Badges are razors - do no harm :-(

[mario_ragucci]

Anyone remember a thread involving what to do, and how far you should take it, with combative PT's? As the wheel went round yesterday, the RN and I were assigned 100yo lady who had bouts of striking out at others, the RN warned me. How can a individual like this harm anyone? She need to have a change and assessment, and started striking the nurse when sheed get near her to assess. I tried to weight her hands down with mine, so we could change wet linen, and any other care.

Dis lady threw kicks at the nurse, the kind that are bad. I couldn't believe it. Then lady grabbed my scrubs up high, like close to me neck, and tried to throttle me. To occupy her by keeping her hands busy was allowing care to go on for about 20 seconds. Then the lady grabbed on me harder and closer to my face and gripped too close to my ID, which has lappel pins on it. Trying to throttle me over the ID = 35mm cut over her topside of hand. RN was magic and had a tega-derm.

If I was the nurse, and swore to do no harm, that would include prohibiting any engagement in violent behavior, even if the PT initiates it. Want to help/do no harm to all PT's, but this, for me, is an example of how much I don't know. Never want to use restraints. This woman had amazing ability to process and use ATP. Man!

With the first punch of a patient, you should step back and leave'em alone and document. I feel considerable guilt over the person's cut. We we're trying to provide care, I wound up allowing a stupid behavior to go on. I'm sorry. :-(

[cargal]

I have been in a LTC facility where the resident stated from the get go "get the hell our of here you *****in bastard" and at any attempt at care he would pinch hard, bite, hit or punch. The CNA's were the first in the line of battle. Everything was tried, from mental health admission to psych medications. Most meds were refused. Other attempts at controlling behavior with meds-hide them in milkshake, ice cream, healthshake, etc. If we did get the meds in for a run, no behavior change was noted, so they were dc'd because of the high cost to the family. There was no solution. The CNA's were told to go in by two's, but that was usually unrealistic as there would often be no one else available. The result was that the CNA's would take the matters into their own hands and absolutely NOT allow the behavior by restraining the hands. Sometimes he got loose and let them have it. It was terrible for the staff. I was afraid of him myself. My advice is to always go in slow and quietly. Assess the mood, and don't startle the resident. Ask their permission for you to do what you need to do and explain it very clearly and simply. I noted that often the aids and nurses go about their business in a loud manner, talking about their personal life, etc. If a resident was attempting to rise unassisted and the alarm went off, there were three or four staff members descending on the the resident, and the subsequent noise was confusing and distressing to the resident. Perhaps it is my Validation Training. This is not always the answer, but sometimes the cumulative effect of all the staff approach can make or break the mood of the resident. Change of shift and loud, abrupt mannerisms can put a dementia patient on edge and increase the liklihood of acting out. But Mario, you are not responsible for the patient's behavior. Just some interventions to think about. For more information on Validation Therapy, see http://www.vfvalidation.org/whatis.html

[Gromit]

I don't know much about Validation therapy (I did read the site -thanks for the link!), and I dislike using restraints, but there are times when it is certainly necessary (like the psych case who is hell-bent on hurting him/herself, as well as any who enter) or the pt who is just unaware of who/what/where they are, and will gladly pull out everything from the NG tube and IV to the foley cath (ouch!).

Just a few days ago, we had a guy on the 2nd floor punch a laminated window hard enough to spiderweb it (and do moderate damage to his hand). Took 5 of us to hold him, and two more to tie the 4-points. Once suitably restrianed, a few drugs on board, and all was calm.

Better living through chemistry -- (Bob)

[DIPLOMATICRN4HIRE, MSN, RN]

When I worked in LTC when I was a LPN, going through Rn school I was working 2 shift 12 hrs baylor. We had a wonderful lady in her mid 90's tiny little thing. But she was a Master and I swear the creative reason for Croutching Tiger Hidden Dragon.

As I was passing meds one night I heard a blood curdling scream come down from the hall which she resided. I ran down the hall as fast as I could, only to find one cna in a ball on the floor with her badge larriet so tight around her throat and the badge end in the womans hand, with blood on the floor from the cna's skull and the Nurse assigned to the patient , with claw marks on her face and throat and a handful of hair in the residents hand. Nurse also bleeding from scalp. I swear to you during the day this lady was as sweet as they come, but at night and some other times she flipped out and broke out a six pack of whoop a$$ on anyone that came by. You had to talk to her like she was a comando to bring her down from her tirates. Vitamin V just made her smile about what was going on, nothing worked. After sending both of my staff to the ER that night and calming down the woman with administrators help(had to call them in no one else would cover the nurse) . She was removed from our facitlity and others that were even close to the amount of violence were transfered to others areas as well. I understand they did this because the Nurse and Cna settled out of court.

Violent patients do not know what they do, but please understand that your badge was an accident and possibly something that you should move when entering a patients room with these tendencys. Introducing yourself each time at the door will help reorient the patient at each entry.

Im sorry that it happened but for every even in life there is a lesson, maybe moving your badge and speaking your name will prevent this from occuring again. Its not like you intensionaly meant to harm the woman.

Just a thought

Zoe

[semstr]

Mario, sorry this happened, but don't blame yourself! things like this happen, unfortunately.

I had a patient ( a little guy, born in Italy in the late 1890), who was as calm as can be, but as soon as he heard another language as either Italian or German, he went absolutely crazy.

Swearing and crashing things around, when you got in his way he would knock you down.

Through Validation we found out, he was a POW in WWI, with lots of bad memories apparently. (his daughter told us)

Doing Validation with him, made things better, not always mind you, but the crashing stopped and he was even able to listen to the English songs on the radio.

So I can recommend Validation! It takes a very good training to do it properly though!

Take care, Renee

[cmggriff]

When entering a room with a combative patient of any age or sex, I always empty all of my pockets and remove any pins, badges and all other attachments. Your own clothing and the patients can be used against you and your co-workers.

Whenever possible enter the room with over whelming numbers of bodies, too. And never go in until you have done everything you need to do to prepare. Gary

[nursedawn67, LPN]

sometimes the care neds to be done even if the resident is combative....if we never did care on the residents when they were fighting some of them would never get any care at all. But like others said be sure that the resident has nothing extra to fight with (name badge, scissors, etc....)