Care Home Nurse Asking for Something to Calm An Agitated Resident with Dementia — Free SCA Practice Case

Character Overview: You are Emmanuel Danquah, 43, a registered nurse and the nurse in charge of the first floor dementia unit at Fernbank Nursing Home. You are ringing about a resident, Hilda Skerritt, who is 84 and has Alzheimer's disease. You have been in charge of this unit for a few months and today it is you and two carers for fifteen residents. You are kind, tired and polite, and you speak quickly. You honestly believe that something to settle Hilda would be kind to her and to the other residents. You have worked in homes where sedatives were put in drinks and you do not know the rules about capacity. You get a little defensive if you feel blamed, but you listen if the doctor is calm and gives you something practical for tonight. You never suggest a cause for her distress beyond "the dementia and the move".

Opening Sentence: "Hello, doctor, it's Emmanuel, the nurse in charge at Fernbank Nursing Home. I'm ringing about Mrs Hilda Skerritt. She's eighty four, she has Alzheimer's and she came to us three weeks ago. She's getting very agitated in the evenings and I wondered if you could prescribe something to calm her down. Something we can put in her tea, because she won't take tablets from us."

History if Asked (Data Gathering Phase)

• ●The agitation: "About a week now. She's fine in the mornings and most of the afternoon. Then from late afternoon through the evening she gets worked up. She calls out 'I want to go home, somebody help me', walks up and down the corridor and bangs on the keypad door at the end of the unit. She says she's got to get home and do the dinners before they all come in. It goes on for hours. She dozes in her armchair after lunch, then she's wide awake, and she's up once or twice in the night."
• ●How she was before: "The first two weeks were better than we expected. She ate with the others, joined in the music session and was chatty. Never aggressive before this week."
• ●The carer being hit: "Four days ago a carer was helping her up from her armchair to take her to the toilet. Hilda swung her arm and caught her on the forearm. No mark, but the carer was shaken. It's the only time."
• ●Leaving the unit: "Twice she's followed a visitor towards the main door, and once a carer found her at the top of the stairs. Nobody's been hurt."
• ●What's going on at that time: "It's our busiest stretch. The tea trolley, handover, the television on loud. Sitting with her works for a few minutes. She hates being told to sit down and gets louder."
• ●Refusing tablets: "She took them fine for the first two weeks. This week she's turned her head away or pushed the pot out of the carer's hand most evenings. She says 'I don't need those, I'm not ill'. She doesn't seem to understand what they're for. She does drink her tea, that's why I thought of that."

Ideas, Concerns, Expectations

Gating note: Emmanuel does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is behind it, what worries him, or what he was hoping for.

• ●Ideas: He thinks it is the dementia and the move. "They all get worse in the evenings, it's just how it is. She's frightened and in a strange place. A bit of something to take the edge off would be kind." He assumes she cannot decide about her tablets. "With her dementia she can't understand them, can she?"
• ●Concerns: He fears someone will get hurt, either a carer or Hilda on the stairs. Other residents are being kept awake. "If an agency carer gets hit they won't come back, and then I'm on my own." Once the doctor mentions pain or bowels, he is embarrassed: "Oh no. That's our miss. I'll have to write it up."
• ●Expectations: He expects a prescription today for something like lorazepam or haloperidol, as a liquid or a crushable tablet, sent by the pharmacy so it can start tonight. "To be honest, I didn't think you'd need to see her."

If Asked: Medical History and Medications

Gating note: Emmanuel answers each of these plainly when the doctor asks about it.

• ●Health problems: "Alzheimer's, blood pressure, arthritis in both knees, and she's quite deaf."
• ●Medicines on our chart: "Donepezil and amlodipine, both on the evening round. Nothing else, no as required ones, no sleeping tablets. Nothing has changed since she came."
• ●Paracetamol: "Her son told us at admission that she took paracetamol at home, two tablets four times a day, from a pack the carers kept in the kitchen. It was bought over the counter, so it wasn't on the list from the pharmacy and we never started it."
• ●Weight and allergies: "Fifty six kilos when she came in. No known allergies."
• ●Hearing and sight: "She wears her glasses. Her hearing aid for the right ear hasn't been in since she arrived. I'll ask her son."
• ●Capacity, power of attorney and family: "Nobody has assessed her capacity, not formally. I haven't seen any power of attorney paperwork in her file, but I haven't gone looking. Her son is down as next of kin."

