Managing Behavior

Objectives:
After you take this class, you will be able to:

  1. Relate some causes of poor behavior.

  2. Detail ways to prevent and manage poor behavior.

  3. Discuss delirium, dementia and Alzheimer’s disease.

INTRODUCTION

Many people with a mental disorder may behave in a way that is not safe. This behavior must be prevented and stopped. Some of these behaviors can harm self or others, including workers in the hospital or nursing home. They put people in danger of injury. Some keep other people from enjoying a quiet and peaceful place. They lower the quality of life for others. Others are just not the right thing to do. They are NOT appropriate. Some of these behaviors may even be against the law.

Many old adults have Alzheimer's disease. This disease leads to dementia. People with dementia are confused. They may also behave in a poor way. This disease can't be cured but the poor behavior can be prevented and managed with good nursing care.

Young people with a mental disease may also behave poorly. These people may act out. They may cause harm to self or others. They also can do things that disturb the peace of others. Some can also be against the law. Again, we must prevent and manage these behaviors.

These behaviors can be prevented and managed when all members of the hospital or nursing home team work together. All of us must increase good behaviors. We must also prevent and decrease behavior that is not healthy and safe. Many people that act out with poor behaviors can change this behavior if we help them to do it.

HOW BEHAVIOR WAS MANAGED IN THE PAST

We used to use a lot of medicine and restraints to control behavior. Some of the restraints that were used in the past are:

  • a vest to keep a person in the bed or chair

  • a bed sheet to tie a person to the chair

  • leather straps to keep a patient in bed

Restraints and medicine did NOT help the problem. They did not stop poor behavior.

Medicine only made the behavior stop for a short time. The poor behavior began again when the medicine did not work any more. Restraints did not stop the behavior either.

They often made it worse. They even led to patient injury and death. Many patients got choked to death when they hung over the side rails of a bed with a vest on.

Medicine and restraints were often used to make the job of caring for patients easier. They were not always used to help the person. Some lowered the quality of the person's life. Others took away the person's right to dignity and good nursing care.

Now, we manage behavior with other kinds of care. It is rare now to see a person take medicine or have a restraint. This happens now only when all other things have been tried and none have stopped a dangerous behavior. They are not used to make our job easier. They are only used when nothing else protects the patient and others from severe injury.

Nursing assistants musk know why some patients and residents act poorly. We must also know how to prevent and control poor behavior without using medicine or restraints. This course will teach you the reasons that some patients act poorly. It will also teach you how you can prevent and manage poor, or bad, behavior.


EXAMPLES OF PROBLEM BEHAVIORS

Behavior can be:

  • Disruptive. These behaviors can upset other patients and residents and make them angry. Screaming, yelling and cursing are examples. Saying the same thing over and over and resisting, or fighting, nursing care are some other examples of this kind of behavior.

  • Prohibited. These behaviors can be against the law. They can make other people be very upset. They can also harm another person. If a person takes, or steals, something or they take their clothes off in the dining room they are NOT behaving the way they should. Rape and putting one's urine on a dining room table are some other examples.

  • Dangerous. These behaviors can hurt the person who does it. They can also hurt others . Patients and residents can get hurt. People that act this way can also hurt self and others. They can hurt others when they hit, kick, bite, spit or throw things. If Mr. Green tries to end his own life (suicide) by putting a gun bullet into his head or he tries to wander out of the nursing home in the middle of the night when it is snowing and he is not wearing any clothes or he tries to eat medicine or cleaning agents, he can hurt himself.

WHY DO SOME PEOPLE HAVE BEHAVIOR PROBLEMS?

Residents and patients can act out for a lot of reasons. Many older people have a behavior problem because they are confused. They may have delirium or dementia. Young people may act poorly because they have a mental illness. Some young people may have delirium, confusion or dementia after a head injury. Depression (sadness), anger, medicines and other things can also lead to a problem behavior.

