MDS Alert

2 types of communication techniques may help nonverbal residents.

Residents who resist or lash out during basic ADL care pose a major care challenge. To come up with interventions that address the underlying reason for the behavior, consider this quick list of questions.

1. Are caregivers explaining what they are going to do for the resident? A person who can't verbalize  effectively may still be able to understand verbal communication, says Carol White, RN, MS, ANPC, GNPC, DNP,CLNC, principal of NationalHI Inc.in Huntington, Ind. If that doesn't work, staff can use pictures to communicate. Picture boards that show symbols of "food, a toilet, or staff moving a patient up in bed can also help enhance communication," White says.

"Using pictures with someone who has late-stage dementia may not work," however, observes Christine Twombly, RN, a consultant with Reingruber & Company in St. Petersburg, Fla. She has seen care staff successfully use a strategy where they demonstrate on themselves what they plan to help the resident do -- "for example, brushing their own hair."

The caregiver might show the person the blood pressure cuff and maybe even try it on herself first -- "things to decrease the fear," advises Michael Partie, a behavioral expert and principal of Therapeutic Options in Newark, Del.

Safety tip: Staff should know that someone has a history of "striking out" at caregivers during care, urges Partie. "Once the caregiver knows that's even a possibility," the person can take  protective steps, "such as going slow and describing what they are going to do in short words" or doing demonstrations of what they are going to do, he says.

2. Does the resident have a primary caregiver serving as a pointperson in his care? Having a primary nursing assistant work with the resident can help reduce resistance to care "as long as the nursing aide providing care has a good relationship with the resident," says Twombly. The CNA really gets to know the resident and becomes "more of an advocate in the patient's caregiving," she adds. Primary CNAs should be involved in the care plan process, Twombly suggests. "They can recognize subtle changes in the resident --  for example, more pain or stiffness."

Personalization tip: White thinks "it's important to have pictures  of patients in their rooms showing them at an earlier time in life when they were ... more able to communicate with others." She finds the pictures "give caregivers something to talk to the patient about and help staff focus on the patient as a person in addition to focusing on the task being performed."

3. Have you done a careful pain assessment? If the resident has dementia and can't verbalize pain, look for diagnoses associated with pain, such as arthritis, cancer, pressure ulcers, etc. "If it hurts," the resident will resist, says Twombly.

"Sometimes pain management -- giving a pain medication prior to delivering care -- can help," she says.

4. Does the resident have a reason to dress and groom? "A person has to want to bathe and comb their hair and get dressed," says Partie. He notes a person once told him "that it's one thing to get people up on time but another for them to have a life worth getting up for." Thus, says Partie, "whether it's 'Monday Morning makeovers' or music or other activities," try to come up with ideas that will help the person want "to get up and get going."

For example, "perhaps the person needs to be more engaged in relationships in the facility, especially if the person's relationships outside the facility are declining or tenuous," says Partie.

5. What's the usual outcome of the person's behavior? If the ADL resistance continues, take a look at the usual outcome -- and you may have the key clue to why the person persists with the behavior. "When people's ability to communicate becomes limited due to a stroke or dementia, etc., they can use the same behavior to effect different outcomes," says Partie. For example, "you can scream to get people to come running in - or you can scream to get them to leave," he points out. So look at what tends to happen related to the person's behavior.

For example, "a person may want privacy during care and act out to drive his roommate out of the room." Or a person's resistance may be the only control he feels like he has left. In that case, maybe the person needs more choices, says Partie.

Don't give up: If the aforementioned strategies don't work, try, try again. White has seen documentation indicating a resident "yells out" during care. Yet there's no follow-up documentation to show how the team investigated the potential causes of the behavior, which might also include stress, excessive noise, and unfamiliar surroundings. And some patients end up on antipsychotic medications "for such behaviors" and suffer from side effects, as a result, she cautions.