CNA Test 5 (T,U,W)

Cultural Variations during End of Life Care

• Some cultures believe dying at home is preferable while others fear death at home

Delirium

• State of severe confusion that is reversible and occurs suddenly • Usually triggered by a rapid onset (acute) of illness or change in physical condition that is life threatening, if not recognized and treated • Signs and symptoms of acute delirium - rapid decline in cognitive function, disorientation to place and time, decreased attention span, poor short‐term memory and immediate recall, poor judgment, restlessness, altered level of consciousness, suspiciousness, hallucinations and delusions • Notify nurse immediately of any resident that begins to exhibit the above symptoms or behaviors and stay with resident

NA's Role in Communicating with Dementia and Alzheimer's Disease Patients

• There are several components when assisting resident with communication o Patience with resident o Show interest in the subject o Offer comfort and reassurance o Listen for a response o Avoid criticizing or correcting o Avoid arguments with resident o Offer a guess as to what resident wants o Focus on the feelings, not on the truth o Limit distractions o Encourage non‐verbal communication

Death

• the natural conclusion to life • Resident's response to it is based on personal, cultural and religious beliefs and experiences

Common signs of approaching death

-blurred and failing vision -impaired speech -decreasing blood pressure -diminished sense of touch -cold pale skin -incontinence(urine/stool) -Cheyne-Stokes breathing -mottling -disorientation

Why a resident is more than a diagnosis?

Residents are more than a diagnosis o Recognize that a person with a mental illness is an individual o Every resident diagnosed with depression, anxiety, paranoia, mania or bi‐polar disorder is different from all the other residents with the same diagnoses

De-escalation of a resident who is agitated while keeping self and others safe

Trust instincts; if nurse aide decides or feels that de‐escalation is not working, the nurse aide should STOP and calmly call for help

Dementia

Usually progressive condition marked by development of multiple cognitive deficits such as memory impairment, aphasia, and inability to plan and initiate complex behavior

Mental illness

a disturbance in the ability to cope or adjust to stress; behavior and function are impaired; mental disorder, emotional illness, psychiatric disorder

Depression

a loss of interest in usual activities

Mental health

a resident's ability to cope with and adjust to everyday stresses in ways that society accepts

Independence

ability to make decisions that are consistent, reasonable and organized; having the ability to perform activities of daily living without assistance

Cognition

ability to think quickly and logically

Trigger

an event that causes other events

Catastrophic reaction

an extreme response

Terminal illness

an illness or injury from which the person will not likely recover; ends in death

Five stages of grief

denial, anger, bargaining, depression, and acceptance

Extraordinary measures

interventions used to restore heart beat or respiratory effort (cardiopulmonary resuscitation or CPR)

First and only objective in de-escalation

is to reduce level and intensity of resident behavior so that discussion becomes possible

Japanese culture End of Life Care

number four means death, so getting medication four times a day could be problematic

Do Not Resuscitate

o A choice of the resident o Doctor writes a Do Not Resuscitate (DNR) order, which tells health care team that the resident does not wish any extraordinary measures to be used if resident suffers cardiac or respiratory arrest

How to de-escalate a resident by looking for meaning of the behavior and being a detective

o Address feelings, not just words o Look at body language and facial expression o Given what is known about the resident, what might the behavior mean?

Environmental Needs of The Resident Who is Dying

- Keeping resident's environment as normal as possible o Room well lighted and well ventilated o Open drapes and door o Play resident's favorite music

Hospice Care NA's role

-Be a good listener -Respect privacy and independence -Be sensitive to individual needs -Be aware of your own feelings -Recognize the stress -Take good care of yourself

5th Stage of Grief

Acceptance ‐ person has worked through feelings and understands that death is imminent

2nd Stage of Grief

Anger - person expresses rage and resentment; often upset by smallest things; lashes out at anyone

How to de-escalate a resident with your posture

o Always be at the same eye level - encourage client to be seated, but if he/she needs to stand, stand up also o Keep relaxed and alert posture o Stand up straight with feet about shoulder width apart and weight evenly balanced o Avoid aggressive stances

How to de-escalate a resident with your behavior

o Appear calm, centered, and self‐assured even if that is not the case o Anxiety can make resident feel anxious and unsafe which can escalate aggression

