NSE 12 GPA Modules PDF

Preview

Summary

GPA modules (1-4) required for clinical practice...

Description

NSE 12 GPA MODULES Sunday, February 23, 2020 11:37 AM

Module 1: introduction to Personhood  An individual's ability to regulate behaviour can become impaired by disease processes that cause brain changes  Dementia is an umbrella term for a set of symptoms for different brain diseases (such as; Alzheimer's disease (most common), vascular, frontotemporal, Lewy body and mixed dementia)  Having dementia can change how an individual experiences the world o Changes in memory, judgement, attention, mood, ability to communicate or complete ADLs o As well as greater feelings of confusion, anger, frustration or fear = responsive behaviours  As a nurse, you must be able to acknowledge that an individual with dementia still has feelings, and if they are not acknowledged, they may respond with challenging behaviour o You must reflect upon both your, and your patients culture, values, beliefs and principles, as they influence care o There is difference between the person and the disease  A person with dementia has: o A unique history o The capacity for interpersonal relationships o Significant others/family o The need for a supportive environment o Many remaining strengths and abilities  Threats to Personhood o Malignant Interactions (unpleasant interactions that are provided to those with dementia)  Infantilize  Treating individual like a baby/child  Outpace  Providing choices/tasks at a pace that is too fast for individual to follow  Impose  Forcing a person to do something that overrides their choice  Label  Describing individual by their diagnosis  Ignore  Having a conversation as though a person isn't there  Intimidate  Inflicting fear on individual, by using threats or physical power o Restraints  Chemical restraints  Medications that are used to control behaviour or restrict freedom of movement (not treat a medical condition)  Behaviours that do not respond to medication include;









Wandering, vocally disruptive behaviour, voiding in inappropriate places, hiding/gathering, dressing/undressing, repetitive activities/requests  Negative side-effects; decreased mobility, increased fall risk, delirium, restlessness, cognitive impairment, confusion, agitation, depression, tardive dyskinesia, MSK+CV+RR problems  Physical restraints  Equipment/devices used to restrict freedom of movement or access to environment  Examples;  Seatbelts  Locked lap trays  Jacket/vest restraints  Limb/waist/pelvic restraints  Wheelchair brakes  Bed rails (all four rails = restraint)  Risks include; increased fall risk/injury, infection, constipation, pressure ulcers, agitation, social withdrawal, discomfort/fear/resistance/anger, death Promoting Personhood o Personhood-Promoting Interactions (interactions that help de-escalate behaviours and build positive relationships)  Validate  Supporting persons feelings/emotions  Collaborate  Working together to enhance a person's abilities (encouraging control and choice)  Facilitate  Accommodating a person's disabilities to allow them to complete task  Play and Celebrate  Encouraging self-expression, joyfulness, and celebration  Relax  Helping a person relax and feel comfortable w/o making any intellectual demands People with dementia have needs with include; o To share, love and give o To feel competent o To have a sense of belonging o To be useful and successful o To feel hopeful Dementia bill of rights o A person with dementia deserves to;  Be informed of one's diagnosis  Have appropriate, ongoing medical care  Be treated as an adult, listened to, and be given respect for ones feelings and POV  Be with people who know their life story (including cultural and spiritual traditions)

       

Experience meaningful engagement throughout the day Live in a safe and stimulating environment Be outdoors regularly Be free from psychotropic medications when possible Physical contact such as hugging, caressing and handholding Be an advocate for self and others Be part of a local, global or online community Have HCP's well trained in dementia care

Module 2: Brain and Behaviour  ABCs of Brain Function o A- Affective (emotions) o B- Behavioural (actions) o C- Cognitive (thoughts)  Information Processing (SPEED) - describes information processing o S- Sensation  External stimuli initiates brain processes o P- Perception  Internal interpretation of the world o E- Emotion  Each memory is linked to an emotion o E- Evaluation  Feelings are evaluated and a response is determined o D- Demonstrated behaviour  Feelings and thoughts become behaviour  Severe dementia brain o Visualizing what the dementia developing brain looks like can help us understand why a person with dementia acts the way they do  Their responsive behaviours don't intend to harm us but to protect themselves



