Advice please? Dementia pt resisting necessary intervention

[Laughingbuddha]

Hi all,I was an LPN for 7 years before just getting my RN. (yay!)I continue to work in a skilled facility in Florida, most of my hours on a subacute busy rehab unit, but 8 hours on a long-term hall. I have worked with dementia patients in some capacity for over ten years, and have usually a library of tools and tricks of the trade to manage to do what is necesary for my patients without conflict and keeping them happy at the same time. But there is always one patient at every facility that has a problem with some aspect of care...as an LPN I used to 'go' with the philosophy of the facility I would be employed at to manage the resistance...as an RN, I want to set the RIGHT example for CNAs and LPNs who will be watching what I choose to do...Question regards: patient with medically necessary urinary catheter. Cath is occluded, but QS urine is leaking around it. At this time no distention. Female patient has knees bent up on bed and refuses to open. Unable to even visualize meatus much less do a sterile insert...Attempted to insert with two CNAs helping to gently hold the knees open-she fought, struck, attempted to bite, etc. Patient left to rest...re-approached after an hour,by myself-with gentle talk and explanations...still no luck. Patient has no anti-anxiety meds etc to help calm prior to procedures.What would you have your staff do that would be most appropriate?Contact physician regarding patient fearfulness/anxiety during certain procedures? Maybe to seek PRN order for essentially a chemical restraint?Contact guardian/poa for instructions regarding resistance to care that will adversely affect physical health if not done?What would AHCA want to see in this situation? Different facilities I have worked in over the years have wildly different answers to this, from massively physically restraining patient with up to four staff holding the patient still, to pre-medicating, to having intervention discontinued.What would YOU do?Thanks to all DONs/ADONs--I respect what you do but wouldn't want your job for all the world! :)

[nurselabrat]

Hi all,I was an LPN for 7 years before just getting my RN. (yay!)I continue to work in a skilled facility in Florida, most of my hours on a subacute busy rehab unit, but 8 hours on a long-term hall. I have worked with dementia patients in some capacity for over ten years, and have usually a library of tools and tricks of the trade to manage to do what is necesary for my patients without conflict and keeping them happy at the same time. But there is always one patient at every facility that has a problem with some aspect of care...as an LPN I used to 'go' with the philosophy of the facility I would be employed at to manage the resistance...as an RN, I want to set the RIGHT example for CNAs and LPNs who will be watching what I choose to do...Question regards: patient with medically necessary urinary catheter. Cath is occluded, but QS urine is leaking around it. At this time no distention. Female patient has knees bent up on bed and refuses to open. Unable to even visualize meatus much less do a sterile insert...Attempted to insert with two CNAs helping to gently hold the knees open-she fought, struck, attempted to bite, etc. Patient left to rest...re-approached after an hour,by myself-with gentle talk and explanations...still no luck. Patient has no anti-anxiety meds etc to help calm prior to procedures.What would you have your staff do that would be most appropriate?Contact physician regarding patient fearfulness/anxiety during certain procedures? Maybe to seek PRN order for essentially a chemical restraint?Contact guardian/poa for instructions regarding resistance to care that will adversely affect physical health if not done?What would AHCA want to see in this situation? Different facilities I have worked in over the years have wildly different answers to this, from massively physically restraining patient with up to four staff holding the patient still, to pre-medicating, to having intervention discontinued.What would YOU do?Thanks to all DONs/ADONs--I respect what you do but wouldn't want your job for all the world! :)

I don't have any real experience in LTC and I'm definatley not a DON. I will be interested in these responses though. In my very humble opinion , I think the guardian should be contacted and informed that the physician will be contacted to get an order for meds that can reduce the patient's anxiety. It is terrible that this patient is in such fear. It needs to be addressed for the patient's benefit. Also what is the facilities policy and procedure. I would think that the physician would want to know his patient was in distress.

[merlee]

Have you tried inserting the cath with the patient on her side, knees to chest? This may be less intimidating. You will need some assistance getting to meatus, but it is possible; I used this technique on elderly women sometimes.

You can only follow your facility's policy.

Best wishes!

[NurseDirtyBird]

Hi, not a DON, but lots of experience in memory care and LTC. You are aware the reason that she's resistive and combative is because she has no understanding of the procedure, who you are, and what is in her best interest. All she knows is some stranger is trying to touch her "down there." There's no way to get her to understand that she needs her foley changed for her own good. You also already know what to do - you posted it! First, contact the POA and let them know what's going on. Sometimes the presence of someone familiar during a procedure can calm the resident down enough to get it done. I've had to contact family for help with this kind of thing before, especially when there's a poss. UTI going on, and the resident is more anxious than usual, and sometimes it worked.

You seem concerned about the possibility of using a chemical restraint. What you should remember is the patient has legitimate anxiety, and it should be treated. If it were a procedure that was extremely painful, you wouldn't think twice about premedicating for pain. Of course you'd do it. Contact the MD.

[VivaLasViejas, ASN, RN]

I'm a DON in a an assisted living facility that specializes in "challenging" residents. This lady sounds like one of my residents, for whom I advocated a suprapubic catheter as she will always need one. Voila! Home health still has to change it out regularly, but the trauma and discomfort are so much less and she doesn't have the painful bladder spasms and constant urge to void that she did with the ordinary type. Hope that helps. :-)

[CapeCodMermaid, RN]

Why does this particular resident need the catheter?

[CoffeeRTC, BSN, RN]

Yes, make sure they really need the cath in the first place. I'd contact the POA to get any suggestions on relieving anxiety (ask if they know what type of meds they've been on or tried for this in the past) Remember that meds minght not help even if you get the orders for premedicating. Sometimes (as the pp stated) no matter what you try to explain to them, it doesn't much matter depending on the stage of dementia, but your approach will matter.

If it must be done, try to get in and get out as quickly as possible..set up your supplies and have extra nd enough help.

[CompleteUnknown]

If the catheter is occluded but urine is leaking around it and there's no distension, you have to wonder if it really is necessary.

If it is, I'd try the side-lying idea first. For the resident, it's generally not a confronting position to be in while the traditional lying on the back with legs apart definitely is.

Either way, undo the bedding from the bottom of the bed and double it over towards the top rather than pulling everything down, it feels much less exposing for the resident to have the bedding around the top of their body as normal when you're doing something 'down there'. We do this for all pad changes and incontinence clean-ups where I work and it makes such a difference with the ones who tend to resist or fight - works like magic.

If you think about it from the point of the view of the person with dementia, someone is coming in, ripping their bedding off and then doing things to them, no wonder some of them fight.

[pinkfish333]

I would inform the physician about this concern, and get their suggestion. At the same time I would inform the POA / family and get their input. Educate them on the pros and cons of having this catheter, and the physician's suggestion. I find being completely transparent with what is going on is best. I hope the resident is ok.