What would you do???

  1. 0 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???
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  3. Visit  Missingyou profile page

    About Missingyou

    Missingyou has '+20' year(s) of experience and specializes in 'Long term care'. From 'Providence, RI'; Joined Nov '13; Posts: 406; Likes: 413.

    36 Comments so far...

  4. Visit  chrisrn24 profile page
    5
    What I would do? Stop immediately. Actually I would've stopped if she was raising her hand to me the first time. Similar things have happened to me and I've said "it's not worth it" and tried reapproaching a few minutes later.

    People with dementia are often unable to be reasoned with, so try redirection and reapproaching.
    cardiacfreak, poppycat, BrandonLPN, and 2 others like this.
  5. Visit  Missingyou profile page
    0
    So,
    you would just walk out of the room and leave Jessica there to continue on without you??
  6. Visit  mvm2 profile page
    9
    I would never lay a hand on (Mary) when she is like that, and I would tell Jesica that she had to stop as well or I'd have to report it. Sure the family wants it, but it is ultimately the patients right to refuse to brush her teeth. Just document it as a refusal and explain to the family that we can keep TRYING to see if we can brush her teeth as requested but that we can not force it upon her if she is that adimit against it. It is abuse no matter how you cut it. And I have to say if a family member would see two aides pinning her down and shoving a toothbrush in her mouth forcefully I am sure they would be changing their request.
    nursel56, Supa K, Dazglue, and 6 others like this.
  7. Visit  schnookimz profile page
    2
    If she has severe dementia and her poa is requesting it, I'm not sure charting that she "refused" is really worth that much. How can she refuse? She has no idea you're trying to help her.

    Address it with the family. If they still want the teeth brushed, they need to be brushed. Not brushing them can lead to severe diseases, including deadly pneumonia.

    I don't consider this abuse bc you are not hurting this woman. I wouldn't use force, Just hold her hands. Speak kindly and gently. You are doing something for her own good.
    Hygiene Queen and KelRN215 like this.
  8. Visit  schnookimz profile page
    1
    Maybe I have these above opinions because I worked for years on a neuro floor, but honestly, what's the difference between this and my dementia patient that tells me he needs to leave the hospital to go play in the street at 11pm. It's not abuse to stop him. I'm keeping him safe, even though he's kicking and punching me.
    KelRN215 likes this.
  9. Visit  mvm2 profile page
    7
    I only mentioned to write refuse down so that it is recorded that you at least tried to brush her teeth. It also sounded to me in this senerio that Jessica WAS forcing herself onto mary. That is what I am picturing and to me is wrong. If you can find gentle easy ways to maybe get Mary's teeth brushed of course you keep trying to see if you can get her teeth brushed. But pinning her down and holding her against her will to brush her teeth I would think is a no no and would be seen as abuse
    nursel56, Autymnfyres, imintrouble, and 4 others like this.
  10. Visit  schnookimz profile page
    0
    If she is non decisional and you write down "refuse" and are sued, I'm sure they would ask how in the world she refused you. There must be a better word for this. Perhaps "unable to complete" along with a progress note.
  11. Visit  chrisrn24 profile page
    1
    Quote from Missingyou
    So,
    you would just walk out of the room and leave Jessica there to continue on without you??
    Of course not. You ideally both leave and reapproach. And try again later. If it doesn't work call the family and explain the situation. Maybe they will come sit with Mary while you try to brush.

    Other posters have suggested good ideas - hold Mary's hands as opposed to hold them down.
    SoldierNurse22 likes this.
  12. Visit  mvm2 profile page
    3
    Quote from schnookimz
    If she is non decisional and you write down "refuse" and are sued, I'm sure they would ask how in the world she refused you. There must be a better word for this. Perhaps "unable to complete" along with a progress note.
    Yeah that would work, or maybe Non compliant perhaps would be a better word. Just as long as it is documented that you tried to brush her teeth but she did not allow you to do it properly is all I was trying to get across in my statement
  13. Visit  Missingyou profile page
    0
    And if Mary did not have dementia, she was of sound mind, but had a stroke and needed assistance, but refused to have her teeth brushed...whether or not she knew of the ill effects of not brushing??
    or
    what about the same scenerio only instead of tooth brushing, make it showering 2x a wk and she refuses everytime?
    or
    Having a BM in her brief and she refuses to be washed up??? (with or without dementia)
    or
    refusing to eat??

