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My dad is in a hospital (acute care) waiting to assignment to residential care. The staff consistently put him in a chair with restraints due to being understaffed. Our family is mortified. What techniques could we give them in managing his random aggression related to sundowning. he is a lamb all day long.

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You could give them a boot in the butt by calling the joint commission or, better yet, go to jointcommission.org and fill out a complaint form. Restraints are the very LAST RESORT. Medications work so much better for sundowning, anxiolytics, antidepressants, or even a small piece of dark chocolate would be far more effective than tying someone into a Posey. Once you tie someone down, animal instinct kicks in, fight or flight, the adrenaline rushes in and makes everything worse instead of better. If it was my Dad, I would be dancing on the Chief administrators head until I got his attention. Pardon my rant.
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I agree with Pam.
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I'm an RN, 28 years night shift, and let me tell you it's not as easy as you seem to think. First off, you need to realize that there are lots of rules and restrictions about using drugs as restraints, the same as using a posey vest, or wrist ties. (BTW, That is what you are suggesting, when you suggest drugs. Drugs are restraints. At least that is how it is officially viewed by joint commission.) And NO, medications do NOT work so much better. Often they don't work at all on these patients, especially in the short term. Otherwise they just snow the patient, which is not a desirable result either. Besides, (in my experience) the powers that be, are far less likely to give orders for the drugs than the posey. As the nurse, I was grateful for any order that would help me keep all the patients and staff safe.

I often felt that what most administrations and most families really expect is magic. Or so it would seem. No one wants their family member drugged, nor do they want them physically restrained. Administration doesn't want the patient falling, nor assaulting other patients and staff, nor do they want their stats to indicated high numbers of patients in restraints or receiving drugs for the purpose of controlling behavior. But above all they don't want to pay for enough workers to keep a one on one supervision of the patients. And even when they pay for a "sitter" that can't stop the patient from slugging her, and the other staff that come to her aid. (Been there, suffered that. Many times)

As for "animal instincts" kicking in, you've got the cart before the horse. When the patient is hitting, kicking, shoving, biting, and peeing on other people, the animal instincts have already set in. THAT is why the restraints are being applied. The restraints are the result, not the cause of the behavior.

Unfortunately, there really isn't a good answer. One of the first things we were instructed to do is contact the family and ask them to come in a sit with the patient. Having also been the "family" of an Alzheimer's patient, I know how unworkable, and often ineffective that is too. Often times the answer was "we can't". And even when they did come, it was minimal help, beyond their being able to call us into the room when the patient was doing something dangerous.