3rd Stage of Grief

Bargaining ‐ person tries to arrange for more time to live to take care of unfinished business; bargains with the doctors or God

Vietnamese culture End of Life Care

o Believe in reincarnation, so quality of life is more important than length of life

Working With The Family Of A Resident Who is Dying

• Interaction and communication of appropriate information per facility policy • Understanding/support • Comfort (information about meals, coffee, etc) • Special visiting policy • Cultural issues/variations

Difference between Dementia and Delirium

Delirium is reversible; dementia is progressive and irreversible

1st Stage of Grief

Denial ‐ begins when a person is told of impending death; person may refuse to accept diagnosis or discuss situation

4th Stage of Grief

Depression ‐ person begins the process of mourning; cries, withdraws from others

How to de-escalate a resident with your body movement and language

o Body movements indicate anxiety and will tend to increase agitation o Minimize body movements, such as excessive gesturing, pacing, fidgeting, or weight shifting o Avoid crossed arms, hands in pockets, or arms behind back since it can be interpreted as negative body language, as well as putting self at tactical disadvantage if attack occurs o Refrain from pointing or shaking finger - Refrain from touching even if some touching is generally culturally appropriate and usual in setting; cognitive disorders in people who are agitated allow for easy misinterpretation of physical contact as hostile and threatening

How to de-escalate a resident with reasoning

o If directed by nursing care plan, explain limits and rules in authoritative, firm, but respectful tone o Give choices, where possible, in which both alternatives are safe ones (for example, "Would you like to continue our walk calmly or would you prefer to stop now and come walk later today when things can be more relaxed?") - approach is most useful with residents who do not have trouble thinking and not residents with dementia o Empathize with feelings, but not with behavior (for example, "I understand that you have every right to feel angry, but it is not okay for you to threaten me or my staff.") - approach is most useful with residents who do not have trouble thinking and not residents with dementia o Suggest alternative behaviors where appropriate (for example, "Would you like to take a break and have a cup of coffee or some water?") o Do not analyze or interpret how a person is feeling o Refrain from arguing or convincing

How to de-escalate a resident with your eye contact

o Maintain limited eye contact o Loss of eye contact may be interpreted as expression of fear, lack of interest or regard, or rejection o Excessive eye contact may be interpreted as threat or challenge, do not stare down resident

How to de-escalate a resident with your facial expression

o Maintain neutral facial expression o A calm, attentive expression reduces hostility

How to de-escalate a resident while positioning yourself for safety

o Never turn back for any reason o Maintain distance of at least two arms' lengths between self and agitated party o Place hands in front of body in open and relaxed position because this gesture appears non‐threatening and positions hands for blocking if need arises

Hindu culture End of Life Care

o Persons are often accepting of God's will o Desires to be clear‐headed at time of death o Prayer helps deal with anxiety and conflict o Blood transfusions, organ transplants, and autopsies are allowed o Cremation is preferred o Believes in reincarnation

Underlying causes of behavior

o Physical or medical conditions (for ex., pain, infection, hunger, medications) o Social or emotional triggers (for ex., resident was startled, nurse aide with bad mood sensed by resident, losses, feeling threatened) o Environmental conditions (for ex., loud and hectic area, too hot/cold, change in preferred schedule, around people resident doesn't like)

How to de-escalate a resident by responding in their reality

o Redirection - draw attention to another subject o Explore triggers of behavior o Engage in resident's story (for example, if resident is upset about husband who passed away years ago not coming to pick her up today, comment that the resident must really care about her husband and ask her to talk about husband)

How to de-escalate a resident with your attitude

o Refrain from becoming defensive even if comments or insults are directed at nurse aide; comments are not about nurse aide; the nurse aide should not defend self or anyone else from insults, curses, or misconceptions about roles or behaviors o Be respectful even when firmly setting limits or calling for help; individual who is agitated is sensitive to feeling shamed and disrespected; resident needs to know that it is not necessary to show that they should be respected; automatically treat them and all residents with dignity and respect

How to de-escalate a resident with your responses

o Respond selectively o Answer only informational questions no matter how rudely asked, (e.g. "Why am I in this g‐d place"?) - this is real information‐seeking question o Do not answer abusive questions (e.g. "Why are all nurses' a**holes"?); this sort of question should get no response whatsoever o Be honest; lying to resident to calm them down may lead to future escalation if they become aware of the dishonesty o Do not volunteer information which may further upset resident

