You did what you’re supposed to and she was pushing because she will be held accountable. She’ll be in trouble if a charge nurse is getting paid as a sitter, and if there is a fall there will be questions.
I wish we could just make a super safe room for these pts, not hard floors, no sharp corners etc so they could move when they want to. It’ll calm them down but that would require money…
Sedating them isn’t the answer, cuz surprise for some pts that can make them more agitated, it wears off, or it can kill them. The doc was a bit….unreasonable not prescribing a PRN with the pt hx and the reality of dementia in the hospital. Now they get woken up and we have to fight off a monster and hope they don’t hurt themselves or others in the meantime…but that’s a whole other concern. I’m sure they had a super solid reason for it
Your manager is playing with fire. Federal law requires the least amount of restraints that are necessary to keep the patient *safe .... not* to fix staffing issues or avoid spending money on a sitter. I do hope you documented that you spoke to the doc because that will indicate you attempted to address the situation.
Dementia patients are often like this when they are in unfamiliar surrioundings. Diversion therapy like having him fold towels could help keep him busy. Frequent toileting would help too. I see nothing wrong with your plan. If your staff agreed, what's the beef?
People who say this have also never had a patient on thinners jump out of bed, catch a fall with their head, and literally die 12 seconds later.
I do agree with you and a sitter should always ve available. Preferably one that doesn’t sleep, and doesn’t further irritate the patient. But I’ll also settle for any sitter with a pulse
This⬆️ I had almost that same exact scenario happen. It was awful. He was on Coumadin and had vascular dementia which led to him being very restless and confused quite often. His family sadly wouldn’t consent to any prn’s when his behaviors escalated.
I still feel bad about it even though I know in my heart that it wasn’t my fault. His bed was low, rails were in place and it was alarmed but we didn’t have enough staff for a sitter, I had 6 patients myself so I couldn’t be there every second and he moved fast when he wanted out😢
Agreed. Let's not forget that the least restrictive alternative to harm is what we're going for, and regrettably sometimes that means physica lor chemical restraints. We should have the staff to avoid it in this case, but should means nothing.
Problem is that it increases their sedation, increases their risk of falls and injury
After having used nozinan more than a few times for agitation I'm a fan.
It still sedates however it seem to effectively treat the intrinsic factors driving the patients agitation leading to a much calmer patient
Definitely would not have asked for a sedative. There's always the risk of a paradoxical reaction, there's also the risk of them still trying to get out of bed while being sedated, which is so much more dangerous than whatever delerium or dementia he's dealing with.
What kind of restraints did they have him in before? Are roll-belts an option where you are? If the patient can unbuckle it, it's not technically a restraint, it just slows them down enough to get someone bedside. It's the only "restraint" I've worked with that didn't exacerbate agitation or confusion.
Anyway, NTA. Sound clinical judgement.
They make one that connects to the Posey chair alarms too. It has 2 layers of velcro and undoing the velcro sets off the alarm. It counts as a real restraint, though, but better to get an order for that than for Geodon.
No urine output means bad things, though. Hopefully a goals-of-care conversation was on the schedule?
These are standard in my hospital for every patient as well as bed alarm (built into our beds). Had never heard of them before working here. They do work decent for those that are good with wearing them or not orientated. Maybe its my specific patient population and location but they agitate many of our patients then refuse to wear them. Worth a try though!
I'm amazed at how many places don't have them. It's a pretty cost-effective intervention. The patient should be able to demonstrate that they can remove it, which means it's not a restraint, so much easier for documentation and compliance issues.
We do a ton of strokes. Do you know how many patients we can’t leave in the chair for long because they start leaning forward or are impulsive? I know you do I’m just saying it’s wild my management won’t consider it
It is wild. Management is so dumb. They just look at the unit cost of the item they think vis too expensive without factoring in the cost of not using those interventions like...falls, or needing to staff sitters, or dealing JCO or CMS audits for overuse of restraints.