Sorry, I don't have any answers for you. I don't think there are any really good answers for this horrible disease. But I do know that I couldn't let it slide, that the only response is to criticize and blame the nurses who are working in this impossible situation.
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I also agree with GayleV, no one answer, no one remedy, we just don't want abuse to anyone in my book.
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I totally sympathize with Gayle V. Yes, family members who don't want medications are in denial. The same group goes to pieces when Papa is secured to a chair. Nurses hands are tied, MD's fear lawsuits, and Admins are often the most clueless of all. I'm not blaming the nurses, I know too many forced to work in understaffed situations. The Chief Admin can get things done, and besides the Chief is so lonely in that big office, so go visit and break up the boredom.
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GayleV - great post and totally right on. I am also an RN and have been physically assaulted, spit on, seen excrement smeared everywhere, by quiet little demented patients who turn into the exorcist for no real reason. It is sad for everyone and extremely difficult for the staff. You can pay for your own sitter during those confused times - but that is not always financially an option. You can call her doctor or the director of the department and insist that the MD write an order for a sitter. They can do this on a 24 hour basis but hospital administration is going to fight you on it. Try this - call her primary physician and tell them that your loved one is a "high fall risk" and needs a sitter because you would hate for your loved one to fall and hurt themselves in the hospital. (If there is an injury in the hospital medicare will not pay for the stay.) Good luck and again GayleV. thanks for the reality check - hugs to all.
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Vital discussion. I agree with Gayle, that restraints are better than drugs, that they are what are used Following kicking and screaming or trying to punch. I also think the topic is very, very complicated, and it is one that I have studied for years. I end up believe that we can do much better in institutions, to train staff - so many staff talk to elders as if they were children, over- explain instead of respond with a smile or a two minute deliberate avoidance of the person - there is a push/pull series of interactions, and many of the examples we have written on other posts, about how to deal with someone who is critical, or abusive, or giving the silent treatment - there are ways to maybe change the schedule to put the difficult person last if you see him acting up, give him more time to calm down. Give people a warning or two before interrupting their prior activity, even if it looks as if it is nothing - people, especially elders, recognise when they are being treated with respect, which means expecting give and take, not just following lists of routines within a time schedule. I don't like the phrase "sundowning" - I find it a horrible euphemism, for what would normally be a need for a nap toward the end of an afternoon. Surely every human being sundowns, benefits from a break in expectations. I understand risks and needs of RNs and all staff, but many seem to expect that an older person should have no depression, no anger, should respond to a long series of caregivers, day after day, when the more frail people are, the more they value routines and familiarity, b
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Maybe just as well that I hit "enter" by mistake, gave me a break in my post. I just find that the healthcare system is set up to follow a medical model, meaning a model where any issues are sent to the MD - this model in my opinion, places medical things above community and paying attention to one another, as human beings in a shared setting, working on ways to both accomodate each other, and ask for cooperation.

In my brother's brain injury program, they have found that if someone is having a tantrum, you can send in a different helper, with a different approach, maybe someone who will take the side of the tantruming person first, use calm voice but few words, to re-direct them to do something else - maybe ask them to give you a hand - something that distracts them.

The medicines just allow the institutions to be managed in a medical model - but even if most doctors are caring and educated people, incidents arise in specific settings, maybe during shift changes for instance. Ask a patient what they were doing, lean with them before asking them to follow. My belligerent brother taught me so much - sorry, I know I must sound arrogant. It took me years, but I am glad that I learned. Interevene, then stop, wait, if they are upset. Be calm. Say OK, good, I'll be back in 5 then. And leave. Specific kinds of things upset different people, not easy to learn in group settings but very helpful to avoid issues. If my brother has just made a mistake, a bathroom mess or he has fallen, or made an error - he may holler and at that time, you cannot reach and teach him to be polite. He's too inwardly upset. Leave him alone if you can't show reassurance and just help him clean up. After half an hour or so, to be calm again, and you can just give him a simple direction. If staff know that, they know how to deal with his upsets, not keep pushing to fulfill chores on lists or follow some schedule.

