Restraints

 

Your approval agency or organization requires you to take a test and self reflection is NOT an option.

A score of 80 % correct answers on a test is required to successfully complete any course and attain a certificate of completion.

Author:    Berthina Coleman (MD, BSN,RN)

Introduction

Restraints are any actions or devices healthcare workers use to restrict a patient’s freedom (Scheepmans et al., 2017). The doctor, or RN using protocols, who follows up with the doctor, decides to use physical restraints. It is never OK for a CNA or HHA to start restraints without direction from a higher-level professional.

Certain conditions may make restraint use necessary when caring for patients for their safety:

• Impaired decision making
• Increased dependency
• History of falls or patients at increased risk of falling and impaired mobility

Underlying conditions that may make restraint use necessary include:

• Psychiatric disease
• Alcohol or drug intoxication
• Low blood sugar
• Head trauma (Boyce et al., 2016).

Other methods of de-escalation should be tried when caring for agitated patients. De-escalation means taking action to try to keep the agitation from increasing. Restraints should be the last resort. Using restraints when caring for patients in healthcare can negatively affect patients and staff. Consequences can be physical, social and psychological.

Examples of physical consequences of restraint use include:

• Pressure ulcers
• Incontinence
• Bruising
• Physical injury up to death

Social consequences include:

• Isolation
• Feeling withdrawn

Psychological consequences include:

• Depression
• Anger
• Fear

Restraint use can negatively affect family members by evoking feelings of anger, worry and guilt. Healthcare workers can also be negatively impacted by their feelings of guilt (Boyce et al., 2016).

Joint Commission Requirements for Checking Patient Who are Restrained

The Joint Commission has stringent requirements for using restraints in the healthcare setting. State, hospital and facility policies usually define how often restrained patients are checked. They define how often the patient’s vital signs are taken. The policies also detail skin integrity, toileting, and range of motion rules. The restraints can and should be removed as soon as the patient is calm and quiet. However, staff should continue to monitor the patient carefully for both the patient’s safety and that of other patients and the staff (Boyce et al., 2016).

While restrained, patients must be watched closely. Some of the checkings may be delegated to the CNA or HHA.

Vital Signs

Vital Signs: Heart rate, blood pressure, temperature, oxygen saturation and respiratory rate.

Comfort

Patient comfort: skin chafing under and around the restraints, hydration, personal hygiene and toileting needs.

De-escalation Techniques

De-escalation techniques should be tried before restraints are used. There are 3 phases of escalating violence. They are:

1. Anxiety
2. Defensiveness
3. Physical aggression

These patterns of aggression are somewhat predictable. Developing violence can be identified before aggression takes place.

One technique is asking the patient, “how can we assist you?” This technique allows the healthcare worker to engage the patient while displaying compassion. Often this is sufficient to put an agitated patient at ease. Another technique is offering the patient food and drinks and helping with toileting if appropriate.

The goal is to treat the patient with dignity and empathy. If the patient continues to be agitated, untrained staff should immediately enlist the help of a trained staff member who can help defuse a potentially violent patient encounter. If the patient continues to be violent despite these efforts, facility security should be called to help keep the patient, staff and other patients safe. When security does arrive, they should gather at a safe distance but within the patient’s view. Sometimes a show of force is all that is required to calm the patient (Boyce et al., 2016).

Restraint Use in the Elderly

Safety in caring for the elderly sometimes requires the use of restraints. Overall, using restraints and restricting mobility in elderly people will result in loss of function in the long run (Dahlke et al., 2019).

Several things cause problems in safety when caring for elderly patients. These include:

• A lack of experience in caring for the elderly
• Mistaking functional decline in the elderly for a normal process of aging
• Lack of access to resources

Leaders at the institutional level must address organizational factors that increase the use of restraint; these may be poor staffing.

Types of Restraints:

Seclusion

Seclusion can be used in both inpatient units and specialized psychiatric units. It was used a lot in the 1980s, but its use has declined due to nursing staff shortages. In addition, most hospitals do not have space to provide seclusion to all patients who need it. Seclusion is a very effective technique for use in aggressive patients.

Note that seclusion can be combined with other forms of restraints, including physical or chemical restraints. Patients placed in seclusion must be reassessed as often as those placed in physical restraints (Kowalski, n.d.).

Limb Restraints

Physically restraining a patient’s limbs is the most common form of physical restraint. Limb restraints can be made from different materials, including leather and cotton. In general, restraints have to be comfortable, easy to apply, easy to remove and easy to clean. Of note, leather restraints are difficult to break or tear, but they are difficult to clean if they get soiled from bodily secretions. Sometimes hard leather restraints have a difficult application and removal processes relative to soft form restraints. Furthermore, that can be problematic when the patient is crashing in an acute setting. Leather limbs are usually reserved for combative and violent patients in whom the need for secure restraints is considered more important and worth the time it takes to apply or remove them (Kowalski, n.d.).