Normal aging vs dementia o Normal aging

    



Independently performs ADLs Can provide details of incidents of memory loss More concerned about their own memory loss Recent memories are not impaired Intact social skills o Dementia  Dependent on others to perform ADLs  Cannot provide details of incidents of memory loss  Other individuals are more concerned about their own memory loss  Recent memories are very impaired  Inappropriate and reduced social skills and behaviours The A's of dementia - (each A represents a domain of losses - cognitive and/or perceptual) o Amnesia - loss of memory ("I don’t know why I am here")  Can result in;  Trying to get home  Strategies;  Can attempt a consistent routine and meaningful activity  In dementia, STM is affected more that LTM (as memories are gained in the order they are experienced and lost in the reverse - ex; they might forget something that happened yesterday but remember something decades ago)  Usually their procedural memory is intact (memory for things without much thinking, such as riding a bike) o Aphasia - loss of language ("I don’t understand what you are saying")  Can result in;  Striking out in frustration  Strategies;  Visual prompts, communication cards  Types  Brocas aphasia  Difficulty producing language  Wernickies aphasia  Difficulty comprehending language o Agnosia- loss of recognition ("I don’t know what this object is used for")  Can result in;  Placing juice cup in a bowl of oatmeal  Thinking someone is knocking at the door when they hear a nurse crushing pills  Strategies;  Demonstrating with gestures  Placing food items one at a time to avoid confusion  Introducing yourself - voice recognition  Avoiding correcting, quizzing or arguing  Introducing objects and demonstrating its function using hand-overhand technique  They may be unable to recognize objects they see, hear, smell, feel or taste even faces may be unrecognizable to them (even their own face) o Apraxia - loss of purposeful movement ("I can’t put my clothes on in the right corner")



Can result in: Laying clothing Hold a brush but can't brush hair Put undergarments over clothing Attempt to leave bed without taking off the covers (missing a step) Smearing feces on hands (miss the step of getting toilet paper) Strategies;  Set clothes out in order + provide clear guidance  Simplify tasks (one task at a time)  Show person what you want them to do (visual rather than verbal)  Give clear step-by-step instructions Apraxia can still occur even if physical, sensory and coordination are still intact May be unable to complete a task without missing a few steps Muscles still have the ability, but brain is not sending the right signal to initiate it Altered perceptions - loss of environmental perception ("I see a stranger in my room") Can result in;  Yelling at mirror "get out of here!" Strategies;  Cover the mirror in room Often experience illusions - distortions of objects, sounds or stimuli in environment that are really there (but interpreted severely differently) Can also experience hallucinations - perception without external stimuli (visualizing something that isn't actually there) Must consider the individuals environment to identify possible triggers for illusions or hallucinations May also experience difficulty perceiving distance and depth (spatial relationships) Apathy - loss of ability to initiate ("I am indifferent about getting up") Can result in;  Sitting in a chair all day and not engaging Strategies;  Initiate interactions and guide activities Different from apathy in depression  Those who are depressed show lack of motivation/involvement/interest and are not able to participate in activities because they don’t feel like it  Those with dementia are unable to initiate interactions to the outside world, however, they are not sad or concerned about it ("initiation center" in brain is not working)  They are dependent on others to interact and engage with them Anosognosia - loss of self-awareness ("there is nothing wrong with me!") Can result in;  Refusing all prompts for personal care Strategies;  Apply knowledge of personal routines  Avoid arguing and be creative in the strategies you plan to implement In other words, when those with dementia have no knowledge of their illness Unaware of their cognitive and perceptual losses Becomes more prominent as dementia progresses     



   o       o   

o  

  

