pacify or orientate? Alzheimers... - page 16

So I have worked my third day as a LVN in a LTC facility. Orientated for one day then turned loose...on the alzheimers lock down unit. 21 residents. A little scary, but I am fairly comfortable, so... Read More

  1. by   Leolion
    I agree that reorientation isn't always the way to go it depends on the situation where I work we have a resident who is always looking for his car and if you tell him that its safe in the garage he is happy but if you say you don't have a car he is very upset
  2. by   Critical LPN
    Quote from joliesmomizaRN
    All I can add here is that as a nurse, Jesskanurse, has a long hard road ahead in learning the difference between textbook knowledge and the real world. I pray, for the sake of all the patients with alzheimers/dementia, that she never comes in contact with them because I believe it would be unethical not to mention cruel to deliberately torture them with information that will only cause them grief over and over again. Sometimes common sense is the best experience you can have as a nurse.

    :yeahthat:...........While yes it is the accepted ( and believe me, document, document..) and proper thing to do to try (operative word), to orient the confused patient, one must remember that someone who has the clinical diag. of Alz. or other psych diag. that does not let them process reality at the moment cannot be reoriented to that moment. It is a horrible thing to feel you are lying to the patient and also the fear that co-workers or pt. relatives will hear you trying to agree with or make up a story to keep the patient happy.

    Do I hold steadfast with my teaching and constantly try to orient the pt. regardless of how it makes her act or feel just to protect my license? Must I be like those in the ivory towers of upper levels of schooling and :mortarboard: management who while are valuble resources and filled with book and controlled (while in nursing school and advanced practice education) situations, that have forgotten what it is really like working on the floors when you are responsible for umpteen patients, each more disoriented then the next? Also the pt. to nurse ratios are worsning everyday , making it impossible for the caring and resposibleness to take time for orienting constantly. Or do I go out on that limb called critical thinking skills (does not just mean critical care nrsg. thoughts and trx., but also the ability to take a challange and think out a process to to the best end result possible.) Also called good old "common sense" back before I ever became a nurse.

    Might try making up a list of the patient's life dreams, family dynamics, life before the mental deterioration: what was their former job in life(this I find can be really educative for you as the nurse,as remember......the past is ususally the most clear and really accurate time they know and sometimes very interesting to you also when you find out they had a really intersting life or a historical event maker. ), were they in the military? Did they do work that helped the military?(like women at the USO's, collecting items like hose, metals etc,. for the war effort?), what is their favorite type of music and ask the family to bring in a few tapes and a recorder, where in the world did they live and let them tell you of the adventures they have had over the years(and if you think the story sounds embellished and fictictional, remember sometimes, truth and reality is stranger than anything that could be made up .

    Always assess(yes ...thats right, assess the moment you are dealing with in the now). How is the patient's rationality, what is your normal raport with the paient? Are you rushed and not going to have time to deal with the possible lengthly aftermath to your question/answer, response when dealing with the pt.? All needs to be considered and if you feel that the patient can (at that moment>>>>>),possibly absorb some truth to whatever the situation, then by all means try to orient. If not, then you learn to pick non truths well leaving them broad and plausible without really lying to the patient. The story earlier in this thread of the nurse and "milking the cows" was a good way to passify the pt. but since she really was lying to the patient, a goody-two-shoes co-worker or family member might overhear and then report her, putting her in a legal bind. I have found that taking the broad sense approach (in this case, making sure the cows were milked) works well without being specific, thus less possible ammunition in a court to be used against you. Perhaps stating that a fellow named John,Mike, Fred or whatever is milking the cows and all is fine, if the patient needs reassurance it is done. After all, surely there is a farmer somewhere in the country that has the name you choose to make up that is doing just that
    (milking the cows), thus not really a lie but using the broad scope of your imagination that will work with the patients (in the now). You did not state it was the cows she was referring to, but that cows were being milked, thus no true lie to patient could be used against you.

    Most patients can be redirected if at the very moment you do whatever it is to passify them, you give them a task or a job to do for you. Sometimes just giving them some papers and have them reorganize them for you or fold some linens all over again. It is well documented in many books and journals that many Alz. patients had type A or obsessive work drive personalities and thus the need for a constant to keep them as grounded as possible and increases their feeling of worth and importance. It is difficult however, to broad lie when it is a specific person they want or want to talk to that is not available . Then sometimes you can get them to tell you a little about this person and what they did together or what common interests they had that can stretch to you shring a common interet or event , therefore, changing the subject in a direction toward you or the patient and off the original person they were trying to get ahold of. Also can lead to someone else that in their social circle that you just might be able to get ahold of . :blushkiss
  3. by   lvs2nrs3535
    Quote from Critical LPN
    :yeahthat:...........While yes it is the accepted ( and believe me, document, document..) and proper thing to do to try (operative word), to orient the confused patient, one must remember that someone who has the clinical diag. of Alz. or other psych diag. that does not let them process reality at the moment cannot be reoriented to that moment. It is a horrible thing to feel you are lying to the patient and also the fear that co-workers or pt. relatives will hear you trying to agree with or make up a story to keep the patient happy.

