Planning for Comfort: Creating care plans for people with dementia Karen mitchell

Learning Objectives: Describe process for obtaining information to create care plans for people with dementia. Identify and address possible, underlying, contributing causes of rejection of care.

Why care plans are important: People with dementia: have trouble thinking have special needs will experience increased discomfort and distress if they receive care and service that isn’t tailored to them it takes a village and the village has to have a plan

Gathering the right information: Social history Family meetings Changes in personal likes and dislikes Staff observations What creates comfort and discomfort Road Mapping

Road Maps What’s a Road Map? How do you use it? Who should develop/use Road Maps?

Road map to comfort Dementia-related Behavior Describe what the person is actually doing, avoid using words such as agitated or combative What it the Person Communicating Consider all possible meanings of the person’s actions   Possible Remedies Consider all possible options that could help

Examples of rejection of care Refusing personal care Pushing others away Hitting others Scratching/biting others Yelling or cursing at others

Why do people with dementia reject care? Startled, afraid, sudden movement, noise PHYSICAL PAIN Environment is noisy, chaotic Tired Bored

A case study-meet Julia Julia lived in the dementia unit at a local nursing home for the past three years. Born and raised in Spain, she loved Spanish folk music and dancing, She also loved the outdoors and walked several miles a day throughout her life to stay fit. As Julia became more confused she wasn’t able to take care of herself very well and had to rely on the nursing home staff for more assistance. Lately during each caregiving episode, Julia looked distressed she began to curse and hit the staff as they tried to help her. Julia had a strong right cross and she sent more than one staff member to occupational health after a caregiving episode went wrong. Julia rejected care so often the staff wasn’t certain they could take care of her. That was until they learned a new way to look at dementia-related behavior.

Julia’s Rejects Care Road Map Julia’s Dementia-specific behavior What is Julia communicating? Possible solutions for Julia? Julia hits the CNA every morning while getting dressed I hurt when you try to change my clothes Give me pain medication 30 minutes before you help me get dressed. Make sure my body isn’t asked to do more than it can. I’m afraid when you change my clothes, I think you are trying to harm me Slow down and use a soft approach when you dress me so I will understand you aren’t trying to harm me. Help me do as much for myself as I can

Comfort care plans Created from the perspective of the person with dementia Goal of care is comfort

Julia’s comfort care plan for rejecting care   Date Problems/Challenges Goals Approaches Staff Responsible I reject care by yelling, kicking and hitting because of pain in my right shoulder and both knees. I will be comfortable during caregiving and I will not resist care through _______________________. (Target Date) ____Use a soft, respectful approach when engaging with me. I prefer to be called Julia  ALL We (both you and I, the staff) are at risk for injury if I reject care because of pain. Neither the staff nor I will be injured as a result of my behavior through ________________________. ____Go slow during caregiving. Remember it’s much easier for me to understand what you are doing if you don’t go too fast.  CNA, NURSE When I reject care I’m trying to protect myself. I’m at risk for increased discomfort because my needs are unmet. I will have all of my needs met through ____Watch my reaction during caregiving tasks for signs of pain especially in my right shoulder. Attempt to eliminate the source of pain as quickly as possible. ____Give me Tylenol 30 minutes before you help me dress and around the clock. Watch for any sign that additional pain management is needed.  NURSE ____If I remain upset or uncomfortable, cease the caregiving task, provide for my safety, and leave. Re-approach me in 10-15 minutes and try the task again. ____Help me put on my brightly colored caftans and play my Spanish guitar music.  CNA

Comfort care plans for people with dementia: People with dementia experience discomfort and distress if they receive care and services that is not tailored to them. Identifying the underlying causes of rejection of care and road mapping to plan care makes comfort possible.

“Failing to plan is planning to fail” Alan Lakein