Soft Limb Restraints

Soft limb restraints are made from cotton or foam material, a single-use device. They are less rigid than hard restraints and are easier to apply. Soft restraints are reserved for patients who are agitated but are less aggressive. Soft limb restraints are less secure than hard leather restraints(Kowalski, n.d.). (Kowalski, n.d.). Four-point restraints are restraints on both arms and legs.

Fifth Point Restrains or Belts

Fifth-point restraints, or belts, are used as an adjunct to the four-point restraint. It functions by restricting the movement of the patient’s torso, pelvis or thighs. Fifth-point restraints are reserved for patients who continue to be dangerous to themselves or others while in a four-point restraint. It can also be used in patients whose behavior prohibits the medical staff from administering medically necessary care, including therapeutic interventions (Kowalski, n.d.).

Patients with a 5-point restraint are at increased risk of aspiration because they cannot turn to their sides if they start vomiting. Also, note that the 5-point restraint must be applied tight enough to prevent the risk of accidental suffocation in case the patient tries to slip under the restraint. These restraints usually require quick-release locks in an emergency (Kowalski, n.d.).

Jackets and Vests

Jacket and vest restraints are reserved for inpatients or patients in longer-term facilities. There are reports of death with the use of jackets or vests related to choking and suffocation (Kowalski, n.d.). In general, jackets and vests are rarely used in emergencies (Kowalski, n.d.).

Leg Restraints

Leg restraints are used in the transportation of patients. Leg restraints are limited in the inpatient or emergency setting (Kowalski, n.d.).

Why Restraints are Used

Restraints prevent agitated or violent patients from harming themselves, other patients or staff members. Restraints should only be used as a last resort after de-escalation techniques have failed. Patients who are noted to be an immediate danger to themselves or others should be promptly restrained without delay.

Patients may need to be restrained to receive life-saving medical care. For example, patients who are intubated and or patients who are sedated and require life-saving treatment.

In addition, patients at risk for elopement (escaping) may also be restrained in very specific circumstances.

Restraints should not be used when de-escalation techniques are adequate. Restraints should not be used on broken limbs, open wounds or skin infections. Also, restraints should be used cautiously in patients with poor vascular circulation. Fifth-point restraints should be avoided in patients with ostomies, feeding tubes, pelvic fractures or multiple rib fractures. Finally, patients with severe pulmonary or cardiovascular disease may not tolerate the presence of a fifth-point restraint over their chest.

How to Apply Restraints

Restraints should be applied rapidly and safely by personnel who are trained in the application of restraints. The restraints must be tied to a non-moving part of the bed frame out of the patient’s reach. A slip knot must be used so that restraints can be untied quickly.

When applying restraints to an actively violent patient, a team of five members is recommended, one team leader and one individual for each limb. Occasionally the presence of multiple team members will be enough to subdue the patient with the need to apply restraints. The patient and family members must be educated about why the restraints are being applied. Also, they should always get clear instructions on the entire procedure.

Problems from Restraint Use

Increased agitation can prevent good communication (Boyce et al., 2016).

Local skin breakdown: physically restricting the patient can prevent them from repositioning and moving. This restriction increases the risk of developing pressure ulcers.

Blood flow problems: If restraints are applied too tight, there is an increased risk of restricting blood flow to a limb.

Breathing problems: Patients with moderate to severe respiratory disease are at risk for breathing problems. For example, a patient with severe obstructive lung disease is at increased risk of respiratory failure if they are in a vest restrained or if they receive certain medication. Tied flat patients cannot easily move to throw up or spit.

That liquid might be sucked back into the lungs, causing pneumonia.

Heart problems: Patients with severe congestive heart failure may be unable to lay flat. If restrained and forced to lay flat, they may be at increased risk of heart and respiratory problems.

Case Study

You are working with a patient in four-point restraints. You are required to toilet the patient every hour while awake. When you re-tie the restraints, you check the tightness to be sure the blood flow is not cut off. If you do not check, a restraint that is too tight can cut off blood flow to the hand or foot. This cutting off blood flow could cause the patient to lose the use of the hand or have to remove the hand.

Summary

Healthcare workers are responsible for caring for patients even when they cannot make appropriate decisions for themselves. At times, ensuring a patient’s safety and the safety of others will require the use of restraints. If necessary, workers must provide compassionate care that follows state, federal and institutional policy.

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References

• Scheepmans K, Casterlé BDD, Paquay L, Milisen K. Restraint use in older adults in-home care: A systematic review. International Journal of Nursing Studies. 2018;79:122-136. doi:10.1016/j.ijnurstu.2017.11.008.
• Boyce SH, Stevenson RJ, Cline DM. Prison Medicine. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. McGraw-Hill, New York, NY; 2016.
• Dahlke SA, Hunter KF, Negrin K. Nursing practice with hospitalized older people: Safety and harm. International Journal of Older People Nursing. 2019;14(1). doi:10.1111/opn.12220.
• Kowalski JM. Physical and Chemical Restraint. In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 3rd ed.; 1481-1498.