If elders live in their homes and they are obnoxious extensively, then as a caregiver, we can say, "sorry, I can't handle this right now. I'll be back in half an hour, see you then." Medically based facilities would do better if they worried less about lawsuits, and more abouit helping staff get interested and devising strategies of interactions, adding checks and balance and staff helping each other, to let someone be, through a meal or in the morning. Human bodies don't operate on a clock precisely, there needs to be more relaxed leeway. Calm staff trying new ways over time to work with someone, yields progress.
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Yes and the hospitals would need to increase their staffing ratio about 100%. Isn't that the real problem - lack of bodies to help other bodies. I can also tell you that hospital administration are bean counters - no they do not care about your loved ones- they care about the bottom line which is $$$ - because that is their job. You can also get those horrible staff members who are just putting in their time for the paycheck and really do not care. Very complicated. Visit often, at unexpected times.
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I don't agree with the above nurses. It is apparent they work in a hospital an acute care facility. It is very difficult to hop the fence and work in a longterm facility as a RN and the same for a nurse who works in longterm facility hopping the fence to work in acute care setting. It is like night and day. I did work in one of the best longterm facilities in the country for 32 years. On the units and in Research. I have seen the elderly return from the hospital in a mess. The elderly do not do well with change. Most hospitals do not do well with the elderly. Yes posey, vests, etc are restraints also medicine can be used as restraints. Physical restraints are dangerous and and cause death if not used properly. Longterm facilities for quite a few years have not use restraints for that very reason. They use chemical restraints. Also, a Geriatrician can order appropriate medication and doses specifically for a patient. Acute care Physicians don't have the same training as a Geriatrician. We have become in longterm care of using chemical restraints vs physical restraints.
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As an R.N., with 40 plus years of experience, and working so much with mentally ill patients, Dementia & Alzheimer's patients, I tell you it is for their safety & well being. No need for you to pull you ego's into this-who is this about you or them?? We must keep patients from hurting themselves. Nurses are not given the staff needed & things will just get worse. Try to find the LIGHT with in him & help him to shine....it's tuff. Then I never got any guarantees along the way....
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The original poster dealt with an acute care facility - her loved one is waiting to be transferred. There are many great nursing homes if you have the resources and money. If you are in a nursing home that only takes medicaid - good luck. I doubt if they get very much individualized care.
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I am a RN since 1986 , and restraints are the last resort I agree with gayle . You don't know what goes on until you speak to the nurse taking care of the patient . I wouldn't call anyone until you speak to the dr , you can't restrain a pt without a dr order there is a protocol that has to be followed and I'm sure they are following it . I think restraints are necessary a lot of the time you can't give a elderly pt drugs they become more confused. I think you need to speak with the dr and find out if they are following protocol before you run and call JACHO . That's your right to call but speak to the staff first have a meeting with the nurses and dr . I think you will find there is a reason and it's not because they are understaffed . Education is the key to understanding the world of medicine . Nurses are not out to hurt pts we are the first line in pt care . I wish you well and hope things work out well with your dad . By the way I work with a geriatric dr and a physiatrist and have many years long term and acute care . Hospitals have very strict guidelines in restraint placement .
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Yes, speaking with the direct staff is the key. And there is a reason for each incident - those are the processes to ask about. What are their alternative ways of managing a time of transition, other than just leaving the patient alone - so many times a patient needs reassurance that someone is paying attention, and in a busy place especially if you get a reputation for being difficult according to the caretakers, people rush to that conclusion most times they hear you upset. So we get a combination of people asking for help, and staff assuming they can wait, or responding in patronizing or hostile ways each time someone with a reputation gets upset. Unfortunately staff usually document what happened during and after the incident, not before - I think that is wrong - they should problem solve to see what could be improved in each case, not track how long the outburst was. You have to ask about the earlier routines and work around those. I just realized that you said the staff "consistently" put him in restraints - I wonder if they do it as a precaution, and it is possible that he would agree to have them on - That's not awful, if they are good about it, and quick to take him out of the restraint as soon as other patients are moved for instance. Restraints could be helpful, but the danger is that people would leave him then too long, and naturally he would get upset at the communication problems and frequent neglect of his voice in the process of care.
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I agree with Ohmeowzer (and I guess you have a cat??!) - about speaking with the staff. I'm grateful for this conversation here for it is not easy to have it quickly in the workplace, and not easy to challenge the management of exteriors (behaviors, through meds or restraints), for voices of prevention sound more scattered and even vague (bring out the best in the patient) - sometimes it's not so easy to find the bestr, especially with rotating staff and many issues.

