For example, someone fairly severely confused, not combative, but who attempts to get up OOB multiple times t/o the night/ is a fall risk, ect..
On our unit, we have a bed alarm, but it gets exhausting responding to that and redirecting t/o night when you are assigned 5 other patients, are in another room, ect.
A 1:1 was not an option as it would have pulled our lone NA.
The resident was not willing to give Benadryl 25 mg.
So then I was wondering how to effectively manage this situation?
Luckily our hospital is able to work out 1:1 without taking staff off the unit. We help out other units, other units help us, float pool CNA/RN, calling people at home to come in for 1:1 if they want etc.
It works for us :-D
Sometimes if we don't feel the quite qualify for a 1:1, we put them on 15 minute checks. Put a sheet on their door to sign that we were there every 15 minutes and we all tag team checking on the patient every 15 minutes with bed alarms on, low bed, mattress the whole works.
Sometimes if they just can't sleep, we will bring them in a wheel chair or recliner and sit them at the nurses station with us. Kinda cute because the patients usually LOVE this (especially at night). You just need to be sure that there is at least one person at the desk at all times.
After lights turned down and limited noise/stimulation
1) Sitter
2) Medication (Benadryl, Ativan)
3) Posi-Vest
4) Soft wrist
5) Wrist & Ankles
Ultimately it's determined by policy/protocol but it's no easy task.
Good Luck...
wowza. In LTC (where we deal with these type of people daily - and several of them) none of these are an option. I can't even begin to imagine putting ankle restraints on someone just because they wouldn't stay where I wanted them to stay.
1. Put them in a recliner at nurses station and everyone just has to take turns talking to them. Yea, I know this is hard to do but sometimes it is the only option.
2. Try a snack
3. Try toileting
4. Assess for pain - sometimes a simple tylenol will do wonders and not knock them out and put them at further fall risk
5. Diversional activities - folding towels, etc like previously stated.
A few weeks ago a pt was trying to clime out of bed ect. Eventually pulled out his foley and tossed it across the room (looked like a crime seen-blood up the walls and the floor). We put him in a Geri chair by the nurses station and tucked in the sheets oh-so nicely around him (no orders for restraints ). He did pretty good, only calling me over to tell me I was such a B!$ch for making him miss his school bus. Nicest guy during the day though.
I think that's pretty harsh (and dangerous) if people are opting to use hand or ankle restraints on someone just to keep them in bed. That can surely increase their anxiety and agitation.
When I did LTC I was in a restraint free facility so usually we would keep that person with us at the nurse's station & give them things to do to distract them. One resident who used to be a nurse would calm down if she was allowed to wheel around and "write people up." We gave her paper, pen and let her write everyone up to heart's content.
Now I'm in acute care our unit does not put a non combative person in wrist restraints. The only exceptions to that is if they are attempting to pull out a peg tube. If they are attempting to pull out IVs we wrap that site in kerlix, if they are going for a foley we will put a diaper on them over the foley. Then they go in a geri chair at the nurse's station. Snacks & drinks are a good distraction & its another way to make sure they are actually intaking something besides NS & meds while they're in the hospital. We'll get the ativan out only if everything else has been tried repeatedly.
Moogie brought up a lot of valid points regarding making sure that there is not a UTI or something else that is making them so agitated. Usually I find that in the acute care setting the dementia patients are terrified because they don't know the nurses the way they do at the LTC, their routine is off and they are bored. There aren't any activities for them to do in the acute care setting.
One of our techs keeps coloring books & crayons in her locker for dementia patients. They really like her & her coloring books.
Answering this is going to be you lifes work. If anyone offers a definitive answer to this problem that works, they will have the eternal gratitude of all nurses, everywhere.
Having a family member sit is almost always helpful, but it is only a viable solution about 30% of the time. Many times family see the patients dementia is just a normal part of thier illness that has been there for some time. Once they are in the hospital, the family can take a "breather" from nightly worry about thier loved one. If they live at a LTC facillity, the family is more likely to see a request for family sitting as an admission that the hospital dosen't know how to take care of thier family member- " the nursing home never calls us... why don't you have enough staff to care for your patients- that is what you get paid for."
It is a rare night when we don't have at least one patient confused and uncooperative. The problem with distraction is- if the patient is scared- "what are you people doing in my house...! Help, Police..." asking them to fold towels isn't going to go over very well. With some patients our docs have had good sucess with "seroquel", and Haldol is common if the condition is violent. Benzos can calm the patient but almost always make the confusion worse. As for Benadryl- you are just going to make them more NUTS without significant sedation.
