First combative pt

[LJR89]

Hi all.

Im feeling a little burnt out. I work in a small tcu and have been dealing with my first combative patient.

They are only only in my care for about half of my shifts, but I still go home wondering what else I could have done going home to prevent their behavior even when they are not my patient. We work hard to make sure their needs are met, and they're not in pain but atleast twice a shift they become so agitated they are grabbing, pulling, swinging, kicking, and spitting at staff.

this pt does have some Nuero/cognition issues. When they are calm they can answer questions and make eye contact. But during these episodes they can't make eye contact and aren't verbal.

Does anybody have any tips on how to avoid these types of behaviors? They tend to happen around the same time. So we know when to look out for them but haven't figured out if there are triggers to address. Weve tried making sure basic needs are met (hungry? Thirsty? Bathroom? Pain? Tired?)but they still seem to occur regularly.

Most of us our staff are fairly new to the unit and many of us new nurses, so some advice from those experienced with combative patients would be so helpful.

Sometimes i I wonder if the sounds of all the call lights and noises just get too stimulating. Would headphones/music be relaxing or is that just sensory deprivation? They don't have the cognitive function or the dexterity to perform simple tasks to keep them occupied currently. So those kinds of activity's have just lead to more frustration for them.

I just want want to help them so much but I have less and less patience each shift. I feel awful having such a poor attitude but I'm so stumped and frankly exhausted at the idea they'll be assigned to me before I even get to work.

Just wishing I knew how to keep him and all of the staff safe.

[Ambersmom, BSN, RN]

Any chance he could be having some type of seizure or a reaction (maybe paradoxical) to a med?

[Munch]

So many different scenarios and causes of combative behavior the answer to this can vary. If the behavior is because of altered status(like RJ's sister) or because of a mental health issue(hallucinations/delusions) approaching that situation with rationality mostly has very little value. These delusions or things they are seeing are very real to them and I find it best to acknowledge(instead of challenge) the belief or hallucination without encouraging it. If a patient is screaming about the FBI coming after them I would probably say something along the lines of "that must be terrible for you" as opposed to "that isn't true." Then I would either wait for mental health or sometimes just letting it run its course depending on why they were altered. I work neurology med/surg so a lot of people are altered due to concussions or other injuries. I myself had a craniotomy and I had hallucinations and its very scary when something is so scary is so real.

Basically in an acute sitatuation its not really the time or place to break someone's belief system. I'm not a CBT practicing psychologist either. Now if someone is being combative and they are just having a tantrum and they aren't altered..then you can try and have a rational conversation and try and put your problem solving skills to good use to try and calm the patient.

[ChryssyD]

Wow, so many good ideas posted here--I'm really impressed. My first thought was sundowning, as this is definitely an issue with many patients who have neurocognitive issues. UTIs are also a major cause of aggressive, atypical behavior. But with most NCD patients, it's about how you approach them.

On my unit we have a lady with Alzheimer's who is very sweet most of the time, but when she first came in, the aides would try to change her brief and she would become combative because she didn't understand what they were doing. Many dementia patients get combative during ADL care--it scares them. We tried letting her do most of the work, wiping herself and pulling up the brief instead of trying to do it all for her, and it worked like a charm. Not all patients are functional enough to do any ADLs for themselves, but we should still encourage them to try--yes, they're old and demented, but they have cared for themselves and others for many years; we have to give them due credit for that.

In general, slow motions, soft words, and gentle touch work the best. But if the patient isn't receptive, do what you have to do as quickly as possible, then take a few minutes to thank the patient for how well he or she did, even if the patient ripped out half of your hair. It isn't their fault--they can't help themselves. Don't take it personally, and try not to restrain--hold and shake hands, distract, sing a song, anything social and non-threatening.

Antipsychotics, benzodiazepines, and mood stabilizers like Depakote can be enormously helpful. Get with your doc--there are ways to deal with the root cause of many of these behaviors, without getting into "chemical restraint." Remember, most of these patients aren't angry--they're afraid.

Thank you for caring enough to seek advice. Good luck--I think you'll do great. :)