Delirium comes on, or appears, very fast and quickly. The person can be disoriented and confused. They may not be able to sleep. Some may see or hear things that are not really there. They may hear the voices of people who have died. They may see someone giving poison to another patient. These things are not true but the person thinks that they are true. This person may do dangerous things or become very fearful. They can react to this fear with dangerous or violent behavior. They sometimes obey the 'voices' and fall down the stairs. They may try to 'escape' the nursing home if the 'voices' tell them to 'escape'. They can hit the nursing assistant with a chair if they 'see' the nursing assistant feed poison to a resident. We can prevent and manage these delirium behaviors.

Dementia is different from delirium. It comes on slowly. The person becomes more and more disoriented or confused in a slow way. The behavior usually gets worse and worse as time goes on. Sleep patterns can change. The person may stay up all night and sleep all day. They can also 'see' and 'hear' things that are not real. Although dementia can NOT be cured, the behavior CAN be managed. Alzheimer's disease is the most frequently seen dementia. Other diseases, like Parkinson's disease and an infection can also cause dementia.

THINGS THAT 'TRIGGER' OR LEAD TO BEHAVIOR PROBLEMS

A person can react to many things by using poor behaviors. They may hit a person if they are cold. They may slap the nursing assistant if another resident makes them upset. They may yell if the patient care area or dining room is noisy. Things that can lead to poor behavior are called triggers. Triggers can be different to different people. Know your patients and what triggers them. Triggers can be:

  • Physical. A person can act poorly because they are too hot, too cold or uncomfortable. They can act out if they are dirty or soiled, tired, sick, thirsty, hungry or in pain. They may be triggered when they have to use the bathroom or bedpan. Others react when they are constipated or they are not able to see or hear what is going on around them. They may need their eyeglasses or hearing aid. Meeting the physical needs of the patient can stop these physical triggers. For example, give them a sweater or a blanket if they are cold. Give them a chance to use the bathroom or bed pan. Make sure that they have their hearing aid or eyeglasses.

  • Emotional. The person may act out if they become sad or lonely when their visitors did not come to see them. They may be upset when another resident yells at them or when they think that nobody likes them. We can stop these triggers by meeting the patient's emotional needs. Let them talk to you. Listen to them. Try quiet music or a backrub to calm them down. If a person is upset tell them that you are sorry that they are upset. Ask them, 'Tell me why you are upset'. Listen to their answer and try to help them.

  • Environmental. Other residents or patients act out with poor behavior if the patient care area has a lot of noise. They can act poorly if the area has too much or too little light. If too much is going on at one time or if the TV or radio is too loud, a person can also act out. Nursing assistants and others should keep the patient care area quiet and calm. It should be well lit. The temperature of the area should be comfortable to the people in it.

  • Communication. A person may get triggered if they can't tell you what they want or need. Or, if they can't talk to other patients and residents, their family or their doctor. Spend time with the patient. Listen to them closely. Use the person's name. Be calm. Do NOT argue with a patient or resident. Sit with the person. Talk to them slowly and at eye level. Do NOT stand while the person is sitting.

  • Related to the care given. Bathing, getting out of bed, eating, dressing, and other things can trigger poor behavior. These triggers can be prevented if we give the person choices and do tasks in small steps. Ask the person to do the task with you. Tell them that they did a great job when the bath, or other task, is done. Reward them with smiles and praise. If they resist, stop the task. Try to do the task later.

ALZHEIMER'S DISEASE

Alzheimer's disease is the most common dementia. No one is sure about the cause of this disease. Some think it may run in families. Others think it may come from aluminum or other metals in pots, pans and eating utensils.

In the early stage of the disease, the individual may be forgetful. They may forget where their car keys are. They may forget to turn the stove off. The person is not aware that they are getting forgetful. Later in the disease, the person may have poor judgment. They can also be confused and agitated. They may not be able to even speak and communicate with others with words.


The early signs of this disease are:

  • Forgetfulness about recent events. The person may remember when they got married 40 years ago but they may not be able to remember what they just ate for lunch.

  • Some trouble doing simple things. A person in the early stage may forget the steps to prepare a meal. They may forget how to wash the peas, for example.