    I think it's sometimes a fine line we, as CNA's, walk. Clearly, it's a health issue if she needs to be washed of BM, refusal or not.
    But, Toothbrushing? showering?? EATING?? Can "forcing" them to do any of these things be viewed as abuse?, at the same time, can NOT getting them done be viewed as abuse too!?

    When in doubt, ask the charge nurse what to do, but still, it depends on how long the refusal has been going on and what it is that they are refusing....still a fine line that frightens me....
  14. Visit  SoldierNurse22 profile page
    3
    Quote from schnookimz
    If she is non decisional
    She isn't non-decisional. She's confused due to dementia. Big, big difference.

    While there are certain things that need to be done for the good of the patient with dementia, it's important to try various avenues of approach before resorting to force. If you do have to do something for a patient against their will, it's also important to use the right means to restrain them. I guarantee that if you bruise or injure a patient while rendering care, even for their own good, you can be charged with abuse, regardless of their mental status.
    Retired APRN, mvm2, and cardiacfreak like this.
  15. Visit  SoldierNurse22 profile page
    2
    Quote from Missingyou
    And if Mary did not have dementia, she was of sound mind, but had a stroke and needed assistance, but refused to have her teeth brushed...whether or not she knew of the ill effects of not brushing??
    or
    what about the same scenerio only instead of tooth brushing, make it showering 2x a wk and she refuses everytime?
    or
    Having a BM in her brief and she refuses to be washed up??? (with or without dementia)
    or
    refusing to eat??

    I think it's sometimes a fine line we, as CNA's, walk. Clearly, it's a health issue if she needs to be washed of BM, refusal or not.
    But, Toothbrushing? showering?? EATING?? Can "forcing" them to do any of these things be viewed as abuse?, at the same time, can NOT getting them done be viewed as abuse too!?

    When in doubt, ask the charge nurse what to do, but still, it depends on how long the refusal has been going on and what it is that they are refusing....still a fine line that frightens me....
    All great questions. I'll try to take them as you present them:

    1. Mary doesn't have dementia but she had a stroke and refuses to brush her teeth.
    I'd start by trying to figure out why she doesn't want to brush her teeth. Is she embarrassed to accept assistance? Is she afraid of something? Is she depressed? Is her refusal due to a mental status change secondary to another condition, such as another stroke?

    For a patient who is A&Ox3 and able to understand the need for personal hygiene, refusal to take care of oneself could be indicative of an underlying issue, such as depression, that needs to be addressed.

    2. Mary refuses to shower x2 weeks.
    Again, if Mary is A&Ox3 and refusing, I'd try to figure out why and assess for mental status changes. I've never forced a patient who is A&Ox3 to clean up, but I've also never had to.

    3. Mary has a BM and refuses to be washed up.
    Again, why? This is clearly a matter of immediate hygiene for not only the patient but for the nursing staff. I'd do all of the above as previously listed (assess for mental status changes, depression, etc) and go from there.

    4. Mary is refusing to eat.
    Well, you sure can't make her eat. Repeat all steps above and discuss a plan of care with the patient's physician. If the patient is at the end of their life, some patients will just stop eating, and there's nothing you can do to change that. If they're A&Ox3, that's their right and it's natural as the body declines to stop feeling hungry/thirsty.

    Bottom line, if you're confused, talk to the patient and try to understand what's going on in their mind. If you're still confused, talk to the nursing staff about the problem. Perhaps they know something you don't or they know a good way to approach the issue.


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