“Florence Nightingale wrote about the importance of quiet for healing.” The peacefulness of the surrounding is considered as an integral part of holistic nursing. How does this work on caring for dementia patients?
A study had been conducted to determine the impact of noise to patients specially the older ones or those suffering with Dementia. After a series of observation, many recommendations were made. Although it meant making major changes and costly improvements, the administration was willing to implement these changes because it would greatly impact the resident’s quality of life. Three of the activity programs were relocated to smaller quiet areas of the building. The lobby was used for the “high functioning residents”. A conference room was utilized for the dementia population and the very low functioning utilized a sensory room.
Because programs were relocated, it meant there was a lot more transporting of the residents by the certified nursing assistants (CNA). The CNAs were asked to transport their residents to programs. For nursing homes, F248 means Nursing Assistants should be transporting their residents to programs. Traffic patterns were changed by placing a gazebo in the middle of the room, so that no one walked through the middle of the rotunda. The ceiling was lowered with special ceiling tiles to absorb sounds, extra chairs were removed, signs were placed around the rotunda reminding staff and visitors to keep their voices low. Residents were asked to either play their music in their rooms or use earphones, or use their radios outside on the patio.
Overhead paging was eliminated, as well as the overhead music was eliminated and the staff was in-serviced about the importance of providing a calm and soothing environment. All of these changes were major changes that affected the overall environment and provided a better quality of life. The facility noticed an immediate improvement in resident behaviors and staff morale.
As part of the yearly Quality Assurance program Dementia Unit Managers should conduct a Noise Study once a year. Different noises can affect behaviors and not always in a positive way. A noise study will clearly indicate what changes need to be made. Staff often times become insensitive to noise because they hear it on a day to day basis. Noise study forms are available at activitytherapy.com.
A noise study should be conducted for a full week on all shifts in every area of the facility that residents utilize. This includes dining rooms, day rooms, hallways, lobby, library, outside court yard and possibly resident rooms. Each area that is targeted will have a noise study conducted for 24 hours. You would be surprised how noisy a facility can be at night.
The nurse unit manager should document all the noises he/she sees and hears such as loud ringing phones, echo, squeaky carts, overhead paging, overhead music, unanswered call bells, staff speaking loudly, overcrowded dining rooms, ice machines, sounds at parties & religious services, dragging chairs across the floor, slamming doors, activities that are noisy, clanking of dishes, scraping of silverware on dishes, TV and Stereo volume, disruptive behaviors, vacuum cleaners and floor polishers, etc. A comprehensive noise study also observes noises from the outside, loud highway traffic, garbage trucks, dogs barking, etc.
Nursing homes are required per the state and federal regulations to provide a proper environment and the level of noise in that environment must be evaluated and corrected. In Assisted Living and Adult Day care settings, even if you do not have federal regulations or state regulations that address environment, it is best practice to provide a proper environment. Have you ever heard a resident state when she is discussing someone in the hallway who frequently yells, “This goes on all day long!” Staff may become immune to it but are we to expect the residents to adjust to this? Isn’t this a form of abuse?
Once you have conducted a noise study, the manager should meet with the team to see which noises can be eliminated. For example, loud phones can be replaced with chimes, overhead paging can be eliminated and replaced with cell phones, pagers and Walkie Talkies, staff talking loudly can be in-serviced, Volume on TV can be turned down, Talk Radio can be replaced with Companion Radio, room call bells can be answered immediately, and squeaky wheels can be oiled, soothing comfort measures can be offered to residents who are verbal and repetitive. Comfort measures would be unique to the individual but some suggestions are large lollipops (screen to be sure they can swallow), life like dolls, rocking chairs (anti tip), soothing music, outside stroll, etc.
It is very important that comprehensive interviews are conducted with family members to determine which clinical interventions or nursing practice worked in the home when someone is noted to be verbally repetitive or yells, moans, grunts, curses, etc. At one facility I consulted with, the newly admitted resident screamed day and night for a full week.
The nursing staff tried all kinds of interventions and nothing worked. At the end of the week, the staff met with family and asked what they did at home to calm the resident. The family stated, “My mom loves to watch wrestling and we left a video in her drawer.” Once this was left on for the resident she was calm! There are great free interview tools with the New York State Department of Health, called the EDGE project. The link is located on the NCCDP web site and these are free resources.
For the outside garden areas, check with your local government office to determine if you are allowed to order a sign and place outside that says, “Quiet Area”.
The point of the study is to determine what noises can be eliminated to provide a soothing environment.
How does noise impact residents? People with Dementia or Alzheimer’s disease can be more sensitive to noise. Combination of noises such as staff talking and music playing can be overwhelming.
Noise affects people differently from a mild response to an over exaggerated response or catastrophic reaction. Their individual coping style and personal tolerance to noise both will impact how noise will affect the resident. Noise can be frustrating, confusing, scary, and can physically hurt. Some common behaviors are yelling, crying, moaning, mumbling, repetitive behaviors, pacing, etc.
Equally confusing to the care giver is the resident’s perception of the noise. Especially, if they cannot tell you how the noise is affecting them. You have to be a really good detective to observe what may be upsetting them. Their behavior can be directly influenced by the noise and their capacity to deal with over stimulation. Some may have a threshold of a few minutes and others may become overwhelmed after an hour. Keep in mind that the staff and visitors coming and going can attribute to auditory stimulation.
Someone with a hearing loss naturally works harder to hear and back ground noise can add to frustration. It is important for those who wear hearing aides to check that the batteries are working. A whistling sound from the hearing aid is frustrating not only for the person wearing the aid but for everyone around them. You might arrange for a hearing test to check for hearing loss or Tinnitus (ringing in the ears).
A person with dementia may have lost physical control in a situation and is unable to make the noise go away. For example, maybe they are unable to ambulate away from the noise, or explain to someone to lower their voice. Losing control can also lead to frustration, agitation, increased pacing, out bursts, spitting, disrobing and masturbation in public places, hallucination and delusions.
Noise and over stimulation attributed to noise can affect self esteem, confidence and can lead to depression. Depression can lead to self isolation and fatalism. For those residents who pace, the noise level may increase their pacing or attempts to “escape” from the locked noisy unit. With an effective holistic nursing and by consistently conducting studies to determine the underlying causes of problems, patient care on Dementia patients can be improved.
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