Night shift: let residents sleep?

[RGuadagna]

I am currently filling in for our regular night RN who is on vacation (read: new to the night shift). Our facility is really focussing on patient-centered care etc, and I was just curious what the routine is out there in other ltc homes with regard to nighttime incontinence care?

My question is this: should we be padding the beds really well and letting them sleep OR should we continue to wake them up several times/night to change linens? If it were me, I'd say let me sleep. However, I could totally understand others not wanting to sleep in urine. So for those who can't speak for themselves, which is the more resident-centered approach?

[Meraki]

My grandmother is in a nursing home and is incontinent and would much rather be left to sleep. She often doesn't go back to sleep once awoken and so if staff come in to change her she only gets maybe 1-3 hours of sleep a night depending on the time they came in. The sleep deprivation greatly decreases her quality of life as her pain (or perception of pain) increases, she gets very nauseated and stops eating and her mood drops and she becomes irritable and depressed. The homes answer - keep waking her to change her and give her extra meds for sleep, pain, nausea and depression. In the end we negotiated that she would only be woken in the morning about 5 am to be changed which still interrupts her sleep but leads to fewer sleep deprived days and greater quality of life. Her skin isn't great but it is a price she is willing to pay to be able to function during the day.

[kew_11]

for skin break down purposes...i would want my patients cleaned up. if night after night they are constantly being wet and not turned, they are going to breakdown fast, and thats another problem on top of everything...

..when im old one day and cant control my bowels i pray that someone comes in to turn me frequently and change me often, i dont care if im sleeping or not :)

[shiccy]

Coming from acute care, faster you get a person out of urine, the better you get rid of incontinence related excoriation and skin breakdown.

Please, from a skin care standpoint, DON'T let your patients sit in incontinence. If they didn't get enough sleep during the night from cleaning up the incontinence, they can always get more after breakfast in way of a mid day nap.

Don't forget the barrier creams!

[Moogie]

My grandmother is in a nursing home and is incontinent and would much rather be left to sleep. She often doesn't go back to sleep once awoken and so if staff come in to change her she only gets maybe 1-3 hours of sleep a night depending on the time they came in. The sleep deprivation greatly decreases her quality of life as her pain (or perception of pain) increases, she gets very nauseated and stops eating and her mood drops and she becomes irritable and depressed. The homes answer - keep waking her to change her and give her extra meds for sleep, pain, nausea and depression. In the end we negotiated that she would only be woken in the morning about 5 am to be changed which still interrupts her sleep but leads to fewer sleep deprived days and greater quality of life. Her skin isn't great but it is a price she is willing to pay to be able to function during the day.

I definitely see your point but I hope that the facility has this written in the care plan. If it isn't in the care plan, even if your grandmother does not want to be awakened to be checked, the state could issue a deficiency based on potential or actual harm because the staff isn't checking her q 2.

I agree with you that she should be the one to determine what she feels contributes to her quality of life and that medicating her is dealing only with the symptoms, not really doing anything about the problem. The approach of letting her sleep is a more problem-oriented solution but it could put the facility into a tough position with the state and in terms of legal liability if she would develop a decubitus or other skin problem.

[SuesquatchRN, BSN, RN]

I definitely see your point but I hope that the facility has this written in the care plan. If it isn't in the care plan, even if your grandmother does not want to be awakened to be checked, the state could issue a deficiency based on potential or actual harm because the staff isn't checking her q 2.

I agree with you that she should be the one to determine what she feels contributes to her quality of life and that medicating her is dealing only with the symptoms, not really doing anything about the problem. The approach of letting her sleep is a more problem-oriented solution but it could put the facility into a tough position with the state and in terms of legal liability if she would develop a decubitus or other skin problem.

YES. And I hope you don't plan to call State when your grandma has a big old pressure ulcer on her ass and goes into septic shock because you didn't want her disturbed.

We'd make you sign an AMA on that one.

[Meraki]

YES. And I hope you don't plan to call State when your grandma has a big old pressure ulcer on her ass and goes into septic shock because you didn't want her disturbed.

We'd make you sign an AMA on that one.

I guess her nursing home has different standards because most of the incontinent folks are continuously wet and they don't change everyone q2h. They don't have the staff to do this and no one would get fed or moved if they changed every resident every time they were wet or even q2h. We had to push to get 5 briefs a day available for her, it would never be in their budget to change every resident as soon as they were wet or even q2h (12 changes a day). the brief they use are according to them good for 8 hours - which I think it is nonsense. From what I can tell the rest of the residents get changed 2x/night and 2-3 times a day at most.

And it is my grandmothers choice to not be disturbed not mine and given she is still cognitively capable of making her own decisions and wants quality of life I support her. This arrangement has been in place for going on 3 years and she has yet to have an ulcer. I truly can not stand when policies and CYA are seen as more important than a person's right to receive/refuse care. We did have an issue with one staff who forcefully changed her against her will while said she was telling them no and stop because it was policy. This is not my idea of good or ethical care. Nor is limiting someone's quality of life so you can check boxes on a State checklist.

