close off all but one at night.

• Keeping hallway conversations to a minimum.

• Whispering or talking quietly in hallways.

Equipment and Environment

• Turning off unused electrical and mechanical equipment.

• Controlling and eliminating all environmental noise as much as possible, such as from telephones, pneumatic tube systems, carts with noisy wheels (such as dietary and medication carts, linen hampers, and barrels on wheels), banging of charts and chart covers, vacuum cleaners, floor buffers, patients turning televisions up too loud, printers, ice machines, or electrical and mechanical noises from heating, air conditioning, and other devices. (The portable X-ray is the medical device found to make the most noise during hallway transport.)

• Reporting noisy items needing repair, such as noisy wheels on moving carts, hampers, barrels, blood pressure monitors, bladder scanners, IV poles, etc.

• Reporting noisy environmental items, such as banging doors or squeaky cupboards, so they can be repaired.

Break Areas

• Make an effort to keep noise down in the break area, especially if doors are open. Although this is your personal time, be aware that break rooms are often the source of a great deal of unnecessary noise that is disturbing to patients. Be considerate of everyone while you are laughing, talking, and enjoying yourself.

Guidelines for . . . Assisting with Sleeping Problems

• Offer H.S. care by making the patient comfortable, giving a backrub, controlling room temperature, adjusting the lights, and eliminating noise in the environment.

• If the patient wakes up frightened during the night, provide support and reassurance. Make her comfortable.

• If the patient wakes up confused, provide orientation to person, place, and time. Assure the patient that he is safe and in the right place.

• If the patient wants to stay awake during the night, provide diversional activities and comfort measures that will not disturb others.

• Warm snacks may be helpful. Avoid beverages containing caffeine.

Patients with Dementia or Cognitive Impairments

Guidelines for . . . Caring for Patients with Dementia

• Be calm, gentle, and flexible in your approach.

• Stay in control of your own responses. Try to remain calm and soothing when responding.

• Be creative when responding. Modify your behavior according to how the patient responds and reacts to you.

• Be matter of fact and non-demanding.

• Speak in a “here and now” time frame.

• If the patient is not agitated, use touch to show you care.

• Speak slowly and clearly, using short simple sentences and words.

• Offer simple choices, but do not overwhelm the patient with options. Best results are obtained if you ask the patient to select one of two choices.

• Break large tasks down into a series of smaller tasks.

• Give the patient familiar, orienting cues for performing ADLs.

• If a patient is combative or agitated, stand at the side when putting on shoes and socks to avoid getting kicked.

• Follow the same routine each day.

• If the patient does not understand, demonstrate what you are trying to say. For example, put the brush in the patient’s hand. Simulate brushing your hair and tell the patient to imitate you.

• Make eye contact when speaking.

• Make sure your body language matches your words.

• Use one-step commands. If the patient does not respond, count to five before repeating. After the patient completes one step, move to the next.

• Avoid rushing the patient. Allow adequate time to complete a task.

• Avoid words such as “don’t,” or “no,” whenever possible. Instead, use words like “do” or “let’s.”

• Alternate periods of activity with rest.

• Monitor for signs of increasing frustration.

• Accept communication even if it does not make sense. Avoid arguing. For example, the patient tells you that her grandmother ate lunch with her. A good response is, “Are you thinking about your grandmother?”

• Concentrate on what the patient tells you, even if it does not make sense. Respond to what you think the patient is saying.

• Do not argue with the patient about fixed, false beliefs.

• Avoid situations that you know are upsetting to the patient.

• If the patient is upset or agitated, avoid turning your back. Keep your face protected or out of his or her reach.

• Keep the environment simple and safe. Do not make changes in the environment.

• Provide activities at the time of day the activity would normally be done.

• Reduce excessive noise and stimulation in the environment.

Activities of Daily Living for Patients with Dementia

• Allow the patient to do as much as possible.

o Use the hand-over-hand technique for personal care and eating. The hand-over-hand technique means that the patient’s hand is placed around an object. The caregiver then places a hand over the patient’s hand and guides the use of the object.

o Give only one short, simple direction at a time.

• Observe the patient’s physical condition. People with dementia are usually unaware of signs of illness.

• Assist patients to maintain a dignified, attractive appearance by helping them with grooming and dressing.

