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Lev <3, BSN, RN 45,732 Views

Joined Jun 3, '11 - from 'Another planet'. Lev <3 is a ED Registered Nurse. She has '4' year(s) of experience and specializes in 'Emergency - CEN, upstairs, troll bashing'. Posts: 2,772 (53% Liked) Likes: 5,134

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  • Apr 23

    Quote from heron
    Every psych nurse I have ever worked with has said never argue with delusional patients ... that goes for delusions due to medical issues as well as psych. I have found that it helps to keep my interactions concrete and directive and to either ignore or deflect delusional statements (i.e. "I'll see about the ice cream later, right now we have to clean you up/check your blood pressure/give you this medicine, etc.") Accept the fact that you cannot re-orient him ... continuing to try just wastes your time and aggravates him.

    And did I mention stop giving him Ativan?
    As a psych nurse, I agree with all of this. You can give the reorientation the old college try, but I wouldn't persist on trying to make the patient AO4 (or as close as you can get), every single time you enter the room. You shouldn't feed into the delusion (i.e., don't agree with the red box being full of Blue Bell) but look for the underlying message and see what you can do for it. "The red box on the wall doesn't have ice cream but I'll see if I can get you some. First I have to...". Just like Heron said.

    Also, while Ativan and other benzos are often relied upon to snow aggressive patients, they can actually be activating/stimulating to a small percentage of the patient population. They do use Ativan to treat catatonia, after all And I see benzos frequently having this paradoxical affect in older patients. When benzos do that to a patient, we'll shelf them and use antipsychotics such as Haldol or Zyprexa to calm them down.

  • Apr 23

    "The red box refrigerator failed and the ice cream melted. Bad electric socket. Nowhere to put any new ice cream. We need the electrician in the morning to fix it."

    Reality orientation is USELESS. You don't argue or contradict. Silence won't work either. Their safety filter doesn't work. And they don't recognize their physical limitations. Very short attention span. No current memory but old memories are 'current'.

    You have to gracefully figure out some 'therapeutic fibbing' approach. LTC/Alzheimer's units' staff know this well.

    The info has to be simple, like child-level. Has to have some logic that even a child could understand. Stays neutral - doesn't commit to a 'yes' or with a 'no'.

    And SHORT, SWEET, and BRIEF.

  • Apr 23

    I think the pt would definitely benefit from a re-vamp of his meds. If he's still on oxycodone as an inpt, then it's time to rotate. There's a reason that "oxy" is called hillbilly heroin ... it crosses the blood-brain barrier very easily and is probably one of the most high-making opioids in use. Possibly the worst option for pain control in a delirious pt, in my view.

    Get rid of the Ativan and switch to haldol, geodon, seroquel ... whatever antipsychotic psych recommends for rapid control of severe agitation r/t delusional or hypomanic states. They did get a psych consult, right?

    Every psych nurse I have ever worked with has said never argue with delusional patients ... that goes for delusions due to medical issues as well as psych. I have found that it helps to keep my interactions concrete and directive and to either ignore or deflect delusional statements (i.e. "I'll see about the ice cream later, right now we have to clean you up/check your blood pressure/give you this medicine, etc.") Accept the fact that you cannot re-orient him ... continuing to try just wastes your time and aggravates him.

    And did I mention stop giving him Ativan?

  • Apr 23

    As others have said, first on the priority list would be to get rid of the benzos, while they are tempting since they give the patient (and you) an hour or so of calm, it only perpetuates and worsens the delirium (aka "pump head" in hearts, even though it's not from the pump).

    The best way to keep a delirious patient from pulling at art lines, chest tubes, and foleys is to not have them in, since the patient is two weeks post-op and still has an art line and chest tubes (and I assume a feeding tube) it would appear the patient has not had a normal post-op course, but the sooner those can come out the better.

    There's been evidence building for the use of melatonin in delirium, not just because it might help them sleep but also because the decreased melatonin production that occurs in the hospital environment might directly contribute to delirium as well.

