Who is in Charge Here?

An angry patient with dementia on an acute psychiatric unit confronts me. Another nurse effectively redirects him. Then, we play cards.

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Who is in Charge Here?

"Who is in charge here?" said Mr. D, a 67-year-old retired police sergeant with dementia.

"Mr. D., I'm the Charge Nurse tonight," I said. "What's your concern?"

"No! Who is the manager of this institution? I wish to make a formal complaint," said Mr. D.

"The manager's name is Ms. G.," I said.

"This place is run like a madhouse!" he shouts. "I don't know when my blood will be taken and I don't know when my medication is coming!" His voice deepened and he fixed his stance. "They took my phone, and my mother is worried about me, and how can I call my mother? They took my damn belt, and my pants are falling down!"

"Okay, let's take one thing at a time," I said.

"You took my phone! Who has my phone? Where's my phone?" he said as he glared at me. "That, oh Charge Nurse, is against the law!"

Just then, my colleague Nurse Maria approached us. She stood about 8 feet to the side of Mr. D. She said, "Mr. D., do you have your mother's phone number?"

Still staring at me, Mr. D answered, "I have it in my mind."

"Let me write it down for you," Nurse Maria offered. "It's 3:30 a.m. You're in the hospital, and everyone is sleeping. In the morning after breakfast, the phone is turned on. I can help you make the call. Let me write that number down." Mr. D nodded while still glaring at me, and said the telephone number. She wrote it down and said, "Now you can rest, Mr. D., because you will call her in the morning. Remember, Juliana and I will help you make the call."

Mr. D. did not break eye contact with me but also nodded. Nurse Maria said, "Now, it's a good idea to go back to bed." Mr. D. nodded and turned toward his room.

What happened? As the interaction escalated between the patient and me, a more experienced nurse interpreted the emotional nature of Mr. D.'s demands and acted as a third party to diffuse the situation. Veselinova (2014) writes, "An individual with dementia may be sensitive to the tone of voice and may feel intimidated or frustrated by extreme levels of speech and tone" (p. 164). Nurse Maria introduced a calm, measured verbal redirection that was fluent with Mr. D.'s actual need for emotional support. Nurses who adapt the way they communicate can encourage increased communication with individuals with dementia (Veselinova, 2014).

Through the night, to build the rapport initiated by Nurse Maria, I returned to Mr. D. to address his needs. He told me he could not sleep, so I offered to set up a recliner near the TV in a quiet corner of the unit. Once his feet were up with a pillow behind his head, he said, "This is fine." Later on, when he said, "I'm tired of this," I walked him to the dining room for a change of scene. The next night at 4:00 a.m., I asked if he would like to play cards to pass the time. He replied, "Black Jack." We played until 5:00 a.m., and that's when he began to tell me about his memories, his family life, and his police work.

The interactions with Mr. D showed me that once a patient has at least one of his needs met, he feels heard and understood. Nurse Maria's keenly placed offer to redirect the patient initiated a workable relationship between a patient with dementia and me. Not only did this diffuse a situation that might have escalated, but it also opened a door to a trusting relationship between Mr. D. and me. The next night, Mr. D actually slept a few hours and at 4:00 a.m., he asked me to play Black Jack with him again.

When your patients angrily confront you, what do you do?

Reference

Veselinova, C. (2014). Influencing communication and interaction in dementia. Nursing and Residential Care 16(3), 162-166. Retrieved from http://www.magonlinelibrary.com/toc/nrec/current

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HangInThere

About HangInThere, BSN, RN

Juliana Luecking is a nurse and writer who grew up in Catonsville, Maryland. She now lives with her wife near a decent pizza shop in New York City.

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Specializes in Geriatrics, Dialysis.

That's a wonderful story and you and your fellow nurse did a great job for this man. I just wish we had the time to play cards at 4 am with somebody who could really benefit from the interaction. In LTC the staffing simply doesn't allow for it. At 4 am the nurse is starting a med pass on two halls and the CNA's are rounding on incontinent residents along with assisting any that are already awake with their various needs. There is usually not enough time to devote to this kind of activity with one resident when there is a unit of 24 dementia residents with a staff of one to two overnight and three staff on other shifts. It's usually the staff doing their absolute best to maintain a calm and relatively relaxed environment when one or two residents start becoming a little [or a lot] agitated. It's not at all uncommon for the majority of the residents to feed off each others emotions and pretty soon there's a staff of two to three trying to calm a whole bunch of dementia residents. We do what we can but not a single one of those residents really gets the attention they deserve when the goal is simply to avoid a unit wide meltdown.

