Tag: hell

A Fortnight in the RAH (part 2)

Brett0 comment

Our 3rd time in the RAH and it is business as usual for us. Bob continues to have a nurse special following him 24 hours/7 days per week. Bob is more agitated this time round and the tasks we performed last time are now too difficult to manage. Showering Bob is almost impossible. Every time we would steer him into the bathroom he would walk out (and sometimes naked). This is embarrassing for all concerned as staff race to find things to cover him up. Unfortunately he will no longer just put clothes on when asked. The dynamic has changed and Bob is now in control.

What I mean by this is that if for example we try to take his shoes off, he may hit, become agitated or walk off. Bob dictates what is happening next and the control we had before is no more. This means we can no longer shower Bob everyday – we do it when we see a window of opportunity. If he is calm and starts to unbutton his pajama shirt we dive for the towel and toiletries bag. The little showering routines no longer work. I used to get Bob to clean his teeth and straight after have his shower.  Now I am lucky if I can clean his teeth at all.

This means we ‘have a new normal’. The hygiene and dressing standards we  have steadfastly maintained can no longer be reached. Bob may be smellier than normal, but it won’t harm him, and that is all that matters. By having a new environment makes caring so much harder. Things get lost, items fall, and the experience becomes a lot more stressful for the person with dementia and the carers. The nurse special follows Bob everywhere he goes and they are not allowed to lose sight of him. This means there are extra people in his room and constant conversations about him which I am sure he can detect. We are talking in front of Bob now as we can’t maintain that dignity as we are on constant alert in his presence, and do not have the luxury of walking to somewhere private to talk.We are finely tuned and constantly ready for a sign of his current mood and are also wary of any hostile move he may make.

Bob’s hands and eyes are the gateway to where he is at. When his hands are soft and floppy he is calm and relaxed. If his hands become rigid and stiff and his handshakes become too firm, we all know this is an indicator that his mood is escalating. When this happens we call for a PRN (extra medication) as we have a very small window of opportunity (4-5 mins) to get the meds into him in a compliant manner. If we miss this chance, Bob will escalate and hit out and yell verbal rants along the ward. This behaviour is confronting, embarrassing and sad in many ways. Bob’s eyes also become very dark and cold when he is agitated. He will look at people with an evil stare and shake his head in disgust. If he swears in general we know things re about to get out of control.

As a family we maintained a constant vigil in the hospitals and nursing home to try and keep Bob as calm as possible and de-escalate any behaviours to avoid any hitting out or code blacks. We are scared that he will be sent to  mental health institution due to the violent behaviour and every time he gets a strike on his medical records, this brings him closer to being placed in a mental health facility. Doctors have told us that Bob would have been transferred a year ago if not for our efforts to calm him, look after his daily needs and our commitment to protect the care staff and nursing staff.

Bob’s behaviours are different this time in that he no longer engages in any activities at all and is constantly on the move. he will pace up and down the ward’s main hallway hundreds of times per day with nurse special in tow trying to stop him entering rooms, annoying others and keeping him safe. Following him all day is extremely taxing and mind numbing stuff, but has to be done. He will yell out wit no notice and this usually makes the ward ‘freeze’ and everyone stares as we try and deal with our next outburst. The environment aon the ward could not be any worse for someone with dementia. It is loud, busy and confusing. Buzzers and machines are constantly beeping, people are always talking and there is just so many people rushing past each other as they try to work in unsuitable conditions. The hospital is in terrible condition and has practically been untouched for 30 years.

The nurses have all experienced the ‘wrist grabs’ and overly hard handshakes. It is no wonder some of them ‘flich’ when Bob makes a sudden move. If they become scared it is very obvious to Bob and he seems to react accordingly and continue the behaviour. We try and teach the nurses what signs to look for and what to do if agitation occurs. I have a pre-written list of instructions placed in the front of his notes to act as a quick reference to ensure the nurses are up to speed. I often stand in front of Bob to stop him entering rooms. This can be confronting but I have few other ways of turning him around. Today he gave me a ‘warning punch’ in the stomach to let me know he was not happy and there is going to be trouble if I keep stopping him from going places.

