Patience Equals Better Care
Monday September 1, 2003
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A minute saved can be an hour lost when caring for patients with dementia, if harried care triggers refusal, aggression, or an extended catastrophic reaction. And for these patients, practices like catheterization and restraints (which cause temporary losses for cognitively intact patients) can inadvertently trigger a permanent loss of continence, ambulation, independence, and quality of life.
Nurses are recognizing these harsh realities of hospitalization and adapting care to meet the needs of growing numbers of patients with Alzheimer's disease and other dementias who are hospitalized for chemotherapy, heart surgery, and other procedures.
"Hospital nurses still believe rushing saves time," says Karen Feldt, RN, PhD, GNP, APRNBC, associate professor, University of Minnesota School of Nursing, Minneapolis, and a geriatric nurse practitioner in clinical practice. "Taking a few more seconds to prepare and talk to patients slowly makes a world of difference and gets more accomplished without catastrophic reactions."
Several studies have suggested correlations between elders' hospitalization and functional decline. The problem is intensified in those with dementia because of difficulties communicating, recalling directions, and recognizing environmental cues.
In addition to loss of memory, judgment, and communication skills, dementia characteristics may include confusion, paranoia, anxiety, agitation, delusions, and aggression. These are exacerbated by illness; increased temperature; disease; dehydration; medications; anesthesia; tests; treatments; changes in routine; and the hospital's unfamiliar sights, sounds, smells, and staff.
Specialized care for patients with dementia includes behavioral interventions, staffing alterations, environmental adaptations, and specialized nursing techniques. One key is improving communication with caregivers, asking long-term care nurses and families about patients' hands-on care, individual preferences, and daily activities.
"Nursing home nurses are experts on dementia and individual patients," Feldt says. "There's a range of dementia behaviors and abilities, and they can provide specifics. Families are incredible resources. If they say, 'This isn't like her,' find out how it's different."
Familiar caregivers can decrease agitation and increase compliance. Some families fear leaving patients alone, while others use hospitalization as a reprieve from caregiving. Families and other caregivers (facility or home care staff) should have open visiting hours, and be encouraged to come when needed. They can help with dressing, bathing, feeding, and soothing patients during procedures, and during late afternoon and nighttime agitation.
Undertreating pain is common with cognitively impaired patients. Caregivers can identify pain characteristics, such as nonverbal expressions and keeping a body part rigid; causes, such as arthritis or other chronic conditions; and effective strategies, such as warm baths, music, or nonprescription pain relievers.
Hospitals may tend to overmedicate behaviors, says Robin Storey, RN, BSN, FACDONA, director of program development and quality improvement at BJC HealthCare, St Louis, and immediate past president of the National Association Directors of Nursing Administration/LTC. "Medication is the last resort for us, and we dose low and go slow," she says. "Instead of automatically using drugs as interventions, we address the cause of behaviors. Look at patients holistically. The presenting problem may be exacerbating the dementia."
Slow-Down Strategies
Going slow with ADL (activities of daily living) assistance is crucial. "Once functions are taken away, they may never come back, permanently disabling dementia patients," Storey says. "It's very important to allow extra time for them to maintain independence and abilities."
That is another reason why it's essential for hospital and long-term care nurses to call and collaborate, she says. LTC nurses can provide baselines, routines, and effective strategies.
Among them are providing choices and explanations while offering assistance. Patients with dementia can't think quickly and may interpret a nurse with a toothbrush as a threat. When confused patients react aggressively, "they're seen as combative, doctors order drugs, and patients no longer can do for themselves," Storey says. Taking time up front saves time at the end."
Catastrophic reactions occur when patients are overstimulated by the environment or overwhelmed by pressure, fatigue, questions, or loss of ability. They overreact and sometimes lash out.
Staff should calmly offer reassurance and redirect the patient, either moving to a quiet area or removing distractions. Rather than arguing or trying to complete tasks, try later, when the patient is rested, calm, and additional staff, family, or a familiar caregiver can assist and provide distraction. Decrease catastrophic reactions by simplifying environments and following individual routines as closely as possible. Introduce new treatments slowly, with step-by-step directions.
The following suggestions were provided by Feldt, Storey, other nurses, and the resources listed here.
Communication
· Approach from the front, identify yourself, and use the patient's name.
· Use short, simple words and sentences. Be slow and specific.
· Give simple directions, one step at a time.
· Allow 20 to 30 seconds for patients to answer questions.
· Avoid in-room intercoms, which can frighten or confuse patients.
· Limit visitors, staff, and students to two or three.
· Talk with, not over, patients.
· Use eye contact. Bend, squat, or sit at patient's level.
Elimination and Catheterization
· Toilet after eating and at least every two hours.
· Label the bathroom with a picture, as well as words; use a nightlight; and keep the door open to encourage use.
· Eliminate catheters as quickly as possible. Provide underwear to minimize access and accidental pulling. Tape male patients' catheters to the abdomen.
· Provide a clear path to the toilet or commode.
Nutrition and Hydration
· Ask family or caregivers about food and beverage preferences and the patient's ability to use utensils.
· Serve small portions of one or two items at a time. Pour beverages; cut food as needed.
· Provide snacks and smaller, more frequent meals. Provide finger foods, lidded cups, large-handled utensils, and plate guards, if needed, to enable patients to feed themselves.
· Use verbal reminders and light physical touches to cue patients to eat.
· Remind late-stage patients to chew and swallow. Otherwise, they may hold food in their mouths.
· Frequently offer the patient's preferred beverages in a preferred drinking vessel.
Oxygen, IVs, Dressings, and Devices
· Use nasal cannulas rather than oxygen masks.
· Turn off bedside sound from monitors.
· Place monitor leads under regular clothing and tuck shirt into pants.
· Put IVs or a saline lock on upper dominant arm, wrap in gauze or stockinette sleeves (with a hole at the site). Run tubing up the arm, under long sleeves, and through the garment's neck. Use normal clothing or a cuffed, long-sleeved surgical gown.
· Keep hands busy with an activity or unused tubing.
· Use an OT splint to prevent arm or hand flexion. (Note: Some states consider them restraints.)
· Tape nasogastric tubes behind the ear and pin or tape to the gown's shoulder.
Walking and Wandering
Walking provides psychological and physiological benefits. Patients may wander to relieve stress or in search of something familiar. Some respond to shift changes or internal clocks, propelled by memories of former schedules and responsibilities.
· Ask family and other caregivers about wandering patterns and strategies.
· Plan and follow patient schedules for walks. Orient them to the environment.
· Assess for pain, constipation, bladder pressure, medication side effects, and status change; treat accordingly.
· Walk patients to a drink, snack, activity, or activity room.
· Provide meaningful, enjoyable activities.
· Use bed and door alarms to prevent falls and elopement from the unit or facility.
For More Information
· Acute Hospitalization & Alzheimer's Disease: A Special Kind of Care - Publication A-28, $2.50, from the Alzheimer's Disease Education & Referral Center, (800) 438-4380.
· The Alzheimer's Association website www.alz.org.
· NICHE-Nursing Improving Care for Health System Elders website www.hartfordign.org.
Wendy L. Bonifazi, RN, APR, is a senior staff writer for Nursing Spectrum.
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