Patient Care or Man Handling???

Dolce, RN · Oct 8, 2008

I feel for you and the patient. Situations like these are extremely difficult. I would suggest coordinating your efforts with the patient's family as much as possible. Do they want him "manhandled"? Are they willing to try to calm down the patient during peri-care? As much as I hate to put families/significant others through the pain of watching their loved one become violent and extremely agitated sometimes it is the only choice.

There are different anxiolytics and it is possible that even though he didn't react well to one he may react more positively to a different one.

Straydandelion · Oct 8, 2008

Does he have Alzheimers? I know AD is usually a gradual onset but more studied the person is, the more it "appears" as if sudden as they are able to mask the symptoms longer. Alzheimer's typically are VERY afraid of water on the average. My mom has Alzheimer's, and we never said the word "bath" etc. but it seems like "a quick cleaning" didn't seem to affect her as much. Different people will have different reactions to words. Possibly try to sit then on the toilet to run water over for pericare? A quick wash before getting them off if they are able? The family may also be helpful but may be frustrated also, looking to you for advise. This article may help hopefully

http://www.guideline.gov/summary/summary.aspx?doc_id=6220

hippylady7211 · Oct 8, 2008

The wife is disabled and lives 100 miles away and his sons live out of state so family assistance is not an option at this point.

We can't even get him to sit on the toilet. He uses wastecans, sinks, corners. Usually you can take them by the hand and guide them to the bathroom but he is resistive to any type of help.

He will refuse to eat unless you start to feed him, standing up, then he will finally sit down for a meal. (I'm not really worried about his food/fluid intake as he will take it on the run. Sandwiches and Ensure are a God sent) however he walks everywhere and wears himself (and staff) down to the point of exhaustion. The only time we seem to get him to sleep is to put him in a gerichair with his feet up (so he can't walk off) and rub his head.

He cries out in his sleep and when he does finally goes to sleep he suckles like a babe.

This is so upsetting to me that I am sitting here at 4am trying to think of something to do.

locolorenzo22, BSN, RN · Oct 8, 2008

Not much you can do. Give quality care, even if he fights, he's gotta get cleaned and washed....can't sit around in wet stuff. You can have that conversation..but you may need to take the "bull by the horns"...GL

JB2007, ASN, RN · Oct 8, 2008

When I worked on a Alzeimers unit we had res do the constant walking up and down the halls until they where exhausted. They would eventually get use to being at the facility and settle down. It is really hard on these res when there is any type of change in their routine, so being is a new place is going to be especially difficult for them. Try to get a routine going with this res, so they feel safe and know what to expect. I know that it will seem like they do not remember, but the routine does help.

Try going slow with this res and telling him in very simple terms what you will be doing. Go one step at a time. A lot of healthcare workers just move too fast for these res to process what is going on and they become more combative due to this reason.

Some res will just be more combative than others. I had one male res that would yell at me, "Get out, little girls do not belong in here." every time I would try to change his breif. He would at times try to take a swing at me, so I always went in with back up.

These res can be some of the most difficult, but the most rewarding to take care of.

pielęgniarka, RN · Oct 8, 2008

I feel for you and the resident. Usually if the MD can't get some meds that work or if our nsg care plans are not working and the res. is not able to get proper care we get MD orders and family consent to send them to a geriatric psychiatry inpatient unit that happens to be in a nearby town. The meds are tweaked & a routine is set and the behaviors usually come back improved or at least moderately controlled after a couple weeks. Your situation also sounds like an infection control issue and danger to the other residents as well. Life may be too overwhelming to the res. and maybe a dementia unit or lock down type living arrangements may work better than a standard nsg home.