A Fortnight in the RAH (Part 1)

Brett0 comment

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Bob spent his first week back at the RAH in Ward R8 and it has been a nightmare. This ward is not a geriatric ward and is more general, but is still a locked ward. It has women only rooms and there is a constant beeping as machines monitor the patients and the nurse call bells keep being pressed. There is a constant hustle and bustle in the ward with people always in the main hallway as doctors, therapists, nurses and administrators cram into tiny bays to document the medical changes with each patient. I do not know how the medical team can think as they have up to 10 people in a bay/station in a space that is only 4 metres long and 2m wide. I can see how information would get lost and how mistakes could be made as the environment is often one of disruption and sometimes chaos.

The conversations between people are very public as they have to be had in the main hallway. There are sometimes patients in beds actually in the hallway due to overcrowding. The nurses set up a temporary screen to try and give the patient some privacy, but it is so public and so undignified. The patient is also not safe as wandering patients can grab at the person in the bed and are almost tempting for the mental health patients. As I am a people watcher, I quickly sum up the situation with many patients and work out the routines and personalities of the nursing and medical teams. I usually find out who is in charge (ward manager), introduce myself and then give them the lowdown and caring tips for Bob.

The doctors usually do their ward rounds between 8am and 12 noon. We are often desperate to to catch the doctors, but it is a frustrating wait as they usually come past us at 11.45 at the end of the round. We anxiously wait for hours and often miss them when we have a coffee break or toilet stop. I tend to stand outside the locked doors as I can see all 3 locked wards from this vantage point (R8, S8 and Q8). I look to see when our doctor has entered a ward and can estimate when they may reach us. This time round we were desperate to speak with the doctor to tell our latest story but have a much more low key approach this time as we know we have limited options and ‘saving’ Bob is not an option, this time we are managing him.

The hospital facilities are really run down and no money is being spent on maintaining them. The side rooms are better than a ward, but the setup within them makes for a very frustrating stay. The super thin single cupboard has no hanging rail so all the clothes are piled up on the bottom shelf. Every time you open the cupboard the contents have to be collected off the floor. The window ledges are too narrow and the same problem happens. There are no shelves anywhere and the ledges over the sinks are so thin your toiletries bag usually ends up in the sink. Some small carpentry work could alleviate the problems. I understand the new RAH room will be like hotel rooms, however we have a long way to go before then and some maintenance is long overdue. We don’t care what the rooms look like, but they have to be functional and more shelving would eliminate much frustration as we often have to work fast to grab clothes, pull-ups, towels, cups etc very quickly due to Bob’s behaviours. Shower heads are hand held and will not stay on the wall which means you have to shower the person one-handed, which is extremely difficult. We are trying to protect ourselves at the same time and the setup is simply not suitable.

Bob is now probably the most difficult patient in the ward as he is mobile 95% of the time and will not engage in any activity for longer than a minute. This means he is in the main hallway day and night and often tempted to enter the wards. Bob heads for the locked glass doors every 10 minutes and shakes at them and tries to find a way out of the hospital. The doors were recently fixed but are now once again broken as Bob had ripped the doors apart in a rage and damaged the closing mechanism. Bob has been allocated a ‘nurse special’  24 hours per day (refer ‘nurse special’ post). They follow him for 8 hours at a time and try and interact with him and keep him out of trouble.

Due to the decline of Dad’s brain his behaviour is nothing short of unpredictable and violent. I do not use the word violent lightly, but is the most accurate description this time round. He will lash out at whoever is in reach when his behaviours escalate and he is in need of medication to de-escalate them. We have timed the meds effectiveness and it takes 45 mins for the prescribed meds to take effect. This means the staff have to identify agitation early and get the meds into Dad before the ‘window of opportunity’ closes and he is too wound up to take them orally. Once the meds are in we have to distract him until they begin to take effect. This is a various tense time and we are all looking for signs of de-escalation. Extra staff tend to be drawn into the situation as Bob becomes verbally aggressive and yells out and hits out at people and the equipment.

Bob engages most people as he walks past them and often grabs at them. This is confronting for all and difficult to handle. His brain decline is at a stage where previous calming strategies no longer work, and he has very little reasoning. This means that changing his pants could take multiple attempts across 3-4 hours and we may not have any success at all. Showers used to be done daily in the nursing home by family members, however we now can rarely get Bob calm enough to have a shower in the hospital. We continue to attempt, but often his behaviour dictates how this goes. Nurses tell us patients from other cultures may not wash for weeks, but we continue to attempt each day regardless.