o









Attention deficits - difficulty sustaining or shifting attention ("too much is going on to focus on this task")  Can result in;  Continually leaving breakfast table  Difficulty filtering out non-important information  Attending to more than one thing at a time  Ability to shift attention (perseverative behaviour)  Strategies;  Minimize distractions, offer simple choices  More difficult to store memories when we cannot pay attention to the information around us  More likely for those with frontotemporal dementia Delirium o "a disturbance in attention and awareness that develops over a short period of time, represents a change from baseline, and tends to fluctuate in severity during the course of the day" o Very common in elderly persons o Can screen using things such as the Confusion Assessment method o Risk factors for delirium include; age, cognitive impairment, severe illness, multiple medications, sensory impairment, sleep deprivation, immobility, dehydration, use of catheters, and previous delirium diagnosis The 3 D's o Dementia - progressive cognitive interference of memory, communication, attention, judgement, ADLs and behaviour  Those with dementia are predisposed to delirium and depression o Delirium - medical emergency with sudden onset and fluctuation  Can cause confusion, altered consciousness, and disturbances in attention, thinking, perception and language o Depression - treatable mental disorder that negatively affects ones thoughts, feelings, memory, behaviour, self-esteem, and physical health Development of dementia and its severity o When in the later stages of dementia, the damage done to the brain can influence the actions of muscles and nerves o Can result in involuntary responses such as tensing up or grasping onto care provider while receiving a bath Grasp reflex o Neurological reflex  Which causes individuals with dementia to instinctively grab onto something or someone during care (or other actions in close proximity)  It is an autonomic response not aggression o Present at birth - with diffuse damage throughout brain due to advancing dementia, reflexes present in infants and newborn can re-emerge  Disappears in the first few years of life o Palm stimulation leads to a grasp o Grasp reflex release  Remain calm and let your arm go limp



o

Because any muscle tension in your arm with stimulate their palm = ↑ grasp reflex  Use the person's name and ask them to let go  Gently tap on the back of the hand to draw attention  Even in the advanced stages of dementia, the person may be able to differentiate between left and right - with cues  Stroke the back of the hand, knuckles to wrist  Stimulate the extensor muscles and helps the person release Thumb release - used to weaken grasp  Grasp the persons thumb joint at each side between your own thumb and forefinger  Slide the persons thumb towards their index finger without forcing movement

Module 3: The Interpersonal Environment  Search for the meaning o P - Physical (ex; delirium, pain, hunger) o I - Intellectual (ex; 8 A's, communication) o E - Emotional (ex; anxiety, depression, fear) o C - Capabilities (ex; ADLs, iADLs) o E - Environmental (ex; noise, stimulation) o S - Social (ex; personality, culture, life story)  Sometimes it may be necessary to incorporate an individual's past when giving care o Families are an excellent source of past history, if not then community agencies or other supports that have known the person  We must also understand yourself - such as our personal response to anger and frustration so you can develop your own interaction style that works best for you  In residential care settings, we must take into consideration that you are working in their home  Creating a caring community is important o "we cannot treat staff badly and expect badly treated staff to treat patients well"  Nonverbal communication o More than 85% of messages we send are nonverbal o How our messages are delivered will impact how the person receives and responds to our message  Therefore we must remain friendly, calm, non-judgmental, and kind  Consider personal space o We have four spaces in which we experience varying degrees of comfort in our physical distance from others  Public: space in which we interact impersonally or anonymously  Social: space in which we tolerate acquaintances or strangers at close proximity  Friend: space in which we are comfortable allowing familiar people, often close enough to touch  Whisper: very intimate space in which we only allow those closest and whom we fully trust  Reassurance position o Stand back and to the side, about a leg length away so that you are not a threat-this communicates respect and offers you an escape route