    Do I hold steadfast with my teaching and constantly try to orient the pt. regardless of how it makes her act or feel just to protect my license? Must I be like those in the ivory towers of upper levels of schooling and :mortarboard: management who while are valuble resources and filled with book and controlled (while in nursing school and advanced practice education) situations, that have forgotten what it is really like working on the floors when you are responsible for umpteen patients, each more disoriented then the next? Also the pt. to nurse ratios are worsning everyday , making it impossible for the caring and resposibleness to take time for orienting constantly. Or do I go out on that limb called critical thinking skills (does not just mean critical care nrsg. thoughts and trx., but also the ability to take a challange and think out a process to to the best end result possible.) Also called good old "common sense" back before I ever became a nurse.

    Might try making up a list of the patient's life dreams, family dynamics, life before the mental deterioration: what was their former job in life(this I find can be really educative for you as the nurse,as remember......the past is ususally the most clear and really accurate time they know and sometimes very interesting to you also when you find out they had a really intersting life or a historical event maker. ), were they in the military? Did they do work that helped the military?(like women at the USO's, collecting items like hose, metals etc,. for the war effort?), what is their favorite type of music and ask the family to bring in a few tapes and a recorder, where in the world did they live and let them tell you of the adventures they have had over the years(and if you think the story sounds embellished and fictictional, remember sometimes, truth and reality is stranger than anything that could be made up .

    Always assess(yes ...thats right, assess the moment you are dealing with in the now). How is the patient's rationality, what is your normal raport with the paient? Are you rushed and not going to have time to deal with the possible lengthly aftermath to your question/answer, response when dealing with the pt.? All needs to be considered and if you feel that the patient can (at that moment>>>>>),possibly absorb some truth to whatever the situation, then by all means try to orient. If not, then you learn to pick non truths well leaving them broad and plausible without really lying to the patient. The story earlier in this thread of the nurse and "milking the cows" was a good way to passify the pt. but since she really was lying to the patient, a goody-two-shoes co-worker or family member might overhear and then report her, putting her in a legal bind. I have found that taking the broad sense approach (in this case, making sure the cows were milked) works well without being specific, thus less possible ammunition in a court to be used against you. Perhaps stating that a fellow named John,Mike, Fred or whatever is milking the cows and all is fine, if the patient needs reassurance it is done. After all, surely there is a farmer somewhere in the country that has the name you choose to make up that is doing just that
    (milking the cows), thus not really a lie but using the broad scope of your imagination that will work with the patients (in the now). You did not state it was the cows she was referring to, but that cows were being milked, thus no true lie to patient could be used against you.

    Most patients can be redirected if at the very moment you do whatever it is to passify them, you give them a task or a job to do for you. Sometimes just giving them some papers and have them reorganize them for you or fold some linens all over again. It is well documented in many books and journals that many Alz. patients had type A or obsessive work drive personalities and thus the need for a constant to keep them as grounded as possible and increases their feeling of worth and importance. It is difficult however, to broad lie when it is a specific person they want or want to talk to that is not available . Then sometimes you can get them to tell you a little about this person and what they did together or what common interests they had that can stretch to you shring a common interet or event , therefore, changing the subject in a direction toward you or the patient and off the original person they were trying to get ahold of. Also can lead to someone else that in their social circle that you just might be able to get ahold of . :blushkiss
    Question....
    Can you really be sued for pacifying a patient who has no memory of day to day living? Is this truly a worry?
    Yikes.
  4. by   leslie :-D
    i tend to doubt that a family member or coworker hearing you lie to an upset, alzheimers' pt, has any legal grounds at all.
    first of all, experts are always changing their theories and proposed interventions. it is not a science.
    the research i did, revealed therapeutic lying is widely accepted.