• Monitor food and fluid intake.

o Encourage and provide sufficient fluids to prevent dehydration.

o Offer the patient a drink each time you enter the room.

o Some patients do not like water, but will drink fruit juice, soda, or sugarless beverages. Provide fluids that the patient likes and will consume readily.

o Too many foods at once are confusing.

o Place one food at a time in front of the patient.

o Do not use plastic utensils that can break in the patient’s mouth.

o Provide nutritious finger foods when the patient is unable to use utensils.

o Avoid pureed foods as long as possible.

o Check food temperatures.

o Prepare foods for eating by buttering bread, cutting meat, and opening cartons.

o Check the patient’s mouth after eating for food. “Squirreling” food (hoarding food in the cheeks) can cause aspiration.

o Weigh patients regularly to detect patterns of weight gain or loss.

o The dining area should be quiet and calm.

• Persons with dementia eventually lose bowel and bladder continence. Taking patients to the bathroom every 2 hours keeps patients dry and prevents skin breakdown.

• Patients with dementia need activities geared to their abilities.

o Avoid large groups or competitive activities.

o For patients in later stages of dementia, use sensory stimulation with quiet music, soft touching, and calm talk.

o Holding puppies or kittens (pet therapy) brings pleasure to severely impaired patients.

o Daily exercise should be planned according to patients’ habits and abilities. The patient who wanders throughout the day may only need range-of-motion exercises.

Wandering and Pacing

Persons with Alzheimer’s may wander or pace for hours at a time. No one knows why this occurs. Some reasons may be:

• They are looking for companionship, security, or loved ones.

• It is a way to handle stress.

The patient may not know where he is, but knows he does not want to be there. He is seeking a state of mind, not a physical location. Ask the patient his intended destination. A man may tell you he is going to work. A woman may say she is going home to cook dinner for the children. Avoid arguing or providing reality orientation. These techniques will probably agitate the patient. Instead, use reminiscence. Talk about the patient’s activities, work, meal preparation, or cooking. Make appropriate comments, such as, “That must be very interesting work,” or “You must have been a very good cook.” Ask the patient about his former work routines. This approach restores the state of mind the patient seeks, reducing stress and the risk of eloping (wandering away from the facility).

Many different things trigger wandering behavior. The facility may keep a log to help identify the patient’s wandering triggers. You will record information such as the patient’s behavior, staff on duty, and temperature and noise in the environment on the log. The nurse uses this information to develop a plan of care. Several studies have shown that noise increases wandering. Health care facilities can be very noisy at times. Loud talking, using the intercom, loud televisions, and other patients calling out can be very upsetting to wanderers. Hot or cold environmental temperature may also be a problem. If the patient is uncomfortable, he may wander to escape. Other common wandering triggers are:

• Boredom

• Unmet physical needs

• Feeling stressed

• Pain

• Hunger

• Thirst

• Needing to use the bathroom

Other, less common wandering triggers are dehydration, illness, inadequate coping mechanisms, medications, and an unfamiliar environment.

Nursing Assistant Approaches. Allow the patient to wander. Using restraints increases anxiety and frustration, worsening the problem. Walk with the patient whenever possible. Adapt the environment to the wandering patient, to ensure that it is safe and secure. It is important to keep the patient’s stress as low as possible, because if he feels overwhelmed, he may wander to elope. If the patient’s stress is not relieved, he may have a catastrophic reaction. As a rule, try to meet the patient’s needs for hunger, thirst, and elimination. If you meet the need, the wandering will cease.

Remember that nonverbal communication can have a powerful effect on patients. Confused patients are very sensitive to the moods and body language of staff members. Send the right message through facial expressions and body language. Approach the patient in a calm, nonthreatening manner. Avoid forcing your own agenda on the patient, which will cause agitation and worsen the behavior. Instead, use gentle persuasion. Avoid making too many demands on the patient during ADLs and direct care. Keep instructions simple and brief. As the patient completes one task, give him another. Be patient, calm, and reassuring. Tell her that she is in the right place, that she is safe, and that you will help her. Compliment the patient on his successes, even if they are small. The patient will probably not remember the compliment, but will feel good about himself. He will be more cooperative and less likely to act out or wander.

Remember that patients who wander will burn extra calories and are at risk for weight loss. Some are so busy wandering they will not sit long enough to eat a meal. Give them finger foods and walk with them, if necessary. Follow the plan of care to ensure that the patient takes in enough nutrients.

Patients who wander may become physically exhausted. They have forgotten how to sit down and may need reminders. Special reclining chairs and beanbag-type chairs may be used to allow patients to rest. Again, the care plan will specify the method to use.

