Rounds, Falls, and Skin issues

[handyrn]

I am a charge nurse in a LTC facility. Just to give you a little history, I am not new at the LTC world. I started as a CNA 21 years ago. After going to LPN school I worked LTC and then went to RN school and find myself back at LTC, so am quite experienced. I am a teacher by nature and volunteer for training and inservices. Recently, I taught an inservice on alzheimer's and special needs. In my research, I found studies that show that with the advances in incontinence products, if your residents are mobile and can reposition themselves in bed, they do not need to be "pottied" every 2 hours. There is no more evidence of skin breakdown when they are pottied and changed every 2 hours than not.

On another note, this same study revealed another "secret." In war days in the concentration camps the prisoners were subjected to various types of torture. Among these was that they were awakened every 2 hours during the night and forced to stay awake for about 10 minutes and then allowed to go back to sleep. This severely disturbed their sleep patterns and thus, made them clumsy and confused during the day due to lack of proper REM sleep. Hmmm, is this what we are doing to our elderly? Is this part of the reason for so many falls and inappropriate behaviors?

And speaking of falls and alzheimer's, did you know that when people have alzheimer's they lose their development in the reverse order of how they gained it? Think of a baby. First they learn to make sounds before they learn to sit up. They learn to walk without shoes before they master walking in shoes, etc. This is why many alzheimer's patient's take off thier shoes. They need to use thier toes to grip the floor which they cannot do with shoes on. When we force them to wear shoes, we are actually causing falls.

How about the whirlpools that are so common in our nursing homes that have been such a necessity for skin issues? Again, studies are proving that bed baths are just as, if not better for the skin than whirlpools. Also, for the confused patient, a whirlpool looks like a pot of boiling water. Would you want to be lowered into that?

The study of alzheimer's disease and long term care issues is really interesting and so in depth. When you dig into it, there is a lot to learn!

[CapeCodMermaid, RN]

I'm hoping with the advent of resident centered care the 2 hour toileting thing will be only a memory. Do you pee every 2 hours? No. It is not natural but for years we've been doing it for fear of reprisal from the DPH. I've had several residents who were incontinent but very alert ask me to tell the staff not to wake them up to change them. They would rather sleep on a wet soaker than be woken up. The DPH tried to make an issue of it, but when I told them the resident's skin was intact AND it was their request (and in the care plan of course) it was a non issue.

And you're right about whirlpools...who needs to be bathed twice a day? All that soap is drying to the skin...give good pericare with toileting and a weekly shower and be done with it.

I hope I don't have to live in a home when I'm old. I don't eat breakfast, like to wear sweats and go barefooted. And I have insomnia so if I am sleeping, please don't wake me up unless the building is on fire!! I pray that patient centered care is a reality by the time I need to go to a SNF.

[RN1989]

I totally agree with your sentiments. Unfortunately in these days of CYA, "they" make us do idiotic things to prevent lawsuits. Of course, it really doesn't prevent lawsuits, it just makes the facilities look like they were doing the right thing by implementing these stupid protocols, so they can hide the understaffing and undertraining of staff.

[CapeCodMermaid, RN]

If we weren't doing all this ridiculous stuff, we'd all have more time to do things that really make a difference in the lives of our residents.

At my facility we try to do things based on logic, reason, clinical appropriateness and residents' wishes. Do we always succeed? No, but if we can show the surveyors that we are following MD orders and resident wishes I don't think we'll get cited.

PS> I've already written my own care plan in case I do have to go to a SNF.

No shoes or socks. No waking me up for anything. No making me eat breakfast or lunch for that matter and if I want to stay up till 3 am, please don't try to medicate me.

[sharlynn]

And you're right about whirlpools...who needs to be bathed twice a day?

LTC's I've worked in have a twice a WEEK bath schedule and residents are allowed to refuse one per week unless they are incontinent.

We also lowered them into still water. The pot didn't start to boil until they were in it!

[CapeCodMermaid, RN]

Does that mean you FORCE them to bathe if they are incontinent? I worked at one facility where the DON was a cleanliness freak. She told the CNAs that the residents HAD to have a shower....they used to put one patient on a shower chair and bring her in even though she was screaming. It was horrible. I suggested baby wipes warmed up in the microwave....or a warm washcloth. The woman didn't smell and the whole floor wasn't subjected to screams. I didn't stay there long after that since it wasn't the only time residents' rights weren't #1 on the list.

[ayla2004, ASN, RN]

we 4 hourly checks turns on pads, at 2am if we know the resident will be okay at this time we leave them to sleep, or if we have a resident who rather not be woken even if wet we leave then

its at 6am we check and change everyone. in between we do breathing checks. got an inservice from continence provider nurses that as a student they used to toilet everyone every two hours and research has shown this weakness continence.

[handyrn]

Such interesting stories from all. The baby wipes idea was a good one. Shame on that supervisor! How absolutely horrifying for the resident, staff, and other residents to witness. I have never heard that the pottying every 2 hours weakens continence but I guess it makes sense. We have one resident that does not wish to be bothered so we order her a special brief that is called and overnight brief that is supposed to be good for 8 hours. Why not use them for all residents? May be a little more expensive but just think of the undisturbed sleep that the residents could get!

[marjoriemac, LPN]

Geez, 2 hourly toileting, unless anyone has been identified as always soaking every 2 hours, we generally do 4 hourly toileting, plus the continence nurse only gives each resident a quota of 5 pads a day! At night, they do hourly room checks, not waking folk up but checking on breathing. During the day, we are a small unit so everyone is readily observed anyway.

[nightmare, RN]

Research showed that if you empty bladder every two hours then the bladder will expect to be emptied every two hours! The trick is to lengthen the time slowly so that the patient can go for longer periods without incontinence occurring. This ,of course,takes up a lot of man-power(woman-power)so the two hourly toileting becomes standard as it is less labour intensive.