Inappropriate sexuality...where to draw the line?

Jo Dirt · Dec 27, 2007

Hi. I was just wondering what you all would do in this situation.
We have a younger patient (52y/o) who came in last week with CVA who needed a craniotomy. During the craniotomy, he had some sort of cardiac episode (I'm sorry I don't really have the details, I'm just the CNA.)
Anyhoo...
At first he was really out of it, would barely respond to verbal stimuli, and didn't appear to have much purposeful movement of any of his extremities. However, whenever anyone stood by his right side, which is his good side, he would reach his arm up and wave it around, until he made contact with whomever was standing there, at which point he would stroke his hand up and down on whatever body part he landed on.
As the week went on, he regained ability to talk, and much voluntary movement of his right side. However, the groping continued. He would continue to caress whomever stood on his right side. As the week went on, it seemed more to me that he knew exactly what he was doing, and was aiming more for the butt and boobs.
He also began expressing some sexual thoughts...moaning whenever we put lotion on him, spreading his legs wide apart and shaking (as best he could) his midsection at us, and calling all of us honey, baby, etc.
This is where I am stuck. Half the nursing staff believes that he really doesn't have much control over himself, and that the behaviour is just a side effect of the CVA.
The other half has labled him a sexual harasser, and wants to call security on him any time he inappropriately touches the nursing staff.
So...what do you guys think? What would you do in this situation? Would you say something to the patient? I don't really want to be too hard on him...in case he can't help himself, but I don't really want to enable harassing behaviour, either.

Laugh at him. What is he going to do?

woody62, RN · Dec 27, 2007

I don't know about this man but I do recall what I was told of my own behavior following a severe closed head injury. I suffered a subdural hematoma and the portion of my brain that was affected was my impulse and anger control. I behaved inappropriately and acted out physicially. It took my neurologist and his Nurse Practitioner to instruct the nursing staff on the inability of myself to control my behavior. And how to deal with me appropriately, withoutout harm to myself or the staff. Before anyone leaps to any conclusions, they need to talk with the neurologist handling his care. In all likelyhood, he is unable to control his behavior and may not even be aware of the inappropriateness of his behavior. Before jumping to the wrong conclusions, the nursing staff need to explore other possibilities. And get advice on how to handle this person appropriately.

Woody:balloons:

Valerie Salva, BSN, RN · Dec 28, 2007

I used to work in a unit for pts with closed head and frontal lobe injuries. Many of them exhibited inappropriate and deviant sexual behaviors, and hypersexuality as a result of their brain injuries.

Maybe your CVA/craniotomy pt suffered similar brain damage?

Kunzieo · Dec 28, 2007

Thanks for all the responses.

I just wanted to clarify..that I wasn't trying to handle this on my own, the nursing staff is all fully aware of his behaviours, he behaves the same way toward ANY female, nurse or aide.

I was off the night before, but I worked last night and I believe neurology had been consulted sometime between last night and my last shift. I don't know what the results were, exactly, but they must have decided that much of it is voluntary, because last night, the nurses were far less tolerant of him and when he groped a nurse and called her honey, the nurse called security.

Security came up and gave him the ol' "we'll respect you as long as you respect us" speech. Which had the effect of making him the worlds biggest PITA.

He used his call light every 5 min asking for personal cares like to be changed, asking for a fresh gown, asking for a back-rub. Security came back up and told him that he was to limit his call-light usage for medical needs only.

Pt continued to ask for back rubs, insisting that they were medical (only he couldn't quite manage to say "medical." Slightly hilarious.)

So, I think the answers are becoming clearer. But thanks for all of your opinions. I had mostly been wondering if, when you don't know, it is better to err on the side of caution and assume he doesn't know what he is doing, or if you should take a proactive approach and nip that kind of behaviour in the bud.

leslie :-D · Dec 28, 2007

I had mostly been wondering if, when you don't know, it is better to err on the side of caution and assume he doesn't know what he is doing, or if you should take a proactive approach and nip that kind of behaviour in the bud.

whether it is voluntary or not, i never tolerate this.

i work w/a lot of the neuro impaired.

and their groping/grabbing, is always followed by a firm, "knock it off".

now, whether they oblige or not, is another thing...