Guidelines for . . . Managing Wandering Behavior

• Consider physical causes for the behavior, including illness, need to use the bathroom, hunger, thirst, and pain. By trial and error, eliminate each cause to see if it is effective in reducing wandering.

o Take the patient to the bathroom frequently.

o Adjust room temperature and ensure that the patient is wearing appropriate clothing for the temperature and season.

o Reduce environmental noise and stimulation; check patients yelling, television, intercom announcements, and other sources of noise in the facility.

o Provide something to eat or drink.

o Inform the nurse if the the patient complains of pain; he or she may not admit to having “pain,” but may admit to having pressure, discomfort, or another unpleasant sensation.

• Check the patient daily to make sure the identification bracelet is in place.

• Always know what clothing the patient is wearing. Write this information down at the beginning or end of each shift. Wanderers are often discovered missing at mealtime, when staff cannot find the patient to deliver the tray. This is commonly a problem for second-shift staff; when day-shift workers dress the patient, staff on second shift may not know what she is wearing.

• If the patient is wandering trying to find his or her room, place an identifying object on the door to the room. Direct the patient to find the object.

• Decrease noise and stimulation in the environment.

• Keep toxic substances, chemicals, matches, and other potentially harmful items in locked cupboards.

• Avoid clutter and safety hazards in the environment.

• Provide adequate lighting. Aging changes in vision make more light necessary to interpret the environment correctly.

• Make sure the patient is wearing eyeglasses and hearing aids, if used. This helps to maintain contact with the environment.

• Remind and reassure the patient that he is safe and in the right place.

• Make sure that the wanderer gets adequate exercise.

• Remove coats, purses, and other items that the patient associates with going outside.

• Avoid trying to reason with a wanderer who is determined to leave. Instead, provide distraction.

• Distract the patient with a magazine, conversation, activity, food, or drink.

• Give the wanderer a repetitious task such as folding towels or sorting items.

• Provide a radio, MP3 player, or portable CD player with a headset. Play the patient’s favorite type of music. This simple distraction is often very effective.

• Avoid telling a wanderer, “Don’t go outside.” Thinking and understanding is a complex process. Instructing the patient not to leave will cause him to think about going outside. (If someone tells you not to think of a green cat, you will think of it. Then you will have to unthink it.) Saying “Stay inside” is a more effective approach with a patient who is cognitively impaired. Communication is best if it is concrete and does not require abstract thinking.

• Monitor and respond to exit door alarms, bed alarms, or other alarms that alert you to a problem with a wandering patient.

• Attach the call signal cord to the back of the patient’s clothing so the cord will pull from the wall and turn the signal on when he rises. Other types of tab signals or magnetic sensor systems may be used to alert staff if the patient rises or attempts to leave the facility through an exit door.

• Leave a nightlight on in the room during the night.

• If nighttime wandering is a problem, avoid letting the patient nap during the day. Limit caffeinated food and beverages after the evening meal.

• Cover elevator buttons with soft fabric or duct tape to disguise them. The soft material permits staff and visitors to push the buttons, but wandering patients will usually not recognize the buttons for what they are.

• Post signs and labels on drawers, common rooms, and other items.

• Display familiar items and pictures in the patient’s room.

• Consider seating the wanderer in a beanbag chair. They are comfortable, but difficult to get out of.

• Avoid the use of side rails. This type of patient may climb the rails and suffer a serious fall.

• Avoid restraints, which often worsen agitation.

• Check on the patient frequently to note her whereabouts. If you will be with another patient for a prolonged period of time, inform the nurse so that another worker can be assigned to monitor the wandering patient in your absence.

• Know where a current picture of the wanderer is located in case he becomes lost.

• Apply a shirt or sweater to the patient and have him wear it for 6 to 8 hours. Remove the garment and place the unwashed item in a sealed plastic bag. Mark the patient’s name on the bag and put it on the closet shelf. If the wanderer does become lost, the garment can be used by a tracking dog. In the event a tracking garment is not available, the dog may be able to pick up a scent from the patient’s pillow.

Sexual Behavior

All humans are sexual beings. Sexuality is a basic human need, according to Maslow. Sexuality does not diminish with age. Sexual expression may be physical or psychological. Always knock before entering a patient’s room and wait for a response before entering.

Many health care workers feel that masturbation is inappropriate behavior. Masturbation is satisfying to the patient and is not harmful. It is an acceptable behavior as long as it is done in a private area. If you enter a patient’s room and find the patient masturbating, provide privacy and leave the room.