How to de-escalate a resident by controling the environment

o Stand with feet 18 inches apart and to the side of the resident; keep a distance of 6 feet o Move others out of harm's way o Remove objects that could harm o Watch client without touching o Keep client safe

Chinese culture End of life Care

o Traditional healing practices include using herbal preparations given only once o Autopsy and disposal of body are not permitted by religion; therefore, organ donation encouraged

How to de-escalate a resident with your tone

o Use low monotonous tone of voice (normal tendency is to have a high‐pitched, tight voice when scared) o Refrain from getting loud or trying to yell over screaming person; wait until resident takes a breath, then talk o Speak calmly at an average volume

Bargaining

person tries to arrange for more time to live to take care of unfinished business; bargains with the doctors or God, 3rd stage of Grief

How religious beliefs affect death

religious beliefs affect a persons experience with death; include the process of dying, rituals,time of death, burial or cremation practices, services held after death, and mourning customs.

Palliative Care

the care that focuses the comfort, pain relief, and dignity of the person who is very sick and or dying rather than on curing him or her

Dying

the near end of life and near cessation of bodily functions

De‐escalate

to (cause to) become less dangerous or difficult

Nurse Aide's Role in Performing Post Mortem Care

• Respect family's religious restrictions regarding care of the body, if applicable • Provide privacy and assist roommate to leave area until body is prepared and removed • Put body in supine position with one pillow under head to prevent facial discoloration • Put in dentures, and if instructed by nurse, remove tubes and dressings • Wash body and comb hair • Put on gown and cover perineal area with a pad

Mental Health and Mental Illness Points to Remember

• All behavior has meaning - looking for the meaning behind the behavior is key • In some instances, such as a resident with dementia, the resident is not responsible for his or her behavior - resident may not be doing things on purpose • Nurse aide can lay the groundwork for successfully handling situations when resident is stressed and agitated by knowing how to communicate effectively day‐to‐day with resident • When a resident's unusual or inappropriate behavior escalates, or increases quickly and becomes more serious, resident may be a danger to self and others o Nursing care plan will include specific details about resident's condition and any special approaches to use when working with resident o An important tool to calm residents who are agitated is de‐ escalation • This is worth repeating: great day‐to‐day relationships are at the heart of de‐escalation

Dementia and Alzheimer's Disease Communication Strategies Used by NA

• Communication strategies to use when communicating with residents that have dementia o Listen carefully and encourage them; do not talk down to them,nor talk to others about them as if they were not present o Minimize distractions and noise o Allow enough time for resident to process and respond; if they have difficulty explaining something, ask them to explain in a different way o Monitor body language to ensure a non‐threatening posture and maintain eye contact o Nonverbal communication is very important to dementia residents o Choose simple words and short sentences, and use a calm tone of voice o Call the person by name and make sure you have their attention before speaking o Keep choices to a minimum in order to reduce resident's frustration and confusion o Include residents in conversations with others o Do not make flat contradictions to statements that are not true

Dementia and Alzheimer's Disease Communication Tips by NA

• Communication tips to use when caring for resident with Alzheimer's disease: o Be calm and supportive o Focus on feelings, not facts o Pay attention to tone of voice o Identify yourself and address the resident by name o Speak slowly and clearly o Use short, simple and familiar words, and short sentences o Ask one question at a time o Allow enough time for a response o Avoid the use of pronouns (e.g., he, she, they), negative statements and quizzing o Use nonverbal communication, such as pointing and touching o Offer assistance as needed o Have patience, flexibility and understanding

Late Stage of Alzheimer's Disease

• Considered terminal stage • Loses ability to verbalize needs; may groan, grunt or scream • Does not recognize self or family members • Becomes bed‐bound • Total dependence for activities of daily living • Body function gradually declines • Death

Culture and Religion during End of Life Care

• Culture and religion provide framework within which personal experiences with death take on meaning • Personal experiences, culture, religion, and age influence resident's individual set of beliefs in ways that may differ from nurse aide's personal beliefs about death • Nurse aide must not impose beliefs upon the resident who is dying, the family, or those people close to the resident who is dying • It is important for team to discover specific, cultural issues in order to provide respectful care to resident who is dying • Individuals from different cultures appreciate being asked about practices. Health care team may ask: o Who is allowed to provide personal care? (In some cultures, a member of the opposite sex cannot provide care) o Does the resident or family have any special customs? o Are there specific post mortem customs that the staff should know?

