8.2 Core Workflows and Decision Points

8.2 Core Workflows and Decision Points

Exam stems describe a behavior and ask for your next action. Memorize these workflows so the correct answer is automatic.

Workflow 1: Responding to agitation or a catastrophic reaction

A catastrophic reaction is a sudden overreaction (crying, yelling, hitting) to a small trigger such as a loud noise, hurried care, or too many choices.

Never respond to combativeness by arguing or by using physical force. Restraints are not used to control behavior and require a physician's order plus documented failure of less restrictive measures.

Workflow 2: Validation vs. reality orientation

This distinction is high-yield.

• Reality orientation reminds the resident of the date, place, and current facts. It helps in early dementia and for delirium, but repeatedly correcting a moderate-to-late dementia resident causes distress.
• Validation therapy enters the resident's emotional reality: you acknowledge the feeling behind the statement instead of correcting the fact. Example: a resident asks for her deceased husband. You do not say "He died years ago." You say, "You miss him. Tell me about him," and redirect.

Workflow 3: Managing wandering

Wandering is dangerous because of elopement and falls, but it meets a need for movement.

• Provide a safe path to walk; do not simply confine the resident.
• Use redirection: walk with the resident, then guide back.
• Ensure ID bracelets, secured/alarmed exits, and supervision are in place.
• Address the trigger: boredom, looking for a bathroom, or seeking "home."

Workflow 4: Reducing sundowning

Sundowning is increased confusion in the late afternoon and evening. Reduce it by:

• Increasing daytime light and activity; reducing daytime napping.
• Lowering evening noise and clutter; keeping a consistent routine.
• Avoiding caffeine late in the day and toileting before bedtime.

Workflow 5: Therapeutic communication moves

Beyond words, your nonverbal approach drives the outcome. These specific moves appear as correct answers:

• Get to eye level and approach slowly from the front; sudden moves from behind frighten residents.
• Use the resident's preferred name; check the care plan for what she answers to.
• Break tasks into single steps and cue one at a time ("Pick up the spoon" before "Take a bite").
• Allow extra time; rushing is the most common avoidable trigger.
• Use gentle touch on the hand or shoulder only if the resident accepts it.
• Match her reality: if she calls you by her daughter's name, do not correct it during care.

Workflow 6: Activity and structure

Meaningful activity reduces behaviors more than any reaction does. Match activities to the resident's remaining ability and former interests: simple repetitive tasks (folding, sorting), music from her youth, short walks, and reminiscence. Failure-free activities preserve self-esteem; tasks that are too hard cause frustration and catastrophic reactions.

Always check the unmet need first

Before any behavior is treated as a "problem," rule out the physical basics: pain, full bladder/bowel, hunger or thirst, fatigue, temperature, and overstimulation. A resident who cannot say "my hip hurts" may instead become combative during transfers. Use this quick scan whenever a behavior starts:

Solving the need usually solves the behavior, and it almost always beats any answer choice that adds medication, restraint, or isolation.

Workflow 7: Reporting and documenting behaviors

The STNA does not diagnose or change the care plan, but accurate reporting drives every decision the nurse and team make. After a behavioral event, report the ABC: the Antecedent (what happened just before), the Behavior (objective description: "struck out with right hand during a shower"), and the Consequence (what you did and what worked). Document objectively and factually; never write opinions like "resident was being difficult." Over time these notes reveal patterns (for example, agitation always at bath time or before lunch) so the team can adjust the routine.

Promptly report any new behavior, injury, refusal of care, or change in eating, sleeping, or alertness. This closes the loop between your bedside observation and the medical response, and it is exactly the judgment the exam rewards over quick fixes.

Decision summary

For any cognitive-care item, run this order: ensure immediate safety, scan for an unmet physical need, use calm communication and validation, redirect to a familiar activity, adjust the environment, and report anything new to the nurse. Restraints and as-needed medication are last-resort tools controlled by the nurse and physician, never the STNA's first move. Choosing the least-restrictive, most dignified action that keeps the resident safe is the consistent right answer.