pacify or orientate? Alzheimers...

[Lfransis]

So I have worked my third day as a LVN in a LTC facility. Orientated for one day then turned loose...on the alzheimers lock down unit. 21 residents.

A little scary, but I am fairly comfortable, so far. (should I be?)

Mrs. X is driving me crazy. For my three days she has asked to call her daughter to come get her.She is going home, looking for her car, easily agitated,etc.

The aides pacify her: "Mrs. X your daughter is at work, you can call her when she gets home from work" " your going home after lunch" This goes on all day.

I am new with Alzheimers behavior. I am new at being a nurse.

I don't feel good about telling her she can call her daughter to get her

"after she gets off work" , or that she is going home.

Is this not implanting the idea even futher, possibly even creating a cycle?

Any advice/ suggestion?

[P_RN, ADN, RN]

Dear hearts and gentle people let's stick to the fascinating topic, and let's make a real attempt not to get into a one on one with a particular poster. Sometimes it takes a tap on the shoulder to get someone's attention and sometimes you really want to use a brick......let's use neither. Address the topic.

We all know opinions are like....uhhh...noses :) ...everybody has one.

[-Midget-]

I've been reading this thread for a while now, and just decided to finally reply to support this "theraputic lying." My grandma has dementia, and before she was placed into a nursing home, my grandpa and I took care of her for a few years. At first, I was convinced I had to orient my grandma back to reality, as was my grandpa. All this did was cause a lot of frustration for all involved. I then figured out that out of the three options I had--telling her the truth, ignoring her, or telling her what she wanted to hear--the latter worked the best. She'd ask about her brother, who's been dead for a long time, and I'd told her I hadn't seen him. This, and many other situations, were easily resolved by telling her something to put her at ease. Now that she is in the nursing home, she talks about going to the store, or Wisconsin, and a while ago she talked about going to Las Vegas. We've had some very intersting conversations. ;-) LOL

[barbyann]

When i was a CNA, many years ago, I worked in LTC. There was an elderly man admitted with ALZ. He had been an Admiral in the Navy and one of the few possesions he brought with him was his Navy dress uniform. He was not happy at his placemnet and was a wanderer. One day I heard commotion at the doorway and was told that the Admiral (in his full dress uniform) was in the parking lot and he would not return to the facility. They had been trying for quite a while to get him inside. The decision had been made to restrain him and put him in a wheelchair to get him inside. I asked to please let me try before any restraints were used. I ran out to the parking lot yelling "Admiral, Admiral, there is a huge problem in the galley and it requires your immediate attention" "Please follow me". He saluted me and we headed inside. He looked delighted to be needed. All the staff was tired from their pegging and pleading. I was the hero for the day.

Answer-bring yourself to their level of thinking.

[RebeccaJeanRN]

Whenever possible, I think kindness should be the rule. If this means that when trying to 'validate' a patient's feelings or concerns, and you find it doesn't work so you just allow the patient to think you are their long dead best friend, so be it. I have only worked very briefly in clinicals with Alzheimer's patients but I had a grandmother who had it. The awful thing is that her suffering was very real to her. She BELIEVED that she really needed to get some schoolwork done for class (she used to teach many years before) and all sorts of other distressful intruding thoughts. When Alzheimers patients are distressed, they really ARE distressed. The cruelty of this disease is that the patient is often haunted by compelling thoughts that are distressful (I need to go meet my husband, I need to get to class, I need to go get Aunt Sally, I need to find that recipe, I don't know where I am, I don't recognize that food...). Its like they can't make sense of their world and are so upset by their own confusion. I think that whatever we can do to make them feel comforted, less fearful, and enjoy their days more...should be the goal. What matter that they know the right year or right time for a fleeting moment? Far more important is that they are not afraid and feel at peace in their environment. I don't know what its like to live in a constant state of confusion and stress, but I can recognize distress and torment when I see it. I think we have to allow that the best therapeutic technique may be different for each patient. Nurses who simply say what a patient wants to hear may not be lazy, but may know that orienting or orientating (my medical dictionary says both are correct), is not a successful approach for alleviating stress for that particular patient.

[sanctuary, BSN, MSN, RN]

RebeccaOne, you are absolutely correct. The patient's response is the best guide in directing the nursing intervention. When people are in late stage dementia, the only compassionate goal is the patient's comfort. I started this work in 1963, when the focus was on "reality orientation". We would inform people that the spouse that they were looking for was dead, had been dead for several years, and watch the melt-down over and over. Finally, we began to understand that s/he would NEVER get it. That meant a re-ordering of our thinking, and revision of the goals. When we concentrated on the patient, and their level of comfort, and made it the primary goal, we worked (sometimes with other family members) to find the path of most comfort. Women looking for children were asked where they went when they tried to get out of chores...Then we used the story from the patient's life. Husbands were frequently "helping a neighbor." Wives were "putting up food." There was an immediate improvement in the energy level on the units. Staff stopped getting screamed at, or slapped, and patients could join in activities if the demons were temporarily at rest. Even those who had to ask the same question every few minutes were less distressed in general. Patients are always the best teachers. It is not being lazy to investigate 47 wrong answers before the correct one is found, nor lazy to have individualized responses for each patient, and remember what to say to whom. It is much harder to do that than to just tell everybody that they are wrong, about the date, the situation or their fear. That's probably easier.

[ktwlpn, LPN]

Sometimes it takes a tap on the shoulder to get someone's attention and sometimes you really want to use a brick......We all know opinions are like....uhhh...noses :) ...everybody has one.

