What would you do???

Nursing Students CNA/MA

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Not what SHOULD you do, but what would you honestly do in this situation:

You work in a nursing home. You have an awesome hall partner (Jessica)who loves taking care of her residents and seems to really care about them...

One of her residents (Mary) has dementia and her family request her teeth be brushed 2x daily. Your hall partner(Jessica) asks you to help because she's a "fighter". The resident "Mary" refuses to have her teeth brushed as soon as she sees the toothbrush. Jessica proceeds to push the toothbrush into her mouth and Mary begins slapping Jessica and swearing. Jessica still continues, and Mary continues to punch, slap, cry, swear, etc....Jessica turns to you and tells you to hold Mary's hands down so she can continue, you tell her it isn't worth it, let Mary be, Jessica calmly insists that it be done as family requests.....

Right then and there, in that moment, what do you do???

Specializes in ICU, PICC Nurse, Nursing Supervisor.

Dementia patients take someone with a special touch. Redirect...re approach and then redirect some more is the key....always ask your charge nurse for help. She actually should come down and try to brush the patients teeth herself just so she can see the behavior and chart accordingly. Brushing her teeth against her will first is illegal but second if can cause her to become so angry that she falls or hurts herself....just not worth the risk. The nurse needs to speak with the family. Many families of dementia patients are just not educated on behaviors that a patient with dementia can exhibit. I cant tell you how many times Ive heard..."my mother would never behave that way".........sometimes they have to be shown......good luck to you

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This perfectly illustrates why being a CNA in a nursing home is such a horrible job. You are faced with these type of no win situations pretty much continually. I personally wouldnt hold down someones hands just to brush their teeth, but there are also many situations where you are doing something against the will of a person who no longer has the capacity to make decisions for themselves and understand what is in their own best interests, and you have family hovering that dont understand their family members condition any more, or maybe some of the family do, and some dont, and they might disagree.

Nearly Everyone whos ever worked as a CNA has faced the situation where a resident with dementia refuses to be bathed or showered. Most CNAs probably encounter this several times a week. What do you do, just let the person go on without bathing for weeks? Of course not, so as a CNA you have the wonderful task of forcing someone to do something they dont want to do, and will fight tooth and nail to prevent, while ensuring that this person is not harmed or injured or abused, while also not eating up so much time that other residents are neglected, and understanding that regardless of what you do, there is always the possibility you will be accused of abuse or neglect. Its easy to say they refused, end of story, but how many times has a new CNA gone up to an RN and said so and so refused, only to be told that they dont have the capacity to refuse.

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Specializes in Psychiatry, Mental Health.

I'm not sure of the details of CNA scope are these days, but I am sure that how I'd handle the situation as an RN and how I'd it as a CNA require different strategies due to the different scopes.

Since a CNA is asking:

If this is Mary's habitual behavior, what does her care plan say? There needs to be agreement and a standardized approach on the part of all the caregivers. Just restraining and forcing the patient/resident is rarely a strategy.

If it's new behavior, it may indicate a change in mental status. (Even confused or demented people can have such changes.) It should be reported to the LVN or whoever is charge for that hall.

Sometimes a caregiver (CNA, family member, RN, whoever) and patient get into this kind of dance and neither one really has a good way to get out of it. It's the caregiver's responsibility to make the change. Maybe someone besides Jessica (i.e. you) can try a different approach that will work. It's not that Jessica is bad at her job or that you are better, but just that sometimes change of person makes a big difference.

If it's the foamy toothpaste that is annoying Mary, maybe you can do oral care with a lemon-glycerin swab for a while. The pleasant flavor might help.

Using a small children's toothbrush might help, or even fruit-flavored children's toothpaste. Be creative!

Yes, this is a health issue, but it's not on the same level as wandering out into the street. Use discernment and good judgement, be sensible, be creative, and get the charge nurse involved is what I sugggest.

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Specializes in Transitional Nursing.

I would say no and I would make her stop what she was doing. Then I would tell the nurse and make sure she gets some much needed education on the 7 kinds of abuse.

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Specializes in Transitional Nursing.

I would also go back later with a toothette and a dab of paste or mouthwash and see what I could do, but I certainly wouldn't use a toothbrush if she always reacted that way.

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What's Mary's response? Why doesn't she like to have her teeth brushed? I understand she has dementia, and I haven't worked with someone with this condition. As stated above, not brushing can cause serious problems. But It sounds like Jessica has her own method, which sounds pretty intense. As CNA's we encourage independence, but sometimes situations like this can be extremely difficult. I just got my licence, looking for work, and this will be something I will one day encounter as well.

Good luck!

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I find it hard to believe what a cna has to put up with especially for the amount of money your paid and the fact that your licensed and skilled. The reality is i could clean carpets for the amount of money i'm paid and i would have to fight with patients, worry about getting my job done in 8 hours and if i was negligent. Worst - when you have to listen to another aid telling you to do something that you really don't believe is necessary because of the situation. I don't believe in pinning residents to get diapers on or brushing teeth. I think its abusive and you wouldn't catch me doing that. I have seen it and i think those aids are really strange ones.

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Just want to make sure you understand a CNA does not have a LICENSE. We are CERTIFIED. Only the nurses and doctors have a License. There is a big differance there

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Specializes in Peds/outpatient FP,derm,allergy/private duty.
I would have the FAMILY come in and brush her teeth twice a day ;)

....yep...seems like the issue needs to be shared and expectations vs reality communicated between family, nursing and the resident's doctor. I would want to know if a seemingly benign request resulted in my elderly parent being forcibly restrained and a toothbrush shoved in their mouth.

Oral hygeine is part of standard of care for anyone receiving care, and a team solution needs to be found.

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Just want to make sure you understand a CNA does not have a LICENSE. We are CERTIFIED. Only the nurses and doctors have a License. There is a big differance there

Except in New Hampshire, where they are Licensed Nursing Assistants.

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Specializes in Med Surg, PCU, Travel.
I would have the FAMILY come in and brush her teeth twice a day ;)

I would agree with this statement, but I'm more wondering..why would the family mention this at all...it all sounds like a set up to me, that they knew she would be combative and for people to get sued. I would stop and go inform the RN so another approach can be found.

What is the sense in having a woman with cleaned teeth but all bruised up and agitated from being held down?

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I would tell the family about the behavior. It's possible that they may not want Mary to get her teeth brushed if it means she gets wildly upset twice a day. If they insisted, I would ask that they come to the facility to brush her teeth a couple times, to see if she would get used to it, not to prove to them that it's impossible. I don't work in LTC but I will often ask a family member to spoon feed some meds crushed in apple sauce to my patient if the patient won't open his/her mouth.

If it continues to be impossible and the family continues to insist, maybe offer an alternative, like rinsing with antiseptic mouthwash twice daily?

I don't think a CNA or nurse should have to fight someone to brush their teeth. People are comparing it to not cleaning poop off someone who is fighting, but there is a world of difference.

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