SEIZURES

 

1. A seizure is a muscular disorder characterized by jerky movements.

(Correct)

2. The cause of seizure varies by age and underlying conditions that may be present.

(Correct)

3. When neurons in the brain fire abnormally, an electrical discharge can cause a reaction in the body known as a seizure.

(Correct)

4. Seizures are classified by Focal and Generalizable.

(Correct)

5. An aura happens during all seizure.

(Correct)

6. The Ictal Phase is the actual seizure occurring.

(Correct)

7. Sometimes a patient is able to state that a seizure is about to happen.

(Correct)

8. In a tonic-clonic seizure, the patient will lose consciousness and experience jerking of limbs.

(Correct)

Your approval agency or organization requires you to take a test and self reflection is NOT an option.

A score of 80 % correct answers on a test is required to successfully complete any course and attain a certificate of completion.

Author:    Kelley Madick (MSN/ED, PMHNP)

Introduction

A seizure is a neurological disorder that affects any age, gender, race or socioeconomic status. Health care providers will most likely be exposed to a patient with seizures or one who is at risk for seizures. The causes for seizures can vary by age although, there is strong evidence to suggest a genetic link (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). In child neurology, seizures are the most common disorder found (Grossman & Porth, 2014). In patients under 20 years of age, the causes of seizures can be from injury, trauma, or genetic disorders (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). In 20 to 30-year-olds, causes of seizures can be trauma or brain and cardiac disorders (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). For patients over 50, the seizures usually stem from stroke, and brain disorders such as tumors (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Seizures can occur across the lifespan and present with several different symptoms. A knowledgeable health care provider can help patients with a seizure condition live a productive life. 

What is a Seizure?

There are several theories as to the actual mechanism that happens in the brain for a seizure to occur. A seizure appears to happen because of the abnormal firing of neurons in the brain that spread throughout the body. When seizures are reoccurring, the person may be diagnosed with epilepsy. In the US, over five million children and adults suffer from epilepsy (“Epilepsy Fast Fact,” 2016).

A seizure happens when neurons in the brain fire abnormally. This electrical discharge causes a chain reaction throughout the body which can cause involuntary movements (Grossman & Porth, 2014). The movements caused by the abnormal firing of the neurons can be seen as a sensory, motor, autonomic, or a psychiatric event. In other words, the involuntary movements can be in any body part or the seizure can be associated with a smell, taste or vision problem. A seizure can occur due to any serious illness or injury where the brain is affected. This can include metabolic disorders, infections, drug abuse, cerebrovascular problems, or brain injuries. However, a seizure can also be due to an emotional response to a stimulus.

Seizures are classified by the International League Against Epilepsy into general and focal. The type of seizure is determined by where the seizure is starting in the brain (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).  Depending on the type of seizure, the patient may move through several phases (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014):

• The prodromal phase gives the patient a feeling that a seizure is about to happen. This may be described as a sense of something about to happen.
• The aural phase is a sensory warning before a seizure such as smell, sweating or seeing a bright light.
• The ictal phase is the actual seizure occurring
• The postictal phase is the recovery or post-seizure phase.

Although each phase does not always occur in every type of seizure, the health care provider can educate the patient on the phases and assist the patient through the phases that do occur.

Focal Seizures

Focal seizures begin in a specific part of the brain and are the most common type of seizure (Trinka et al., 2015). Patients can be aware of a focal seizure, which is called a focal seizure, without impairment or awareness (Grossman & Porth, 2014). This means that the seizure occurs with the patient being aware of what is happening. Often these patients will say they know the seizure is coming. This sensation is the prodromal or aural phase (Grossman & Porth, 2014). The patient may have a sudden flood of emotions such as joy or anger. They may also report hearing, smelling or tasting something that is not really there (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).

A focal seizure can also occur with impairment of awareness (Grossman & Porth, 2014). In this type of seizure, the patient will lose consciousness and does not remember the seizure (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). The seizure may begin locally but can progress throughout the brain and body. Often times, there will be repetitive, not purposeful, movements such as lip-smacking, rubbing of clothing, or grimacing (Grossman & Porth, 2014). The patient may exhibit confusion, hallucinations, uncontrollable fear, a flood of ideas, or seem to be daydreaming (Grossman & Porth, 2014). Often the seizures will progress to tonic-clonic seizure activity. Typically, these patients do not have a warning or aura phase as in the focal seizures without impairment in awareness.

Focal seizures begin in a specific part of the brain and are the most common type of seizure (Trinka et al., 2015). Patients can be aware of a focal seizure, which is called a focal seizure, without impairment or awareness (Grossman & Porth, 2014). This means that the seizure occurs with the patient being aware of what is happening. Often these patients will say they know the seizure is coming. This sensation is the prodromal or aural phase (Grossman & Porth, 2014). The patient may have a sudden flood of emotions such as joy or anger. They may also report hearing, smelling or tasting something that is not really there (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).

A focal seizure can also occur with impairment of awareness (Grossman & Porth, 2014). In this type of seizure, the patient will lose consciousness and does not remember the seizure (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). The seizure may begin locally but can progress throughout the brain and body. Often times, there will be repetitive, not purposeful, movements such as lip-smacking, rubbing of clothing, or grimacing (Grossman & Porth, 2014). The patient may exhibit confusion, hallucinations, uncontrollable fear, a flood of ideas, or seem to be daydreaming (Grossman & Porth, 2014). Often the seizures will progress to tonic-clonic seizure activity. Typically, these patients do not have a warning or aura phase as in the focal seizures without impairment in awareness.

Generalized Seizures

Generalized seizures happen when both hemispheres of the brain are involved (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Typically, these patients will lose consciousness and exhibit body and limb movement during the seizure. However, there are types of generalized seizures that involve only a brief episode of altered consciousness, repetitious movements, or lack of muscle tone. Generalized seizure activity tends to be varied due to more brain involvement. These seizures are further divided into six categories: tonic-clonic, absence, myoclonic, clonic, tonic and atonic (Trinka et al., 2015).

A tonic-clonic seizure, formally known as a grand mal seizure, is the most common type of generalized seizures. The patient will experience a loss of consciousness, contraction of the muscle group (tonic) for a short period then jerking of the extremities (clonic). The patient may also show signs of cyanosis due to the muscles of the respiratory system contracting, incontinence, tongue biting, and excessive salivation (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Seizures of this type usually last 60 to 90 seconds (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). The patient may be exhausted and sleep for hours afterward. They may not feel normal for several days and have no memory of the seizure (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).

Absence seizures are non-convulsive events. These were formally referred to as petite mal seizures. These typically occur in children and rarely continue beyond adolescence. (Grossman & Porth, 2014). Absence seizures are characterized as a blank stare, motionless, and unresponsiveness. However, there can be motion in areas such as lip-smacking, eyelids, or lack of postural tone. The seizures typically last only a few seconds and then the child is able to resume normal activity (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Sometimes the seizures are very subtle and may even go unnoticed. The child may complain of seeing flashes of light or may hyperventilate (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). They may also appear to be daydreaming. Although the seizures do not last long, if untreated, may occur up to 100 times a day (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).

Myoclonic seizures are brief muscle contractions. They are seen as bilateral jerking of muscles typically of the face, trunk, or one or more extremities (Grossman & Porth, 2014). Sudden and excessive jerk of the body and extremities can be seen. These seizures can also happen in clusters and can progress to tonic-clonic seizures (Grossman & Porth, 2014).

Clonic seizures typically begin with a loss of consciousness and sudden hypotonia. The seizure is then seen as limb jerking that may not be symmetrical (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).

Tonic seizures are seen as sudden onset of increased tone which is held typically in extensor muscles. These seizures are often associated with falling (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).

Atonic seizure is the sudden split-second loss of muscle tone leading to a slackening of the jaw, drooping of the eye, or falling on the ground (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). The seizures are also known as drop attacks. They tend to start suddenly and the patient loses consciousness. However, consciousness returns usually as a person is falling. They can resume normal activity immediately (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).

Impact on lifestyle

Patients with seizures usually cannot drive and have difficulty finding employment. Independence of the patient is an issue that can lead to depression and anxiety. Community resources and services can help the patient maintain a productive life(“Managing my seizures 101,” 2014). The caregiver can help the patient express their feelings and find alternative methods to maintain daily activities.

Patients and parents of children who have seizures experience stress, fear, and possibly psychological comorbidities such as anxiety and depression (Wu, Follansbee-Junger, Rausch, & Modi, 2014). Children may have problems in school and socializing with their peers. The caregiver of a child with seizures or epilepsy may suffer from fear of their child being stigmatized and from significant family stress related to their child’s well-being (Wu, Follansbee-Junger, Rausch, & Modi, 2014). A caregiver can help connect the parents with resources and help alleviate fears by allowing them to express their feelings.

What Can The CNA Do to Help?

The overall goals are to keep the patient safe, free from injury, and maintain daily activities.

Help the family and the patient express their feelings about the disorder. There may be stigmatism concerns or anxiety about the next seizure. Help the family or patient seek out community resources to aid in daily activities such as getting to the store or appointments. Make sure the patient or the caregiver can identify any signs that may indicate an impending seizure and what to do if a seizure occurs.

The risk of injury and trauma during a seizure is a concern. Be sure they understand to move furniture or objects away from the patient when a seizure occurs. Educate the patient and caregiver on the possibility of falls and breathing problems during a seizure. If the patient has a medical bracelet, ask that they wear it when in public. Preparing the patient and the caregiver for seizures can help decrease the likelihood of injuries.

