[mary761]

I am new to the LTC environment and am working nites as a CNA in a subacute center until I pass my boards. I need some suggestions about dealing with a resident.

My first 2 nights at work, Ms. X rang her call bell every 10-15 minutes the entire shift, requesting help to the BSC so she could move her bowels. Most attempts resulted in nothing; a few times she moved a pea-sized or quarter-sized nugget of soft stool. After about 20 times of answering her call bell (I'm a S-L-O-W learner) I told her she was not moving her bowels and she needed to rest and give her bowels a chance to "move things along" to the point where she could have an actual bowel movement. Her response was to (WARNING: Put your snack down now) dig chunks of stool out of her rectum with her sharp fingernails, ring her call bell every 10-15 minutes, and "show" me that she did indeed need to use to BSC. After these actions, she passed pea-sized and quarter-sized nuggets of stool with frank blood. Needless to say, by the end of the shift I was exhausted.

Last nite, I heard in report that she had been to the hospital for a surgical procedure and was therefore on bedrest for the night. Further, they had cleaned her bowels for the procedure, so she no longer felt constipated. Hallelujah!

10 minutes into my shift, the calls started again. This time, she was calling for the bedpan so she could void. Each attempt resulted in approximately 20 cc of urine. If I did not IMMEDIATELY answer her call bell, she screamed "HELP ME!!! HELP ME!!! I HAVE TO GO SOOOO BAD!!!" at the top of her lungs, waking the other residents. After 4 visits with the bedpan, I put a brief on her and told her she was not voiding enough each time to feel a full bladder. I assured her that the brief would keep her from getting wet if she "accidentally" went, and that I would be back once every hour to check her and put her on the bedpan if she needed to go. This resulted in an even greater acceleration of her demands, claiming that she "couldn't let it go" into a brief, and screaming at me that I "don't know what it's like to be on medicine that makes you have to go so often".

The nurses tell me she has "other things" going on (what, exactly, they won't say) and that there is nothing ordered to calm her down. One nurse helps me with her constant demands, but the others turn a deaf ear or pop their head in long enough to tell her I'll be there as soon as I can (which causes a new round of screaming).

I'm running my @$$ off trying to keep up with her and my other 25 residents, and I'm already dreading work ON ONLY MY 4TH DAY!! Any suggestions?

[stressednurse]

Good luck with passing boards.
When you do and a nurse aid says that a patient cannot have a BM and has passed very small balls of BM multiple times....please intervene and give the patient something to assist with this before that patient starts to dig themselves out.
When a patient has urgency to void and little or no urine each try...please intervene and call a doc for testing for UTI or voiding problems.
Oh yeh and please give some feedback to the really wonderful nurse aids that reported the problems to you so they know what the problem was and what will be done (no you are not violating HIPPA laws telling another care giver what they need to know to give the best care possible to the patient)
I work LTC in a sub acute unit as an RN and I also supervise at the same facility.
If your nurse on your shift does nothing then let the next shift nurse know what is going on.

[lllStephanielll]

I agree with stressednurse. We have people like this at the LTC where I work...thankfully they take scheduled doses of clonazapam with ativan prn. The MD needs to be aware of the situation. She obviously has a psychiatric diagnosis. She needs to be worked up for UTI (which she probably does not have) and put on psych meds.

Just my two cents.

Stephanie

[earle58]

it's too bad you're taking this on yourself....it does sound like further testing needs to be done BEFORE she's put on anxiolytics....ua/c&s and kub to start...is her abdomen soft? is there active bowel sounds x4? many times when patients are constipated it affects their ability to urinate. please, discuss these concerns with someone who can do something.....

leslie

[michelle126]

Sounds like a few of my pts. This is why its good for nurses to be CNAs first. It does sound like a UTI and constipation. Are the nurses treating her for either? Sounds like it might help to take turns answering her call bell with another CNA. Try to set limits with this lady too...(easier said than done!) Using a sedative probably wont help either.

[mary761]

Thanks for your replies. Forgive me for not making myself clear. I should have been more specific. Her bladder was not distended, her urine was clear and yellow, no obvious odor, and she had a C&S done 2 weeks ago (negative). She is on the same bowel protocol as all residents. On the night she passed stool, she was not passing hard nuggets--the stool was very soft--barely formed. Forgive me for being blunt, but when she was "digging herself out", she had to really SEARCH to find a little bit of stool to "prove" to me that she was right. It is my understanding from talking to the other CNA's that this behavior has been going on for months. If it is not bowel or bladder issues, it is repeatedly requesting blankets to be replaced or removed, or demanding that dentures be placed in or taken out of her mouth repeatedly.

I see your point and I apologize if I sounded as if I care more about my convenience than her care. I don't feel that is the case, because it appears that the physical causes of her demands have already been addressed. In my opinion, this is more of a psychological issue, and I was looking for guidance as to what I can do within the limits of my role as a CNA, as the person primarily responsible for providing her physical care, when the nurse won't get involved?

[earle58]

mary,

what a lovely asset you are to your facility.
since the primary nurse won't get involved, ask her what is realistically expected of you with such a demanding patient? it still is up to the nurse to address any psychosocial issues, whether it's a psyche consult or contacting the patient's md. for the nurse to ignore these excessive demands, is not taking full responsibility and the burden should not be placed on you.

you need to speak with someone that can address your concerns. best wishes.

leslie

[Hellllllo Nurse]

I worked in LTC for years. There are some pts who have psych issues and will demand our attention and manipulate us to death.

And yes, these residents can make us angry, exasperated, and push us to the end of our patience. We may even dislike these residents a great deal. This is all perfectly natural. As long as we continue to treat the pt as we should, there is nothing wrong or inappropriate about the way these residents make us feel.
There is no need for us to feel guilty for having negative feelings about some of our pts.

There have been times when I have told a resident "Mrs X, I have X number of residents to care for besides you. Your constant calls prevent me from giving them any attention. Some of them are far sicker than you, and they really need my attention now. I will come into your room once every hour, but no more often than that." I then hand the person the call light and leave. I keep my word and check on the pt once every hour.

Sometimes this approach is effective, and sometimes it's not. We had an extremely demanding pt in the last LTC I worked at. I cannot even describe to you how demanding and manipulative she was. Staff were rotated to prevent any of us from being assigned to this pt for too long. This pt had worn her family out with her demands. They were a nice family for the most part, but they'd just had it. I really felt bad for them. They felt guilty for putting her in the nursing home, and they visited often, but I really can't blame them. This woman was horrific.
One CNA was pushed beyond her limits by this resident and actually screamed at the resident. The CNA was permanently moved to another hall. I wish I could have moved to another hall!
Maybe you can have your assignment rotated. I know how exasperating these people can be. You have my empathy.

[donmomofnine]

Can you get social services involved? At my facility they are super helpful when if comes to stepping in on this type of situation. They would probably meet with the resident, doc, and family and come up with a "contract" for behavior ~ something like the other poster recommended about checking in once per hour. You should not be left alone to deal with this problem~ it's a team effort!


And then this would all be careplanned so all staff was on the same page with this resident!

[lllStephanielll]

I can completely understand you, Mary, when you describe the problem...this is not a medical condition of constipation or UTI. She is definently displaying psych behaviors. Treat it as such. It is not being neglectfull to lay down firm boundries with her. When staff are spending all of their time in one resident's room the rest of the residents are being neglected.