4:30 in the Afternoon: Exit-Seeking, a Push, and Pain Nobody Asked About

What to do:

1. Approach from the front, at her eye level, saying her name - never from behind or with a hand on her arm. Touch from behind is what triggered yesterday's push.
2. Join her reality instead of correcting it. 'You're thinking about the children getting home. Tell me about them.' Arguing that her children are 60 years old produces fear and anger, not insight - she cannot be re-taught out of this every afternoon.
3. Redirect to a real task she can succeed at. 'I could use your help - can you help me fold these towels / sort this mail / set the tables?' People who feel useful stop needing to leave.
4. Walk with her, don't steer her. 'Let's walk together - I'll come with you.' Movement together discharges the restlessness.
5. Offer a snack and something to drink, and check whether she needs the toilet.
6. Reduce the noise and crowd in the hallway during that hour; sundowning is worse with stimulation.
7. Keep her in sight and notify the nurse if she is escalating.

What to avoid:

• Physically blocking the door or holding her arms - that escalates and can injure both of you.
• Restraints of any kind, including a lap belt or a wheelchair pushed against a wall, without a licensed order and never as convenience.
• Correcting, quizzing ('Do you know where you live now?'), or reasoning.
• Rushing her. Every step of the setup says 'staff are in a hurry'; slow down and she will too.
• Taking the behavior personally and labeling her 'combative' in the chart.

The push was communication, not aggression. Plausible causes, and every one of them is checkable:

• Pain. She has knee arthritis, her acetaminophen was due at 1400 and was given last at 0800 - she was hours past her window at 1630, standing on arthritic knees at a locked door. Pain is the most under-recognized cause of 'behavior' in dementia.
• Startle and fear. Being grabbed by the arm from the side by someone she may not recognize reads as being seized.
• Being rushed. 'Staff are in a hurry' plus a locked door equals resistance.
• Loss of control in a place she has lived in for six days.
• Delirium on top of dementia - consider it if there is any new confusion, change in sleep, or a recent illness. Six days into a move is a high-risk window.

How it changes your approach:

• Ask her about pain directly ('How are your knees today?'), watch her face and guarding when she stands, and report to the nurse so analgesia can be timed.
• Request the PRN acetaminophen 45 to 60 minutes before care - a shower at 1700 with no analgesia on board is a setup for another push.
• Change the approach: front, eye level, name, one instruction at a time, choices ('shower or wash at the sink?'), no grabbing, allow double the time.
• Change the timing: move the shower to morning when she is calmer, and give her the same caregiver each time.
• Never chart 'combative' as a trait. Chart what happened and what preceded it.

Report to the nurse:

• New physical aggression (pushing) - a change from baseline, which is what makes it reportable rather than routine.
• The probable pain: arthritis, PRN acetaminophen last given at 0800, due at 1400, standing and weight-bearing at the door at 1630. Ask whether the dose can be scheduled rather than PRN, and whether timing can be adjusted.
• Three days of shower refusal and refusal to sit on the toilet with rushed staff - the nurse needs to know, both to protect her skin and continence and because refusal is a symptom.
• Exit-seeking at 1630 to 1800 daily - pattern and time.
• Any sign of delirium (new confusion, fluctuating attention, new incontinence, poor intake) so the nurse can screen for a urinary tract infection or other cause.
• Any injury to the aide or the resident from the push.

What the care plan should reflect - and you are a legitimate source for these suggestions:

• Shower in the morning, not during sundowning; consistent caregiver; choice of shower or sink wash.
• Analgesia 45 to 60 minutes before bathing or ambulation, as ordered.
• Approach techniques: from the front, name first, one step at a time, no grabbing, extra time.
• Evening activity at 1630 - folding, sorting, a walk - and reduced hallway noise.
• Toileting schedule with privacy and no rushing.
• Door alarm and supervision per policy, with no restraints.

Document objectively: 'At 1650 resident at unit door with purse stating she must get the children from school; redirected to folding towels, walked with staff to activity room, remained there 30 minutes. No distress noted.' That record tells the next shift what works.