Help with sundowning residents (long)

Specialties Geriatric

Published

I'm a new nurse (7 months) I started working the 3-11 shift recently and the first few hours of my shift have been pure hell lately. I have one resident in particular who becomes agitated and every day is looking for her parents, brother, husband, etc., and frequently escalates into violent behavior. She shouts and screams at other residents and throws things and rips stuff off the walls. She won't leave me or the other staff alone. She tries to rally the other residents to help her and then becomes angry at them. Day shift doesn't address the problem because she's not usually like this on their time.

Another resident complains of SOB & CP constantly, but her vitals are always fine. She's been worked up extensively. Her O2 sat is a little low but if you give her oxygen she'll take it off and then scream she can't breathe. She made herself a DNH. I have tried to placate her, give her extra attention, ignore her, been firm with her, but NOTHING works. She'll come to me more than 30x a shift. It also looks terrible to visitors and other staffers to see a nurse ignoring a resident complaining of CP or SOB.

I just need some tips for dealing with these residents because nothing I do seems to work (except PRNs which they won't take if agitated anyway).

Help, I'm ready to quit because I'm afraid I'll lose it and yell at the resident or another person on staff. It's been really hard to not lose my patience.

Any tips would be a lifesaver. Thanks.

After you have exhausted all suggestions and you still have problems. This is dementia care, sundowning is symtom of the disease. 1:1, oh sure on LTC staffing, interventions, activities helpful but lasts only a little while do to the poor attenion span/short term memory. We try to keep the worst of them on the unit to keep tabs on them, some motor around and get into trouble with other residents. We have a resident that after 4:00pm she starts to chant "vita, vita over and over, another paces, another wants to go home and trys to leave, setting the alarms off it's a zoo!! It's like night and day between the AM and PM shift. My advise is have lots of patience, keep your cool. Suggest a inservice or class on dementia care may be helpful. Hang in there!!

I recently had two patients similar to those, although not at the same time. One was discharged a few hours before the other. Patient #1 had chest pain from a broken sternum and she was terribly anxious. She got herself worked up a lot. My other patient sundowned and I swear I had the same exact conversation with her ten times in one hour, plus she kept trying to get up out of bed and she was really unsteady on her feet. Nothing I could say could assure her that a) her family could find her, and b) we all knew who she was. Ironically enough in between our conversations she even called up her family saying that all of us nurses were "strangers" and she had no idea where she was, this after fairly constant re-orienting. I was lucky in both cases because family members were there to distract the patients for at least part of the time. I found that keeping a close eye on the patient who was the sun-downer but NOT parking my cart right in front of room was a good idea. It seemed like just seeing me outside of her room triggered her almost every time and once I moved to where I could still see her very well but she couldn't really see me, she calmed down a lot. As far as my anxious patient with the sternal pain, I knew she got the cardiac work-up practically every day, and of course psych consults. I have to admit I never did figure out how to get her calmer. Having a really anxious patient almost always makes me anxious too. Hopefully I'll learn how to deal with them better in the future. :)

I think that in LTC, nurses get used to certain behaviors, or are too busy to chart all of the incidents.

Make an effort to do so, plus I really like the graph idea! I've been charting the behaviors on some of these chronic patients, and the DON says that's the only way we'll be able to get things done.

Oh God love the sundowner's because sometimes it's hard for the rest of us to.

As far as #1 "problem child" goes, I agree with a lot of these suggestions. Had one like this, major league blow ups around 8pm. Luckily his doctor happened to be on the floor at the time and actually got in there with the rest of us to wrestle him back in his chair (it eventually took six of us!). She ordered a STAT one time Haldol order and then sat down with all of us to get our suggestions. He ended up being put on several meds but none of them worked well or worked for more than 2 or 3 doses. Now though, he's declined to the point of being bedridden and just doesn't have it in him anymore to get agitated. I told the others though, watch out when he does go off again because that's not going to be a good sign.

As for #2... if all medical roads lead to nothing majorly wrong, then it could be anxiety related. Had one similar and after the doc put her on 0.5 of Ativan every evening, things drastically improved. She's happier and we all get a bit of a break. The dose wasn't enough to sedate thank goodness, but it was enough to calm her.

Best of luck.

Oh and one more VERY important thing....

DOCUMENT, DOCUMENT, DOCUMENT!!! If the person is verbally abusive to staff or others, quote every word... even the four letter ones.

WE DO BEHAVIOUR MAPPING WITCH COVERS 24 HRS AND 14 DAYS. iT GIVES US A RECORD OF BEHAVIOURS, APPROACHES TRIED, AND RESULTS. WE THEN HAVE A RECORD FOR THE DRS WHO CAN REQUEST GEREACTIC PSHYC TEAM TO GIVE THEIR APPROACH. WE THEN GET THE DAY STAFF INVOLVED IN GIVING SAY RESPERIDAL OR OLAZAPINE MID AFTERNOON ON A TRIAL BASIS IN SOME CASES OR HAVE FAMILY VISIT BETWEEN 4 AND 6PM. AS YOU SEE CHARTING IS THE KEY. AND ANY SHIFT CAN START THIS PROCESS. ALL STAFF ARE THEN INVOLVED.

PS IN OUR NURSES MAG. WE ARE NOW HAVE THE TOP MOST DANGEROUS JOB!!! MORE DANGEROUS THAN BEING A FIREMAN OR POLICEMAN ECT!!!

Specializes in acute care and geriatric.

We have a snoozeline room that works like a charm for these problems. Look it up, it is worth it!

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