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Am I right in my thinking working on the dementia unit?

Posted

I have been wanting to ask this for a very long time, and it has been the first ethical issue I have faced in nursing. I am employed at a nursing facility that is one of the largest in the area, and won awards from the state two years in a row for not having any errors during inspections from the health department. I'm a junior nursing student working on getting my BSN. Anyways to the situation...

I was employed to this facility and was placed on the dementia unit. Many on this unit were very bad off, some threatening to kill you if you asked to give them a bath. I understand dementia. I understand that many of these people are confused about their surroundings and have lost the ability to care for themselves. I get it. However, many times while I was at this facility, I was forced to give patient care. For instance, say "Chuck Norris" was to get a bath today. I'd approach him and say in statement form "Hey Chuck, I'm giving you a bath after dinner real quick okay?" Often they would say no. I would reapproach them multiple times, sometimes using the word "water therapy" or something instead.

However at this facility if a patient did not get a bath, we often would steer, physically push or pick them up physically and put them in the bath tub. I do not care what mental state you are in, that is wrong. These patients sometimes cried and became terrified of us. I cannot morally give care to someone like that. You reapproach the issue. Sometimes I have sat down and talked with a patient, and calmly and directly tell them what is going to happen or what I am going to do. Sometimes looking them in the eye helps to fmake them focus. And they do as I ask (usually haha). Anyways I was told if I did not give a patient a bath on their assigned day I would automatically be fired.

Separate issue but several LPNs asked me to apply skin lotion that was ordered for the patients, but I'm not sure if I am permitted to do that?

What's your take on this? I felt wrong how care was performed and felt I was working in a prison, not a nursing facility. Just felt so morally wrong at the time.

That is tough. I work on an inpatient gero psych unit with alot of dementia patients. While they have a right to refuse cares, it is usually because they don't know what is going on. We are taking care of them and that includes keeping them clean. If they are being so aggressive and resistive tell the nurse. She/he should medicate them if needed and then you guys could re approach in 30 minutes or so. The doctor should also be aware of this. Sounds like the patient might need some "med loving" as the dr on out unit says.

As for the lotions, sometimes that happens. If your not comfortable just state that.

JBudd, MSN

Specializes in Trauma, Teaching. Has 39 years experience.

Skin lotion is a non-medicinal part of bathing. It is simply doing skin care; and is best applied directly after a bath.

Yea we have to keep them clean and tale care of them, but not in the way we are doing it

Also our facility does not believe in using anti anxiety medications to calm a pt. Before giving any sort of care. We are not permitted because they have the right to "freak out" as I was told.

RainMom

Has 7 years experience.

Is it possible to perhaps try modifying to a bed bath rather than a full bath when the pt is resisting (especially when refusal is only occasional)? Also, what time of day are you bathing? Some pts that are resisting in eve may be perfectly docile & willing in the morning or afternoon.

I worked second shift. I suggested that to management but it never worked out.

RainMom

Has 7 years experience.

I worked second shift. I suggested that to management but it never worked out.

Then family may need to be brought into the equation. I know that is not exactly your place to do that as the aide, but a gentle suggestion during a visit that Chuck doesn't like to bathe before bed may open up the discussion between family & nursing/management to modify the time/method of bathing. Sometimes the doc will put in misc nursing orders for things like that too : "Pt to shower daily in AM"

Doesn't make sense that residents aren't able to bathe at different times through the day. Mgmt needs to get a clue.

Sounds like where I used to work :(

Regular skin lotion, if not medicated is within the aides scope of practice and is part of patient care. As mentioned by another member is it possible to do a modified bed bath? For some people they have a realistic fear of being in the shower or in a bathtub. If you are allowed to do a bed bath this may be less tramuatizing for them. Also when I worked with patients that had dementia or other illnesses such as schizophrenia I found that singing while doing the shower or even other care would help to calm them down. I even had patients that would start singing with me, the key is to find something that is going to help calm them and distract them from what is going on which may be causing anxiety.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

That is heartbreaking. I agree with PPs that a multidisciplinary care conference is needed to try to determine if there are any causes for Chuck's refusal (and Jackie, Jet, and Jean Claude's refusals, if this is a common problem). Maybe it's something as simple as Chuck has always taken a shower at 0500, and a PM one just doesn't feel right to him. In the meantime, when doing HS cares wash his underarms and peri areas really well; do whatever foot care you as a CNA are able to do (skin intact? Soak them in a basin w/ lotion or peri wash or shaving cream. Gently buff them w/ a washcloth. Skip nail clipping if it's required to be done by the RN/LPN etc.)

But to physically force someone, naked, into a tub or shower...that to me seems like battery. It's not an immediate safety risk to the pt to skip a shower (vs. cleaning up stool or repositioning, which if neglected can quickly cause skin breakdown.)

If it were me, after bringing these issues up with your DON and if they are still insistent that you shower him or be fired, honestly I would quit that position before they get the chance to fire you. Then contact the ombudsman.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

Oh, and applying lotion can be delegated to the CNA. When I was a CNA, actually we applied it to everyone (unless they refused it) after their shower. If the pt had very dry skin, the RN/LPN might remind us that we should apply it. And actually it makes sense for the CNA to do it, since you are the one that has the pt undressed for their shower or am/HS cares.

I thought the same thing as many of you guys. I'm sorry but just carrying someone in is physical abuse. Or at least bordering it. I remember another aide was fired because she accidently put a patients socks in the laundry at the facility that was a favorite of the patients. It was supposed to be in the patients own laundry and was misplaced for several days but was found. Didn't matter. Aide was called up to administrators office, screamed at by the Nun (its a Roman Catholic facility) for 20 minutes then fired. I have not worked at this place since last August since starting school up again for fall semester, and plan to call in with my resignation soon. I mean we are all adults, if I make an error, talk calmly and find a solution, not sound like an inmature lunatic.

But honestly if I am ever faced with this situation again and the RN does not agree, should I just take it up the chain of command until I get an answer? And if after that should I consider reporting it to my state department of health?

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

Yes, although it would be the LTC ombudsman you'd report to. If you Google "(your state) long term care ombudsman" you'll find the info.

Thank you for caring and for your efforts to do the right thing!

But honestly if I am ever faced with this situation again and the RN does not agree, should I just take it up the chain of command until I get an answer? And if after that should I consider reporting it to my state department of health?

Another though that worked with some of my residents, try covering them up with hand towels or shower blankets. Uncover as you wash, recover with clean towel. It helped with some of my folks.

I had one lady who hated the tub but would get in for me only because I played Frank Sinatra in the tub room for her. She would bounce her foot and sing the whole time.

I agree that it's not ok to physically force someone but you also have to try to find a way to provide proper care too even if it means using 10x the towels or belting out show tunes.