Advance Directive

• Dying resident must have living will, which outlines choices about withdrawing or withholding life‐sustaining procedures, if terminally ill • Living will must be written while resident is mentally competent or by resident's legal representative

Maintenance of Respect, Dignity and Quality of Life

• Every human being is unique and valuable, therefore, each person deserves understanding and respect • Dementia does not eliminate this basic human need • Person‐centered care maintains and supports the person regardless of level of dementia • Residents' abilities, interests, and preferences should be considered when planning activities and care • As the disease progresses, adjustments will be required in order to maintain dignity • Important for staff to know who the resident was before the dementia started An individual's personality is created by his/her background, including o Ethnic group membership (race, nationality, religion) o Cultural or social practices o Environmental influences, such as where and how they were raised as children o Career choices o Family life o Hobbies • Humiliation is disrespectful, degrading, and can increase likelihood of disruptive behaviors

Importance of Mental Health and Mental Illness

• Great day‐to‐day relationships are at the heart of de‐escalation • The nurse aide can come to know what is normal for particular resident and what signs resident may have that he or she is becoming agitated

Hospice Care

• Health care agency or program for people who are dying (usually less than six months to live) • Purpose is to improve the quality of life for a person who is dying • Provides comfort measures and pain management • Preserves dignity, respect and choice • Offers empathy and support for the resident and the family • Works with staff as well as resident and family

Emotional And Psychological Needs Of the Resident Who is Dying and the Family

• Identify incidents that affect resident's moods; note behavior changes and report to nurse immediately • Approach resident and dying process with dignity • Respect each resident's idea of death and spiritual beliefs • Offer support/understanding • Be supportive • Respect the resident's and family's spiritual beliefs • Encourage family members to participate as much as they can • Remind family of what to do if they are alone with the resident when death occurs, for example, in a home‐care hospice setting, they should call the agency to speak with the on‐call nurse • Do not always think that you need to say something; words are not always appropriate or important - being kind, caring and concerned is • Present a positive attitude and provide positive physical and emotional care • Give resident and family privacy, but not isolation • Be a good listener and use good communication skills • Spend time with the resident even when not providing care. Your physical presence is reassuring • Do not take anger directed at you personally

Nurse Aide's Role in Mental Health and Mental Illness

• Important to recognize appropriate and inappropriate behavior and function so nurse aide can : o Report inappropriate or different behavior and/or function to the nurse immediately o De‐escalate behaviors • Has many chances to observe and get to know resident

Middle Stage of Alzheimer's Disease

• Longest of three stages • Increased restlessness during evening hours (sundowning) • Increased level of memory loss; starts losing ability to recognize family members • Requires assistance with activities of daily living • Increased problems with communication, ambulation and impulse control • Increased behavioral issues; may become violent at times • Urinary and fecal incontinence • May experience auditory or visual hallucinations and become suspicious of caregivers

Early Stage Alzheimer's Disease

• Memory loss begins to affect everyday activities • Difficulty remembering names of people, places or objects • Difficulty following directions • Disoriented to time and place • Increased moodiness, agitation or personality changes due to forgetfulness or embarrassment • Has poor judgment and makes bad decisions

Importance of End of Life Care

• Most people die in hospitals or long‐term care facilities • A nurse aide's feelings about death affect care given • A caring, kind, and respectful approach helps the resident who is dying and family

Death: Signs That the Resident has Died

• No heartbeat • No respirations • No response when resident is talked to or touched • Bowel and bladder incontinence • Enlarged pupils that do not respond to changes in light • Eyes are fixed on a certain spot • No blinking

Nurse Aide's Feelings About Death

• Nurse aide must recognize and deal with own feelings and attitudes toward death in order to provide essential support to residents who are dying • Many factors influence attitudes, such as age of NA, personal experiences, culture, and religion • First encounters with death and dying can be frightening • Nurse aide can use co‐workers as support system for dealing with the experience