With an upset dementia patient, ensue that you are standing outside of the intimate space, about a leg length away while offering reassurance o Ensure that the person is calm and steady, and be prepared to step in if necessary  Stand about a quarter turn to the side, maintaining genuine eye contact with your hands in a relaxed, open palm position to indicate you mean no harm (this positioning communicates respect, honors personal space, and allows you to be stable enough to turn and exit if you need to move away quickly) o Allow the person to regain physical and emotional control Stop and Go o S -Stop (whatever you're doing can wait)  Take your focus off the task and make the person a priority o T - Think (give your full, undivided attention. Why is this happening?)  Think about the triggers o O - Observe (recognize cues and acknowledge the emotional message)  Reflect upon your own reaction  What message are you sending the person through your body language, facial expressions, and tone? o P - Plan (consider when to resume care and how to modify your approach)  Knowing about the person can help you develop approach strategies such as music, humor, control, choice, etc. o GO  Use gentle persuasive approaches (the communication strategies listed below) Signs of impending protective behaviours o These behaviours are signs for us, they let us know the person needs us to change the plan somehow. o Sometimes the sign may be subtle (as subtle as a certain look in the persons eyes) o Impending protective behaviours include:  Pacing  Restlessness  Ridicule  Swearing  Increased loudness  Rigid posture  Gripping arm rests, bed rails, etc.  Clenched fists Behavioural escalation cycle

o



Baseline  Knowing the individual is the first step to this, so we know what they are usually like when they are calm or their generally usual behaviours.  Knowing their baseline allows you to identify when initial signs of escalation occur o Anxious behaviour  Signs of growing anxiety are one of the first indications that something is wrong and we need to take notice to change our plan o Verbal protective behaviour  As they continue through this cycle, the verbal expressions that may be presented as yelling, swearing, ridicule, screaming, or crying o Physically protective behaviour  Further escalation can = physical behaviours such as hitting, kicking, spitting, or throwing things o Recovery  Can take minutes to hours and varies with the individual and circumstances  Must be mindful of remaining triggers and observe for possible additional physical responses Communication strategies o Minimize distractions and noise o Approach from the side o Make genuine eye contact o Introduce yourseld o Give clear directions







o Stay calm, be patient o Use persons preferred name o Speak slowly and clearly with calm tone o Use simple language and familiar words o Give brief, one step directions o Visual demonstrate what youre saying o Always speak to them as an adult o Use verbal praise and nonverbal communication o Avoid arguing, confrontations, and quizzing o Be prepared to repeat yourself o Use humor, music, rhythm, exercise and pets Validation therapy o A method for connecting with confused older adults and acknowledging the meaning behind their behaviour  Process if validating and respecting the individuals feelings in whatever time or place is real to him/her, even though this may not correspond with our "here and now" reality Validation and reality orientation o Validation  Understand the persons reality  Emotional  Subjective  Respect the persons sense of reality  Allows us to avoid blatantly lying or truth-telling o Reality orientation  Reorient the person to present reality  Factual  Objective  Confront errors in the persons sense of reality Verbal redirection o Unsuccessful verbal redirections  Dismissing  "your purse hasn’t been stolen, you must have misplaced it"  This approach fails to validate the individuals feelings which can negatively impact their trust in you  Negating  "you don’t need a purse anyways"  Can create doubt in their value and sense of purpose  Ignoring  "Don't worry about it, I will get to you later" o Successful verbal redirection  Validate the persons reality and emotional state  "your purse has been stolen, I understand why you're upset"  It's helpful to repeat their request - shows that you are listening to them  Join in that persons reality and listen to his/her perspective  "you need to keep looking for your purse? Well, I am trying to find someone too. Let's look together"





Joining them in their quest builds trust and leads you to distraction sooner  Distraction is then easier and works best with people who has severe memory or attention problems  "let's look for you purse over there where people are having coffee"  Ex; activities, snacks, drinks, music, puzzles, etc.  Works best for those with memory or attention problems  Redirection may finally be possible without directly thwarting the now-forgotten goal  "that coffee smells good, would you like a cup?" Supporting families o Families who engage in verbally protective behaviour when they are upset, sad, and discouraged o These gentle and respectful de-escalation techniques can also apply to families o Ensure confidentiality

Module 4: Gentle Persuasive Techniques  Doing nothing is having a plan o Avoid the urge to touch the person unless it is an extreme situation o Remove bystanders  Provide person with privacy and space to express themselves (removes pressure of an "audience") o Give undivided attention o Offer support from a distance  Grabs o Remain calm and let your arm go limp o Use person's name and ask them to let go o Tap or stroke the back of the person's hand  Self-protective techn...