If you enter a room and find two consenting adults engaged in a sexual act, provide privacy and leave. Adults have a legal right to do whatever is pleasing to them, as long as it is not medically contraindicated and both partners are mentally capable of consent. Do not pass judgment on the patient’s choice of partner or methods of sexual expression.

Facility staff is responsible for protecting patients who are physically or mentally vulnerable to unwanted sexual contact. Sexual contact with unwilling, alert patients who are physically unable to defend themselves, or with confused patients who cannot give full informed consent, is sexual abuse. Sexual abuse is a violation of patient rights and is illegal. No health care worker, visitor, or other patient may sexually abuse others. If sexual abuse occurs, the police are notified. Anyone who sexually harasses or abuses a patient or care provider should be reported to the nurse, manager, or other appropriate person according to facility policy.

Sometimes patients may make unwanted sexual advances toward the nursing assistant. The patient’s desire for sexuality is normal, but the choice of partner is not. If a patient makes sexual advances, do not ridicule or belittle him or her. Be patient and understanding, and speak to the patient in a matter-of-fact manner. Tactfully inform the patient that the behavior is not acceptable. Follow your facility policy for reporting sexual advances.

Disrobing

Sometimes mentally confused patients disrobe in public areas. Patients who are bedfast may remove the covers many times each day, exposing their bodies to anyone who looks in the door. This sight can be traumatic to a young child who is visiting. It is your responsibility to keep patients covered. This may be a difficult task. As with all other behavior problems, look for a cause. Frequently patients disrobe because they need to use the bathroom. Other causes are uncomfortable clothing and very warm environmental temperatures. The patient may be bored or tired and ready for bed. Evaluate the situation and common triggers of the problem. Sometimes there is no apparent cause.

You are not permitted to put the patient’s clothing on backward to keep him or her from disrobing. Ask the nurse to contact the appropriate person in your facility to obtain clothing that fastens in back and is difficult for the patient to remove. Consult the care plan and nurse about approaches to use. Find out whether tying the sheet to the side rails of the bed constitutes a restraint. Tying a sheet to the bed or chair is usually a restraint, but wrapping it around the patient’s body only, then tying it in back, may be effective. If the sheet does not limit the patient’s movement or access to his own body, it is not a restraint. Monitor the patient who disrobes frequently and do your best to keep him or her covered.

This table lists types of inappropriate sexual behavior, potential triggers, and ways to manage the behavior.

Managing Inappropriate Sexual Behavior (General Guidelines)

|Behavior |Possible Trigger (Antecedent) |Approaches |

|Sexually suggestive |Needs more affection, sense of belonging, |Focus on the patient, not the behavior |

|comments, |satisfaction of need to be touched |Remain calm, do not overreact |

|inappropriate sexual |As dementia progresses, the need for human contact |Inform the patient that the behavior is not appropriate |

|behavior |is often expressed more physically |Redirect the patient calmly and firmly |

| |Environment reminds patient of sex |Involve the patient in activities program |

| |Fatigue, sensory overload, discomfort, boredom |Do something the patient likes, such as listening to music, |

| | |taking a walk, or having a snack |

| | |Give the patient something else to do |

| | |Leave and return later |

| | |Change your behavior |

| | |Change your physical position or approach |

| | |Touch the patient in an appropriate manner, such as by |

| | |putting lotion on arms and hands |

| | |Find ways of incorporating appropriate touch into daily |

| | |routine |

| | |Offer soothing objects to touch, fondle, and hold, such as |

| | |stuffed animals or dolls |

| | |Assist in making the patient look good and feel physically |

| | |attractive |

| | |If the behavior occurs at a certain time of day, keep the |

| | |patient involved in a purposeful activity during this time |

| | |Do an environmental audit. Hot? Cold? Too much stimulation? |

| | |Too little stimulation? |

| | |Offer to take the patient to the bathroom |

| | |Move the patient to another location |

| | |Encourage and reward appropriate behavior |

| | |Be aware of cues indicating unmet intimacy needs |

|Sexual gestures with |Misinterprets caregiver’s intention |Distract the patient during personal care |

|staff or inappropriate|Patient misinterprets cues; perceives another’s |Avoid sending the patient mixed sexual messages, even in a |

|touching during |touch as sexual, such as touching or sitting next to|joking manner |

|personal care or ADL |the patient and touching his body with yours |Ask a caregiver of the same gender (as the patient) to |

