improving care of older adults with challenging responsive behaviours
TRANSCRIPT
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Improving Care of Older Adults with Challenging Responsive Behaviours
BC Quality Forum 2017
Presented by Marcia Carr and Patricia Roy – Clinical Nurse Specialists Fraser Health
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Disclosure
Marcia Carr and Patricia Roy have no affiliation (financial or otherwise) with a commercial organizations
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Connecting
Introductions
Name and title
Where do you work?
What is your one biggest concern when caring for an older adult who is experiencing challenging responsive behaviours?
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Why is this important?
↓ harm/injury of pt. & staff
↓ length of stay with effective care
planning
Improved pt. care
↑ application of best practice
↑ staff confidence with CRB
Budgetary issues for Added Care
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Focus of this session
To provide direct care providers with practical evidence-informed strategies to improve the quality of life and care of older adults experiencing challenging responsive behaviours by:
Identifying what are the challenging responsive behaviours
Identify root causes and triggers
Identify proactive care planning strategies
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Session Outline
Background
Associated diagnoses with CRB
3 theories behind CRB
Applying the theories: Case Study – group work
Summary of key learnings
Evaluation
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Background
Initiated by Senior Leadership d/t cost of 1:1 “sitters” & bad media,↑ in staff
injuries, PSLS reports, & code whites
Prov. Violence Prevention mandated
Reg. Clinical Practice Guideline 2010 and implemented in 2012
Work now with Workplace Health to blend PVPC and CRB to increase staff safety and confidence with their care
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Delirium, Dementia & Depression (3D’s)
Delirium - acute onset of cognitive decline with a
fluctuating course of altered consciousness.
Dementia - insidious, progressive cognitive change
without much fluctuation occurring over months to years.
Depression - a mood disorder marked by lack of
interest, inactivity, difficulty with thinking and a significant change in appetite and time sleeping.
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CRB Theories
***All Behaviour has Meaning***
Behaviour is related to 3 responses:
Protective response (Talerico & Evans, 2000)
Needs driven response (Kovach, Noonanm,
Schildt, Wells, 2005)
Stress Threshold Model - Environmental Press response (Dawson,
Wells & Kline, 1993)
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Powtoon
Note: the theories behind the behaviours
http://www.powtoon.com/show/dVtwb902sFz/challenging-responsive-behaviours-crb/#1/
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Protective Response
Related to the person’s need to protect self from a perceived threat or fear
For example, Health Care providers are strangers to the person/pt. and when we try to do personal care the pt. may resist; this is understandable because we are invading their personal space and privacy
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Needs Driven Response
Person/pt. has an unmet need and is trying to communicate this need in the only way they are able
Basic needs include:
Physical: thirst, hunger, toileting, cold/warm, sleep, rest
Emotional/psychosocial: feeling out of control, lonely, afraid, & lack a sense of belonging
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Stress Threshold/ Environmental Press Response
The person’s inability to manage or cope with a certain amount of stimulation (threshold) or “press” from the environment and the behaviour is a response to this stimulation
Causes an inner tension, leading to a sense of feeling overwhelmed or not in control
Some triggers:
Overstimulation: alarms, TV, noise
No/under stimulation: boredom, loneliness, lack of conversation
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Case Study with Harold
Harold is admitted to a medical unit with pneumonia. He has been on the unit for 24 hrs and was in Emergency for 2 days.
o 82 years old retired professional boxer. 6’3” 200 lbs
o History of: moderate mixed dementia, gout, COPD, CHF, several recent TIAs
o Smoker x30 years.
o Lives in rancher on acreage with wife Harriet who is quite petite. Have been married for 63 years
o 4 children and 5 grandchildren with middle, single daughter living the closest
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Case study cont.
Harold has become increasingly restless, agitated, climbing out of bed, pulled out his IV and foley and keeps removing his O2. He was up roaming all night, his balance/gait is not steady & almost fell
He continues to call out for Harriet
Harriet was sent home because she was exhausted.
His room-mate is very ill so nurses are coming in the room, turning on the lights frequently to suction & Tx. Two family members are at bedside 24/7
Every 5-10 minutes, Harold says he has to “pee” but he resists assistance.
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Case study cont’d
He grabbed the nurse and then pushed her forcefully away. The nurse calls “Code White” and 3 people rush in to respond.
Staff apply 4 point Pinel restraints and give 5 mg of Haldol IM.
Harriet is called to come in to help settle him
A 1:1 sitter is now at the bedside
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Group Activity
Use the case study and the highlighted behaviour trending worksheet to develop a care plan for one identified behaviour and the theory that is contributing to the behaviour (e.g. protection or unmet need or environmental stress)
15 minutes to develop
Select a person to report out for your table
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Reporting out
How many think the CRB is due to
Delirium?
Dementia?
Depression?
Combination?
Each table reports out
Please just add on any additional points to prevent duplication
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Summary
CRB/AVB involves a team approach:
Safety of patients, families & staff
Investigation (observation) & communication
Care planning (48/6)
Pt/person identification (purple dots)
Documentation
Resources
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Wrap Up
Review Biggest Concern
poster
Care Plan answer key
Evaluation
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Questions? Thank You!
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References
Cohen-Mansfield, J. (2000). Theoretical Frameworks for behavioural problems in dementia, Alzheimer’s Care Quarterly, 1, 8-21.
Cohen-Mansfield, J., Marx, M., & Werner, P. (1992). Agitation in elderly persons: An integrative report of findings in a nursing home. International Psychogeriatrics, 4, 221-240. (Needs)
Kolanowski, A. (1999). An overview of the need-driven dementia-compromised behaviour model, Journal of Gerontological Nursing, 25(9), 7-9.
Long, S. (2005). Caring for people with challenging behaviors: Essential skills and successful strategies in long-term care. Baltimore, Maryland: Health Professions Press.
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References
Smith, M., Gerdner, L., Hall, G., et al. (2004) History, development and future of the Progressively Lowered Stress Threshold: A conceptual model for dementia care. Journal of American Geriatric Society, 52, 1755-1760.
Talerico, K. & Evans, L. (2000) Making sense of aggressive protective behaviours in persons with dementia, Alzheimer’s Care Quarterly, 1(4), 78-88.