Afternoon Agitation and a Daughter at the Door
Mr. L is 88 with moderate dementia, admitted three weeks ago. Every afternoon around 1500 he becomes restless, paces the hallway, and refuses his shower; he has refused three days running. It is now 1510, he is calling for his wife, who died two years ago, and he has pushed your hand away twice when you approached with the towel. His daughter arrives at 1600 for a scheduled visit and has already told the charge nurse by phone that she expects him to be "clean and showered" when she gets there. The shower room is free and there is another aide on the unit.
1. What is your approach in the next 30 minutes, and what would you deliberately not do?
Read the worked answer
Rule out causes before treating it as "behavior": Is he hungry, wet, in pain, too warm, overstimulated by the hallway noise, or needing the toilet? Late afternoon restlessness often tracks with fatigue and hunger. Offer a snack, toileting, and a quiet chair away from the traffic.
Do not:
- Correct him about his wife. "Your wife died two years ago" re-grieves him each time and does not change what he is feeling. Meet the feeling: "You miss her. Tell me about her."
- Argue with or physically steer a person who has pushed your hand away twice - that is a stop signal. Continuing is a restraint in effect, even with no device.
- Promising the daughter a shower you cannot deliver.
Do instead: Offer a choice - "shower now, or after your daughter's visit?" - and accept the answer. If he chooses later, that is a plan, not a failure. Warm washcloth and fresh shirt now is a reasonable alternative that preserves dignity.
2. He finally agrees to a shower at 1620, during his daughter's visit. What do you do about the scheduling conflict, and how do you handle the daughter?
Read the worked answer
Take the yes. A cooperative moment with a person who has refused three days running is not the time to protect a 1600 visit slot. Ask the other aide to sit with the daughter for a few minutes, or tell her at the door: "He's chosen to shower right now - it's the first time in three days he's agreed. Give us 20 minutes."
With the daughter:
- Lead with what she actually cares about - that he is clean and cared for - and frame the delay as her father's choice, which it is.
- Do not defend the three days of refusals as if they were staff laziness; explain gently that afternoons are hard for him and that forcing him was not an option.
- Do not discuss his care in the hallway, and do not promise it won't happen again.
Report: the refusal pattern, the time of day it clusters, what worked (choice, quiet, snack), and the daughter's expectations - the nurse needs that before the next care conference.
3. What is the difference between this resident's right to refuse and the care plan's expectation, and how do you document the conflict?
Read the worked answer
The distinction: The care plan describes what is offered and how often; it does not override a resident's right to decline a specific intervention, and dementia does not remove that right. What the aide owes is repeated, respectful offering, attention to why, and reporting - not compliance by persuasion or force.
Document:
- "1510 - restless, calling for wife; offered shower, declined; pushed hand away x2; stopped. Offered snack and toileting; accepted snack. Calm with 1:1 conversation about wife."
- "1620 - accepted shower with one assist; no injury."
Why: A bare "refused shower" reads as noncompliance and leads nowhere. The same entry with time, trigger, behavior, and what worked is what lets the team find a schedule - for example, mornings instead of 1500 - which is the actual fix.
Also report, don't decide: whether this is a change in condition needing assessment is the nurse's call.