|activities |Environment reminds patient of sex |provide personal care |

| |Mistakes caregiver for partner |Remain calm, do not overreact |

| | |Inform the patient the behavior is not appropriate |

| | |Respond to the patient in a matter-of-fact manner |

| | |Remember and be aware that the behavior is a symptom of the |

| | |patient’s illness |

| | |Be aware of your own behavior, body language, and the message|

| | |you send |

| | |Decide ahead of time how you will react if a patient makes |

| | |inappropriate sexual advances. Advance planning will help you|

| | |react appropriately when confronted with the situation. |

|Removes clothes |Too hot in environment |Check and modify room temperature |

|Exposes self |Need to use the bathroom |Take the patient to the bathroom |

|Undresses in public |Clothing uncomfortable |Make sure clothing fits properly, is comfortable and not too |

|Wears only a shirt |Memory loss, forgets to put on clothes |tight |

| |Unaware of environment; may think he is in his |Allow the patient to rest in bed |

| |bedroom or getting ready to bathe |Dress the patient in clothing that opens in back or is |

| |Tired, wants to go to bed |difficult to remove (do not put clothing on inside out or |

| |Does not remember rules of social behavior |backward; use clothing designed to open in back) |

|Fondles self in public|Genital irritation |Check for irritation at an appropriate time |

|Masturbates in public |Reacts to what feels good |Remove the patient from public area and provide privacy |

| |No longer has judgment, awareness of appropriate |Give the patient repetitive manual activities, such as |

| |behavior |folding towels |

|Makes inappropriate |Other patient may remind him or her of a former |Inform the patient that the behavior is not appropriate |

|advances toward other |partner |Keep patients separated as much as possible |

|patients |Other patient may be giving cues that are perceived |Monitor helpless patients carefully; protect helpless |

|Engages in sexual |as sexual advances, such as a woman lifting her |patients |

|behavior with another |skirt |Seat male patient away from female patients |

|patient |Mistakes other patient for his or her partner |Have staff member of same gender provide care |

|Touches someone else | | |

|in an inappropriate | | |

|way | | |

Validation Therapy

Validation therapy is a technique developed by Naomi Feil, who is a social worker, actress, and researcher. She describes the therapy as a way to communicate with persons over the age of 75. It is also used for patients who have Alzheimer’s disease and cognitive impairments. The program is based on the belief that developmental tasks from earlier years must be resolved. If they were not resolved, they will emerge in old age. The elderly person may display many emotions in trying to conclude them.

Feil’s research has shown that using validation reduces the need for restraints. It helps patients regain feelings of dignity and self-control. It also increases staff morale. Feil stresses the following concepts:

• Maintaining the identity and dignity of patients is important.

• People with dementia can feel good about themselves.

• All behavior has a purpose. Some disoriented behavior may be acting-out of memories.

• Patients’ memories and feelings should be acknowledged.

• Cognitively impaired patients have the right to express their feelings.

• Patients must resolve living to prepare for dying.

• The elderly have experienced many losses. Many have lost the ability to cope.

• Living in reality is not the only way to live.

Disoriented patients are worthwhile. Staff can give them joy by allowing them to express their feelings. Each person was once a child, then an adult. Patients deserve to be cared for with dignity in their final years of life.

When using validation, allow patients to express their feelings. Reassure them that the feelings are worthwhile. Use a calm, non-threatening manner. Speak in a loving tone of voice. When the patient describes an emotion, assure him or her that it is okay. A book, videotape, and training program are available for facilities using this technique.

Using validation is an excellent way to communicate with elderly persons. It is also effective for patients with Alzheimer’s disease and cognitive impairments. The program is based on the belief that developmental tasks from earlier years must be resolved. If they were not resolved, they will emerge in old age. The elderly person may display many emotions in trying to conclude them. Feil’s research has shown that using validation reduces the need for restraints. It helps patients regain feelings of dignity and self-control. Patient response to this therapy can be very encouraging. Seeing positive responses is very rewarding to staff.

Reminiscing

Reminiscing  is the act of remembering the past. It is a normal activity for all people. One of the developmental tasks of the elderly is a life review. Reminiscence helps patients complete this task. Studies have shown that reminiscence programs can improve cognitive function; a group of women studied had excellent results. Almost everyone enjoys this activity.

Reminiscence is an effective one-to-one activity for patients who have behavior problems and cognitive impairment. The patient discusses his or her past. You will ask questions and make comments. If the patient expresses feelings and emotions, accept them. Reassure the patient that feeling this way is okay.

