Getting hit!

Mirai Kangofu · Mar 10, 2006

While we're on the topic, what constitutes unlawful restraint when defending one's self? When someone swings at me, my first reaction is to grab their hand or arm, or break their grip by bending their fingers back. By law, I can't do that, can I? When I ask the nurses, they tell me that I need to get out of there and respect their refusal, but what about attacks? One CNA told me that all you can do is block with your forearm. Today, I had to hold a woman's arm down because my too-large rubber glove got stuck in her contracted fist and she took the opportunity to scratch me up. I tried to write an incident report, but they want me to just put it in the nurse notes because it didn't break the skin. It ticks me off that patients are "provoked" or "misunderstood" when they fight, yet a nurse/CNA who will not allow abuse is a bad nurse.

Also, what's the deal with demented patients who won't cooperate, especially when it comes to showertime? If I respected any refusal, people would never get showered or changed. It seems like a very hush-hush thing, that you should get them to do it as long as nobody's witnessing the screaming resident.

Marylou1102 · Mar 10, 2006

You say these residents are demented and acting out. Why are they acting out? There is almost always a reason for their behavior. Are they hungry, thirsty, wet, dirty, hot, cold, in pain? They can't verbally relate what they want so they react on instinct only.

The first thing I would do is see if the Dr. would prescribe a routine pain med on a trial basis. It can be as simple as Tylenol or Darvocet. A lot of elderly people live with chronic unrelieved pain.

Then I would see if they have a UTI. In the elderly a UTI will cause all sorts of behaviors.

It might be the approach used. I don't know what you do but I have seen staff talk down to these patients. They will walk into a room and treat them as little children. If they need to be cleaned the staff will sometimes yank the covers off with no concern for dignity or privacy. Even with dementia these patients still have a sense of pride.

Finally, if you can just leave, wait a little while and then try another approach. Speak in a calm and quiet manner. If they are in an alternate reality go there with them. To them that is the truth and any attempts to reorient will only alienate your patient. I would suggest that you approach your administration about some dementia training for the nursing staff. It is really invaluable and all LTC staff are required to have extensive training yearly.

These residents can be terribly frustrating to care for, but it can also be very rewarding.

Mirai Kangofu · Mar 10, 2006

1) I'm a CNA, and I can't talk to doctors, and I work in a Catholic facility that opposes treating residents like animals, never mind the fact that it harms thae staff

2) I don't talk to resident like babies, nor do I neglect to try to see if they're in pain. IN fact, I've been reprimanded for trying too hard to go the nice way and playing along with delusions and fantasies. I get this lecture every time I try to figure out what to do if someone hits me, but no real answers of what I am allowed to do if it happens. I can't just pretend that it's never going to happen even if I take every precaution. Imagine being taught how to prevent any household accident in the world, but never being taught to dial 911 or administer first aid. I know the big picture, but I want to know what I can do at the second that an attack happens. I don't want my license revoked for defending myself, but I'm not going to turn the other cheek and let myself get beaten up and get denied workman's comp because I havne't worked long enough to be eligable. I can't always leave the room immediately, such as when I'm transferring a resident and she suddenly decided that she's scared, or if she's in the shower. Some people will scream and fight no matter what, and we have to get our tasks done, and I'd be charged with neglect if I let them sit contentedly in their own feces.

CrunchRN, ADN, RN · Mar 10, 2006

I wish I had advice, but unfortunately medications are the answer to this problem when all other accomodations have been made (such as environmental and emotional factors that may contribute).

As I am sure you know some people with dementing disorders may progress to violent and inappropriate behaviors. Medications can treat this and they are not permanent because usually the disease wil progress beyond this point and then the meds can be stopped.

Your problem here is that the family is declining all medications. A care conference needs to be held and the team needs to educate them about the facts of life. These are that the nurses will not care for him if it put's them in a physically threatening situation, and that any decent facility will not accept a patient with these behaviors as it put's their staff and other resifdents at risk. They need to be presented with the reality that they may have to take this person home if they cannot find placement and that is unlikely if the violent behavior is uncontrolled.

I wish you the best of luck in this situation and strongly urge that you not care for this patient until proper steps have been implemented for your safety. If enough of you do this the facility, medical staff, and family will have to take action.

I do not believe in medicating people unless it is truly indiciated and in this situation it is.

I am currently involved in Alzheimer's research and there is a lot of data that supports this. Medscape is a good resource to find this information.

snowfreeze, BSN, RN · Mar 10, 2006

Dementia cannot be reasoned with. Geropsych units and dementia behavior units have staff with the training and docs with the knowledge to deal with these issues. Generally the least physical restraint is best used along with proper medication. Small units allow for freedom to move about for most residents. Difficult families are educated over and over and over again.

Sheri257 · Mar 10, 2006

Ugh - I swear people who don't get hit by patients have absolutely no understanding. I had a confused gentleman try to smack me during a bedbath, and I told my instructor I wasn't really comfortable going back in (he wasn't my pt, I was helping another student). In my evaluation she said I needed to work on my therapeutic communication with difficult patients. She compared it to this one time she had to take care of a woman who had just terminated a pregnancy, and since she was Catholic she had a hard time. Then later I was describing a different issue (unrelated to the hitting) with the pt to another student and my instructor pipes up with "I remember him, you had such a hard time with his personality!" Yes, not wanting to be hit = personality conflict. :uhoh21:

That is ridiculous ... I have never been more upset then when I was hit, kicked and spit on by a patient. You're right ... people really don't understand how horrible it is until it happens to them.

