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.

[sallyrnrrt, ADN, RN]

It's difficult, But try hard to maintain therapeutic relationship

[Davey Do]

they become so agitated they are grabbing, pulling, swinging, kicking, and spitting at staff.

Antipsychotics and benzodiazepines seem to work well with these patients.

Perhaps the sporadic influx of dopamine in the brain is the cause of these bouts of agitation and aggression. Antipsychotics work through inhibiting dopamine reception, subsequently decreasing agitation and aggression. Benzodiazepines also assist in decreasing acutely aggressive behaviors.

[ruby_jane, BSN, RN]

First off, kudos to you for realizing that this is getting to you. You mention neruro/cognitive issues: is the doc aware of what sounds like a new, escalating behavior? Is this sundowning or does it happen during the day?

I remember a patient I had in nursing school. We saw her for three days running and at baseline she was very sweet, kind, alert, and oriented. By day three she was horribly confused, combative, and, as it turns out, had a UTI.

[JKL33]

I like the way you write about your question/concern. Clearly you want to do the best you can for patients.

One thing that doesn't help and often seems to make things worse is when caregivers begin talking very loudly. Reprimands also don't work when the patient is unable to process what is being said. The cacophony that can be generated by people who want the patient to stop what s/he is doing might be one of my bigger nursing-related pet peeves. Patients just don't respond well to that. Sometimes talking softly in lower tones really helps and even if it doesn't solve everything it's not going to hurt (and it helps keep the staff calm in the process, too).

[Crush]

You mention this starts happening at certain times. So maybe asking the doctor for something to give these pts before said time would be something to look into. You sound like you really care and are doing all the right things so far. Certainly any stimulus reduction at those times has potential to help.

[amoLucia]

Antipsychotics and benzodiazepines seem to work well with these patients.

Perhaps the sporadic influx of dopamine in the brain is the cause of these bouts of agitation and aggression. Antipsychotics work through inhibiting dopamine reception, subsequently decreasing agitation and aggression. Benzodiazepines also assist in decreasing acutely aggressive behaviors.

I'm not as knowledgeable as DD, but I too was thinking along the lines of something like fluctuating hormonal levels.

OP, you mentioned noise levels. I think as healthcare practitioners we underestimate the effect noise has on humans. We pay lip service to previous investigations that confirm noise as a trigger, but little is done. You may have stumbled upon something.

[Tenebrae, BSN, RN]

My first thought would be hes not understanding whats going on and feelng completely freaked out and dealing with the situation in the best way that he can.

Dont feel bad though I once had a dementia patient who screamed from the minute she woke up to the minute she went to sleep and all the staff including myself were getting utterly burnt out. It wasnt until I sat down with a dementia expert to brainstorm and we ascertained that with the patients multiple Dx they may have having huge amounts of pain that they were unable to express and were dealing with the situation the best way they could. So we started in with some regular analgesia and while some of the challenging behaviours remained, she became much more settled, much less screaming and hurling abuse and afterwards I was like "seriously why the heck didnt I figure that out months ago"

You mentioned when the patient is calm they are able to converse well, so would it be an option to sit down with them and ask them "How can we help you make this time easier to deal with"

other questions include

- do you hurt

- do you find everything gets too much

- and cover the other basic needs as well

But most importantly talk to this person and let them know that you are there to help them and if there is any thing the patient can tell you to make that easier for all, that would be really helpful. Often when people demonstrate behaviours that challenge, when someone sits down with them and askes them how to do things differently and really involves them in the process, they feel valued and respected on the most basic level

[Tenebrae, BSN, RN]

The one thing I have found when dealing with people demonstrating challenging behaviours is to acknowledge that often their angst is often more to do with how they are feeling about the situation than us

[RJ 55]

I'm sorry you are going through this. I have taken care of many combative patients and it is never easy. The patient you are describing takes me back to a memory (before I was nurse). My sister had woken up from a coma after being in a bad car accident. She had to have a ventriculostomy because of the swelling in her brain. My sister has always been sassy and a little impulsive but always sweet and gentle. She was a completely different person....swinging, biting, spitting and swearing. It was terrifying. We didn't know if she was going to stay like that forever. Fast forward....over a decade later she tells us that she did remember behaving that way. She thought that were aliens and we were trying to do medical tests on her. I remember one night walking into her room she.had her hand wrapped around her throat and said she wanted to die. She didn't want to leave like this. It broke my heart. We eventually got her back but after her TBI she is just a different person. She isn't violent but she is different. When I have a patient like this, it reminds me of my sister. It reminds me that there is a person in there and they aren't behaving this way I order to make my life hell. They are living their hell and it's my job to help them. It helps me to focus and not become frustrated. I have gotten hurt over the years. I have had my head slammed in walls. I have gotten choked and my wrist twisted. So I make sure I have resources and I do things safely. I tell them and their family what I am doing." I'm restraining you because I don't want you hurting yourself or anyone else". "I will take off these restraints when you stop xyz". Or "I'm giving you this medication to help you relax, so you don't hurt yourself or anyone here". I reiterate that I'm here to help and not hurt them and they are in a safe space. Working with patients like this is challenging and sometimes scary. Just know that they need your help.

[Workitinurfava, BSN, RN]

Sometimes patient become triggered by certain things. The key is to try to find out what they are before the outburst if you can.

[tigerlogic]

Your attitude toward problem solving is fantastic. I wish there were more nurses like you.

I apologize, I'm not familiar with the term TCU. I'm assuming some sort of transitional care unit where you are either taking care of people waiting for placement or are helping them with some type of rehab? My background is ICU and ED-- restraints and heavy medications tend to be in our tool boxes for combative patients but those aren't necessarily good for lower acuity situations. Arguably, they aren't good for most situations based on the papers coming out on PTSD post ICU. Below are some other things to consider.

Thoughts:

Is the person incontinent? Could changing him prior to this time of day help?

Is he watching TV? Is something triggering? Is he used to getting a different channel/show?

Are there smells that happen at that time of day from the kitchen? The cleaners?

How is the light in the room? Could he be in a different position or location so that the light wouldn't bother him.

Noises certainly can be triggering, can you limit them or teach him what they are so they aren't so disturbing?

Can he hear someone else in distress and be responding to that?

Are his clothes, shoes, socks too tight because his legs have been in a dependent position?

Is he overhearing staff that are speaking about topics or in a language that he finds triggering?

Is a therapy pet visit an option?

Would changing his bathing routine be possible?

Is he having an allergic reaction to something that could be prevented or treated with benadryl? (Benadryl and Atarax are great drugs)

Is he hungry? Are his blood sugars Ok?

Any suspicion for a UTI?