  • Some trouble finding the correct word to say. They may not be able to use the correct word in a sentence. They may use the wrong word. This makes it difficult for others to understand what they are trying to say.

  • Forgetting what day it is. They may forget the date and even what day of the week it is. Calendars with the day of the week and date can help these people.

  • Forgetting where they are. Some may forget that they are in a nursing home. They may think they are still in their own home. They may forget how to get back home. Some can wander the streets. Others may forget that they were admitted to the nursing home a month before.

  • Poor judgment and a lack of common sense. Some may forget to turn the tea pot off until a fire starts. They may forget to watch the child they are baby sitting. They may drink bleach because they think that it is water. They may wander to dangerous places and do dangerous things. Some patients or residents may be fine during the day but become confused during the night hours. This is called 'sundowners syndrome'.

  • Lack of good thinking skills. They may forget how to take care of their checkbook or how to count change in the grocery store.

  • Putting things in the wrong place. A person in the early stage of this disease may put a pen in the freezer and ice cream in their clothes closet.

  • Personality and behavior changes. The patient or resident may be sad, cry, and be moody or angry. They may act nervous, confused or filled with fear. Some can get frustrated and not willing to wait for you to help them. They will act out on these feelings. For example, they may shout at other residents if they are angry. They may try to 'escape' the nursing home if they are afraid.

  • Lack of interest in other people and some things. People with early Alzheimer's disease may not want to be with other people. They may not want to do some of the things, like cooking, that they liked in the past.

  • Less able to learn new things as quickly as they did in the past. Some people with this disease need more time to learn and to understand new things. Nursing assistants and others must spend more time with them to learn new things.

  • Loss of physical ability. Some people lose their sense of balance and the ability to move and use objects, like a fork or spoon. They may need another person to tell them how to use everyday things.

The later signs of this disease are:

  • Loss of both short term and long term memory. Some patients with dementia may not know their own family members when they visit.

  • A lack of ability to perform some or all of the activities of daily living. Nursing assistants and other health care workers must help these patients meet their activity of daily living needs. Some residents and patients may have to be dressed, fed and cleaned.

  • A complete lack of ability to speak or communicate. Give these people the time they need to tell you what they want or need.

  • Disorientation to time, place and person. The person may not know what time of day it is. They may not know the day of the week or the current year. They may not know where they are. They may also not know who they are.

  • Very poor judgment and common sense. Some patients are a very big safety risk unless they are protected from harm by nursing assistants and other health care workers. They need a very safe environment to protect them against injury, harm and even death. Some become so confused that they are not able to make any health or financial decisions for themselves according to the law. It is their durable power of attorney and their 'living will' or advance directives that often guide the kind of care they will and will NOT get.

  • More severe personality and behavior changes. They may become very agitated, hostile, angry, aggressive or depressed. They can hurt others and they can hurt themselves. They may be paranoid, or 'hear' and 'see' things that are NOT real. Wandering and getting lost may be a very big safety problem.

  • Severe sleep disturbances. They may NOT sleep during the night. They may wake up VERY confused.

  • Loss of control over body functions. They may become not able to hold their urine and feces. They become incontinent.

  • Trouble swallowing and eating safely. They may cough, choke and push large amounts of another person's meal into their own mouth.

  • Loss of appetite and loss of weight. Unless they are fed and given fluids, they will get sick and even die.

Patients and residents with Alzheimer's disease can have problem behaviors that are disruptive, unacceptable and dangerous. These behaviors must be prevented and managed.


HOW CAN BEHAVIOR BE MANAGED?

The best way to manage disruptive, unacceptable and dangerous behavior is to prevent it. The best way to manage it is to stop it before it starts. The prevention of poor behavior needs the help of the whole team, including nursing assistants.

If a disruptive, unacceptable or dangerous behavior can't be prevented, the entire team must know how to keep all from harm. Managing and preventing poor behaviors increases the quality of life for all patients and residents. It also protects all from injury.

