How do you deal with disoriented patients?

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    I'm a pretty logical person, so I become absolutely at a loss when I have a disoriented patient who wants to do something that isn't possible. I haven't started working in the ICU as an RN yet because I just passed my boards this week, but here were some situations I encountered during my ICU externship last year where I didn't really know what to do:

    Example 1:
    Lady with breast cancer with mets to the lungs had SIADH. She had a foley in, and 2 chest tubes that pulled out 5L fluid the previous day, was on fluid restriction, and had Na in the 120s. She was a very sweet woman and didn't have hallucinations or anything blatant like that, but her behavior came off as being sort of hysterical at times and ranting & raving. She kept begging me to take out her foley because it was bothering her. But since her major issue was with fluids and Is & Os monitoring would be extremely important, I don't think that would have been a possible option. Also, with Na in the 120s...staff usually don't do the demands of patients who are not likely to be in their right minds. Except that she was technically A&Ox3. And she kept screaming about how she knew her rights, and she knew that she was allowed to refuse treatment if she wanted to and she wanted her chest tube & foley out right now!!! So, I didn't know what to do (and it wouldn't have been my judgment to make anyhow, I was just the student. But also the person who had to talk to this woman face to face for the longest period of time...). I mean, she does have the right to refuse treatment of course...but...what do I say to her? "Sorry, we think you're batty so you no longer have the right to refuse treatment"? I tried explaining why they were necessary, and offered her the morphine that she was prescribed if she had pain, but she didn't care about the explanations and didn't want the morphine. I tried giving her a backrub, distracting her by getting her to tell me stories, and those measures worked for short periods of time. She would get into a story and forget about the chest tube and foley for a while. And sometimes she'd fall asleep. But then she'd suddenly remember that she didn't like them again and start screaming again. *sigh* I was so worn out by the end of that day. What would you all have done?

    Example 2: Recently extubated COPD patient was definitely disoriented. Kept insisting that I "check her mail" that was "right over there! Don't you see it!! WHY WONT YOU CHECK MY MAIL??". She got really aggravated with me because I wouldn't let her climb out of bed to go to the bathroom (fall precautions, had a foley in). I tried explaining to her that she had a catheter sitting in her bladder, and that she wasn't supposed to climb out of bed yet, but she was to confused to understand. So she was all like "help me put on my shoes so I can go to the bathroom" and "why are you aggravating me????" when I tried to keep her from climbing out of bed. *sigh* another tiring day. I tried combing her hair, distracting her, etc etc. but it didn't work for more than 2 minutes. What do you do with patients who are constantly trying to climb out of bed and picking at their lines and get really mad at you for trying to stop them from doing that? Do you just suck it up when they yell at you to "shut up" and "leave me alone" and keep at it? I mean...you can't very well just let them get out of bed or pull out their IV right? So what do you do?

    Advice would be extremely appreciated.

    Thanks,
    Newbie ICU nurse
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  3. 9 Comments so far...

  4. 1
    The first intervention that I usually try is to reorient the patient.

    If, (usually when) that fails, my unit will usually start the patient on Haldol or Risperidone for acute delerium. We tend to avoid the benzodiazepines since they can exacerbate delerium in some cases.

    I also try to coordinate with the day shift staff to try and return the patient's wake/sleep cycle. Especially if the patient has been intubated for several days they wake with no idea of day or night, and the constant activity of the unit doesn't help. We give them medicines for sleep during the night to encourage nighttime sleeping, give them their bath on dayshift, interact with them to keep them awake on days, and restrict the administration of drugs that cause sleep during the day. We also simply try to get them to the floor where they can have a more normal routine.
    drenched likes this.
  5. 1
    "Also, with Na in the 120s...staff usually don't do the demands of patients who are not likely to be in their right minds. Except that she was technically A&Ox3. "