Most patients with seizures are taking one or more medications. Review signs of toxicity or adverse reactions that may occur. Adverse reactions can include, lethargy, confusion, sleep problems, slurred speech, nausea, vomiting, diarrhea or vision problems. Poor hand and gait coordination, lowered cognitive functioning, and decrease general alertness may also be signs of a problem. If any of these signs occur, report them to the nurse.

Make sure the patient or caregiver understands the treatment regimen. Some patients require blood work to be done regularly to monitor the levels of medication in their bloodstream. Ask if the patient is getting blood work done regularly and when the last blood draw occurred.

Ask the patient about their daily routine. The patient needs to stay hydrated, eat well and take all medications as prescribed. Be sure to remind them to avoid alcohol and drugs.

Observe for any signs that a seizure has occurred. This can be seen as an abnormal respiratory rate, bitten tongue or cheek, cyanosis, high blood pressure, incontinence, or weakness. Report any findings to the nurse.

What if The Patient has a Seizure While I am There?

Some patients know that a seizure is coming. They may report a flashing light. Sweating, flushing, dilated pupils, altered level of consciousness, or a dream-like state may be observed as well. A blank stare or eyes rolling to the back of the head may also signal an absence seizure. Brief involuntary muscle jerks may signal a myoclonic seizure. A tonic-clonic seizure may be signaled by sudden body stiffening then the relaxation of muscles, labored breathing, cyanosis, tongue biting, or incontinence. After a seizure, particularly a tonic-clonic seizure, the patient may be drowsy, weak, confused, have difficulty talking, complain of headaches or muscle aches (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).

Note the time the seizure started and when it stopped. If it has been determined the patient about to have a seizure, help them to the floor if they are standing, loosen constrictive clothing, and do not restrain them. Call for help. Move furniture or objects away from the patient. Do not put any objects in their mouth but you may try to hold the patient’s head for support or place something soft beneath their head. Once the seizure is over, turn them on their side to prevent choking. Report the incident immediately to the nurse. Make the patient comfortable. They may be embarrassed and tired (Pulliam, 2012; Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Comfort them and assure them they are safe and help is on the way.

What to Report to the Nurse

Immediately report any seizure activity (Pulliam, 2012). The report should include how long the seizure lasted, description or type of seizure, and if any injury occurred. If the patient reported any aura or if you observed any changes in the patient before the seizure happened, be sure to tell the nurse. Report vital signs and if the patient is resting comfortably after the seizure. If the patient was transported to the hospital, be sure to report the name of the hospital.

Also, report any adverse reactions to medication. Discuss any concerns the patient or caregiver has regarding the medication regiment. Report any observations you may make while with the patient that is different from their baseline. This may include the level of consciousness, gait changes, increased seizure activity, changes in vital signs, or changes in physical appearance (Pulliam, 2012).

Conclusion

Seizures can have a devastating effect on a person’s life and activities. Stigma, anxiety, and fear can be an issue and cause the patient to develop unhealthy activities. The CNA can provide care by understanding the different types of seizures, and the impact this disorder can have on the patient and the family. Remaining open to discussion and encouraging expression of their concern can help the patient and the family cope with this disorder. Also, understanding how to keep a patient safe during a seizure and caring for the patient afterward are important skills to know when working with patients. Supporting the patient and the family can decrease their concerns and fears as well as promote productive functioning of daily activities. 

CASE ONE:

Mrs. Johnson is a 72-year-old female with a history of absence seizures and has recently been diagnosed with epilepsy. She currently lives with her husband who has been taking care of her. Recently, Mrs. Johnson has had several new tonic-clonic seizures. You have been assigned as her new home health caregiver. Upon entering the home, Mrs. Johnson’s husband rushes over to you and tells you his wife is having a bad seizure. When you enter the room, you find Mrs. Johnson on the floor in a clonic reaction. What should you do first? What are the other steps you need to take?

First, call for help. If possible, ask Mr. Johnson to help you move objects away from her to help keep her safe. Either hold her head in your lap or place a towel or something similar under her head. Loosen clothing, especially around her throat. Be sure to observe the time you found her and the time when the seizure stopped. Obtain vital signs and sit with Mrs. Johnson keeping her comfortable until help arrives. Call your nurse and report the incident.

CASE TWO:

Mr. Smith is a 50-year-old male who has been recently discharged from the hospital due to a car accident. You are in the home for a follow-up visit.  His wife is with him. She tells you that her husband has been acting oddly. She tells you he seems disoriented at times; he will smack his lips and grimaces for several minutes. She tells you he seems confused as well. Mr. Smith tells you his wife is imagining things. He feels fine. What is happening with Mr. Smith and why? What are your next steps?

Mr. Smith may be having focal seizures. This can sometimes happen in adults after a trauma has occurred. The injured area of the brain has neurons that are firing abnormally. This causes a chain reaction throughout the body which can cause seizures to occur.