Social History and Lifestyle Impact

• ●Hilda: A widow. She lived alone until three weeks ago with carers calling four times a day. Her son arranged the move after she left the gas on twice and got lost walking to the shops. She was a sewing machinist in a clothing factory for over thirty years and likes strong tea with two sugars and the radio. Her room is bare because her son's photographs are still in a bag in the wardrobe.
• ●Her son: He visits once a week and she is calmer while he is there. He feels guilty about the move. He knows nothing about the request: "I didn't want to worry him, and honestly he might say no."
• ●The unit: You are on duty all of today and tomorrow. The practice home round is not until later in the week. The home's homely remedies policy includes paracetamol for a couple of days, and the pharmacy delivers the same day if a prescription is sent early in the afternoon.

If Asked: Associated Symptoms

Gating note: Emmanuel answers only when asked. Observations are read from this morning's chart. If asked to examine Hilda or feel her tummy, he says he is not the right person and would feel better with someone seeing her properly.

• ●If asked about pain: "She rubs her knees and says 'my legs, my legs' now and again. She winces and grabs the chair arms when we stand her up. She can't really tell us how bad it is."
• ●If asked about bowels: "The chart says she hasn't opened her bowels for five days. She's not on any laxative. No vomiting, no leaking that we've noticed, and I don't think her tummy's swollen."
• ●If asked about urine or burning: "She hasn't complained of burning, she's passing urine as normal and there've been no new accidents. We did a dip last night because she was unsettled and it was negative."
• ●If asked about observations: "Temperature 36.8, pulse 82 and regular, blood pressure 134 over 78, breathing 16, sats 96 on air, sugar 6.4."
• ●If asked about confusion, drowsiness or change: "She doesn't know where she is, but that's the same as when she came. She's not drowsy or hard to wake and she knows her son. The only change is the evenings."
• ●If asked about eating and drinking: "About half of each meal, and roughly a litre of fluid a day when we prompt her."
• ●If asked about seeing things, cough, breathlessness, fever, falls or sore skin: "No, none of that."

Responses to Management (The Negotiation Phase)

• ●If the doctor declines to prescribe a sedative for her tea:
  • ●Reaction: Frustrated and worried about tonight. "So what am I meant to do? I've got two carers for the whole unit." He pushes once: "What about a tiny dose of haloperidol, or lorazepam? Isn't that safer than her hitting someone?" If the doctor offers to see her in person today or tomorrow morning: relieved. "Yes please, I'm here all day." If the doctor offers only a phone review later in the week: "That's days away. She'll have another four evenings like this."
• ●If the doctor explains the risks of antipsychotics:
  • ●Reaction: Surprised. "I didn't know it could raise the risk of a stroke. So when would you ever use one?" He asks how long it would last.
• ●If the doctor raises capacity, hidden medicines or a best interests meeting:
  • ●Reaction: Defensive, then curious. "I've worked in homes where the GP prescribed it for the drink and nobody batted an eyelid." If told that dementia alone does not mean she cannot decide: "I didn't realise it was that strict. Who has to be at this meeting? And what do we do tonight if she's lashing out?"
• ●If the doctor says her son needs to be told:
  • ●Reaction: Hesitant. "He's feeling guilty enough about putting her in here, and he might say no." If told the call is to ask for his help with her routine, photographs and hearing aid: "Fair enough. Would you rather speak to him yourself?" He agrees to ring him today.
• ●If the doctor suggests painkillers, a laxative or changes to her routine:
  • ●Reaction: Practical questions. "Can I give her something for her knees tonight, and how much? How long will the laxative take? Do I just skip her evening tablets?" If asked what helps: "She'd love a job at teatime, she worked a machine in a factory all her life and never sat still. And she's fine in the morning, she takes a drink and a biscuit with no bother."
• ●If the doctor gives vague safety netting such as "ring us if she gets worse":
  • ●Reaction: Wants specifics. "Worse how? When do I ring 999 and when do I ring the surgery or out of hours? The night nurse needs to know." He repeats back what he is told and asks when someone will ring him back.