Advice please

CapeCodMermaid, RN · Mar 18, 2012

We let our residents sleep and wake on their own schedules. Breakfast is buffet style and is available from 7am to 1030am. Wandering is defined as moving about without a destination or purpose. We don't medicate people if they want to wander about the unit. There is always something for them to do if they want to participate. I go in on every shift and have seen the 11-7 aides playing word games with the residents who don't want to sleep. Culture change can be a slow process. I've had staff complain that Mr Jones constantly tries to stand up and walk. At first their answer was to medicate him. With some discussion, coaching, and a PT eval, the decision was if the guy wants to stand up and walk, then the staff will take him for a walk. It's worked so far. He's less agitated and hasn't had any falls.

Kittypower123, BSN, RN · Mar 18, 2012

Residents have rights - those rights include the right to refuse (showers, medications, activities, going to bed when they choose, etc.) Medicating a resident because their behavior is inconvenient is wrong. If a resident doesn't want a shower - they have the right to refuse. If the resident wants to go to bed at 4pm, she has the right to do so. If they want to wander around the unit at night, they have the right to do so.

Giving an anti-anxiety med before attempting the shower can help with compliance - but the resident still has the right to refuse both the med and the shower. We don't know what has happened in the resident's past that may be causing or increasing the anxiety they feel about showering. When I was a CNA, we had a lady who refused showers. The only way we could get her into the shower was if I sat on the shower bench with her, while another aid cleaned her. I got very wet, but she got clean without being traumatized. Sometimes you have to think outside the box and try some things that may seem a bit weird.

joanna73, BSN, RN · Mar 18, 2012

I also work LTC and I completely agree with the approach. Kindness and a calm tone go a long way. We have one resident who likes to hoard our bibs in her room. No big deal. It makes her happy. We just put them back in the laundry. And many of them are bored and hungry at night. I will often have 2 or 3 up late having a snack. The other night, one resident says to another, "This is a nice hotel, isn't it?"

legalbeagle2 · Mar 18, 2012

I would do the same thing.Who takes showers on 3rd shift anyways? If the lady needing shower was soiled,I wd have my CNA's try sponge bath vs traumatizing her with a shower. I think medicating patients is the first "go to" so often anymore,and the reasons are getting more ridiculous! Graet job!

runforfun · Mar 18, 2012

I'm not a nurse, I'm actually currently preparing for my first semester of nursing school. All I want to say is that I very much appreciate everything the nurses have said in this thread. What ever happened to putting yourself in the patients shoes, or the shoes of their loved ones? Would you want to be drugged if you really just weren't tired, or be forced to shower when you didn't want to? Of course not! I understand that yes, sometimes someone might NEED to be cleaned, or if they haven't slept in days, maybe they need medication, but it is so nice to know that not every nurse would force these measures on a patient or resident simply because "that's our schedule and that's how we do things". I have a 94 year old grandmother, she is currently living on her own and more than capable of caring for herself. If that were to ever change, I would hope she was placed in the care of people like you!

Sparrowhawk · Mar 18, 2012

I always try pain medication first (non narcotic then work your way up) A lot of times agitation is pure pain... If Jenny Sue doesn't want her bath, well we'll keep trying until she does, but I'm not giving an Ativan tos omeone just so she can be clean, pain pill yeah...knock her out no. Now if a little lady is so anxious she's shaking, I'd say that's an appropriate use of ativan.

Nascar nurse, ASN, RN · Mar 18, 2012

We have a lady that survived the holocaust concentrations camps. She absolutely freaks out in the shower room. I told the staff to quit trying FOREVER - she would be just fine with a good bed bath the rest of her life. There is absolutely no reason to put that poor thing thru the post tramatic stress event caused by a shower. Careplan it for what it is and be done with it - surveyors be damned (although I seriously doubt to ever have a survey problem with the way we documented it).

SHGR, MSN, RN, CNS · Mar 18, 2012

This is the best AN thread EVAR. Not only do I want to work with y'all, I would place any of my loved ones or myself in your care at your awesome LTC "hotel!"

CapeCodMermaid, you should write a book about your workplace culture, advocacy for geriatric population, and "change for the better." I sincerely mean that.

wooh, BSN, RN · Mar 18, 2012

We let our residents sleep and wake on their own schedules. Breakfast is buffet style and is available from 7am to 1030am. Wandering is defined as moving about without a destination or purpose. We don't medicate people if they want to wander about the unit. There is always something for them to do if they want to participate. I go in on every shift and have seen the 11-7 aides playing word games with the residents who don't want to sleep. Culture change can be a slow process. I've had staff complain that Mr Jones constantly tries to stand up and walk. At first their answer was to medicate him. With some discussion, coaching, and a PT eval, the decision was if the guy wants to stand up and walk, then the staff will take him for a walk. It's worked so far. He's less agitated and hasn't had any falls.

This place sounds WONDERFUL. If I end up in a LTC, this is what I want it to be like.

Long Term Care Columnist / Guide · Mar 18, 2012

My philosophy of medicating for "agitation" has always been simple; I don't medicate when a resident is driving ME crazy. I medicate when they're driving themselves crazy. When the 1:1 with a cup of hot cocoa and some calming words doesn't work and the resident is bouncing off the walls worrying about their child missing the last bus home from school---and the child is 48---that's when it's time for a little Ativan to take the edge off.

As for showering......I know what shower rooms in LTC look like, and if I were a resident I'd refuse to go in there on principle! They are cold, first of all, and older people loathe being chilled; they are also unfriendly in appearance with all that neutral-colored tile and those white walls, and frankly, just the knowledge that other residents had been in there would cause me to say "oh HELL no!" Yecccchhhhhh.

For those residents, I careplan the daily PTA bath, and let the State do with me as it will. Besides, how old do people have to be before they earn the privilege of thumbing their noses at the rules well-meaning but clueless bureaucrats put in place?

wooh, BSN, RN · Mar 19, 2012

Besides, how old do people have to be before they earn the privilege of thumbing their noses at the rules well-meaning but clueless bureaucrats put in place?

Hehe! LOVE. :)

NJayne17 · Mar 20, 2012

You are the nurse for that shift you have to do what you feel is right.

I too work with alzheimers and related dementia residents, and often feel that other nurses simple abuse PRN meds used for anxiety/aggression in order to not have the hassle of dealing with them.

I try snacks, drinks, toileting first. Watch for signs of pacing, outbursts, wanting to leave.

Monitor closely. If this does not work, then use prn meds. They are effective for reducing aggressive behaviors but should be used cautiously. JMHO.