    Tire them out as much as possible during the day and maintain a normal sleep-wake cycle as much as possible, Seroquel at night, get rid of all alarms that aren't absolutely necessary, music, etc. At some point he'll finally get some normal sleep and get over the hump, at which point he'll probably sleep for two days straight, which will freak the doctors out, give them the Ativan you aren't giving the patient.

  • Apr 23

    On my unit we avoid giving benzo's and benadryl to the older population since it tends to aggravate the problem of psychosis/delirium.

    We try risperdal/seroquel/haldol instead, some of other things you can do to help is dim the lights, customize your alarms to prevent nuisance alarms (e.g. knowing your patient has A-fib, but monitor dings every minute telling you it's A-fib), playing music in the room via pandora or other service/device. Lastly sometimes placing the patient on a 1:1 helps.

    I try not to put mitts and/or soft wrist restraints because more often than not it makes the patient even more agitated and next thing i know they bit off a mitt, cotton is everywhere and an IV is out.

  • Apr 23

    Environmental control? And you don't say how old he is.

    With my gero-psych dementia pts, I found that a soft minimal light with gentle music helped. They do need to be able to see surroundings.

    One time I found a gospel radio station and the first song was "Amazing Grace". That LOL stopped her thrashing about and fell asleep for about 30 some straight minutes. Never saw anything like it before that. And NOTHING has quite worked as immed as that time.

    Religious/gospel does seem to work best. 'Elevator music', 'easy listening', and then 'big band/1940s' all seem to work with a geri population of 70 y/o & up.

  • Apr 23

    Agree with Heron: benzos and opioids are likely not helping. There are other options for both categories that they provider can use.

    Soft wrist restraints and mitts are also an option, though those are usually an "we tried everything else first and nothing worked" option. Still, they could help, and they could (should!) always be removed once the patient is asleep.

    Also you need to really dig for the cause of the delirium, as it's a symptom of an underlying problem. It could be the meds. But it could also be an infection (related note: my father caused a Code Green because he was delirious d/t a respiratory infection. They needed 6 staff to control him). Or it could be an electrolyte imbalance. How do his labs look?

  • Apr 23

    UTI? How is his fluid load?

  • Apr 23

    Ditch the benzos, they are probably aggravating, if not causing, the delirium. On my AIDS unit we frequently encountered delirium. The psychiatrist always immediately d/c all benzos and treated with antipsychotcs. Consider re-evaluating the opioids. In hospice, we frequently found that rotating to a different opioid helped to limit adverse reactions.

  • Apr 21

    Dear OP,

    I am so sorry to tell you what you probably wouldn't like, but here is the reality:

    - it is schools which lure students into nursing by promices of crisises-secure, well-paid jobs.
    - it is schools which set uselessly high standards for admission.
    - it is schools which spread lies about "job security" for nurses and thus attract adult, mature second-career seekers there
    - it is schools which fill schedules with academuc fluff which takes a lot of time and brain to study but has zero practical importance
    - it is schools which tell students about 500 things they can do with their BSNs
    - and then it is workplace which treats these VERY bright, VERY highly motivated, still young, ambitious people like underhumans.

    Do you really expect that someone bright enough to pass college stats with A (plus all other hard science classes) will allow himself to be treated like the worst crap in human history for long when he sees the same sort of dude drinking coffee and putting orders online 8 to 5 weekdays for twice more money? That someone who was a boss himself for years will allow someone twice younger yell on him for breathing 0.652 times/min more than "we always do here"? It's not gonna happen, and NP schools know it. That's why they are so darn successful.

    My NP program did a test on my MSN class for a group of DNP students. The questionnaire was about NETY and lateral violence. 90+% students stated that they had experienced it, 70% of them "more than just a few times" or "systemically". Mean class GPA cumulative 3.89, mean nursing work stage 2.5 years at the moment of admission (the program requires at least 12 months). Does it tell you something?

    Since, with healthcare as it is today, the standards of nursing education cannot be decreased, you can reasonably do only one thing: make students and new grads loving bedside. Make them welcome. Invite the brightest, the most daring and ambitious with open hands. Make academical achievement seen and matter. Weed out any remnants of NETY and lateral violence. Make job more physically and mentally tolerable. Make nurses more autonomic, more responsible, make their voices heard. Stop customers' and policies' kissing. And stop singing into school's lies.