leslie

NurseyBaby'05, BSN, RN · Dec 28, 2007

whether it is voluntary or not, i never tolerate this.
i work w/a lot of the neuro impaired.
and their groping/grabbing, is always followed by a firm, "knock it off".
now, whether they oblige or not, is another thing...
leslie

:yeahthat:

Multicollinearity, BSN, RN · Dec 28, 2007

I'm surprised nobody has mentioned getting a neuropsychologist to evaluate the patient. This is what they specialize in - the intersection of behavior and neuropsych issues. They are very good and even have specialized tests to help determine if the patient is able to control behavior, to detecting malingering, and area of brain damage, etc. They can do far more in this area of specialized testng and behavior than a neurologist can do.

al7139, ASN, RN · Dec 28, 2007

I have seen several pts with head injuries, CVAs, and post MI/Arrest that showed inappropriate behaviors that are sexual in nature. Even when they can follow commands, do things for themselves, etc. I agree that some part of the brain can be damaged that would normally prevent pts from acting on their impulses. This does not mean that it should be tolerated. You have to set limits with them as you would for any patient. That being said, don't expect them to comply without reinforcement. They truly can't help it. I have had pts masturbate in front of me, try to grab me in places that I don't want to be grabbed, and when it happens, I am firm with them, and tell them that they cannot do that and to stop. They usually do, but the next time I have to go in their room, they are right back at it. They do not remember me telling them they cannot do that to me or while I am there. It is very frustrating and disturbing to some people. I try to document the behaviors, and to let the attending know and recommend a neuropsych consult for them if it has not been done, then I read the consult notes, to see what the recommendations are for treatment, or better yet try to talk to the doc about my concerns.

In short, don't allow it, but try to understand that they really can't help it in most cases.

Amy

locolorenzo22, BSN, RN · Dec 28, 2007

Perhaps a male perspective is called for...I work(as a CNA) on a neuro floor, and we have plenty of impulse control problem patients. Many of them do NOT realize what they are doing, or that they have had the same behavior 5 minutes beforehand (I have to pee...."you just went pee") etc. Try approaching it with the following....instead of nurses/aides saying "don't touch me", try redirecting his hands towards his chest, grab his wrist(lightly) and place it back down over the other side, try reminding him that "the quicker we get you done, the quicker I can quit bothering you." also, maybe it's a way of him trying to communicate "LEAVE ME ALONE!!" I had that happen to a few of my fellow aides, and when I went in, sat down and started talking for 5 mins...realized that the guy just wanted us to quit poking, prodding, and "fing wiping me all the dang time..." I listened and just went in when I had to...that's all you can do. Try asking his neuro, or asking nurses to see what neuro has said about patient...and go from there...Let us know what's going on...

Christie RN2006 · Dec 28, 2007

I also work with a lot of neuro patients... 2 of out my 3 last night were neuro... anyways, I have seen similar situations several times with some of our neuro people. How they act all depends on where the injury is. Sometimes neuro patients lose their sense of right and wrong. I remember one guy that kept going for grabs and we had to keep tell him "that is not appropriate" this man also liked to play with himself and play in his poop. Neuro patients at unpredictable and they do some of the craziest things!!

woody62, RN · Dec 29, 2007

I'm surprised nobody has mentioned getting a neuropsychologist to evaluate the patient. This is what they specialize in - the intersection of behavior and neuropsych issues. They are very good and even have specialized tests to help determine if the patient is able to control behavior, to detecting malingering, and area of brain damage, etc. They can do far more in this area of specialized testng and behavior than a neurologist can do.

I couldn't agree with you more. But how about our peers and physicians? Why do we automatically assume that a patient can always control his behavior? Why do we always assume that he is just being smart when he acts inappropriately? Why do we find it so difficult to accept that a person may not have any control over his inapprorpriate behavior. I didn't have any control over my aggressive behavior. I could no more control my sudden outgageous outburst, then I could stop breathing. But my peers expected me to because 1) I was oriented to all three spheres therefore I can control my behavior and 2) because I was known to be a R.N.

I am sorry but people who have suffered head injures or CVA's, cannot always control their behavior, no matter how oriented to time space and person he may be. Fear can instill more fear in a patient. And it may even get a patient to comply with the staff's wishes. But sometime it will not. And then what happens to the staff and the patient? Nothing good.

Woody:balloons: