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?
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.
Not for convience but.. I think of it this way.. If a resident doesnt' get it and shes off the walls.. getting up out of her chair, slapping, hitting punching ,refusing care. You are going to regret not giving the PRN to her while she was still manageable. And now you have to call the MD for an IM haldol order because there is no possible way you are getting ANY PO meds in her. And shes becoming a threat and could possibly injure herself, staff and other residents.
So there's a small window of time where it is appropriate to give it.. but not too late where the resident will just spit it back at you.
Back when I worked in the LTC, we used to let the agitated patients who would not sleep stay by the nurses' station in geri-chairs or wheelchairs. Sometimes, we would let them color, do puzzles or tell us stories depending on what the temperament of a particular resident was. Oh, what amazing life stories I heard from these dear souls. Most times, the residents are just lonely or don't feel good or have full bladders and when these needs are met, they are usually good to go.
I don't think in all my years working in the LTC I saw restraints used, I don't really think it's a good idea to use them in such instances as it does nothing but further agitate the resident(s).
Toss them in a recliner or w/c at the desk until they are ready to fall asleep.
and a snack while they''re sitting there.
many of these folks, snooze during the day and also their po intake is poor...so they're hungry and awake at noc.
nothing like a pudding or graham crackers, with cup of milk...very soothing.
i loved it when they sat near nurse's station...enjoyed talking with them.
during eves, i'd have some of them call my young kids at home, to say good-night...they loved it.
In order:
After lights turned down and limited noise/stimulation
1) Sitter
2) Medication (Benadryl, Ativan)
3) Posi-Vest
4) Soft wrist
5) Wrist & Ankles
heck no!!
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.
Well you could always go to your unit's "secret stash" grab some combo of benedryl, ativan, or narcotic of choice....but then you might be intubating them by the morning.....
I usually just accept it is going to be a long night, take my work to their bedside and watch them closely (we don't have the option of a chair at the nsg station)....get the help of a sitter/family if possible and let your co-workers know you got one that might be trying to make a run for it so they will also keep an eye on them...No matter what keep'm safe and as a last resort you can always do restraints. Generally speaking with experience you get a feel for the patients and treat them individually....I don't know of a single solution for all situations.
I did read how as little as one night of inadequate sleep can cause dementia like s/s in our elderly hospitalized patients. Patients have got to get quality sleep but even at home they be awake most of the night. You might also ask the patient/family if sleep is a problem at home and if they take anything to help them rest....Good luck.
Sorry, I have another question on this bona fide nurses thread.
I read what EmergencyNurse posted vs. what people from other settings (LTC, hospice, etc.) posted. Are the different approaches actually valid depending on the setting?
The reason I ask...
My MIL with dementia has been in quite a few different settings: ER, floor/unit, rehab, LTC. Every facility has approached her behaviors differently.
ER=depended on me to sit with her while she was receiving blood--they wrapped her IV site, lifted the end of her ER bed so it would be more difficult for her to wiggle off the end, etc.), but after two hours of it (trying to get up, unwrapping the IV site, etc.) I was exhausted. They snowed her with Ativan. God forgive me for my relieved reaction, and my 20 minutes of crying on the attending physician's shoulder.
floor/unit: depended on me to sit with her. I watched her like a hawk, but when she finally fell asleep, I fell asleep in the chair. I woke up three hours later to IV out, Foley out, blood everywhere, and her heading down the hall with butt cheeks a-flappin'. They put a posey on her and gave her some Ativan.
rehab: depended on me or someone we hired to sit with her. We couldn't continue to provide a 24/7 sitter (our 8-hour/day in-home caregiver or me), so they would have CNAs rotate or bring her up to the station when someone else wasn't available. They allowed her no freedom at all because they weren't equipped for that.
LTC/dementia unit: She's all over the place, and they allow it. Only recently, they have started using a wheelchair restraint because of her symptoms that can cause her to fall.
I'm not asking about the appropriateness of the different approaches related to my MIL. But, I think I can see the differences in approaches related to setting. My question is: are all the different approaches valid, or is there a definitive, not to be deviated from way of handling dementia patients regardless of setting?
I think the definitive thing not to do is to treat the patient from convenience. If it is the best for the patient (safety first) then tie them up and knock them out....if it keeps them safe, not so we can check our FB account; considering not what we do but the motive behind it. Nursing is so subjective, there are many ways to accomplish the same task and there are always lots opinions on which way is best. I think if we keep the patient's best interest at heart we usually make the best decision.
You also generally want to use the least restraint approach first, regardless of the setting. In other words, have a sitter, toilet, snack, whatever...before using chemical or physical restraints.
As many others have said....we usually get them up, put them in a geri chair, give them something to eat or drink, and keep them up until they start to get tired. I don't use medications or restraints at night for our residents. It's more effective to just get them up for a while, especially if they're a fall risk. Sometimes they might need to sit on the toilet for a bit and then go back to bed. Just depends.
This works alot of the times. I realize this is two different worlds, but if they are coming from LTC, alot of times this is what we will do with these pts. Call the LTC and ask if there is any routine that works. Might be as simple as warm milk and a snack. I'm not sure if they get a late evening snack in the hospital, but they can be used to it from the LTC.
Benadry and Ativan doesn't always work with the dementia patients either. (unless you are giving them in larger doses if they are tolerant and then it builds up and you will see them sedated during the day and you then are starting a bad sleep cycle)
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Forever Sunshine, ASN, RN
1,261 Posts
Not for convience but.. I think of it this way.. If a resident doesnt' get it and shes off the walls.. getting up out of her chair, slapping, hitting punching ,refusing care. You are going to regret not giving the PRN to her while she was still manageable. And now you have to call the MD for an IM haldol order because there is no possible way you are getting ANY PO meds in her. And shes becoming a threat and could possibly injure herself, staff and other residents.
So there's a small window of time where it is appropriate to give it.. but not too late where the resident will just spit it back at you.