How do you get a very combative patient to take a shower

  1. 1
    I have a client who refuses showers. He comprehends most things but seems withdrawn and has alzheimers. When asked if he will let us give him a shower he gets agitated. If we explain that it is important that he is clean for hygeine and health reason he gets more agitated. if we say his family really wants him to have a shower because they care about him, he gets even more agitated.

    Distracting him doesn't work because he knows that we want to give him a shower. He starts yelling, slaps, punches, kicks and squeezes my arm if we come anywhere near him in an attempt to give him a shower. He is a two person assist so for him to be that agitated makes it really hard to give him a shower when he is trying to hit us. Its amazing how strong people get when they are angry even if they are elderly - it really hurt when he held on to my wrist with all his might. One of us tries to hold their hands to prevent the punching but its still not easy.

    The nurse is going to see if a agitation med will work right before the shower. Anyone experience this and how do you manage it?
    Joe V likes this.
  2. 19 Comments so far...

  3. 3
    Give him a bath.
    Seriously.

    He sound like a person with advanced dementia.There has been way too much effort (from both the staff and the patient).
    on this issue. Perhaps drawing a bath ( I know.. where are we gonna find a bath tub?) would be an alternative.
    You could present him with a basin of warm water and coax him to do the basic wash up himself. ( I know.. who has time for that).
    Sedation would be the last ditch effort... however, does the medical team know what s going on?
    Sounds like time for a multi-disciplinary meeting to address this issue ( I know, who can arrange that ?)

    Good luck, and thank you for caring.
    canoehead, Pat2012, and VivaLasViejas like this.
  4. 4
    Unfortunately, you can't "snow" the guy just to get him clean......that is, in effect a chemical restraint, and thus legally (and ethically) squishy. As demented as he probably is, he still has the right to refuse care, and refusal to shower/bathe is an almost universal problem in long-term care facilities.

    I'm assuming the interdisciplinary team is involved here and is well aware of the impasse. The resident needs to bathe, because he is at risk for skin breakdown and quite frankly, he's stinking up the joint. However, there are probably as many reasons why demented elderly people don't want to bathe as there are elderly demented people; your job is to find out this one's reasons and try to modify them so he can receive hygiene without physically hurting someone.

    Some of the possible reasons: He grew up in an era when you took a bath on Saturday night, whether you needed one or not, and thus is not used to more frequent bathing. He might have nearly drowned as a kid and is afraid of water. He may not like having water sprayed in his face. He may be cold, and the usual nursing-home shower isn't exactly a warm, friendly place. He may not understand what staff are trying to do to him. He may not like being naked in front of people, especially those of the opposite sex. He may be in pain. He may be embarrassed. He may be fearful of something you don't know about. And, he may just be a mean old dude who needs a boot in his backside to straighten him out---I once had a resident who would shower ONLY when one of us would pretend to be his commanding officer and bark orders at him, just like in his Army days!

    Get creative. If there are family members available, they can often give you insight as to where the problem may have originated, as well as what works. Take the carrot-and-stick approach, and offer the resident his favorite goodie if he allows himself to be showered (give him extra if he'll do it without taking a swing at a caregiver). Bring him a washbasin, cloth, and a towel and cue him to wash whatever he can reach, and use one of those soapy shower caps like hospitals use to get his hair clean. Let him have as much control as possible, but don't ask him if he wants a shower/bath; the default position is always "NO"!

    Hope this is helpful to you. Good luck.......I know one old fella who literally had to be dragged to the hospital and physically placed in one of the Jacuzzi tubs, clothing and all, because his poor little wife hadn't been able to get him into the shower or even change clothes, for TWO YEARS. They literally had to soak his clothes off.......then, they couldn't get him OUT of there because he found out he liked it! To say the least, it was an APS case from there on out.
    Last edit by VivaLasViejas on Jul 8, '12
    canoehead, ktwlpn, Pat2012, and 1 other like this.
  5. 1
    Excellent answer Vegas!

    Be creative and think outside of the box. Will he let you or is he able to wash himself in the bathroom or bed bath? Think small too...maybe start by soaking his feet in a tub or wash basin? This will take time to accomplish and trust me, I know time isn't something we all have in LTC.
    VivaLasViejas likes this.
  6. 0
    I would try to do a bed bath and foster as much independence as possible to preserve autonomy. You may also want to research the AJN website or a library that has it, because they always have great suggestions for working with patients with Alzh and/or dementia. Also, I have read in numerous articles that it is better to take a step by step approach with a task such as a shower or even bed bath. Also, have you tried asking him what it is he doesn't like about the shower? Sometimes there is something about the process that might be bothering them. Is there a nurse or CNA that gets along with him? Maybe he needs someone he see's regularly....
  7. 1
    If he's that freaked out by the shower, see if he can wash his own face, hands, and peri area. Leave the rest alone.
    VivaLasViejas likes this.
  8. 2
    There's nothing wrong with giving an agitated resident some ativan or even geodon prior to the shower, if its ordered for him. It's not "chemical restraint", that's being a little melodramatic. That's what PRN meds are for.

    I can think of a few reidents I give a PRN IM geodon injection 15 min prior to their shower on the alzheimers unit. It always calms them down enough so that they don't resist.

    Otherwise, like CapeCodMeremaid
    said, just let him wash himself. Or give him a bedbath if he'll allow it. In this line of business not everyone will get a shower every week. Not going to happen with every resident.
    DSkelton711 and merrywhiterose like this.
  9. 2
    Geodon is an antipsychotic. PRN use is not allowed unless there is a scheduled dose as well. Unless the man reeks of urine or has horrible skin issues, let him be.
    VivaLasViejas and ktwlpn like this.
  10. 0
    I worked in a LTC facility where the rules were arbitrary ~ residents MUST be bathed on their shower day, they MUST eat meals in the dining room ~ despite combative/inappropriate behavior.

    Needless to say the caregivers were routinely subjected to combat in the shower room, and inappropriate behaviors in the dining room (aside from the "normal" screaming/cursing/food flinging more than one resident passed away at the table.)

    Nursing judgement was frowned upon. Being creative was not allowed.

    I hope that your interdisciplinary team is more understanding and is willing to come up with a better way to make your resident comfortable with hygeine.
  11. 3
    Can you imagine how scary a shower is to someone with dementia?

    You get dragged out of the familiar and taken to a scary looking place by people you hardly know and are undressed and cold and then you get hosed down.....

    There are some established best practices for bathing people with dementia. you can research them on-line and/or call and talk with the activity director at your nearest Alzheimer's/dementia care facility.
    VivaLasViejas, Fuzzy, and Pat2012 like this.


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