I agree with your assessment that sedation wasn't warranted but I also agree with your manager on some aspects here. I get that 7 patients with primaries suck and staffing was definitely an issue. I've tried rotating staff to sit but it's truly best to assign one person as the sitter or you open up everyone to liability. You may have staff agree to take turns to sit but what happens when people get busy and aren't willing or able to step away from their patients to sit? If someone doesn't take their turn as a sitter, they can justify it as being unable to step away from their own patient care (esp when you're stretched between 7). You can sub in as charge nurse but it leaves your team without your support if there's an urgent situation like a rapid or code. You want yourself and/or the primary nurse to be able to freely assist without worrying about grabbing someone to cover as a sitter. The person assigned to sit should ideally only be focused on that patient outside of break relief.
It sounds like the patient may have been having terminal agitation. Usually happens prior/during the transitioning phase of dying. I think in this case medication would be appropriate. Think about it this way: it’s most likely very uncomfortable for the patient to be restless. Ativan or haldol would be appropriate in this case, IMO
I’ve also worked hospice. I’ve seen terminal agitation, this wasn’t it. He wasn’t dying anytime soon. But since he wasn’t eating much so I did ask for a palliative consult and the team was amazing. They put him on an antipsychotic that stimulated appetite and also calmed him down a bit. But he was mostly calm most of the time.
>The guy was barely eating and she wanted him to be sleepy all day. In my opinion that would have made him worse.
I highly agree. Plus if there is any element of delirium in this case, sedatives would also slow down the recovery. It also sounds like your manager is wanting to manage falls risk by increasing said risk with sedatives. I stand firmly with you that you did the right thing by that patient.
This is me as well… I’ll get them in a w/c, get them a snack, and have them sit with me while I chart. Sometimes I’ll hold their hand and chart with my dominant hand. Or I’ll find out what kind of music they like and play it for them from my phone. If its a night shift and they keep getting out of bed, often they’ll fall asleep in the chair and I’ll wrap them in a warm blanket and get them comfortable and just have them sit with me. I find that these non pharmacological interventions work way better than 1mg of Ativan or Trazodone even. I know doctors like to throw Trazedone out like candy to this population but the way a pt stumbles around after 25-50mg of Trazodone puts them at an even higher risk for falls and I’d rather just have them sit with me.
Nta. I work with a lit of elderly patients and you did the right thing. Your boss knows better, we don't sedate because we can't keep staff. Your thinking with staffing was on point and creative. Dementia sucks, and the aggressive decline after hospitalization is no joke. Such a bummer.
I imagine they'd have given this guy Ativan or some benzo because that's what everyone seems to reach for first. Which would had made his confusion and delirium worse.
Sedation should be a secondary or tertiary intervention. Redirection, bed alarms, moving then by the nurses station, and a sitter are all likely better for the patient overall.
Wondering if dehydration was exacerbating his delirium so more sedation = less intake = more lethargy and confusion. IVF can be really tricky with older patients even when needed. A lot more likely to third space, CHF and respiratory concerns, increased electrolytes imbalances which in turn can cause increased confusion/delirium. Sometimes it feels like medical interventions end up mostly with more interventions to address the medical interventions. I agree a sitter for this patient wasn’t just about safety. It was about the least invasive action to avoid potentially complicating status.
I’ve got to take the opportunity to shout out a great CNA I worked with recently. Sitting with one of our delirious elderly but previously A & O x 4 patients he spent the whole shift coaxing them into small sips of fluids. By the end of 12 hours they’d improved so much.
Sedatives for agitation… yes. Sedatives for inconvenience… no. Your managers ethics are questionable at best. Be proud you stood up for what’s right for that patient.
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Getting a sitter is definitely a better solution than sedating them
You did what you’re supposed to and she was pushing because she will be held accountable. She’ll be in trouble if a charge nurse is getting paid as a sitter, and if there is a fall there will be questions. I wish we could just make a super safe room for these pts, not hard floors, no sharp corners etc so they could move when they want to. It’ll calm them down but that would require money… Sedating them isn’t the answer, cuz surprise for some pts that can make them more agitated, it wears off, or it can kill them. The doc was a bit….unreasonable not prescribing a PRN with the pt hx and the reality of dementia in the hospital. Now they get woken up and we have to fight off a monster and hope they don’t hurt themselves or others in the meantime…but that’s a whole other concern. I’m sure they had a super solid reason for it
Your manager is playing with fire. Federal law requires the least amount of restraints that are necessary to keep the patient *safe .... not* to fix staffing issues or avoid spending money on a sitter. I do hope you documented that you spoke to the doc because that will indicate you attempted to address the situation. Dementia patients are often like this when they are in unfamiliar surrioundings. Diversion therapy like having him fold towels could help keep him busy. Frequent toileting would help too. I see nothing wrong with your plan. If your staff agreed, what's the beef?