PREVENT disruptive, unacceptable or dangerous behaviors.

  • Know your patients and residents. Know what kinds of things lead to poor behavior. Know the things that help your patient to behave correctly. For example, give the patient a bath in the morning if they are less confused and agitated in the morning. A bath during the afternoon or evening may make this patient angry and resist care completely. Very often, poor behavior occurs while care is being given to a patient or resident. Try to calm a patient during care. If a patient is calm and happy sitting in a certain place for meals, do NOT make them move to another place unless they choose to. Keep things the same and keep things simple to prevent poor behavior. Know the best routine for the person and stick to it.

  • Know what triggers poor behavior and try to keep the person from these triggers. Eliminate all physical, emotional, environmental, communication and care triggers. Meet the person's needs so they do NOT react with disturbed behavior.

  • Give simple instructions and repeat instructions if needed.

  • Listen to the patient or resident. Many patients and residents will act out with poor behavior because they can't make their needs known. No one is listening to them. They may want or need something and no one can understand what they want. They will then get angry, aggressive and hostile to others. Spend time with your patient. Let them ask you questions. Help them tell you about their feelings. Help them tell you what they want. Use pictures if needed. Repeat back to them what you think they said or wanted to make sure you have really heard and understood them. Be clear and calm when communicating with these patients.

  • Observe your patients and how they act with others. If another easily annoys a patient, encourage both patients to go to a different place for an activity or event. Give them a healthy way to use their energy. If another resident keeps going into your patient's closet, ask them to leave and explain to them that this behavior is not acceptable. A lot of aggressive behavior happens when one person goes into another's private spaces, like their room. If your patient spits on another patient for no reason, talk with your patient and explain to them why this is wrong. Allow the patient to speak and encourage them to do something, like play a group game, rather than spit. Do not get upset if the patient forgets and spits again. Some need constant and short reminders several times a day.

  • Approach a very confused from the side and speak face to face. Speak slowly, calmly and use simple words. Ask simple 'yes', 'no' questions. NEVER argue with the person even when they are wrong. Try to distract the person to a new or different thought.

  • Keep the patient care area simple. Keep noise down. Make sure that there is enough light. Keep schedules and routines the same for people who act out when things are changed. Limit choices if needed. Some patients and residents get nervous and frustrated if they have too many choices. Encourage patients and residents to go to well supervised and structured activities if they are at risk for poor behavior when things are not structured. Also, many do better if they have the same people care for them each day. They may not do well with new people or in rooms with a lot of people. Keep stress low.

  • Keep the patient care area safe. Safety is VERY important. Bed alarms, alarms that ring when a wandering person tries to leave the building, an area without clutter and dangerous chemicals, like medicines and cleaning liquids, and very careful patient identification are some things that can be used to prevent injury to patients that are in danger of hurting self or others.

  • Try to re-direct wandering and other poor behaviors by making the person feel safe, secure and needed by others. Some nursing homes have wandering or exercise tracks so people can safely wander outside the building and in a big circle that ends in another entrance to the same building.

  • Help the person get the diet and fluid they need to function well and without poor behaviors

  • Keep your attention on the person and not the task. It is the person and how they are feeling that is important. If a person gets angry during an activity of daily living, break the task down into small parts. Encourage the person to be as independent as possible. Praise the person for their self care efforts. Some may be helped with a bowel and bladder training program or a prompted, scheduled voiding program.

  • Provide activities that meet the patients' and residents' needs and prevents poor behaviors. Clocks and a large calendar or poster with the day of the week, the date, the season and the day's weather often help to orient people to time and current reality. Other socialization and activity groups, like reality orientation groups, holiday parties and reminiscence groups are often helpful.

  • Alternate rest periods with activity. Tired patients may act out with behaviors that are disruptive, unacceptable or dangerous. Encourage sleep by keeping a regular bed time, having the person change into pajamas and providing a quiet environment. They may do best by also getting up at the same time each morning. Patients and residents also need a way to use their energy. Exercise groups are sometimes helpful.