Dementia and Alzheimer's Disease Communication Techniques Used by NA

• Nurse aide's method of communicating with the resident with Alzheimer's disease is as critical as the actual communication • Utilizing the following techniques will decrease frustration for both the resident and nurse aide o Obtain resident's attention before speaking and maintain attention while speaking o Address resident by name, approach slowly from front or side and get on same level or height as resident o Set a good tone by using calm, gentle, low‐pitched tone of voice o If conversation is interrupted or nurse aide or resident leaves room, start over from beginning o Slow down, do not act rushed or impatient o If information needs to be repeated, do so using same words and phrases as before o Speak clearly and distinctly using short, familiar words and short sentences, and avoiding long explanations o Emphasize key words, break tasks and instructions into clear and simple steps, offer one step at a time; and provide resident time and encouragement to process and respond to requests o Use nonverbal cues, such as touching, pointing or starting the task for resident o If the resident's speech is not understandable, encourage to point out what is wanted or needed

Physical Needs of The Resident Who is Dying

• Positioning o Place resident in most comfortable position for breathing and avoiding pain o Maintain body alignment o Change resident's position frequently to avoid pressure ulcers • Cleanliness o Providing skin care, including back rubs o Bathe and groom resident frequently to promote self‐esteem • Mouth and Nose o Clean sores or bleeding in mouth following Standard Precautions o Provide oral care as needed. Cover lips with thin layer of petroleum jelly o Check for difficulty swallowing or choking o Gently clean nose o Offer drinking water as often as possible • Nutrition o Offer resident's favorite foods; include liquids or semi‐liquids o Offer foods frequently and in small amounts o A balanced diet is not a primary concern • Elimination o Keep the resident's skin and linen clean o Provide perineal care as often as necessary

Alzheimer's Disease

• Progressive disease characterized by a gradual decline in memory, thinking and physical ability, over several years • Average life span following the diagnosis of Alzheimer's disease is eight years, but survival may be anywhere from three to 20 years • Because Alzheimer's disease is progressive, it is separated into three stages: Early (Mild), Middle (Moderate) and Late (Severe) - each stage is different and will require different actions on the part of the nurse aide

Impending Death: Signs That the Resident is Within Hours or Days of Death and Should be Reported to Nurse

• Psychological and physical withdrawal • Decreased level of alertness, with increased periods of sleeping • Circulatory - slows as heart fails; extremities become cold; pulse becomes rapid and weak • Respiratory - irregular, rapid and shallow or slow and heavy o Cheyne‐Stokes breathing - when resident takes several shallow breaths followed by periods of no breathing for 5, 30, or even 60 seconds; does not cause the resident discomfort o Noisy respirations o Apnea - respiration stops • Muscle tone - jaw may sag; body becomes limp; bodily functions slow and become involuntary • Sensory - sensory perception declines; may stare yet not respond, lack of blinking; hearing is believed to be the last sense to be lost • Loss of urinary and bowel control as the muscles in those areas begin to relax • Dark‐colored urine in very small amounts as a result of decreased blood supply to the kidneys

Feelings And Responses By The Resident's Family, Friends And Other Residents During The Dying Process

• Realize that even if the dying process is prolonged, staff and the family may not be prepared for the actual moment of death • Staff maybe shocked or surprised when death actually happens; these feelings are normal • Recognize variety of feelings/responses maybe displayed-guilt, anger, sadness/depression, avoidance, denial, acceptance, relief • Listenempathetically • Demonstrate caring,interested attitude •Observe for changes in other residents(such as signs of depression, etc) and report/record appropriate information.

Communicating with Dementia and Alzheimer's Disease Patients

• Residents with Alzheimer's disease often experience problems in making wishes known and in understanding spoken words • Communication becomes more difficult as time goes by • Changes commonly seen in the resident with Alzheimer's o Inability to recognize a word, phrase o Inability to name objects o Using a general term instead of specific word o Getting stuck on ideas or words and repeating them over and over o Easily losing a train of thought o Using inappropriate, silly, rude, insulting or disrespectful language during conversation o Increasingly poor written word comprehension o Gradual loss of writing ability o Combining languages or return to native language o Decreasing level of speech and use of select words, which may also cause the use of nonsense syllables o Reliance on gestures rather than speech