Sundowner

The term "sundowning" refers to a state of confusion at the end of the day and into the night. Sundowning isn't a disease, but a symptom that often occurs in people with dementia, such as Alzheimer's disease. The cause isn't known. Once the morning comes, people who had this "sundowning" episode are more alert. They are no longer that confused patient.

I.

I saw this first hand. There is two meaningful things in this story. The meaning of how It feels to fail a patient. The meaning of how it feels to see this patient sundown at night but in morning, flip a 180 and become a different person completely.

I got report on a patient, lets call her Betty. The report I got was not the report I should have been given. According to the nurse handing the responsibility of patient care to me, the patient had some "bouts" of confusion, but was easy to redirect and orient. She was a post operative patient that needed vitals frequently, medications, IV fluids...The list could go on. I take the report and run with it. I go and see my other patients first, compared to my others, Betty seems like a low acuity and priority.

By the time I get to Betty...Betty has taken off her blankets, her gown, leaving her girls open and lying in her armpits...She has taken off her blood pressure cuff, her pulse ox sticker (That I myself, usually can not get off peoples fingers very easily)...She has removed the cotton IV sleeve and ten layers of tape to find her IV line and pull it out. I walk in and she is calmly rubbing her hands on what ever she can grasp. And I'm like okay...Dress up, vitals, new IV start. I am most excited about the last one. Something about starting an IV makes me happy. I get her dressed because I know it is the best thing to do, but quite honestly she doesn't care if she is naked and I've seen more body parts in the last ten years that it just doesn't even phase me anymore. You'd have to have an extra boob or 2 foot long dick to shock me. I get Betty comfortable then go for my IV. She doesn't budge as I stick a needle in her forearm. She just lays there. She talks about how she is in her sister's bedroom, about how the cats will not stay off her bed, and the door bell ringing that she can not answer. I start trying to orient her to where she is and letting her know there are no cats or door bells. After about 20 minutes of that I decide I am not going to win this. They teach us to always orient the patient in school, tell them truth...But after 20 good minutes I am ready to just talk about the cats so we can go on to another topic. So we do. We talk about cats and how they are all over the hospital room looking for food and beds. Whatever. No harm done. The night goes on. Betty constantly pulls on her Foley (catheter that drains her bladder), her blankets, her attends and pulls on the sleeve I used to cover her IV. Under that sleeve is my hell of a tape job to keep her IV in place, that sucker was going to stay in... and did. She would moan and ask to use the bedpan frequently. It was like a crying baby you could not calm, she would just moan and fuss and pull on things. We'd put her on the bed pan, she would pee maybe 50ml. It was like really? Okay well Betty do you feel better? She would tell me yes and then continue fussing with everything she could get her hands on. There was no communication that you would have expected from someone in her state of mind. As the night went I felt myself getting internally frustrated with her. I controlled my tone and my actions and was never in anyway abusive. I just had had it with her. And I felt like I was neglecting my four other patients. Which madw me feel bad also. I tried to get through the night, try to reassure her, constantly put her back together and at 5 am she finally falls asleep. We tip toe past her room careful not to wake her up. I carry around the feelings with me feeling badly for myself. Why did I get so irritated. The patient didn't know any better. I kept reminding myself "this is someones grandma" and if any nurse was shitty with my grandma, I'd have their ass. It's not like a harmed her, I just was flooded with aggravation and then self defeat making myself believe that maybe I was not a good nurse.

Betty woke up at 6 or so. She stated she needed to have a bowel movement and asked if we could help her to the bedside commode. When the nursing assistant came and got me, I was like really? Ya I guess we can try I thought, but I am only trying because she is 50lbs so I know if she falls or gets unsteady I can hold her. Would you believe this patient got up to the side of the bed and on to the toilet without problem? Her vocabulary was clear and appropriate. She told us she would call when she was done. I didn't trust this at first because she had been on a bed alarm all night for being impulsive and trying to escape her bed. The nursing assistant assured me she had come around and was alert and oriented; I waited by the door since it's my license on the line for little grandma Betty. Turns out Betty was as alert and oriented as you and I are. She called. She cleaned herself up. We got her back to bed. Then I talked to her for about 10 minutes about her surgery, her doctor, her breakfast menu... She was clear as day. She was not confused at all. It was like talking to a completely different person. I was so blown away, I didn't know what to think... Or what to say...