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Specializes in Psych (25 years), Medical (15 years).
That's a wonderful story and you and your fellow nurse did a great job for this man.

I agree, and with all due respect, Juliana, this was not a difficult patient. The interventions and the way in which they were carried out were exemplary, yet basic and elementary.

This patient sounds as though his dementia isn't advanced, in that he could remember a phone number, his memories, his family life, police work, follow directions, and play cards!

Being sensitive, speaking in low tones, and giving support is the way to deal with any patient.

I've worked with patients diagnosed with dementia who could waylay a staff member with one punch and have no memory of it five minutes later. Having the zippity-do-dah knocked out of you, wrestling the patient down to prevent injury to him and others, giving a chemical restraint, and then have no idea when the next time he's going to go off is a patient with advanced dementia and difficult with which to deal.

This is an example of an off-the-beaten path successful intervention:

A patient diagnosed with dementia that I worked with continually would check his pockets asked where his wallet and keys were. He would be informed that they were locked up with his other valuables and he would get them back upon discharge. The patient would voice understanding and then return a few minutes later checking his pockets and asking where his wallet and keys were.

I had this patient write a note to himself on a card, basically saying, "Your wallet and keys are in security and you will get them back when you are discharged" and sign his name.

The next time he checked his pocket for his wallet and keys, he found the note, read it, and his anxieties were put at ease.

Once again, your article contained a nice little story, but was nothing to shake a stick at.

Perhaps I need to just shut up and write an article, eh Juliana?

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Specializes in taking a break from inpatient psychiatric nursing.

Okay, I see where you guys are coming from.

So there were some things I omitted from my OP. For instance, the patient was built like a tank. And, he had attempted to strangle me during an earlier stay on our unit.

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Specializes in taking a break from inpatient psychiatric nursing.

Please share every possible intervention to increase safety and reduce those all-to-familiar unit wide meltdowns. For aggressive patients with borderline personality disorder, I have made a written list with them at the start of my shift. We review it to check off their demands as they are met. I've seen these patients verbally assault every staff member, one by one, who passes through the unit - from dietician to supply clerk.

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I really liked reading about the interventions. And like Davey said, "I've worked with patients diagnosed with dementia who could waylay a staff member with one punch and have no memory of it five minutes later. Having the zippity-do-dah knocked out of you, wrestling the patient down to prevent injury to him and others, giving a chemical restraint, and then have no idea when the next time he's going to go off is a patient with advanced dementia and difficult with which to deal."

We had a patient with mid to late stage Alzheimer's as his diagnosis, though with advancing medical research, it would probably be more associated with TBI. You see, he had been a boxer his whole career. One Monday, he was so agitated, he punched a male CNA in the chest hard enough to actually stop his heart. After this, the staff wouldn't go near him alone, always with 2 but usually with 3 or 4. I was in my office later in the week and heard shouting that was done by multiple people and getting louder. I went to see the commotion and saw this resident being held down in his wheelchair by several staff members, while he fought them. One look at this mans face told me he was more scared and confused as to why they were holding him. I told them to leave him go and approached him in my usual calm manner, getting down to his level and asked him what he needed. After stuttering several incoherent words, I assured him I was there to help and got him to focus only on me, and not the surrounding 'army' of staff. He calmed enough to tell me that he had to use the bathroom.

This poor man was simply agitated by the need to use the bathroom. As he was unsteady, he was in a wheelchair and staff saw his trying to get up as a possibility that he would try to hit them as he had done to the earlier mentioned staff member. They were all betting that when I approached him alone that he would punch me and kill me...literally. But hopefully, they saw that all he needed was assurance that someone would listen and take the time to allow him to work through his anxieties long enough to find the words to communicate his needs. I walked him to the bathroom myself and returned him to his chair with no further problem.

There are many different ways to approach those with various Dementia's. Not all of them can be listed here. But watch and learn...from ALL of your staff. You may be surprised at the imaginative ways that help! And take the next step for the sake of your patient's and fellow staffers, include these interventions in the care plan and daily report. There is reason to reinvent the wheel when the very real possibility of harm to self, other patients or staff could be a potential problem and the solutions so easy. Best of luck to you!

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