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BEHAVIORAL DISORDERS, A NURSE'S PRIMER


This article is to assist you in developing strategies to help these clients develop better means of coping with their behaviors. You will find a decrease in your anxiety, know how to approach the clients, develop ongoing relationships and be able to provide quality care to your clients.

Introduction

Nurses often find themselves face to face with individuals with intellectual disabilities. These disabilities stem from any number of sources: congenital anomalies, brain injuries, tumors, prematurity, metabolic and neurological disorders, cerebral palsy, infections, to name a few. These clients pose challenges in and of themselves. Some clients are unable to speak, some may be immobile, they cannot tell you if they are in pain, afraid, stressed, feel ill or are just fine. Making the situation even more complex is that these clients are at higher risk to have behavioral problems. They may act out their feelings by using non-verbal communications, by using self-injury techniques, they may hit, bite, obsess, be compulsive, have tantrums, etc. It impairs our ability to give these clients adequate and safe care.

Presentation of Behavioral Deficits

Along with cognitive impairments, clients may have an impaired ability to communicate, are socially challenged, have sensory processing impairments, have attention deficits, may exhibit obsessive or repetitive movements or actions, behaviors, or activities. Each individual exhibits different symptoms, and symptoms may change with age.

Social deficits are based on the assessment of age-appropriate development but may include a failure to respond to the client's name being called, resisting touch, preferring to play alone, failure to develop peer relationships, poor eye contact, no interest in sharing enjoyment or interests, lack of empathy, and general disregard when one attempts to speak to the client. Verbal or communicative deficits may include delayed speech or the inability to speak, the loss of ability to use words and sentences, and difficulty understanding questions or conversations. Another verbal deficit exhibited may be echolalia, or repeating words and phrases in place of normal language. He or she may also be unable to initiate conversations or continue one. An inability to communicate effectively can lead to increased agitation in this population

Stereotypical behaviors may include constant motion, rocking, spinning, hand-flapping, or other repetitive movements. A client may also develop an obsession with a specific object, such as the wheels on a toy truck. If a client exhibits these symptoms, it may be a method of self-stimulation or a sign of increased agitation or it could be a method of self-stimulation. It is important to note that this behavior should not be interrupted nor should a client be restrained because this is a coping technique for some clients. Abrupt or forced cessation of the behavior can also lead to increased agitation.

Hypersensitivity to light, sound, taste, touch, or smell may also be exhibited. Identifying if a client has any specific sensory alterations and the client's coping mechanism may assist you by avoiding certain triggers. You may observe certain self-injurious behavior. Examples of such activities may include head rubbing, skin picking, eye poking, self-biting, and head banging. Although uncommon, they constitute some of the most challenging patients. This is more commonly seen in nonverbal clients with impaired cognitive functioning and altered sensory processing.

Interventions

The client's caregivers are your biggest allies, include them in your treatment plan. They are armed with the knowledge needed to best accommodate the client's special needs. The family can readily identify a client's triggers and the best method of communication and inform the nurse of critical details to ensure that the client is less likely to become agitated and more likely to comply with the treatment plan.

It is of utmost importance to identify the manner in which the client best understands information and how the client best expresses his/her needs. Establish if there are limitations in the client's ability to communicate. Your inability to communicate properly with the client may increase their frustration and can potentially trigger aggressive behaviors, which could compromise the client's and personnel safety.

The family or caregiver should also be able to inform the nurse of the best method with which one should speak with the client. Most clients respond best to short, succinct commands. Avoiding the phrase "no" is important when communicating with this population. The use of visual aids, such as picture schedules, communication boards, and labeling of objects in the rooms, has proven to be an effective communication tool.

Clients with behavioral or cognitive deficits prefer routine. A routine is a comfort mechanism for the client. All attempts should be made to regulate the client's schedule and abide by as much of the home schedule as possible. Keeping meal times, activities of daily living care times, and play times the same can decrease the anxiety and agitation levels of both the client and the family. It is important to be aware of the client's favorite objects, they oftentimes act as a source of comfort. The patient may prefer certain foods or has a hypersensitivity to smells, the nurse should accommodate these preferences to decrease the number of variations from the regular routine. The nurse caring for the client should also advocate to minimize interruptions to the client's sleep pattern, they often struggle with sleep. If the patient is medically stable, avoiding overnight vital signs and medication administration during established rest periods may help reduce the anxiety level of the client. If disruptions to the established schedule need to occur, informing the client of the change in concrete, simple terms should be attempted prior to performing any new tasks.