The wife is disabled and lives 100 miles away and his sons live out of state so family assistance is not an option at this point.
We can't even get him to sit on the toilet. He uses wastecans, sinks, corners. Usually you can take them by the hand and guide them to the bathroom but he is resistive to any type of help.
He will refuse to eat unless you start to feed him, standing up, then he will finally sit down for a meal. (I'm not really worried about his food/fluid intake as he will take it on the run. Sandwiches and Ensure are a God sent) however he walks everywhere and wears himself (and staff) down to the point of exhaustion. The only time we seem to get him to sleep is to put him in a gerichair with his feet up (so he can't walk off) and rub his head.
He cries out in his sleep and when he does finally goes to sleep he suckles like a babe.
This is so upsetting to me that I am sitting here at 4am trying to think of something to do.

CoffeeRTC, BSN, RN · Oct 8, 2008

I too feel for you! Every so often we get new admits like this. Staff gets worn out quick. Other residents see this and are upset. It wouldn't be so bad if we weren't a mix of pts and mostly dementia, but we've been more short term rehab and less alz dememtia and ltc.

Care plan, care plan, care plan. CYA with good nurses notes too.

So...First off try to be consistant. Have a few of the same staff take care of him. That said, note that the staff will get burned out quick if they have him and a full assignment, so you might need to be creative there.

Go with the flow. I

f he seems to be calmer or more receptive to a shower or inct care at 3am...do it at 3 am. If he seems to pee in the lobby after lunch...try to steer him to a bathroom or his room at that time. (this is a hard one for us...we are such a small facility so when we get folks that like to pee in the trees in the lobby...it is a big show).

For one of our resistive residents the family purchaced a higher quality inct brief that would hold more or work better and needed changed less frequently than our cheaper brands. Good skin care when you can and use a barrier.

Drugs normally don't work with these type of residents. You either end up over sedating them between giving them meds and the fact that they are so exhasted from being overly physically active or they get even more agitated, combative and wandering. Sometimes they need that sedation to take a rest and will then gradually slow down after the meds get adjusted.

I agree that this placement might not be the best. It is difficult to transfer these pts once we accept them (or maybe our administration doesn't try hard enough). A locked dementia facility would be best.

DaMale Nurse · Oct 8, 2008

Previous post have already covered most of the really good interventions that you have to try first. I have worked with allot of pts at a inpatient pscy unit where this comes up pretty frequently. Bottom line is it's your job to care for the pt, even if they are not able or willing to take care of themselves or even to accept your help. So if nothing else works talk to the docs about a restraint order so you can force the issue. A doc can eventually justify a restraint order for peri care and bathing issues. Just make sure you CYA on this. Document all interventions, when you did them, and that they didn't work. Of course you need to look at you facility but in mine RN's can do a manual restraint for up 15 min and a restraint w/ leathers for up to one hour without a doctors order. So good luck.

CapeCodMermaid, RN · Oct 10, 2008

YIKES!!! If we did leather restraints for ANY reason in this state, we'd all end up in jail. No doc I know would give an order, nor would any nurse take an order, for physical restraints just to provide care. Glad I don't live in WA.

Try some Ativan before care or as a previous poster suggested, if he is this bad he probably needs a geri psych admission for med management.

Furwillfly · Oct 11, 2008

I live in WA and my guess is DAMale works in a hospital or something, because we can't use leather restraints where I work; so lets not stereotype. :)

Talking about interventions of this gentleman, have we a behavioral intervention list? Have we attempted to see if he has a medical reason for his agitation? Like a UTI? Labs...thyroid...etc? If he is difficult to give meds to a short term order for Ativan cream, or perhaps Zyprexa IM, just to provide cares etc....what oral meds is he on?

For inappropriate toileting a "Onesie" works wonderfully!

I work with residents like this everyday where I work.....it's not easy; you gotta try everything to figure out what is wrong and what will work for him. I would keep calling his doctor until I got an decent order, he may get mad, but he would be 'on board' then. Our doctor doesn't like me very much, but I'm not there for him, I'm there for the resident.

SuesquatchRN, BSN, RN · Oct 11, 2008

Sometimes you just have to get a couple of nurses and a couple of aides and undress him and get him to the shower.