Advice on dealing with confused patients

[SubSippi]

I work on a tele floor, but lately I have been getting patients whose medical diagnosis is "Alzheimer's, waiting for placement." I'm a new nurse, so I'm not sure how common this is, but what has been happening is that a family suddenly decides that they are no longer going to care for their family member who has dementia, and brings them to our ER. The ER doc admits them, and then the nurses essentially become their babysitters until a spot opens up at a nursing home or whichever LTC facility is most appropriate for them. These patients hardly ever have any sort of medical illness (other than diabetes).

Best case scenario is they are pleasantly confused, won't stay in their rooms, try to take their gowns off in the hallway, poop in weird places, etc. Sometimes I try and get them back in their rooms, and I'll stay in there to do my charting. Sometimes I'll let them sit at the nurses station and give them some towels to fold or some other sort of project, which will generally keep them occupied for about 15 minutes.

The worst are the ones who accuse me of holding them hostage, and are constantly crying or yelling about something. Nothing will keep these patients occupied.

We can't put them in a roll belt or any other kind of restraints unless they are violent or are actually TRYING to leave the hospital, not just wandering. The doctors might have some anti-anxiety meds ordered PRN, and while that might (or might not) make them less anxious, it certainly doesn't keep them from getting up and wandering around. When I've asked for something stronger, I've been told that they don't sedate for "nurse convenience," and we can't get a one on one sitter unless the patient is suicidal.

The other nurses I work with pretty much just say we gotta deal with it and hope nothing bad happens. Since these patients pretty much need to be watched 24/7 I'm doing good just to give the meds to my other patients. This is frustrating when I have ventilated patients, or patients on insulin drips...and I'm having to chase someone's confused, but otherwise healthy, mama down the hallway before she busts up into someone's room, or wanders outside in the middle of the night.

Since restraints and extra sedation don't seem to be options, does ANYONE have any tips/advice on how to get these people to stay put or calm down? Or on how to convince their doctor that the 1mg PO Ativan q6h isn't really cutting it? I am at a loss, and they are driving me insane.

[jadelpn, LPN, EMT-B]

This is when you go to your nurse manager and ask that since you are a tele floor, and not a long term care facility, that you are able to make use of patient sitters. If your facility doesn't have any sitters, then a CNA. Patients who are wandering and such need to be on a 1:1 observation.

[SubSippi]

When I have requested a sitter, I was told that we only have those for suicidal patients.

They are on wandering precautions, but for us that just means a different colored gown and the bed alarm. We keep the hallway doors shut, but they're not locked and people can still get through them.

[Nursetastic]

You have vents and insulin gtts on a tele floor? AND confused patients? What is your patient load like? Sounds very unsafe all the way around.

[xoemmylouox, ASN, RN]

I can't imagine. Unfortunately I don't have any advice to offer other than make sure you have malpractice insurance.

[SubSippi]

They're patients who are on long term vents, we have six patients. It's crazy up there...I like it sometimes. But yeah, throw in a confused patient and it becomes way too much.

[Esme12, ASN, BSN, RN]

Unfortunately they are a necessary part of nursing. Many physicians will place them on telemetry floors because the staffing is better. They need a specific amount of time inpatient to be eligible to be evaluated for long term placement....an expensive requirement of medicare.....it used to be 3 days.

There isn't much you can do. I caution you about closing doors for a patient that is confused can get in a lot of trouble behind closed doors and can be considered a form of restraint and certainly NEVER lock them

Seven categories of elder abuse have been described by the National Center on Elder Abuse (NCEA), formerly the National Aging Resource Center on Elder Abuse. Categories include the following: Elder Law Abuse Law & Legal Definition

• Physical abuse is defined as any act of violence that causes pain, injury, impairment, or disease, including striking, pushing, force-feeding, and improper use of physical restraints or medication.
  
• Psychological or emotional abuse is conduct that causes mental anguish. Examples include threats, verbal or nonverbal insults, isolation, and humiliation. Some legal definitions require identification of at least 10 episodes of this type of behavior within a single year to constitute abuse.
  
• The miscellaneous category includes all other types of abuse, including violation of personal rights (eg, failing to respect the aging person's dignity and autonomy), medical abuse, and abandonment.
  

They are exhausting to be sure.....their habits of stooling in odd places and eating or painting with feces is a brain dysfunction associated with dementia

An article on AN discusses this.

Coprophagia And Scatolia In Demented Elderly Residents

[advsmuch08]

Sometimes giving them a warm bed bath helps. I try to do the meds and assessments for the confused patients first, earlier in the night. I keep the lights dimmed so as a cue for night time but I leave a small light on through the night and leave their doors open to watch them closely. Bed alarms on. Frequent rounding. Lights in the hallways are dimmed. Plus we try to keep them in rooms closest to the nurses station. I'll turn on the relaxation channel or the radio channel and play soft music. If able, I'll bring my computer right by their doorway to chart and keep an eye on my other rooms. Obviously, this all depends on time, staffing, and acuity, etc.

[classicdame, MSN, EdD]

I read a study done in LTC facilitites indicating that the wandering might be due to hypoglycemia - they are looking for food. Many do not eat appropriately, so get hungry between meals. Try a little snack. I have a feeling that until someone gets injured there will be no changes as they all require an expenditure.

[dudette10, MSN, RN]

For the the dementia wanderer on the tele floor I often work on, we get them comfy at the nurses station with magazines and snacks...a place where there is always at least one nurse or NA available at all times. the responsibility for safety is shared, and it allows the assigned nurse to adequately care for her other patients, too. its too much for one nurse, quite frankly. The patient is bored,bored, bored and isn't getting the stimulation sitting in a private room.

[HappyWife77, BSN, RN]

We have an activity table that has stuffed animals that talk or sing little clips also photo albums and magazines, playing cards and as someone else mentioned, wash clothes to fold. Maybe you can suggest to the doctor to prescribe melatonin, because it helps with sundowners. Music therapy if possible when they are winding down. Sometimes they need to go the restroom as well.

[MomaNurse]

If there's an area where the patient could come to harm, put down a black mat. For example that isolation room or stairwell door. The wanderer will perceive it as a hole in the floor and won't cross it.