Write down what Mrs. Johnson has reported. You will also want to include what Mr. Johnson has said as well. Obtain vital signs and observe for any injuries including tongue or cheek biting. Review Mr. Johnson’s medications and when he takes each one. You will also ask if he is sleeping well, if he is eating, and getting enough fluid. You can educate both Mr. and Mrs. Johnson on seizures. There are types of seizures where the patient is not aware they are having a seizure and are able to resume their daily activity immediately. This type of seizure still needs to be monitored and treated. Education of when to seek help and if community resources are available will be helpful to Mr. and Mrs. Johnson

Your approval agency or organization requires you to take the test.

References

Epilepsy Fast Facts. (2016). Retrieved April 17, 2016. (Visit Source)

Grossman, S., & Porth, C. (2014). Porth’s pathophysiology: Concepts of altered health states (9th ed.). United States: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M. M., Bucher, L., & Harding, M. (2014). Medical-surgical nursing: Assessment and management of clinical problems, single volume / edition 9 (9th ed.). Philadelphia, PA: Elsevier Health Sciences.

Managing my seizures 101. (2014, October ). Retrieved April 16, 2016. (Visit Source)

National Stroke Association. (2015, November 16). Seizures and epilepsy. Retrieved April 17, 2016. (Visit Source)

Pulliam, J. (2012). The nursing assistant: Acute, Subacute, and long-term care (5th ed.). United States: Prentice Hall.

Trinka, E., Cock, H., Hesdorffer, D., Rossetti, A. O., Scheffer, I. E., Shinnar, S., ... & Lowenstein, D. H. (2015). A definition and classification of status epilepticus–Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia, 56(10), 1515-1523.

Wu, Y. P., Follansbee-Junger, K., Rausch, J., & Modi, A. (2014). Parent and family stress factors predict health-related quality in pediatric patients with new-onset epilepsy. Epilepsia, 55(6), 866-877.

OCD

 

Case Study I

Mary works as an administrative assistant to a company CEO. She is known for being meticulous at her work and very organized. She makes sure the CEO’s office and the waiting room are perfectly put together. “Everything is in its place,” she says. Everyone who enters the office must use hand sanitizer before they can approach her desk. She becomes visibly upset when someone walks in and does not “clean” themselves first.

Jack is a college student. He does not have many friends, as his routine will not allow for usual things college students do. He walks the same path every day to his classes and counts the steps there and back to his dorm. He has his meals at designated times and wears certain clothes on particular days of the week. His mother tells him he is very predictable, but he likes it that way. One day on his way to class, the sidewalk was torn up to repair a water pipe. He was so upset that he could not continue to class and instead walked back to his dorm and paced the rest of the day.

Mary and Jack suffer from what is called obsessive-compulsive disorder or OCD. OCD is a common and very disabling disorder. It is characterized by uncontrollable thoughts, the obsession and repetitive behaviors, the compulsion (APA, 2013). The behaviors are an attempt to alleviate the anxiety caused by the thoughts or obsessions.

How Common is OCD?

Once thought to be a rare disorder, obsessive-compulsive disorder is now known to be one of the most common mental health disorders. Just under 2% of the population have OCD (NIMH, 2016). In fact, according to the World Health Organization, OCD is one of the highest ranked disorders for disability worldwide for ages 15-44 (WHO, 2001; Kessler, et al, 2012). OCD symptoms can vary in degree, type, frequency, and severity. Unfortunately, the cause of OCD is not well known. It is suggested that OCD is caused by both genetic and environmental factors (Markarian et al, 2010). There are some studies, according to the National Institute of Health (2016), that have identified serotonin issues.  

Other studies have linked female hormone fluctuation with OCD (Pinkerton,2010). Still more studies have suggested links between OCD and rheumatic fever that involves the body’s immune response possibly affecting the central nervous system (Murphy, Kurlan, & Leckm

an, 2010). Typically, a person with OCD also has other disorders or co-morbidities such as anxiety, mood disorders or another mental health issues.

It is estimated that OCD affects roughly 2.2 million Americans in any given year (Kessler et al 2012). OCD affects men and women equally, and the prevalence seems to be similar across all races and ethnicities (Grohol, 2015). The median age of onset is 19 (NIMH, 2016). Younger onset seems to be associated with more severe symptoms and higher rates of comorbidities including ADHD, Tic disorder, and anxiety disorders (Mancebo, et al, 2014).

OCD has a significant effect on daily activities including work, school, and personal relationships (Markarian, et al, 2010). Patients typically report issues with their family life leisure activities and friendships. They may also avoid social situations recognizing the increased anxiety. Carrying out the compulsive acts is extremely time-consuming and interferes with other normal activities. Some studies have linked severity of OCD to a decreased quality of life (NIMH, 2016).

