Dealing With Difficult Patients Translation of Evidence and Best Practice Research Paper

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Difficult Patients

Mitigating Risks from Dementia

Providing adequate care for an individual suffering from dementia presents many difficulties for nurses. Patients with dementia often have debilitating conditions such as Alzheimer's or similar neurologic diseases which are progressive, thereby making it challenging for them to remember, think lucidly, communicate effectively or complete activities of daily living. Furthermore, dementia can cause rapid variations in mood or even modify personality and behavior. With the tremendous number of elderly in society more and more nurses are required to care for patients with progressive dementias. It is imperative that a diagnosis be reached early in the course of the cognitive impairment and that the patient is closely monitored for coexisting morbidities. Nurses have a central role in assessment and management of individuals with progressive dementia. This essay provides some evidence-based practical strategies for managing the behavioral problems and communication difficulties often encountered in this population.

I currently work as a nurse practitioner for a non-profit hospice inpatient facility with 36 beds in Cape Coral, Florida. On a daily basis staff must tackle issues related to difficult patients. Patient are often angry, sad, emotional and sometimes delirious and in cases with severe dementia can become combative. This forces nursing staff to be cognizant of these critical issues in order to avoid injury to staff and patients and to calm patients in distress. All medical staff at the facility is required to undergo training in dealing with difficult patients. Recently, the number of occurrences has increased dealing with injury to staff and complaints from patients. This has unfortunately led to an uptick in worker's compensation claims as staff struggle to effectively manage these patients while also being compensated for the risk involved. The key issue to be learned from my personal experience is that when dealing with problematic patients having the correct approach can help mitigate obstacles when dealing with one's patients.

Dementia is a mental state defined as a progressive deterioration in mental and physical state, a decrease in function and an increasing in the need for assistance to complete daily tasks. Individuals with this condition often have co-existing medical conditions close observation and which can impact the course of their dementia's progression. Beyond physical illness, factors such as a change of scenery and medical interventions are known to worsen the symptoms of dementia. This work will examine appropriate plans of care and treatment to manage this condition during the patient's residence in a nursing home. Nursing care should be patient-centered and strive to recognize the patient's uniqueness as well as their particular needs. Nurses should regularly and repeatedly explain the diagnosis to the older person and any family while giving relevant information about sources of help and support. During the course of a patient's stay in a nursing home, when behavioral problems occur, non-pharmacological management strategies should be sought first. Many elderly patients with dementia do not require sedation and sedatives may cause worsened delirium and increase the risk of falls. Antipsychotic drugs should be reserved for more serious problems, such as delusions and hallucinations, serious distress or agitation (Fletcher and Zimmerman, 2010).

Principles of dementia care

People with dementia and their care givers often have many needs and problems. Rather than highlighting all the possible areas of need and the numerous problems that could be encountered, it is often more useful to think of guiding principles, such as the following practice guidelines based on a variety of scholarly sources (Goodman, 2011; Kuske, et al. 2009):

Principle 1: People with dementia have the same human value as anyone else, irrespective of their degree of disability or dependence. This means recognizing the status and worth of people with dementia. People with dementia should therefore: Always be listened to; not be abused physically, psychologically or socially; be spoken to kindly, as one would expect to address a respected member of society.

Principle 2: People with dementia have the same varied human needs as anyone else. This means services should respond to the full range of their needs within the mainstream of society. People with dementia: Have the right to the same sources of health care provision as anyone else; Have the right to a secure and safe environment; should have a good diet that optimizes their health; Have the right to expect relaxation and recreation.

Principle 3: People with dementia have the same rights as other citizens. This promoting the rights of people with dementia who use services. People with dementia have the right to: Express their views about the service; be able to make choices; Independent advocacy; Expect first class care, which aims to satisfy the interests of the patient, not that of the nurse.

Principle 4: Every person with dementia is an individual. This means providing person-centered care. People with dementia have the right to: Express their individuality; satisfy their individual taste and their own clothes and belongings.

Principle 5: People with dementia have the right to forms of support, which do not exploit family and friends. This means safeguarding the quality of life of families and other caregivers. People with dementia have the right to expect that: The care they require will not place an excessive strain upon the people they love and respect; Their informal caregivers receive the appropriate professional support; Their informal caregivers receive the information they require about dementia and services; Available and appropriate referral to agencies from nursing staff (Purnell and Paulanka, 2008).

Management of Confusion

The following guidance, developed primarily for patients with acute confusion (delirium), is also relevant to patients with dementia. Management should also be directed at the reduction of the symptoms of confusion. The patient should be nursed in a good sensory environment, with a reality orientation approach and with involvement of the multi-disciplinary team (Williams, et al., 2009). This includes: Good lighting levels; Regular and repeated visible and verbal clues to orientation (e.g. clocks, calendars); Reassurance and explanation to the patient and care giver of any procedures or treatment, using short simple sentences; Sensory aids should be available and working where necessary; Avoidance of inter and intra-ward transfers; Continuity of care from nursing staff; Avoidance of physical restraints; Maintenance or restoration of normal sleep patterns; Approach and handle gently; Eliminate unexpected and irritating noise (e.g. pump alarms); Ensure fluid balance and meeting nutritional needs; Attend to bowel and bladder elimination; Encouraging visits from familiar friends and relatives may help to calm an agitated patient. Communication with the relative regarding the nature of the confusion is essential (Aud, et al., 2011). Where relatives are asked to assist in the care of a disturbed or agitated patient, an explanation of why their involvement is necessary and how they can help should be given by the nursing staff.

Wandering and Agitation

Patients who wander require close observation within a safe and reasonably closed environment. It is often preferable to try distracting the agitated wandering patient rather than using restraints or sedation. Relatives could be encouraged to assist in this kind of management. Attempts should be made to identify and remedy possible cause of agitation - e.g. pain, thirst, and need for toilet (Care, 2010). Patients with dementia often exhibit confused speech; it is usually preferable not to agree with confused communications but to adopt one of the following strategies: Tactfully disagree (if the topic is not sensitive); Change the subject; Acknowledge the feelings expressed - ignore the content (Purnell and Paulanka, 2008).


All sedatives may cause delirium in patients with dementia, especially those with anticholinergic side effects (such as chlorpromazine). The use of sedatives and antipsychotics should therefore be kept to a minimum. Drug sedation may be necessary in the following circumstances: In order to carry out essential investigations or treatment; to prevent patients endangering themselves or others; to relieve distress in a highly agitated or hallucinating patient. It is preferable to use one drug only, starting at the lowest possible dose and increasing in increments if necessary after an interval of 30 minutes. The preferred drug is haloperidol -- Orally, as tablets or liquid, up to a maximum of 2 mgs daily in divided doses, or by intramuscular injection to a maximum of 2 mgs every 6 hours. It is important to note that there is clear evidence of an increased risk of stroke in elderly patients with dementia who are treated with risperidone or olanzapine. Patients with dementia should therefore not be started on these drugs. Careful consideration should also be given to prescribing these drugs for patients with a history of cerebrovascular disease (Zimmerman, et al., 2010).


The main complications of dementia for which nursing staff must be prepared to encounter are: Psychiatric and behavioral disturbance; Delirium and Depression (Kleinpell, 2009).

Psychiatric and behavioral disturbance

People with dementia are likely to present with a wide range of psychiatric and behavioral problems and these difficulties in the context of cognitive impairment constitute the main burden for relatives and the greatest challenge for the caring professions. The following may feature in people with…[continue]

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