Sorry ... when I am assaulted ... I don't care about their condition. I'm not going to be assaulted again.

:angryfire

chadash · Mar 10, 2006

It does sound like there needs to be more inservice education from psyche folks for those who deal with dementia patients. Yep, reasoning does not work, psychiatric meds may help.

By medicating pts, (excuse, I know nothing about meds!) if you mean sedating into oblivian, yep, I don't like that idea...may even make mobile pts more likely to fall. But aren't there appropriate psych meds for specific mental illnesses that manifest in dementia patients that would help? Anxiety, fear, paranoia: I would think it would be unkind to not treat these things.

a practical hint:

Sometimes, I would walk into a patients room, and it was clear they were having some delusion, or even hallucination, and it was clear I was headed for a bad time. Or maybe they just did not want me to do something. I would back out, and give it a little time, re enter as if it was the first time, and sometimes find that there response was totally different, and they did not even remember I had been there earlier. Don't try to talk folks out of their delusions, retreat to fight another day.

purplemania, BSN, RN · Mar 10, 2006

another point to consider - the patient who strikes out at others may also harm himself.

Also, worker's comp is not cheap. I would file a claim each and every time there was an incident. That will get Admin into looking for alternative measures.

zacarias, ASN, RN · Mar 10, 2006

Maybe this is illegal but I think if a resident (confused) tries to hit you and you grab their hand and put it down, this is completely OK. I mean what is this soccer where we can't use our hands? The resident trying to hit is assaulting and you grab him (battery) to protect yourself? To me that's what every nurse should do. You are entitled to protect yourself when being attacked.

LandDRN · Mar 10, 2006

Been there. However the pt did not have dementia. he was an 80yr old ex-serviceman, who said he wasn't going to take "crap from a bunch of women." His nurse was in trying to get a blood pressure cuff on this pt who had called to say he was having chest pain. his pressure was elevated which made the dynamap cuff much tighter which ticked him off. I was at the bedside titrating his nitro gtt and had my back towards him. He grabbed me by the arm and right ear and knocked me to the ground, kicking and punching me. I never even saw it coming. I was bruised all over and had a torn earlobe. The md was horrified after it took 4 staff members to pull himself off of me and I walked out of that room to the desk. The next day they assigned me to the pt in the next bed. I said I didn't want to step foot in that room and they told me I was not allowed to refuse a pt. As I walked in he told me I was lucky his didn't "rip my F^%%&*G face off." His S/O at bedside chuckled and said he's always been a fiesty person even as a young man. Had to walk out, stunned and speechless! I NEVER turn my back to even the nicest of people now.

Mirai Kangofu · Mar 10, 2006

Dementia cannot be reasoned with. Geropsych units and dementia behavior units have staff with the training and docs with the knowledge to deal with these issues. Generally the least physical restraint is best used along with proper medication. Small units allow for freedom to move about for most residents. Difficult families are educated over and over and over again.

THANK YOU THANK YOU!!!! I wish that people would look beyond superficial pity and black and white perspectives to realize that restraints are necessary, yet people will always blame the caretaker for somehow provoking the demented resident. Some of the less demented residents might start putting up a fight after I tell them stuff like that I can't give them prn meds right away but I'll tell the nurse, then act confused, innocent, and make up stories once a nurse comes in the room. This certainly doesn't help, and encourages such residents to keep up such behavior to get their way.

Antikigirl, ASN, RN · Mar 10, 2006

You guys are awesome..thank you so much for the words of support and advise!

I took a course in working with developmentally disabled on how to deal with agressive behavior. Sadly that really helps when you are there when it happens, not as well when you have to save your CNA...LOL! Three bodies in a small room was a bit of a squeeze to free someone. But we were able to do it without having to call security...and we got the pt into bed.

The CNA had worked in many adult homes, and she and I came up with a plan. If we raised the knees of the bed it was harder for him to get out and he would tire. Also when doing ADL's we simply took a bath blanket and made sure it was over his torso and arms...not in a restriant as much as seeing his movements quite clearly under the blanket and having him manipulate the blanket and give us a few more seconds! That was helpful in some part of his care.

I did document everything, wrote an Incident report (so did the CNA), talked to admin. I also talked to the family who was instructed they needed to spend time in there since he was so confused. I also brought up exactly what another poster mentioned about diabetics or heart patients needing medicine so do dementia patients!

Also, we did find that if he was even remotely wet, he would be more agitated...just too bad that was about every 5 minutes (I am not kidding!).

He did have pain issues so I tried to give him tylenol when he was agitated, but he would not take anything by mouth, so I would have to resort to PR...which I am sure he would have refused so that left me feeling kinda bad! That didn't seem to help the agression

Calm dark room as well, and I put on classical music for him to enjoy. I would use a nice calm voice unless he was striking out, then a firm voice saying "sir, you can not touch me in that way, that hurts, stop" then just "stop" after that (this was my routine each room entry...just incase he had word association probelms...the easier the better).

I did what I could and gave that information to the other nurses so they too could try these techniques for not only safety but continuity for his care (routine is best with dementia). Sadly this is a hospital and not a LTC or ALZ unit...there isn't going to be any real routine for him, always a new face...and well...that is the way it goes.

Nurses did play with the idea of refusing pt care, I said I couldn't. He needs care badly, and if we give up on him...well then how will his needs be met? Everyone understood that...so trying hard to provide a safe yet routine schedule is our goal so that he can get placement (well okay placement is our goal big time..LOL!).