Karen Bryan, OTR/L
Clinical Manager
June 19th, 2012
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Identify agitation triggers
Describe interventions for each of the 10
levels of the Rancho Los Amigos Scale
Identify ways to handle agitation
Verbalize escalating behaviors
Have knowledge of ways to de-escalate
Define CAPE and response techniques
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a)
b)
Action response to the perception that one’s
vital interests are being threatened
Verbally
Physically
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1)
2)
3)
4)
For YOU:
Tired
Overwhelmed- home responsibilities, work
responsibilities, family, church
responsibilities
Stress – deadlines, documentation, demands
by others, expectations of self
Work related factors: poorly functioning
equipment (computer issues), short staffed,
low census, productivity, visionware
demands
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1)
2)
3)
4)
5)
For Patients:
Tired
Unfamiliar settings
Loss of awareness: what they can and
cannot do
Loss of control: told what to do, when to do
it, and where to do it
Loss of privacy
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Anxiety
Fear
Pain
Anger/Frustration
Illness
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Behavioral-cognitive evaluation tool
Used to describe the characteristics of
behavior or stages of recovery a patient is
experiencing
Used by team members/family to understand
appropriate treatment plans
Progression of levels
No show of any observable change or
response in behavior
 Patient may appear to be asleep and does not
respond to words, physical contact, visual
stimulation, or pain
 Family members and staff should keep in
mind that the patient might hear and
remember what is going on in his/her
environment
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Patient may show a reflexive response to
painful stimuli, repeated sounds, sights,
touch or movement and may/may not have
eyes open
Patient may respond slowly, inconsistently, or
after a delay
Responses may include chewing, grunting,
sweating, increased blood pressure/heart
rate, moaning and/or moving extremities
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Patient appears to be more alert and is awake
off/on during the day
Patient will respond better and make more
movements than before
Patient may begin in respond to simple
yes/no questions
Responses will be inconsistent, slow, and
directly related to specific stimuli
 Family:
1)
2)
3)
4)
5)
Orient the person repeatedly
Keep room quiet and calm
Allow patient frequent rest breaks
Bring up personal things that are familiar to
the patient
Keep in mind the patient will need extra
time to respond
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Patient may appear to be very confused and
frightened.
Patient may attempt to remove restraints and
act-out
Patient will be highly focused on basic needs
Patient may have trouble concentrating,
listening, following directions, and
understanding the need to be in the hospital
Verbalizations are frequently incoherent
 Family:
1)
2)
3)
4)
Re-orient the patient and reassure them
that they are safe and encourage
participation in therapy
Speak to patient in a calm voice and avoid
auditory distractions
Continue to show familiar objects/pictures
Allow patient as much movement as is safe
and do not force him/her to do things
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Preparing for Level V:
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Patient will be alert, not agitated but may
wander randomly
Patient may confabulate
Patient will have continued difficulty with
orientation
Patient will be able to follow simple directions
Patient will continue to focus primarily on
basic needs
Patient may perseverate
Patient may be impulsive
Family:
1) Be encouraging and reassuring
2) Continue to review orientation and repeat
things as needed
3) Begin a memory journal
4) Continue to limit environmental distractions
and visitors as needed
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Patient is inconsistently oriented
Able to carry out a simple routine with
assistance
Trouble with sequencing of activities
Patient more aware of physical problems than
of thinking problems
Continue to be impulsive and say or do
things too fast without thinking first about
safety or outcome.
 Family:
1) Discuss things that have happened during the day
to help improve memory.
2) Continue with memory book with less assistance
3) Slowly back off with assisting the patient with a
task/activity
4) Continue to encourage participation with therapy
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Patient consistently oriented to familiar
environments
Increased ability to perform self care
Personality changes maybe more apparent
Trouble paying attention in distracting or
stressful situations
Patient not totally aware of the extent of their
impairments
Patient will exhibit trouble with initiation
Patients expect to return home to their
previous lifestyles/work
 Family:
1) Be aware of patient’s lack of safety awareness and
poor judgment skills
2) Allow patients to make simple decisions
3) Continue participation in therapy
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Patient consistently oriented
Able to initiate and carry out familiar tasks
More aware of impairments and will begin to
compensate
Personality changes maybe more apparent
Begins to recognize and acknowledge
inappropriate social interaction/behavior
Still have difficulty with memory with increased
stress in unfamiliar situations
May have thinking problems that are not
noticeable to people who did not know them well
before.
 Family:
1) Allow patient to make simple decisions with
guidance as needed.
2) Encourage continued therapy
3) Help patient as needed in activities and situations
where there are problems with memory, problem
solving, and thinking.
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Patient able to follow multiple directions, and
switch back and forth between activities.
Patient much more aware of abilities/deficits
Patient will acknowledge other’s needs and
feelings and will respond appropriately
Patient will know how to handle more
stressful situations
May be able to use assistive memory devices
to recall daily schedule
 Family:
1) Treat the person as an adult and allow him/her
freedom for increased independence and offer
support when needed and/or requested.
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Patient able to multi-task in all environments
Able to accurately estimate abilities/deficits
May still require extra time for planning
ahead and deciding how to react to certain
situations.
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Nonverbal behavior
Verbal behavior
Acting-out behavior/physical behavior
Verbal
Nonverbal
Acting-out
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Avoid overstimulation:
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Be consistent:
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Stay calm:
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Give step-by-step directions:
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Do not talk down to the patient
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Allow response time
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Maintain a sense of humor
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Remember to praise the small gains
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Stimulation programs
Restraints
Wander guard system
Behavior modification program
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Private room
Patient door closed
No bright lights
Keep room clutter to a minimum
Visitors limited to immediate family only 2 at
a time for 15 minutes in duration
No TV or radio
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Quiet environment
Consistent and structured schedule
Speak softly with short, simple questions
Ask “yes” or “no”
Meals are to be eaten in room with
supervision
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Patient’s door is closed approximately half of
the day
TV or radio time of no more than 2 hours per
day
Keep room clutter to a minimum
Consistent therapists and nurses
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Therapies in a quiet, non-distracting
environment. Patient may leave the floor with
therapist of treatment in a quiet setting.
Visitors limited with specific duration of time
Patient may/may not eat meals in the dining
room. (To be determined by team)
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Definition: “Restraints are any method of
restricting an individual’s freedom of
movement, physical activity, or normal access
to the body.”
May need to be used for:
1) Safety of individual
2) Safety of family members
3) Safety of staff
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Available for those who might be at risk if
they left the floor unattended.
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Only used if the patient has the cognitive
skills necessary to participate in a reward or
positive reinforcement program.
Used on patients that exhibit undesirable
behaviors.
Driven by reward and positive reinforcement
for desired behaviors.
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Must set limits
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Must contain the aggression
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Help problem solve as to why situation
occurred
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Think of alternatives
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Redirect behavior
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Am I able to sense when my patient is on the
verge of becoming agitated?
Am I able to try to de-escalate them?
Am I doing what I can to provide security,
consistency, and encouragement to my
patient?
If not, what changes can I personally make or
encourage others to consider?
Please feel free to contact Karen Bryan @
[email protected]
or
Office phone: (405) 644-5381