This sundowning is someones way of punking me? It's like God gave these patients two different personalities... Then bam when the sun comes out- The patient's state of mind is back to normal. I couldn't look at Betty without thinking WTF? Betty are you in tight with Ashton...Am I being punked?

II.

Part two of another confused patient I recently had. Was a man. Let's call him Dick. Dick had been nonverbal for his stay at the hospital. He would rather sit in his dirty sheets and not eat than move or talk to anyone. Dick has dementia. None of these descriptions fit when I first started to walk in and talk to Dick. He answered my questions and was appropriate. I don't bug him and try to move him in bed although he looks all lopsided and wrinkled up in sheets. I heard he is a fighter. I offer to help him move in bed, he says no. I hang my IV and go see my other 3 patients. When I get back to check on Dick, he smells like shit. Fuck. Okay guy it's you and me and we are going to get you changed. I try to roll him and gain his cooperation...He fights. We just turned into WWF hospital style #winning. I finally get him over on one side so I can start to clean his sheets and get him off his attends (diaper)... I start to clean his hairy asshole with washcloths, of course Dick has a hairy ass and of course he ate glue because this shit is sticky-er than I have ever seen in my 10 years of patient care. There is not a lot of shit, but what is there is sticky icky icky! I've seen asses and shit but not like this. To make matters worse his pubic hair in front was so long the shit flowed back into his ass so there was all this matted hair with shit stuck in it. Ugh. I don't call for help. I just decided I am going to go for it. I let him know what I am about to do. I start whipping like a mad women. Then he thinks its appropriate to tell me "Stop fucking with my asshole" over and over again. At this point I am like really? Could you shut up and I'll clean you hairy asshole! All I needed was staff to come in and be like... "Um, JJ, what are you doing in here?" ... So I can reply, "Oh nothing I am just living the damn dream in here, care to join?"...Ugh. I quit. I'm sweating my balls off trying to get this guy clean and my back is hurting. I get most of the hairy shit and honestly I left some there, done fighting. I slapped on a new attends, covered him in sheets and went on about my way... Ya right, an hour later the same patient, Dick, tries to pull out his IV. He manages to get all the tape off and gets the lines from his IV fluid unattached. This sneaky little unhook makes two things happen. From the first line, coming from a large bag of normal saline, lots of normal saline ran freely into his bed, soaking his sheets, Yes- love when there is wet sheets. The second line from is vein has blood flowing out onto his shirt. Even better .Now it looks like I murdered him, shot dead in the middle of the gut. Fuck. Okay. I save the IV (get kinda excited about that) then tape the fucking shit out it. That IV is going to last another 30 years. I then wrap a sleeve around it. That is a fight. He keeps asking me "What are you doing?" I reply, "fixing your arm Dick!" Then time to change this mans shirt. I almost went EMT mode on him was gonna cut it off with trauma sheers....but I got Dick to participate enough to lift his head and put his arms up so I could slide the shirt off. Don't worry about the bed, I laid down towels where I could under him and that would be the end of that battle. I got him into a hospital gown wrapped him in warm blankets and said goodnight while turning off all the lights. Go mimis Dick!

It's internally frustrating fighting with adults, specially confused ones. You have to be sneaky, creative and quick! I feel like calling my boss in the middle of the night to let her know the deal for me to stay on her Med/Surg floor for a year is off! But I don't. I give report to the next nurse and tell her "God bless you my child"... I leave the floor and feel like shit. I get so frustrated with these confused patients. And that is just real. I have the ability to control my reactions and words...I don't cause any harm to these patients when I am boiling inside... But I still feel bad after wards, more for myself, because I feel like I shouldn't feel like that...