    -remember they may be alert and oriented x3, but her GCS would be a 14/15- Yes she knows where she is and what is going on, but clearly her decision making capacity is impared. She is not totally with it. I would have gotten an order for haldol or valium or something to keep her calmer. The haldol would have helped with any delusions. The other day for example, we had a patient with a subdural bleed. He was able to walk, talk, knew the date, time, why he was here, but he would still do weird and bizarre things like disconect the iv's, and disconect the foley to go pee so he had to be a 1:1 constant as he kept disconecting his central line. Your patient probably didnt have the right to refuse treatment, and I would have told her that she is not thinking clearly and the treatments have to be done. If she was a danger to herself of pulling out her chest tube or central line, then we would restrain her on our unit. Its for their safety. All she would need is a pneumo or an air embolism.




    " What do you do with patients who are constantly trying to climb out of bed and picking at their lines and get really mad at you for trying to stop them from doing that? Do you just suck it up when they yell at you to "shut up" and "leave me alone" and keep at it? I mean...you can't very well just let them get out of bed or pull out their IV right? So what do you do?"

    With her she has the potential to become aggrivated/abusive. I would try to cluster my care so I didnt have to bother her when not necessary. Again, on our unit she would probably be restrained. It wouldnt need to be terribly tight, but enough to prevent her from getting out of bed. Definately get some haldol ordered as she is clearly hallucinating.

    Remember, most patients at one time or another in ICU have delerium/ICU psychosis. Try googeling it and you will find info. Its is almost always transient and goes away when they are better and close to discharge. To prevent ICU delerium from getting really bad, try to ensure they get sleep at night by getting all your work done before 23-2400 hrs to ensure longer rest periods. Minimize light in the room at night. You will have to wake them up at 4 am for assesments, but do whatever care you need to do then. The narcotics and sedatives may contribute, but may be necessary in the short term.Having someone thrash around in bed is doing more harm than good. Sometimes having family in to visit helps, but sometimes it doesnt depending on the family.


    Keep in mind, if the delerium suddenly gets worse, assess your patient. Are they dehydrated? Neurological defecits that werent there before?

    Hope this helps
    drenched likes this.
  6. 0
    Thanks for the advice. It is very helpful. I will definitely try to cluster care to leave the patient alone. But when constant supervision is necessary it's hard not to interact with them. =/

    I guess everyone takes verbal abuse differently. One nurse was belligerent right back to her disoriented patient when he started randomly yelling at her and upped the Haldol. Another nurse was just like "All right dear, I'm sorry you feel that way" when her disoriented patient was yelling "YOURE AN UGLY *****!! BIIIIIIIITTTCH!! LEAVE ME ALONE YOU HAG! I HATE YOU!!" I'm not sure what my style is yet. I don't intend to pick fights with or yell at patients of course, as that's unprofessional. But at the same time, I think I have too much pride to just let someone yell things like that at me, disoriented or not, while all the patients & staff in the unit are listening & cringing.
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    I vividly remember one older woman, victim of an RTA, concussed and confused. She swore like a Billingsgate fish wife and made sexual comments and suggestions that made everyone blush!! Two days later she turned into the nicest, prim and proper lady you've ever met! No one every had the heart to tell her what she had been like when concussed even when she asked "I hope I haven't been too much trouble" Bless her!
  8. 0
    Quote from nightmare
    I vividly remember one older woman, victim of an RTA, concussed and confused. She swore like a Billingsgate fish wife and made sexual comments and suggestions that made everyone blush!! Two days later she turned into the nicest, prim and proper lady you've ever met! No one every had the heart to tell her what she had been like when concussed even when she asked "I hope I haven't been too much trouble" Bless her!
    Oh my! o.O And that reminds me of this other 60s-ish lady who was as normal as could be during the day, but unexpectedly sundowned and pulled out her IV and bled everywhere and required 5 nurses to hold her down when she went for her NG tube. She was fiesty! She spat in this one nurse's face and called everyone animals and told us all that we "should be ashamed of yourselves!" and really dug her nails into people and drew blood. The next day she was back to her normal-as-could-be self and didn't remember a thing. She just kept saying "I'm so embarrassed. I can't remember what happened, but I think I might have behaved badly..." She was a very sweet lady too =P
  9. 1
    Quote from drenched
    Thanks for the advice. It is very helpful. I will definitely try to cluster care to leave the patient alone. But when constant supervision is necessary it's hard not to interact with them. =/