The program can also be done as a group activity if done with a leader who is skillful and sensitive to the feelings of the participants. Books, tapes, and kits are available for reminiscence programs. Your activities department may have a formal reminiscence program, but you can also use this approach individually with your patients.

• Past experiences are remembered and enjoyed as we think of pleasant times from the past.

• As people age, the tendency to reminisce increases, and the activity becomes more important.

• It is an appropriate activity for patients with dementia if long-term memory is still intact.

• Reminiscing may serve as a life review. Elderly people often review the past experiences of their lives. This can bring back unpleasant memories. If these experiences are resolved, peace of mind can be found.

• Reminiscing can help people adapt to old age. It helps to maintain self-esteem. It allows them to work through personal losses.

• When we listen to patients reminisce, we understand them better.

Reality Orientation

Reality orientation  is a technique in which patients are reoriented to time, place, person, and season. The subject is controversial: Some facilities do not use reality orientation, believing that it worsens agitation in some patients. The technique is most effective in orienting patients with delirium. Memory loss in delirium is a temporary condition. After the patient recovers, the confusion clears. Newly admitted patients who are confused by the change in environment may also benefit.

A large calendar is placed in the patient’s room. Each day is marked off. Large clocks are placed throughout the facility. Signs with large letters label areas, equipment, and personal items. This enables the patient to find his or her way about the facility.

To be effective, reality orientation must be used by all staff during each patient contact. The goal is to give the patient a sense of identity in time and space. It may decrease anxiety in some patients. When approaching patients, call them by name. Tell them who you are. Do not expect them to remember you.

The principles of reality orientation are to treat patients as adults and maintain their dignity. When using reality orientation:

• Speak clearly and directly; avoid speaking loudly

• Use repetition; speak slowly if the patient does not understand

• Allow enough time for the patient to process thoughts and respond

• Keep instructions and responses simple and brief

• Maintain structure in routines

• Make sure patients are wearing hearing aids and eyeglasses, as appropriate

• Promote independence

• Frequently provide orientation about the day, date, time, season, and weather

• Avoid making patients feel like you are putting them on the spot or criticizing them

• Answer questions honestly, but avoid information that is upsetting

• Avoid reinforcing the patient’s confusion

• Do not tease the patient about his or her confusion

• Avoid arguing with patients who are delusional

Although reality orientation is effective with some patients, do not depend on it for keeping patients safe. For example, showing a confused patient how to use the call signal may be effective when you are in the room. Patients with cognitive impairment have short-term memory loss, and will probably forget how to use the call signal as soon as you leave the room. Do not depend on the patient’s memory or safety awareness to prevent falls. Use other approaches, such as frequent monitoring or restraint alternatives, to address safety issues.

Guidelines for . . . Reality Orientation

• Use reality orientation (RO) only if it does not agitate the patient.

• Always treat patients who have dementia as adults, with respect and dignity, no matter how confused they are.

• Allow patients to be independent as long as possible.

• Speak clearly and directly. Avoid the temptation to speak louder when the patient does not understand you.

• Give simple, brief instructions and responses.

• Allow adequate time for the patient to respond.

• Be polite and sincere.

• Make sure the patient has clean eyeglasses and is wearing a hearing aid, if used.

• Establish and maintain a structured routine.

• Set clocks and watches to the correct time.

• There should be clocks with large numbers around the facility.

• Place large numbered calendars in rooms and cross off the days as they pass.

• Signs with large letters and color codes on walls, floors, and equipment help patients find their way around the facility.

• Call the patient by name. Disoriented patients usually respond to their first names.

• Tell the patient your name; do not expect the patient to remember you.

• Use RO in conversation with patients; for example, “It’s only March 5th today but it is warm outside.”

When using RO:

• Do not put the patient on the spot. For example, do not ask, “Do you remember who I am?” or “Do you know what day this is?”

• Answer questions honestly but avoid overwhelming the patient. If a patient whose husband is deceased asks, “Is my husband coming today?,” it is cruel to answer by saying, “Remember, your husband died two years ago.” This response will likely trigger a catastrophic reaction. It is better to answer by asking another question or redirecting the patient, such as, “Tell me about your husband, Emma.” She will receive pleasure from reminiscing and will probably work up to present time on her own.

• Never argue with a patient’s reality. Arguing increases agitation and anxiety when a patient is delusional. Many delusions are based on past experiences. The patient who is disoriented believes the experience is happening now.

• Do not reinforce the patient’s disorientation.

• Remember that a pleasant facial expression, relaxed body language, and a caring touch are the most important aspects of caring for confused patients.

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