[RGuadagna]

Thanks to all who commented and understood that I am trying to find the best procedure for the comfort and good care of our residents.

Clearly I was tired and should have been more explanatory about the "letting them sleep." I was not implying that we ignore incontinence altogether during the night as I am well aware of the skin issues and would NEVER advocate for someone "sleeping in their own urine." I work in LTC; for many of our residents, it is their home. My problem is that if someone came barging into my room every two hours during the middle of the night turning lights on and (many CNAs are not quiet and gentle, no matter how many times you speak with them about it) rolling me over - I would never get a good night's sleep and my overall quality of life would be worse.

I agree that rounds - looking in to make sure people are asleep, not getting oob, still breathing, etc. should continue - at least every 2 hrs. I just wanted input on other LTC routines because apparently our CNAs need very clear and direct instructions.

[SuesquatchRN, BSN, RN]

Q4H changes max according to NYS guidelines. And yes, I care about those little state checkboxes. I have to. To ignore them constitutes neglect.

[Meraki]

Q4H changes max according to NYS guidelines. And yes, I care about those little state checkboxes. I have to. To ignore them constitutes neglect.

Q4H max - that is great. I'm all for changing residents as often as possible. I also though respect my grandmother's right to sleep in order to maintain some quality of life. Thankfully we are in Canada so no worries about lawsuits - they just careplan based on her needs.

[Moogie]

And it is my grandmothers choice to not be disturbed not mine and given she is still cognitively capable of making her own decisions and wants quality of life I support her. This arrangement has been in place for going on 3 years and she has yet to have an ulcer. I truly can not stand when policies and CYA are seen as more important than a person's right to receive/refuse care. We did have an issue with one staff who forcefully changed her against her will while said she was telling them no and stop because it was policy. This is not my idea of good or ethical care. Nor is limiting someone's quality of life so you can check boxes on a State checklist.

I agree with you. She absolutely has the right to refuse care and to have her wishes honored. If she is able to consent to care, she is able to refuse care and if she would be unable to consent, it would be up to the family to make those decisions for her. It sounds that in your case, everyone is on the same page and is planning her care according to her wishes.

The trouble is---when people aren't on the same page, when wishes are not communicated, the facility ends up in a tough position, caught between meeting a certain standard of care and doing what is truly best for that resident. My concern is---unless it is in the care plan---which in your grandmother's case it probably is if it's been the past three years---it is hard for someone outside the facility such as a state surveyor to be certain that there are her wishes. If it is not clear that these are her wishes or the wishes of the family in the event she would not be able to consent, someone from the state would not know for sure and think that the lack of checking her q 2 was due to negligence.

Deficiencies that occur because of actual harm can result in penalties for the institution that range from fines to losing its ability to admit Medicare patients to losing its right to hold CNA training courses. I agree with you that the CYA mentality does not always mean that good care is given but I would also hate to see a place penalized for trying to honor a resident's wishes.

When I have pointed out to other staff that a resident with dementia might have difficulty sleeping and that his/her agitation and anxiety increase when we wake him/her up in the early morning to check blood sugars---and point out that the blood sugars have been stable for weeks---I have been accused of being "too lazy" to do an accuchek. I knew that waking up the resident would mean that he/she would be tired and agitated during the day but it made no difference. The blood sugar was stable and checking the person was asinine but without a change in the doctor's order there wasn't much I could do.

I really hate being caught between what is best for the resident and what other people THINK is best but unless the resident or family consents to or refuses certain cares, nurses and CNAs working in LTC are caught between the proverbial rock and a hard place.

[SuesquatchRN, BSN, RN]

Q4H max - that is great. I'm all for changing residents as often as possible. I also though respect my grandmother's right to sleep in order to maintain some quality of life. Thankfully we are in Canada so no worries about lawsuits - they just careplan based on her needs.

I'm not worried about lawsuits, either, as much as I do the government.

Somewhere between the resident's right to sleep and Q2H incontinence care lies the reality. And frankly, in no LTC in which I've ever worked would your gramma need to worry about being awakened Q2H- or even Q4. It's all I can do to get my residents who need it turned Q4H.

[nurse grinch]

Grouping care is a very good suggestion. Take care of all comfort needs when doing pm care and/or vitals. Rounding Q 1 hour is required in the hospital where I work. The nurse on the odd hours;the aides on the evens or vise versa. This increases patient safety and decreases call light noise at night. Also, use your sense of smell at night. When you're peeking in a room take a sniff. More often than not that's the first thing that tells you if a patient needs changed without having to disturb them.

As far as getting your patient/resident to go back to sleep;if you have a few minutes ( I know, that's not usual.) sit with them and hold their hand and talk for a little while. If they have been awakened and don't remember where they are, this is a comfort. They know that they aren't alone. They'll usually calm down and go back to sleep or rest quietly.

Most importantly, if you work in a hospital, you never know when a family member will show up.