    I guess everyone takes verbal abuse differently. One nurse was belligerent right back to her disoriented patient when he started randomly yelling at her and upped the Haldol. Another nurse was just like "All right dear, I'm sorry you feel that way" when her disoriented patient was yelling "YOURE AN UGLY *****!! BIIIIIIIITTTCH!! LEAVE ME ALONE YOU HAG! I HATE YOU!!" I'm not sure what my style is yet. I don't intend to pick fights with or yell at patients of course, as that's unprofessional. But at the same time, I think I have too much pride to just let someone yell things like that at me, disoriented or not, while all the patients & staff in the unit are listening & cringing.
    Your pride needs to be the least of your concerns when dealing with disoriented patients! Who cares about who's listening and cringing? Are you worried about impressing someone? :trout:

    Hopefully when you figure out your "style" it will involve doing what's best for the patient. Belligerence and verbal abuse to confused patients should not be on your list, no matter what you see or hear your peers doing. Not only is it non-therapeutic, it's unprofessional and sounds totally ignorant.
    canoehead likes this.
  10. 0
    Quote from SICU Queen
    Your pride needs to be the least of your concerns when dealing with disoriented patients! Who cares about who's listening and cringing? Are you worried about impressing someone? :trout:

    Hopefully when you figure out your "style" it will involve doing what's best for the patient. Belligerence and verbal abuse to confused patients should not be on your list, no matter what you see or hear your peers doing. Not only is it non-therapeutic, it's unprofessional and sounds totally ignorant.
    Um...whoa there. Are you slapping me in the face with a...fish? (??) lol. I agree with everything that you're saying, which is why I specifically said I WOULDN'T engage in belligerence & verbal abuse, and it goes without saying that patient well-being is tantamount. I'm just looking for other options that aren't just standing there & doing nothing, and AREN'T abusive. I asked the question because I figured that with such an experienced populace of RNs on these boards, people would have creative approaches to these situations. (And they do! Thank you all for your advice!)

    Cheers!
  11. 0
    Quote from drenched
    Um...whoa there. Are you slapping me in the face with a...fish? (??) lol. I agree with everything that you're saying, which is why I specifically said I WOULDN'T engage in belligerence & verbal abuse, and it goes without saying that patient well-being is tantamount. I'm just looking for other options that aren't just standing there & doing nothing, and AREN'T abusive. I asked the question because I figured that with such an experienced populace of RNs on these boards, people would have creative approaches to these situations. (And they do! Thank you all for your advice!)

    Cheers!
    Not slapping... um... waving around?? LOL!!

    I guess my post came across rather ugly; it certainly wasn't meant that way, rather, I was trying to be stern. I have had some "experiences" with people who shout at confused patients and of course it NEVER works. And truly you can't think about what others are thinking when you have a hollering patient. It is not a personal reflection on you as a person or their nurse. It just happens sometimes.
  12. 0
    Quote from SICU Queen
    Not slapping... um... waving around?? LOL!!

    I guess my post came across rather ugly; it certainly wasn't meant that way, rather, I was trying to be stern. I have had some "experiences" with people who shout at confused patients and of course it NEVER works. And truly you can't think about what others are thinking when you have a hollering patient. It is not a personal reflection on you as a person or their nurse. It just happens sometimes.
    Haha whoever designed the emoticons for these boards deserve creativity points :P Stern advice duly noted! Luckily I haven't seen staff be outright abusive to patients yet...doesn't sound pretty.


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