Yet I believe a big piece of the difficulty is a communication problem between patient and medical care implementers - of all different kinds, so they resolve things by running to the MD, but local issues can be resolve with some curiosity, so that MD calls are not necessary a lot of the time. One key piece to add (and I wonder how I could design training in this stuff) - but one piece would be to assure many staff, that many elders expect a response if they call or speak up - and it's OK if that response is "No, not now. I'll come back in 10 minutes." In my home care work, I've seen some staff assume it's OK for Pts to wait because they are busy, or settling in - OK, we do not want patients to expect to be treated like princes or princesses. And some ask for that. But giving them no response is an anxiety provoking way to answer, for it leaves the ambiguity about whether or not they have been heard, understood, if their request is OK at this time - no reply leaves them out of the picture. I find that when I respond to most utterances from them, don't try to lead them to be cheerful, but I can be cheerful myself and show I'm glad to see them - and respond to their requests with "Not now", or "I hope this can be soon", a hug, or something that says, "you are on my radar screen and I look forward to getting to you soon" - is a way to allow caregivers a breather - they don't have to run every time there is a verbalization, if they reassure the person of when they'll come.
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Do your homework before you place your loved one in a home.
Ask how they handle aggressive behavior.
Visit often BEFORE you place your loved one.
Keep abreast of the drugs and medications used in the home or facility.
Ask about staff and background checks on employees.
Do your own research.
Too many families trust an imperfect system.Often they are in a hurry to place a family member and get on with their own lives.
They judge the home or facility on a one hour tour or brochure.
They often make the assumption that money buys excellent care.
Time for a wake up call.
Facilities are short staffed.
Meds are used to regulate everything from bowel movement to sleep.
Restraints will be used to protect both client and caregivers.
If don't like these scenarios then you'd best keep your loved one at home.
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I am an RN was in the business for 32 years. I heard no one mentioned what happens to the elderly once they get sick and change their routine and they end up in the hospital. Most who have any type of dementia will have a delirium. You can't medicate them because you will just make it worse. Many years when patients returned from hospitals. We didn't fill them with medication or did we restrain them. Many different staff members sat with them and kept them safe until the delirium had past. You see a very different person. My mother, I cared for her for 12 years of her life. The last 8 years I lived with her. I will never forget the night My mother was hospitalized and I had to leave and my mother was in need of her scheduled Ativan. I saw her get more agitated. They promised me she would have her Ativan ASAP. Well I got a call from the attending telling me my mother had a reaction to the Ativan she got 4 hrs later at midnight. That was bulls**t! It was there neglect. That pushed her over the edge. They restrained my mother in 4 point restraints. I went to the hospital and caused a lot of trouble the following day. My mother was put in a private room away from the noise. The number one problem was she was put on a cardiac floor with a lot of monitors going off. Just enough to set my mother with dementia over the edge and she had a delirium. She was able to tell me what happened. It has always stayed with me. She told me an "Irish doctor was talking to her and then there was two black orderlies tying me up. I kept calling your name but, you didn't come. I thought they where going to slit my throat and kill me" I never forgot it! My mother died at home with Hospice care, she had nights where she was very agitated. Throwing the sheets over the bed side and stripping. My mother would be mortified if she ever realized what she had done. I never used a posey. I always used chemical restraints. Which worked just fine. She never remembered it the next day. For the nurses in acute care. Think of what you would do with you own parents. Acute care nurses and Physicians just don't understand. You claim you have Psych and Geriatricians who write the orders. In nursing in general I hear burn out. I understand funding and administration. The paperwork is never ending. But, the bottom line is posey's are not the answer. How would you feel if you had someone working under your license put a restraint on a patient and the patient died from the restraint. You would lose your license and your job. There is no ego trip. But, just hearing the horror stories of restraints. I would never use one any I never had a patient get hurt. Hospitals have a lot to learn as there is more Alzheimer's and Dementia in the coming years. Doctor's and Nurse's in school today. Their last rotation is Geriatrics. I have no Regrets.
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My grandparents had restraints (tied into wheelchair with a shirt/vest thing) because they would wander about, too aggressive, and would not behave. They were already tried on various medications to no avail.
I don't have any problem with them being in the restraint, it is more civilized to have them like that, than to allow them to go injure someone else, or themselves.
Yes, if you don't like the restraints, try taking care of that elderly person in a rage all by yourself. At some point, you too will want to just tie them up---it' s only natural to need to restrain them!
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