Symptoms of OCD

The first thing to note is that OCD tends to come and go. Although OCD was previously considered an anxiety disorder, it is now classified in the DSM-5 as a disorder on its own, separate from anxiety (APA,2013). OCD involves obsessions and or compulsions that cause anxiety and interfere with functioning. Typically, the person has obsessive thoughts that are only relieved by specific actions or compulsions. People with OCD are generally aware of their obsession and compulsions occurring and that they are unreasonable, which causes more anxiety. Think of this as the brain not able to turn off.

According to the DSM 5, OCD has four criteria (APA, 2013). First is the presence of either obsessions or compulsions. Obsessions are re-current persistent thoughts, urges, or images that are intrusive and unwanted and cause distress to the individual (Nichols, 2015). The person tries to ignore or suppress the obsessions or stop them with specific actions. 

The second criteria are the compulsions which are repetitive behaviors that the person feels driven to do in response to the obsessive thoughts. The person believes these rules are very strict and must be done to alleviate the thoughts (Nichols, 2015). The acts are done to relieve or reduce anxiety or prevent a bad situation from happening. However, the acts are not a realistic way to stop the anxiety. Third, the obsessions and compulsions must interfere with daily life to be considered a diagnosis (APA, 2013). Finally, the acts must take up more than an hour per day and interfere with functioning (APA, 2013).

Some common themes for obsessions include germs, dirt, contracting a disease, making a mistake, religion, causing harm to others or sexual in nature (Nichols, 2015). Common compulsions include cleaning, washing hands, checking a task, counting, arranging objects, making lists, or repeating words or phrases (Nichols, 2015). Patients may have multiple thoughts and multiple compulsions usually fitting into one theme.

An example is:

Theme: Germs

Obsession: Not wanting to be touched due to fear of getting sick from germs.

Compulsion: Excessive handwashing especially when touching things. May have to wash hands a certain number of times a day.

Rumination may also be mental compulsion. Ruminations or excessive thoughts also occur in OCD and usually center around past events or self-worth (Darr & Iqbal, 2015). A rumination is simply a train of thought that is undirected and does not lead to a solution. Ruminations typically revolve around religion, philosophy, or metaphysical topics such as death or mortality (OCD-UK, 2015). An example is the person questions what the meaning of religion is. They think about all the theoretical possibilities, philosophies and scientific studies about religion. The person would dwell on this thought for long periods of time. They would appear preoccupied and distracted.

Normal Versus Abnormal; What to report

Although normal routines and rituals are a part of everyday life, for someone who suffers from OCD the rituals and routine does not have a purpose and can be harmful. It is important to assess if the obsessions are aggressive or violent in any way. If the patient has thought to hurt themselves or others or the compulsions are violent acts, the nurse needs to have a full report. Also if the patient begins to describe hopelessness or panic is observed, it is also important to tell the nurse. If the obsession or compulsions will not stop and it appears that the patient is becoming more agitated and unable to control the thoughts and acts, the nurse will need a full report. Be sure to report the content of the thoughts or obsession as well as what acts are carried out. Note if there is a pattern to the compulsions or thoughts (Clark, 2015). Also notice the mood or affect as well as appearance and gestures. Take note of how the client reacts and interacts with patients and staff. Nonverbal body language also speaks to how the person is feeling and if the patient is becoming agitated or not (Clark, 2015). For example, if the patient is stating they are fine but they are pacing and wringing their hands, they are probably becoming agitated. It is important to intervene with the nurse at the beginning stages of agitation to keep the patient and others safe.

If the patient becomes increasingly agitated or violent, including verbalizing aggressive thoughts or actions, make sure you remain calm, speak slowly, softly, and call for help (Hegner, Acello & Caldwell, 2009). Monitor body language of yourself and the patient. For example, do not put your hands on your hips as that may be taken as a challenge. Position yourself at a right angle to the person. Do not stand directly in front of them. Maintain a distance of 3 to 6 feet when possible (Hegnar, Acello & Caldwell, 2009). Avoid sudden movements. And make sure that the exit is accessible. Do not let the person come between you and the door. Listen to what the person is saying so that you can report it to the nurse. Acknowledge that you understand that the patient is upset. Never argue or become defensive.

How to Work with a Patient with OCD

When working with the patient suffers from OCD remember that you are playing an important role in their daily functioning. Supporting the patient by helping them manage anxiety, obsessions, and compulsions is important as well as helping them find solutions to decrease anxiety and triggers. If there are triggers, attempt to identify and remove the triggers in the patient’s environment (Hegner, Acello, & Caldwell, 2009).