    There always will be some who go to nursing school with the single goal of getting advanced degree. Accept it. But for the rest, you can make this change if you and everyone else treats them good enough.

    Sorry for being blunt. But when a majority of MSN class in a quite high-ranking institution openly states that all of them practically run away from bedside due to unhuman conditions there, it means something.

  • Apr 21

    When it boils down to it, I really wish that nursing was less blue collar and more decorous and professional. Some of my colleagues sound and act like rowdy high school kids. They forget there are patients in the rooms and loudly socialize at the nursing station.

    They form immature cliques and and engage in lowbrow social posturing, making ribald remarks. A few of them make egregious grammatical errors in every day speech.

    I'm hardly a prudish stick in the mud, but if nursing is going to be a true profession we need to start acting like college educated, white collar people who don't spend our down time in bars...

  • Apr 19

    I'm an ICU nurse, and I know I couldn't handle LTC. Twenty patients, my GOD! I cannot imagine taking care of 20 patients -- although I do remember taking care of 15 med/surg patients. My Med/Surg patients would take a handfull of pills and SWALLOW them. I didn't have to crush them in applesauce for this patient or mix them with ice cream for that one, and somehow keep straight which is which. When I took them to the bathroom, most of them remembered why they were there and took care of things. Showers and baths weren't negotiations . . . . But I digress.

    LTC is a valuable specialty. My mother had Alzheimer's and was in A wonderful ALF, then a wonderful LTC for the last several years of her life. I cannot imagine doing what those nurses do. I tried taking care of Mom at home for three weeks before I was psychotic from sleep deprivation. The minute I closed my eyes, Mom was either trying to burn the house down, going outside barefoot in her nightgown (Wisconsin in January -- 37 degrees below zero) or stuffing rags in the drains before turning the water on full blast . . . stuff like that. I don't know how people do it. By the time we got her into an ALF, I was hallucinating from lack of sleep. And those nurses handled all of her antics as if it was no big deal -- just all in a day's work -- without making her (or me) feel as though she was exasperating them. Those are skills I just don't have. I have incredible respect for those who DO have those skills and use them to create and maintain an environment where my mother was safe, comfortable and felt cared for. There are some truly amazing LTC nurses out there, and I'm terribly fortunate to have encountered so many of them in my mother's illness.

  • Apr 19

    My mother just had to be admitted to a LTC facility last week. I can only hope that the nurses that are taking care of this wonderful, 95 year old woman, who took care of others all of her life, don't look at taking care of her as "lame." She has lived her life for others and deserves dignity and respect from anyone taking care of her.

  • Apr 19

    I went back and read the thread you started about a year ago in which you also insulted the LTC specialty. You fell over yourself apologizing when you were called on it then. Those apologies don't seem to mean much, as this is truly the way you really feel, about all of those nurses and about yourself. How do I know this? Because here we are, exactly one year later, having the exact same conversation.

    Brutal honesty here.....I have no patience for this. If you hate it, go do something else. You are past the year mark. Reapply at the hospital that fired you if you would rather be there, but knock off this "poor me" stuff. It is unattractive and habit forming. You aren't a victim of anything but your own imagination at this point.

  • Apr 19

    I don't really like passive aggressive and that is what this sounds like to me. You would rather do a different kind of nursing and you feel like those are the cool kids and you aren't cool enough to be one of the cool kids so you will post here about how not cool you are in hopes that people will jump up and tell you no no no, you really ARE cool...or at least, that is how it reads to me.

    Your skill set is both needed and valuable. If you want to do a different kind of nursing, go for it. LTC is not "lame" and nobody in nursing deserves a poor paycheck. Geriatric care is a wonderful specialty full of really REALLY special people. If you don't want to take pride in what you do, we can't help that, but I can tell you, tons of nurses in LTC DO take pride in what they do and rightly so. Don't insult them in your attempt at validation for yourself. They don't deserve that.


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