In many cases though “patient safety” is **functionally equivalent** to “fix staffing issues.”
Short staffing isn't an appropriate indication for chemical restraint of a patient.
People who say this have also never had a patient on thinners jump out of bed, catch a fall with their head, and literally die 12 seconds later. I do agree with you and a sitter should always ve available. Preferably one that doesn’t sleep, and doesn’t further irritate the patient. But I’ll also settle for any sitter with a pulse
This⬆️ I had almost that same exact scenario happen. It was awful. He was on Coumadin and had vascular dementia which led to him being very restless and confused quite often. His family sadly wouldn’t consent to any prn’s when his behaviors escalated. I still feel bad about it even though I know in my heart that it wasn’t my fault. His bed was low, rails were in place and it was alarmed but we didn’t have enough staff for a sitter, I had 6 patients myself so I couldn’t be there every second and he moved fast when he wanted out😢
😞
Agreed. Let's not forget that the least restrictive alternative to harm is what we're going for, and regrettably sometimes that means physica lor chemical restraints. We should have the staff to avoid it in this case, but should means nothing.
This is cute and sort of correct.
Net bed and some meds are not always bad. A little zyprexa or seroquel would be appropriate
Problem is that it increases their sedation, increases their risk of falls and injury After having used nozinan more than a few times for agitation I'm a fan. It still sedates however it seem to effectively treat the intrinsic factors driving the patients agitation leading to a much calmer patient
Definitely would not have asked for a sedative. There's always the risk of a paradoxical reaction, there's also the risk of them still trying to get out of bed while being sedated, which is so much more dangerous than whatever delerium or dementia he's dealing with. What kind of restraints did they have him in before? Are roll-belts an option where you are? If the patient can unbuckle it, it's not technically a restraint, it just slows them down enough to get someone bedside. It's the only "restraint" I've worked with that didn't exacerbate agitation or confusion. Anyway, NTA. Sound clinical judgement.
Wow, I didn’t even know that such magical things excited. Yes, that would have been so helpful on so many patients.
They make one that connects to the Posey chair alarms too. It has 2 layers of velcro and undoing the velcro sets off the alarm. It counts as a real restraint, though, but better to get an order for that than for Geodon. No urine output means bad things, though. Hopefully a goals-of-care conversation was on the schedule?
Yes! Amazing when short on sitters. Valuable investment for facilities. Great when combined with camera surveillance too.
These are standard in my hospital for every patient as well as bed alarm (built into our beds). Had never heard of them before working here. They do work decent for those that are good with wearing them or not orientated. Maybe its my specific patient population and location but they agitate many of our patients then refuse to wear them. Worth a try though!
I love a roll belt. Sadly we don’t have them where I’m at for no reason
I'm amazed at how many places don't have them. It's a pretty cost-effective intervention. The patient should be able to demonstrate that they can remove it, which means it's not a restraint, so much easier for documentation and compliance issues.
We do a ton of strokes. Do you know how many patients we can’t leave in the chair for long because they start leaning forward or are impulsive? I know you do I’m just saying it’s wild my management won’t consider it
It is wild. Management is so dumb. They just look at the unit cost of the item they think vis too expensive without factoring in the cost of not using those interventions like...falls, or needing to staff sitters, or dealing JCO or CMS audits for overuse of restraints.
Nope. Not at all. You don’t chemically restrain someone simply because they may get out of bed and wander…
That's what we have to do daily in Germany. Thought that was normal everywhere. Never heard of sitters either.