First, acknowledge the patient’s anxiety, rituals, and compulsions without judging them. Usually, a patient with OCD has a great deal of shame about their condition. Approached the patient calmly and slowly. Never show shock, or criticism of their behaviors. Let the patient know that you are aware of their anxiety. For example, you might say “I notice that you had to turn the light switch on and off three times today. That must be exhausting.” This will help to establish trust and build a therapeutic relationship (RNspeak, 2012). Also reflecting the client’s feelings can reduce the anxiety the patient feels. If the patient needs to act out their compulsion allow them to do so as long as it is safe. Not allowing the patient to act on their compulsion can cause increased anxiety and even panic. Encouraging the patient to talk about why they have to do the behavior and what it means, can also help them to relieve anxiety (RNspeak, 2012).

You might suggest a diversional activity such as singing or drawing to help move attention away from the unwanted thoughts. If possible, engage the patient in groups to distract them. Planned activities such as groups or other activities that require concentration, can help to relieve anxiety. Also assess the patient’s needs carefully. For example, do they need to rest or do an activity that is less strenuous? Monitor the patient’s eating habits and drinking habits making sure they are hydrated and have the nutrition they need. In addition, make sure they are using the bathroom and are cleaning themselves using a shower or bed bath.

Focus on the patient’s strengths when planning care. Remember that all behaviors have meaning and are meeting the needs of that person; be accepting. Help the patient set limits for themselves suggesting alternate activities or expression of feelings. Remember that the therapeutic relationship and communication is one of the most important interventions to offer. Also, be an attentive and active listener. Identify the patient’s feelings and level of anxiety while they are completing compulsive task or having intrusive thoughts. Report to the nurse any harmful thoughts or the inability to control themselves.

These patients will most likely be on medications to help control their disorder. Be aware of side effects and try to help keep the patient comfortable. Most of the side effects will disappear after a few weeks. The patient may complain of nausea, insomnia, dry mouth, headache, diarrhea or agitation (Kizior & Hodgson, 2015). Make sure the patient is eating well and getting the fluids they need. If agitation is seen, attempt to distract the patient with tasks or an activity that requires concentration. For insomnia, a quiet relaxing environment can help. Also, make sure the patient does not drink caffeine later in the day (Mayo Clinic, 2013). Be sure to tell the nurse of any side effects you notice.

Let’s Review

Obsessive Compulsive disorder is a debilitating disease that impacts the persons daily functioning. Typically the patient exhibits uncontrollable obsessive thought or ruminations about a particular topic. They then try to relieve the thoughts by completing an act or a compulsion. Although the act may or may not temporarily relieve the obsessive thoughts, it is important, as a caregiver, to understand and be patient. The patient is aware of their thoughts and acts and may be shameful or frustrated. Never attempt to stop them from completing the act and never argue with them. Chances are there is a treatment plan in place to limit the compulsive acts or distract the patient. Be sure to follow the treatment plan to help the patent overcome anxiety and symptoms. Be aware of any excessive activity or harmful thought to report to the nurse. 

Case Study II

Mr. J has been assigned as your patient today. In the report, you are told he has been acting oddly since being admitted yesterday. You are told he likes to count things and gets agitated when he is not allowed to finish counting. As you walk into the room to introduce yourself, you notice he has his finger in the air moving it as though he is counting something. You stay in the door for a minute then walk toward him smiling. “Hello, Mr. J” you say watching him closely. When he does not respond, you begin to observe that he has not washed recently, and his gown is stained. You assume that his bed sheets also have not been changed, as they are wrinkled and dirty. Mr. J still does not respond to you.  You also notice that his tray of eggs and juice are untouched. “Mr. J,” you try again, “I am your nursing assistant today, Jenny. Can I get you something else for breakfast?” Mr. J stops what he is doing and turns to you. Angrily he yells, “No, get out now! Get out!” Mr. J picks up the cup of juice and throws it at you.  What do you do?

First assess the environment and make sure that Mr. J is safe and not a danger to himself.  Make a mental note of his appearance, his actions and how he reacted to you. Next, find the nurse and report your observations. “Should I have allowed Mr. J to continue counting? What if it took all day?” you ask the nurse. The nurse tells you that Mr. J suffers from Obsessive Compulsive Disorder. She tells you that patience and communication are very important when working with Mr. J. Along with the nurse, you come up with a plan of care for Mr. J.

The first plan is to try some distraction. Upon your suggestion that Mr. J needs to wash and get on some clean clothes, the nurse suggests that you try giving Mr. J a washcloth if he will not move into the bathroom. Ask him to wash his face with five strokes, his arms and legs with five strokes each. Since he threw something, it might be a good idea to keep the tub of water away from him. You can rinse the washcloth when needed.  Since Mr. J likes to count, see if he will go to the common room where there are puzzle pieces for him to count. He may want to count the steps to the common room, and that is ok. Perhaps if he will calm down, he can attend a group today where he can concentrate on something else. Once he is settled in the common room, you can attend to his bedding.

You feel that this is a good plan and start working with Mr. J, remembering what the nurse told you about being patient with him. You understand his disorder better after talking more with the nurse, and feel you can work with Mr. J to get him to the common room where he calmed down and participated in the groups.

Your approval agency or organization requires you to take the test.

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