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.

[martymoose, BSN, RN]

Hmm, interesting. we use the mats, and all they do is serve to trip up the pt .They're supposed to help them if they fall.Might as well bubble wrap the pt.

[loriangel14, RN]

I have lots of these patients but we have a few things in place to deal with them. We are not a locked unit but the wandering patients have wanderguard bracelets that cuase the doors to lock if they approach them and alarm if they get out.We have aTV and we try to distract with movies and we have an activationist that does activities with them.The worst ones are seen by an MD that specializes in geriatric mental health and he medicates them appropriately.A lot of these patients are waiting for LTC placement.

All we can do as staff is keep an eye on them as best we can.The most agitated ones will get sitters.

[martymoose, BSN, RN]

A dilemma we deal with is the ones who think they can walk independently, but can't. So they are constantly setting off bed/chair alarms( cause they won't sit still) , causing the whole staff to go running to stop them where they are trying to get up.Sometimes at least 10 pts of 28 are on these alarms( med tele floor)

Kinda hard taking care of any other pts who might be really sick( ie- on drips:no: ) when we are constantly redirecting those demented pts.

I wish Dr's would be more proactive in dementia behavior and use the appropriate meds. It's not for convenience, it's for pt safety!Cant exactly mat the whole medical floor....

[kaela_v]

I work on L&D and have COMPLETE respect for y'all on med/surg/tele floors!

I never have more than 3 labor patients OR maybe 5 couplets (5 moms and their newborns) at a time and none of them are actually sick, let alone demented!

I can relate to the staffing issues though, a mom in labor should be a 1:1 but we rarely have the staffing at night to allow that!

Good luck, though!

[Maddie86]

I am a Unit Manager at a LTC facility. I have worked with dementia in one way or another since the beginning on my nursing career 6 years ago. I'll tell you what I have learned works best for me. Keep it personal, speak softly as you can and make your voice as pleasant and as sweet as you can. Be sure you smile widely or look concerned, whatever suits the situation the best. Smiles go a long way. Your initial approach to a confused and/or a combative patient is key. Try to make eye contact with them and keep it, get their attention focused on you if you can and keep it there. Ask them questions about themselves: where did they grow up, what did they do for a living, where and how did they meet their husband or wife, etc. With a pleasantly confused patient, this works 95% of the time. You did well with the towel folding. Usually if you figure out what they did for a living, you can come up with some creative ideas related to that to keep them occupied. A lot of my older folks used to work at a cotton mill in my town. I have loads of clothes and sheets we bring out for them to get their hands on and they will fold alllll day long. If they did something with their hands, find something for them to do that will resemble that feeling in a tactile manner. Something familiar such as this almost always has a calming effect. I had a little woman who was a housewife. I would go into her room and put things out of place, unmake the bed, etc. She would go back in and clean everything up. Just some ideas, hope it helps!

[MomaNurse]

Hmm, interesting. we use the mats, and all they do is serve to trip up the pt .They're supposed to help them if they fall.Might as well bubble wrap the pt.

Not the padded floor mats that are used to prevent injury from falling out if bed. Black or dark colored mats like a rug that are used in hospitals or facilities. An advanced dementia patient prone to wandering will likely perceive dark color as a void. It's pretty effective. That way you can save the bubble wrap to keep their fingers busy popping!

[CapeCodMermaid, RN]

Cards, dominos, snacks, puzzles, magazines....busy work.

I've never seen Melatonin work with sun downing....try some trazodone...fewer side effects than Ativan

[LadyFree28, BSN, LPN, 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.[/quote']

This is what worked for me in the past when I worked in a Tele Floor as a tech; we were the floor that would get the pt's waiting for placement. Why also works is the activity table like HappyWife suggested, which can be placed over the overbed tray or a "busy" pillow. Both have sensory activities that keep them busy. Now that I work in LTC, I find keeping them busy is key; interaction is a HUGE deal because, think about it-if half of your brain is deteriorating, you can't always control your impulses anymore; and your perception is ANYTHING but normal, how would you feel??? Having a loss of control, no matter how confusing, is going to have some effects of the stages of grief.

I agree with suggesting trazadone like CapeCodMaid suggested. I would also get a psych consult as well; sometimes they have a great insight in determining if the patients may have underlying depression and/or anxiety, and what would be the safest medication management to use to benefit the patient.

I hope that with the impending changes of the healthcare delivery system, there will be units specifically for monitoring patients for placement into a LTC.

[canigraduate]

First, if you can, have anyone with a few extra minutes take turns walking them. Sustained exercise usually wears them out and they will sleep for an hour or two at a time. Sometimes, once you get them to sleep, they will be out the whole night.

I second the busy work idea by Maddie86. I once had a demented man who used to be a carpenter. I gave him some toy tools and some odds and ends of tubing and such. He built and re-built all kinds of things for HOURS. I had another lady who had been taking care of children her whole life. I gave her a couple of dolls, bottles, "diapers," and some doll clothes. She had the cleanest and best cared for "babies" I have ever seen.

At one time, I worked on a geriatric unit and we had a closet with donated materials that we could use. Staff and visitors would often contribute to it. You can get a lot of peace and quiet from old magazines, word puzzles, and coloring books. Maybe you can suggest something similar for your unit.

[SubSippi]

It sounds like I need to hit up some yard sales and bring some toys to work with me!

[boogalina, ADN, ASN, BSN, MSN, LPN]

Wow, so many amazing ideas on this thread! As a patient sitter, I had good success handing patients a short strip of telemetry leads. The different surfaces (metal snap, cloth patch, slick plastic backing) would give a patient a tactile activity that lasted several hours and kept those hands away from that central line!

I wonder if there are specialized products that could provide this tactile amusement (more safely b/c I would worry about a a patient swallowing a tele lead if not 1:1 supervised). Seems like there are a million things for infants but not much for geri patients.

Something relatively inexpensive and that could be kept by the patient?

[Anthony South]

I hate taking care of confused Pts. I am a person of common sense and logic. So confused people, criminals, people with ADHD, and others who their actions don't make sense, don't sit well with me. I work in the ICU and thankfully, as long as we nurses can show a Pt can be harmful to himself, the doctors here will order restraints. In your situation, I have to say that once you get the feel that you are putting your license on the line when these Pts have a high risk really hurting themselves, it's time to get a job somewhere else like ICU, L&D, or work in dialysis, case management, or hospice. These Pts will hurt themselves and you'll be to blame.