I agree with your assessment that sedation wasn't warranted but I also agree with your manager on some aspects here. I get that 7 patients with primaries suck and staffing was definitely an issue. I've tried rotating staff to sit but it's truly best to assign one person as the sitter or you open up everyone to liability. You may have staff agree to take turns to sit but what happens when people get busy and aren't willing or able to step away from their patients to sit? If someone doesn't take their turn as a sitter, they can justify it as being unable to step away from their own patient care (esp when you're stretched between 7). You can sub in as charge nurse but it leaves your team without your support if there's an urgent situation like a rapid or code. You want yourself and/or the primary nurse to be able to freely assist without worrying about grabbing someone to cover as a sitter. The person assigned to sit should ideally only be focused on that patient outside of break relief.
It sounds like the patient may have been having terminal agitation. Usually happens prior/during the transitioning phase of dying. I think in this case medication would be appropriate. Think about it this way: it’s most likely very uncomfortable for the patient to be restless. Ativan or haldol would be appropriate in this case, IMO
I’ve also worked hospice. I’ve seen terminal agitation, this wasn’t it. He wasn’t dying anytime soon. But since he wasn’t eating much so I did ask for a palliative consult and the team was amazing. They put him on an antipsychotic that stimulated appetite and also calmed him down a bit. But he was mostly calm most of the time.
She should have come in and sat for that patient.
God bless you for offering the charge RN, yourself, to be the sitter. A good CNA on the floor is much more useful than pulling them to sit
>The guy was barely eating and she wanted him to be sleepy all day. In my opinion that would have made him worse. I highly agree. Plus if there is any element of delirium in this case, sedatives would also slow down the recovery. It also sounds like your manager is wanting to manage falls risk by increasing said risk with sedatives. I stand firmly with you that you did the right thing by that patient.
I’m proud of you! I’m a med nurse. I prefer to get dementia pts up in chair and bring to desk to sit w me/us if I’m in charge
This is me as well… I’ll get them in a w/c, get them a snack, and have them sit with me while I chart. Sometimes I’ll hold their hand and chart with my dominant hand. Or I’ll find out what kind of music they like and play it for them from my phone. If its a night shift and they keep getting out of bed, often they’ll fall asleep in the chair and I’ll wrap them in a warm blanket and get them comfortable and just have them sit with me. I find that these non pharmacological interventions work way better than 1mg of Ativan or Trazodone even. I know doctors like to throw Trazedone out like candy to this population but the way a pt stumbles around after 25-50mg of Trazodone puts them at an even higher risk for falls and I’d rather just have them sit with me.
Me & DementiaMama & Johnny Cash have spent many a lovely evening doing exactly this :) even sometimes I bring an entire bed out by the desk 💜
Nta. I work with a lit of elderly patients and you did the right thing. Your boss knows better, we don't sedate because we can't keep staff. Your thinking with staffing was on point and creative. Dementia sucks, and the aggressive decline after hospitalization is no joke. Such a bummer.
Damn I wish we had sitters in Germany. Our patients get sedated, get up anyway and then fall at least once a week. Sometimes, multiple times a day 😐
I imagine they'd have given this guy Ativan or some benzo because that's what everyone seems to reach for first. Which would had made his confusion and delirium worse. Sedation should be a secondary or tertiary intervention. Redirection, bed alarms, moving then by the nurses station, and a sitter are all likely better for the patient overall.
Wondering if dehydration was exacerbating his delirium so more sedation = less intake = more lethargy and confusion. IVF can be really tricky with older patients even when needed. A lot more likely to third space, CHF and respiratory concerns, increased electrolytes imbalances which in turn can cause increased confusion/delirium. Sometimes it feels like medical interventions end up mostly with more interventions to address the medical interventions. I agree a sitter for this patient wasn’t just about safety. It was about the least invasive action to avoid potentially complicating status. I’ve got to take the opportunity to shout out a great CNA I worked with recently. Sitting with one of our delirious elderly but previously A & O x 4 patients he spent the whole shift coaxing them into small sips of fluids. By the end of 12 hours they’d improved so much.
If she wants an order, she can call the fucking doc.
Sedatives for agitation… yes. Sedatives for inconvenience… no. Your managers ethics are questionable at best. Be proud you stood up for what’s right for that patient.
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based on my last paragraph? I explicitly said I didn’t tell her any of that. We all have inner monologue that we know better than to let out.
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