(-spewing coffee all over my keyboard- ) I know it makes me less of a person but please pass me the brick. Seriously though I think the reason why parts of this thread have gotten a little "testy" is because so many of us really feel a passion for working with these patients..There really is an art to communicating with those afflicted with dementia.I'm sure that the rest of you who have found your niche with them have experienced the same kinds of frustrations throughout your careers as I have.I've worked acute care and been unable to give the time to these pts that they needed and instead had to resort to restraints,medications and my least favorite method - the dreaded geri chair in the hallway of the hospital.I've seen them loose their dignity.I've worked in plenty of LTC settings that also did not address their special needs in an appropriate manner. I have seen the effect that short staffing with poorly trained nurses and cna's has on this population (even loud ancillary staff can set off the entire unit) I've worked with staff whose behaviors had an adverse effect on the residents-I have had to complete the incident reports for these staff memebers when they got hurt. I've spent countless hours trying to comfort and re-direct a resident after a staff member has snatched their stockpile of coffee cups or stuffed animals because they felt they had to be in control and could not take the time to communicate...It's frustrating and sad.The unwillingness of many to attempt to learn the techniques to communicate with these people properly is just a symptom of the bigger problem.To many in our society these people just don't matter any more.........I don't believe that......I do believe that karma is a *****.....

[supernurse65]

"Therapeutic lying" is absolutely inappropriate. It is unethical and in my opinion, it implies pure laziness on the Nurse's part. Telling the patient what you think 'they want to hear' does nothing for them therapeutically.

It's sad that so many Nurses just take the easy way out by 'pacifying' these people.

"Think of a time you've been lied to. Say your 12year old son said he would be at his friend's house but in reality he went to park to skate with a bunch of kids you don't know. You most likely would be upset that your son lied. If you had dementia, however, you may never remember your son saying where he'd be. He gets home and says, "I had a great time at the park." Whether or not you remember does not change the fact that he lied. It is no different when speaking to a client (patient). They may not remember their daughter isn't coming to get them, but it doesn't change that you lied to them."

Continue to re-orient your client. Why? It's respectful, it helps combat dementia, and redirecting can help rebuild short term memory.

P.S. The correct term is 'orient,' NOT 'orientate.'

Maybe you should try working with alzheimer's patients or read a book about it. This is absolutely appropriate.

[supernurse65]

No experience working with dementia/alzheimers patients huh? Been doing this over 20 years. The staff the insist on reality orientation gets cussed, hit, bit, spit at, etc and the resident can become agitated beyond belief. The staff the goes w/ the therapuetic lying ends up with calm happy residents. Lazy?? Takes alot more energy to be running around a building pretending to milk cows then just say "There are no cows out there" and walk away.

:yeahthat: :yeahthat:

[Multicollinearity, BSN, RN]

How we make children feel safe comes to mind. We don't always answer their questions truthfully. We answer what they can handle as age appropriate. I think our approach would be similar with those in the stages of moderate to severe dementia. The aim is the same with a small child. Keep them feeling safe. Keep them feeling secure. Both little children and moderate/severe dementia patients lack the mental capacity to handle (and/or remember) all of the truth. Comfort is the goal.

Someday when I'm a little old lady - if I have dementia...I hope my nurses will shield me from the truth. Because I would just want comfort and I'd lack the mental capacity to fully understand and remember. But what do I know. I'm just a pre-BSN student. I do know that if my grandmother's nurse had attempted to orient her to reality every time she had asked for her sister or husband (both deceased) it would have been an agonizing scene. You wouldn't tell a 4 year old on September 11, 2001 that we don't know what is going on and that terrorists are trying to kill us. You would tell that 4 year old that she is safe and mommy will take care of her. I see the same treatment intent and goal with the dementia patients.

Only one who lacks an understanding of what dementia is - would say orienting is the goal. It isn't possible in the later stages.

[indigo girl]

How we make children feel safe comes to mind. We don't always answer their questions truthfully. We answer what they can handle as age appropriate. I think our approach would be similar with those in the stages of moderate to severe dementia. The aim is the same with a small child. Keep them feeling safe. Keep them feeling secure. Both little children and moderate/severe dementia patients lack the mental capacity to handle (and/or remember) all of the truth. Comfort is the goal.

Someday when I'm a little old lady - if I have dementia...I hope my nurses will shield me from the truth. Because I would just want comfort and I'd lack the mental capacity to fully understand and remember. But what do I know. I'm just a pre-BSN student. I do know that if my grandmother's nurse had attempted to orient her to reality every time she had asked for her sister or husband (both deceased) it would have been an agonizing scene. You wouldn't tell a 4 year old on September 11, 2001 that we don't know what is going on and that terrorists are trying to kill us. You would tell that 4 year old that she is safe and mommy will take care of her. I see the same treatment intent and goal with the dementia patients.

Only one who lacks an understanding of what dementia is - would say orienting is the goal. It isn't possible in the later stages.

You show good sense and compassion. Your future patients will be blessed to have you as a nurse.

indigo

[Multicollinearity, BSN, RN]

Actually, as I think about it, I'm sure that there are certain treatment techniques that academics would be loathe to put in print even though they know sometimes it must be done. This is where experience comes in. I'm sure 'therapeutic lying' is one of them.

I do know that my BSN program cannot possibly teach me everything I need to know. It will only provide a foundation. I imagine you learn the basics, and hone the critical thinking skills necessary to keep on learning for the rest of your career. I like the phrase "license to learn" that I have heard here. I'd listen to those who have decades of actual experience, add that to my college education, and come to a common sense conclusion. Oh, and once in a blue-moon academia is wrong.

[Multicollinearity, BSN, RN]

You show good sense and compassion. Your future patients will be blessed to have you as a nurse.

indigo

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