    but what is more important, is the intent.
    when anyones' intent is to relieve suffering (no matter what form it takes, or how it manifests itself), then you are indeed upholding your oath "to do no harm".
    i will repeat, i am not rubberstamping this particular intervention to all alz patients.
    rather, it is implemented specific to the pts' presentation, the stage of the dementia, the level of disorientation/agitation/fear. there are many consideration when applying it.
    but any judge (if it even made it to court, which i highly doubt) would agree with the goal of removing stressors and bringing peace to the patient.
    i would bet my nsg license on it.

    leslie
  5. by   lilypad2424
    Has anyone ever seen "The Notebook?"
  6. by   lilypad2424
    Thank you. Well done, etc.
  7. by   Nascar nurse
    Quote from earle58
    but any judge (if it even made it to court, which i highly doubt) would agree with the goal of removing stressors and bringing peace to the patient.i would bet my nsg license on it.leslie
    Me too. And if they didn't... is it really an enviornment I want to be a part of anyway? Nope not me, just not gonna tell a sweet little ole lady that her husband died 30 years again over and over. Cruel and heartless.
  8. by   P_RN
    We keep a "Notebook" at Mama's. I also had written a short story about how my parents met. She reads it many times a day. And each time she says "This is my life story."
  9. by   MedSurgeMess
    Quote from lilypad2424
    Has anyone ever seen "The Notebook?"
    Loved it...bawled my eyes out...best love story ever...going to go watch it now
  10. by   grandee3
    My first nursing job was on a LTC Alz. unit. It was very sad at times.
    I had a patient come to the dest saying "I'm here to buy a new car." And another man who was trying to hook up with one of the ladies, came to the desk and wanted to rent a motel room. A few days later he was shipped out to a psych unit because he was found on top of the woman in her room.
    (they both still had their clothes on). His wife was soooooo wonderful, when she was told why he was transferred she said, in a calm, low voice "He never acted like that before, I wish I could have my husband back.) The woman was only 59 years old and was one of the saddest case of Alz that I have ever seen.
    What really made my heart sink was the residence that never got a visit, call or card from relatives. I guess some people deal with it in different ways. I guess they cant stand to see their family member in that state.
  11. by   Katnip
    Quote from Jesskanurse
    Yes, It may be unethical in YOUR OPINION to tell her that... but any ethics board would tell you that you are wrong. As for your last sentence: How do you know what will damage your resident and what wont?? You dont. You are just using your own feelings and displacing them on the patient. You think it will damage her. Who are you to decide this? THAT is why it is unethical. What if there is a stage of the grieving process that she hasn't gotten through just because nurses are uncomfortable seeing her in anguish? I think that is what is happening. You cant have peachy happy patients all the time. Sometimes that anguish is therapeutic for them.
    If you bother to get to know your residents you do know what will harm them.

    By the same example you use here, how do you know that what she needs is to relive pain over and over again? How do you know that she hasn't already gone through the grieving process but your "orienting" her takes her back to a very painful stage.

    I agree that you cannot just rely on theory and what other people who do not have experience in the field say.

    My geriatrics instructor told us the same thing you are seeing here. In the very early stages of Alzheimer's or similar dementia it's ok to do some orienting. But at some point they reach a stage where they no longer live in this reality and agitating them just to make yourself feel better is wrong.
  12. by   quibron
    wow! how wonderful to know so many of you are extremely aware of how to help a dementia patient with what you term 'therapeutic lying'. I am an RN and wish you were all working with me. However, definitely not you Jesskanurse. How would you like to be given bad or frightening news about your life 10times to 200 times every 24 hours, or even once...? well that is how these people react to reality orient (whatever makes you happy here). How about 'dont be silly, your over 80, your mums dead, so's your dad" as an answer to "I've got to get home, mum will be worried sick, she doesn't know where I am". being asked 50 or more times a day.....the grief may only last a few moments or minutes, but it is there and recognisable....go back to selling books or something but PLEASE keep away from nursing until you learn how to be a nurse as you will meet these sweet, wonderful and sometimes quite dangerous people in every aspect of nursing and I certainly would not like your ideas anywhere near someone I love or look after.
    And good on you Lfransis, keep asking questions and don't give up, you will feel like you are walking on a cloud when you leave work once you get to know and understand all these different wonderful people we call dementia's. And we do have cows around our facility, so don't even have to pretend, actually a very pacifying pastime for them to watch the cows.
  13. by   Katnip
    If I have Alzheimer's and someone told me over and over that, no my son Andrew isn't coming because he died a long time ago, that would be so cruel.

    I cannot imagine anyone wanting to do such a thing. THAT would be unethical.

    At the end of my life, let me have the peace of having my loved ones with me, even if it's only in my imagination.

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