  • Relieve stress. Promote relaxation and other things that lower stress. Pet therapy, music therapy and socialization or exercise groups can lower stress.

  • Report all patient changes to the nurse in charge. If a patient condition or behavior changes they may be at risk for acting out behaviors. Report all patient changes.

  • Attend classes and take courses, like this one, so you will always know how to prevent and manage poor behavior.

  • Be a team member. Follow the patient's behavior management plan of care. Everyone on the team must be consistent. They must all say and do the same things with the patient.

MANAGE disruptive, unacceptable or dangerous behaviors when they occur.

  • Stay calm, speak softly and show respect. If inappropriate, dangerous or disruptive behavior occurs, speak to the patient(s) calmly, slowly and with respect. Have them sit to chat. Sit next to them.

  • Stop the task you are doing.

  • Call for help if you need it.

  • Protect all the residents from injury. Use some basic self defense skills to protect yourself. Stay far enough away from a person so that they can't hit you. Try to sit the person down. Put a pillow on your chest if a person is trying to punch you in the chest. Do NOT fight back. Do NOT pull away if you are grabbed. Stay calm and talk with the person. Remove the person(s) from harm if your words and instructions do not stop the dangerous behavior.

  • Meet patient needs. If a person is making noise, find out if they are hungry, thirsty, wet, dirty, in pain, too hot, too cold or tired. Meet these needs. Feed the person that is hungry. Give water to the person who is thirsty, etc.

  • Safety. People that wander need special care. Make sure the area is safe and that the person who wanders can NOT get hurt. Listen to and respond to alarms on doors immediately. Try to get the wandering person into an activity, like exercise. Stay calm and let the person know that you are there to keep them safe. Patients and residents who try to leave and go home, can also be managed. Try to let them tell you why they are lonely or sad. Ask them to help you with a small task so they feel like they are important. Have them call a family member so they can feel safe. Some nursing homes use a tape recorded message from a family member so they are not called in the middle of the night. These things help the person feel safe and secure.

  • Report any disturbed behavior. What triggered the behavior? What happened? When time was it? Where did it happen? How long did the poor behavior continue? Was the behavior mild, moderate or very severe? Who else was involved? What did you do to stop the behavior? Did it work? What made the person return to normal behavior?


Summary

Preventing poor behavior and managing disturbed behavior takes a team effort. Some times the patient may get medications and psychological help to prevent disturbed behavior. But, most patients can be managed with a team that prevents poor behavior.

The nursing assistant is a very important member of the team’s effort. EVERYONE must report and communicate patient changes. EVERYONE must follow the plan of care. EVERYONE must prevent and manage disturbed behavior.

References

Abrams WB, Beers, MH and Berkow R. (2010). “Alzheimer’s Disease”. [online] http://www.merck.com/pubs/mmanual_ha/sec3/ch27/ch27b.html

Alzheimer's Association of Los Angeles. (1999). “California Workgroup on Guidelines for Alzheimer's Disease Management”.. [online] http://www.guideline.gov
 

Berman, Audrey, Shirlee Snyder, Barbara Kozier and Glenora Erb. (2010). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. 8th Edition. Pearson Prentice Hall.

Hall, GR. (1996). “Alzheimer's Disease and Chronic Dementing Illnesses. University of Iowa Gerontological Nursing Interventions Research Center”. [online] http://www.guideline.gov

Mayo Clinic Health Oasis. (2010). “Alzheimer's Disease”. [online] http://www.mayoclinic.com/health/alzheimers-disease/DS00161

National Institute on Aging and the National Institutes of Health. (2010). “Alzheimer's Disease”. [onlnie] http://www.nia.nih.gov/Alzheimers/AlzheimersInformation/GeneralInfo/

Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.

Wold, Gloria Hoffmann. (2008). Basic Geriatric Nursing. Elsevier Mosby.

Wyckoff, Rick, Linda Wyckoff and Katherine Heart. (2010). “The Case for Behavior Management”. [online] http://www.geroservices.com

 

Copyright © 2010 Alene Burke


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