As Director of Nursing in a Long Term Care facility I had the unique privilege to care for many precious people diagnosed with Alzheimer’s disease. Caring for these patients has many rewards and challenges. Compassionate care is essential to successfully care for patients with Alzheimer’s. Each patient is incredibly unique and their care has to be adapted to their unique individual needs.
I have had nurses come to me with black eyes, bruises and scratches complaining that Mr. Benson in 12B was “combative”. I knew Mr. Benson very well and every time I saw him he was quietly counting his money or sweetly whistling while wandering the hallways. He had a classic case of Alzheimer disease.
The disease is relentless and unmerciful in the way it manifest itself. The care of these patients is challenging because each patient is different and their symptoms are different. You cannot predict the stages or the progression. Treatment has to be individualized. There is no standard nursing care plan for Alzheimer’s. God sent me one such patient to care for and I would like to share with you what we all learned from him.
His speech was garbled and made no sense but he talked a lot. He could not really carry on a meaningful conversation but he thought he was making sense. He would just jabber so sweetly as long as someone would listen, compassionately. He may not have been able to talk coherently but he could detect a fake smile a mile away. He would let me hug him and would hold my hand as we walked together. As I made my rounds each morning he would usually catch up with me and walk along with me. When I went into another patient’s room, he would patiently wait for me. All he wanted was love, and I fell in love with this precious soul.
When the nurses started complaining about him being combative I just could not understand it. He was so sweet and docile with me, I knew there had to be a cause for the combativeness that they were reporting. I observed his care for a few days and I quickly determined why he was being “combative” with his morning and evening personal care.
I came in early, early one morning and I snuck (yes, I snuck) in through the adjoining bathroom to secretly observe these alleged combative incidents. It only took a second for me to realize why he had blacked a few eyes. The LPN and the CNA were in the room. They were coming at him in all directions, talking loudly and getting aggravated at him for not cooperating. “Mr. Benson, raise your arms and put on your shirt, we have to get ready for breakfast now, come on, and quit fighting.” Mr. Benson was a little late for breakfast that day because we had a pop in-service on Alzheimer’s and the correct approach.
The nurses learned that you cannot bark a million orders at a person with Alzheimer’s, or anyone else for that matter. Nurses cannot be so active and in a hurry around them unless they really want a black eye. I taught the nurses that they must make slow deliberate movements and explain things in short sentences with only one command at a time. They had to learn that they must approach them carefully and never from behind unless you really do desire a black eye. You must smile when you speak to them. If you are faking a smile they can tell a fake smile from a real compassionate one. It is amazing to me that an Alzheimer’s patient can’t perform the most basic of task but they can distinguish a fake smile from a genuine one. They can distinguish fake love from genuine love.
It took some practice for my nursing staff but they finally got used to the new approach.
Giving him a bath was a different story. I do not care how sweet and kindly he was approached at bath time, he was gonna fight it and it was my job to find out why and fix it. At the time we had an antiquated whirlpool tub that raised the patient up in a chair and then lowered them into a full tub of swirling water. He was absolutely terrified of that whirlpool. So we tried showers instead and started with his feet working up to his head. He was still combative and became so distressed during bath time. Something had to be done, but he also had to be clean.
Finally, one of his grandsons came in for care planning and he told us that Mr. Benson had never taken baths or showers. He had always used a basin. So we changed the care plan and started using a basin in his room. It worked. He would even take most of the bath himself that way if we set it up for him. The miracles of communication.
He presented yet another care plan dilemma leading us to eventually having to lock the guest bathroom in the lobby. He would go in there and dip a cup of water, or whatever was in there, out of the toilet and drink it. If we tried redirecting him he would get very angry with us. This wasn’t good for him or for us. We locked the bathroom and with careful observation and documentation we determined the time of day that he usually did this. At that time we would go ahead and offer him some water and take him to another bathroom.
It is not that we were not offering him hydration or not taking him to the toilet as we should, it was just that he was doing this dipping business at times that we did not expect. Our assessment revealed that he always went in for a dipper full right after lunch. We knew he had eaten well and drank his fluids on his tray at lunch so nobody really thought that he might still be thirsty at that time. I don’t think he was thirsty.
We talked to his family and discovered that it was a habit, and old farmer’s habit of many years. He had always kept a barrel of rain water and a dipper close by when he was working on the farm. That is how he got refreshment during his long farming days. So we started having the med nurse offer him a cup of nice “spring water” after lunch. He was satisfied and happy with that and the guest got their bathroom back.
I loved Mr. Benson. I know I am not supposed to have favorites but I have to confess, he was one of mine. He would come in my office and jibber jabber to me. I acted like I knew what he was saying, just agreeing and smiling and laughing with him. He loved to count money so I got him some play money and he would be fascinated for hours with it.
He could not pronounce a sentence anymore but when the Christian Church came and sang hymns-he was the first one in the activity room. He could sing every word to every hymn they sang. It was amazing to watch. It was so obvious where his love was.
The story about Mr. Benson is to prove that individualized care planning and compassion come hand in hand. Without real compassion and caring for him we could have never individualized his care plan to such an extent. If we had not have cared deeply for him and his well being we would have missed the opportunities to provide care that enriched his quality of life. The nurses would have continued to have black eyes.
I will never forget the first time I saw him. I guess it was my first day on the job. I was making rounds and there he was working very hard to get out of a Geri chair that was facing the wall in the corner. I had no idea that putting someone in such restraints violated any state or federal regulation but I did know that it wasn’t right and I didn’t like it, not one bit.
I checked his chart and he was on so many psychoactive drugs that it was a wonder he could move. I went home that day, did not sleep much and came back very early. There he was, still in the same spot. My heart just sank. He looked so sad and he was still working diligently to get out of the chair. I asked the “veteran nurse” why they had him in that chair. She said because he “relieved” himself in the corner. I immediately made them get him out of the chair and take him to the bathroom. We had a little in-service on taking patients to the bathroom. I knew I had my work cut out for me. And I also knew that those nurses hated to see me coming, I was about to turn their world upside down.
We put him on a bathroom schedule that was adapted to his individual needs as far as we could asses. With some care in a few weeks he had no episode of incontinence in the corner. His habit of relieving himself in the corner again stemmed from his past as a farmer when I am sure he used the nearest tree many times. The nursing staff thought that he was doing it for meanness or spite or something. They just did not understand. But they did know that they would put him in that chair and leave him there until he was exhausted from trying to get out. There were some nurses that were actually punishing him by putting him in the Geri chair and locking him in.
To make sure they knew how that felt, my administrator and I had a mandatory in-service on restraint usage. I had a nice lunch and plenty of cokes for the nurses. Then I went over the regulations and reasoning for not using restraints as punishment. Almost to the end of the in-service, when everyone had eaten and drank a coke or two, I took volunteers to sit locked in a Geri chair. I locked them in, turned them towards the wall, dismissed the in-service and turned out the lights and shut the door. I stood outside the door. At first they laughed and carried on but by the time 15 minutes were up that were yelling and wanting out. -point made. Believe me they went and told everyone how that felt. I had the full attention and cooperation of the nursing staff after that. We reduced restraints successfully and they all understood why.
Mr. Benson lived out his days in happy oblivion until Alzheimer’s progressed and he passed away quietly in his sleep. I sleep better knowing that we did all we could do to make his days comfortable and happy. All it took was some compassionate caring nurses who were willing to make things better, and firing a few who didn’t.
Excerpt from the recently released book, THE NIGHTINGALE PROTOCOL by Angela Posey-Arnold RN BSN