While trying to encourage the use of a routine, using the same caregivers may also decrease patient anxiety. This familiarity with the nurse and the nurse with the client and family will add an element of trust to the relationship. It also allows the nurse to be more adept at the subtle non-verbal communications made by the client. The nurse will then be better attuned to the feelings of the client. This may improve the client's compliance with the treatment plan as well as decrease the likelihood of aggressive behavior due to the client's fear of new and different elements.

These clients are frequently challenged by sensory overload. The nurse should work with the family to identify if the patient is particularly agitated by touch, sound, smell, sight, tastes, or foods. Each client is different, by identifying the client's unique agitators the nurse is able to make the client as comfortable as possible. It is recommended that staff members turn off cell phones and pagers while working with these clients. The nurse should also approach the client individually in a calm, non-threatening manner and avoid approaching the client in a group. Activities are important for a client. The nurse caring for the patient should obtain appropriate toys, games, and activities that can be used in the client's room. Specific activities should be offered at specific times, again supporting the consistent routine.

It is important to determine if the client for whom the nurse is caring has any known emotional disturbances or what causes the greatest amount of aggravation for the client. Frustration for clients can stem from challenges with communication, change, or overstimulation. Crowds, unfamiliar environments, and illness can also cause frustration and lead to challenging behaviors in clients.

An example of a particularly challenging task for clients with and without special needs is taking medications. The administration of a medication can lead to increased frustration, agitation, and challenging behavior in clients because they may not understand what or why medications are being administered. Clients have used challenging behavior to escape demands. Therefore, offering a reward each time a client successfully takes a medication can establish a pattern of positive reinforcement and better compliance with the therapeutic regimen.

It is also important to determine the best methods to comfort the client. Many of these clients do not have verbal skills and may not be able to clearly communicate if they have pain. Pain levels of clients could be discerned from their facial activity when noted by observers. The use of nonverbal pain scales, such as the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale and the revised FLACC scale, which incorporate a parent's description of individual behaviors, are recommended for clients with cognitive impairments. The nurse should also ask the family what methods work best to soothe the patient at home. He or she should then incorporate those techniques into care and ensure that all staff caring for the client are aware of appropriate pain relief methods, as well as de-escalation techniques for periods of increased agitation.

Incomplete handoffs can be particularly detrimental to the safety of the client and the personnel caring for the client if critical information on necessary methods of communication, the client's triggers that may lead to increasing agitation and anxiety, the daily schedule, and the client's preferences are not clearly or completely relayed.

Conclusion

Successfully caring for the client with cognitive, physical and behavioral disabilities requires the nurse to acknowledge that this patient population is unique and requires a thorough assessment, multidisciplinary planning, advanced knowledge of the client's special needs, and close collaboration with the client's family.

In order to offer relevant nursing, your focus needs to be on the patients' abilities and not on their disabilities. This is translatable regardless of whether a patient's disability is cognitive or physical. The starting point for nursing was when the nurse acknowledged and saw the person behind the patient.



Summary of Nursing Interventions to Assist in the Care of Behavioral Disorders

Know the Triggers for Anxiety and Frustration What the Nurse Can Do
1. Change in structure, routine • Conduct in-depth interview with family/care providers. • Keep the routine consistent. • Follow home schedule as much as possible.
2. Poor or failed communication • Use literal terms and direct communication. • Avoid metaphors and figures of speech. • Use visual or appropriate communicative aids.
3. Anxiety/co-morbid conditions • Avoid hostile body language.
4. Being told "no" • Use short succinct commands. • Avoid using "no." • Provide rewards for positive behaviors.
5. Redirection from preferred activity • Identify and place toys and activities in client's room. • Help client
6. Unfamiliarity with environment and caregivers • Provide continuity of personnel. • Label room objects with words or pictures; the client may be able to point to object of desire if nonverbal.
7. Unable to get what he or she wants and acts out • Avoid restraining an agitated client.
8. Illness and pain • Use the FLACC or other appropriate pain scale to identify discomfort in the client with limited verbal ability.
9. Overstimulation — sensory issues such as noise, crowds, proximity of others • Turn off phone/pager when entering patient room. • Decrease environmental stimulation; keep lights, noise and monitors off if possible.
10. Other • Stay calm! • Contact and involve multidisciplinary team when developing plan of care.



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