By the way, a geri chair with tray and/or seat belt is defined by the Joint Commission as a restraint. Anything more than 2 side rails up that restrict activity is a restraint. Be careful in how you document these interventions, and what orders you get to CYA. There have been cases of nurses getting sued for "kidnapping" or "assault" for applying any restraint without appropriate orders. Just because you have the best intrest of the patient in mind, dosen't mean the family isn't nuts enough to sue you and/or the hospital.
put them as close to the nursing station as possible. toilet. snack if they want. 1:1, no need for physical or chemical restraints if confused. confused is not combative or agitated. drives me nuts when a nurse just wants to medicate a pt to "keep them quiet"
After lights turned down and limited noise/stimulation
1) Sitter
2) Medication (Benadryl, Ativan)
3) Posi-Vest
4) Soft wrist
5) Wrist & Ankles
Ultimately it's determined by policy/protocol but it's no easy task.
Good Luck...
I would be fuming if I found out this is what my resident received in the hospital. LTC residents are not patients of a psychiatric facility.
To the OP- Keep them with you. They are in a strange place. Strange people they don't know. They are probably afraid. They love being behind the nurses station. I had a resident back there with me today. I put her where we usually sit to chart and give report. She started saying, "I'm in charge! I'm in charge!" I asked her.. if you are in charge.. Can I go home early today??. .. She said to me.. "Can you go home early? No you cannot go home early!"
Also taking them for a walk around the hallways helps tire them out a bit.
After lights turned down and limited noise/stimulation
1) Sitter
2) Medication (Benadryl, Ativan)
3) Posi-Vest
4) Soft wrist
5) Wrist & Ankles
Ultimately it's determined by policy/protocol but it's no easy task.
Good Luck...
What?? No way!!
I had a pleasantly confused pt the other day and kept him at the nurses station with me. With lots of help from my fellow nurses, we basically baby sat him all day, but in the end....he was kept safe and I rather enjoyed his company. (;
A few weeks ago a pt was trying to clime out of bed ect. Eventually pulled out his foley and tossed it across the room (looked like a crime seen-blood up the walls and the floor). We put him in a Geri chair by the nurses station and tucked in the sheets oh-so nicely around him (no orders for restraints ). He did pretty good, only calling me over to tell me I was such a B!$ch for making him miss his school bus. Nicest guy during the day though.
put them as close to the nursing station as possible. toilet. snack if they want. 1:1, no need for physical or chemical restraints if confused. confused is not combative or agitated. drives me nuts when a nurse just wants to medicate a pt to "keep them quiet"
I get the sentiment...but....
It's never that I would want someone to settle down b/c it's an inconvience for me. I want them to be comfortable as well, for them and the other pts. Sometimes, when all else fails, a little judicious PRNing is in everyone's best interest.
I can't tell you how many times I've been dealing with one or two seriously unstable pts (for what our floor is designed to handle) and praying that Ms.Lizzie next door, who is also my pt, will just not hit the floor while it's going on. If I've got one having seizures that won't stop and another in respiratory distress so bad that we're looking at code status, I just don't have the time to keep up with someone trying to get up every fifteen minutes. And on nights, when we have more than one pt on the floor going downhill, it takes up most of the staff to deal with them...which leaves few options for those high fall risk pts.
It's a sucky situation all around. Meds should not by any means be the only choice, and I know there are some out there who don't even think about other options, but generally I don't think the philosophy behind using them is to just keep 'em quiet for the nurse's convience.
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). He did pretty good, only calling me over to tell me I was such a B!$ch for making him miss his school bus. Nicest guy during the day though.
We gave her paper, pen and let her write everyone up to heart's content. 
Jenni811, RN
1,032 Posts
Luckily our hospital is able to work out 1:1 without taking staff off the unit. We help out other units, other units help us, float pool CNA/RN, calling people at home to come in for 1:1 if they want etc.
It works for us :-D
Sometimes if we don't feel the quite qualify for a 1:1, we put them on 15 minute checks. Put a sheet on their door to sign that we were there every 15 minutes and we all tag team checking on the patient every 15 minutes with bed alarms on, low bed, mattress the whole works.
Sometimes if they just can't sleep, we will bring them in a wheel chair or recliner and sit them at the nurses station with us. Kinda cute because the patients usually LOVE this (especially at night). You just need to be sure that there is at least one person at the desk at all times.