Demanding Patient

RN92 · Mar 30, 2005

Just curious what his diagnosis is. He obviously has some "mental limitations" (whether its abnormal lab related, mr related, etc..). He needs something stronger to sleep at night...talk with the Doc.

Depending on what the cause is...if feasible - you need to set limitations with him. Let him know you cant be at his beck and call and that the call light does not gaurantee "speedy" service. Also, on your end...try and anticipate what his usual requests are ahead of time. I'm sure you've tried some of this - be firm, very firm with him - and get him well so he can go home.

LPN1974, LPN · Mar 30, 2005

He needs to be evaluated by his physician.

Call his doctor.

He's not sleeping in the daytime is he?

Is his family aware of this?

**canoehead, BSN, RN** · Mar 30, 2005

Stand there and verbally cue him. Do not do anything for him that he cannot do for himself. He will- like a child- do everything he can to make you do things his way so initially the problem will seem to get worse unles you present a unified front.

Once he gets the message you will be able to say to him "what do you think you should do?" instead of "you need to lie down" and he will hopefully have caught on.

Make sure you praise him for doing things by himself, for working out his own solutions to problems, no matter how small.

bikeracer5313 · Mar 30, 2005

Family aware. They believe everything he says. If he said there are little green men running around-they believe it! Dr. is aware-family refuses sleep meds-anti-anxiety meds. It is a TOTAL control issue. There is no way to anticipate needs--he wants sleep and to lay down (most common request.) others include making sure the call light is on-or he totally refuses to admit he had it on in the first place.

Long Term Care Columnist / Guide · Mar 30, 2005

And I'll bet his room is at the farthest end of the hall.......

I'll tell you right up front that meds are not the answer for patients like this gentleman. There isn't a medication in the world that's designed to cure people of excessive self-involvement. But the next question to ask would be WHY he is so self-involved? What is triggering his demanding behaviors, and what does he really need?

My guess is that this fellow is fairly new to the facility. He has probably also been catered to by his wife and/or family for most of his life, and doesn't know how to cope with being alone....to say nothing of being just another nursing-home resident! It also sounds like he is relatively high-functioning and could be just bored to death, especially if your facility houses a lot of totally dependent patients who don't interact much. Whatever the cause, he is literally crying out for help.....he needs company, he needs stimulation, and he definitely needs more sleep than he is getting if he's on the call light all night long.

If he has family who are readily available, you might trying asking them what he was like before he came to your facility. Has he lost a close friend or family member recently? What did he like to do for relaxation or fun? What kind of work did he do? Does he have any friends now who might come to see him?

Even more importantly, ask the resident himself what he wants and needs; chances are, he is lonely and desperate for someone to talk to. His call-light 'abuse' and frequent demands may be his way of controlling the situation and literally forcing people to spend some time with him. It sounds as though he is fairly intact cognitively. Perhaps, once you've determined what his needs really are, you can make a bargain with him, set some limits, such as "I've got such-and-such that I have to do right now, but I will be back in X-number of minutes and then I'll be free to spend fifteen minutes with you". Then ask him to 'group' his requests so you can do them for him during the allotted time while you talk, tuck him in bed, or whatever it is he wants.

Over time, as he learns to trust that some time will be set aside for him each day or evening, he may decrease the number of calls and requests. It doesn't always work out that way, but you'll never know unless you try it; in the meantime, you may want to find out whether he was a day- or night-shift worker......if he worked nights for 40 years, there's not much use in trying to change his sleeping patterns now!

Good luck to you..I know these types of residents/patients are quite a challenge.

begalli · Mar 31, 2005

LPN1974 said:

He needs to be evaluated by his physician.

Yep, and the doc needs to write for a psych consult.

I would seriously consider explaining to him the concept of crying wolf.

redwinggirlie · Mar 31, 2005

Get this all the time. I ask what they will do when they are not in the hospital. I do this in a conversation set for just that, conversation. I pick up on what they plan, what their current situation is, etc... we just talk. When the next call light comes on for the "Put the blanket on me" I say make yourself at home.

No, it's not that easy at all times. Sometimes, though, people need to know they need to be in charge of their own lives. Get your people a psych consult. Let them learn to take care of themselves. One patient said they called so often because they could get attention. Maybe some people just need a touch, a care, an explanation that they are not your only patient, and that you will check on them from time to time....

Antikigirl, ASN, RN · Mar 31, 2005

Eval by MD or psych eval (or both) and also get your administration involved so they can set some ground rules on the "services" he thinks he is entitled too vs reality.

I have this happen ALL THE TIME at my assisted living facilty. Poor things..they do spend a darned fortune to be there, and normally when they first come in the sticker shock leads them to believe that the nurse basically is in that room 24/7! Considering that caregivers do all direct care and meds, they are shocked to find that out of 160 residents, there is only one nurse, and quickly come to terms that their expectations are too high (some of them anyway).

I have also found that services like a private caregiver or 'sitter' are available and covered by insurance also. This may be a option, or there are volunteer groups available for very limited times (usually not at nights or weekends though).

Having activities and not letting one oversleep during the day helps set a sleeping schedule as well..which could be of great benifit! Sleeping schedules and stress cause so much anxiety you can't quite put your finger on...look into that .

Also, if you have service plan coordenators...make sure this is documented well in your service plan...like "resident will do his evening ADL's by self" that way...at least how it works with us, if he requests help he has to be put on an interium for increased services for two weeks, if it continues he is charged for those increased services. Sadly that is the way of business, but can be a reality factor in overestimation of services.

Good luck...I hear ya oh too well!!!!!!!

As far as the family...this can be a very potentially bad bad probelm! Imagine if he was to be in pain and they decline pain meds because they are too scared (and uneducated)! A physician needs to know this and schedule some time to speak with the MEDICAL REPRESENTIVE for him out of that family and set the record straight! A person with anxiety issues deserves the help we can provide, including and not limited to medications. A family that would deny antianxiety medications is like a family that will be the first to flip out and start screaming 'sue' if he got an order for morphine or oxycontin for severe pain or worse...the one that will screaming DNR you for calling 9-11 when he is breathing and has a pulse and just fell!!!!

The family needs to be educated, and well...another part of the wonderful world of nursing...family dynamics!

Lawnurse · Mar 31, 2005

can you keep a log of every time he calls out and what he wanted?

maybe you could have him initial after every entry. Then the family/MD would be more willing to believe.

He could even rate each call-out with his level of satisfaction. Then ask him why he continues to call out when the need was just taken care of. I think this is called "presenting reality" in psych nursing.

on a sarcastic note, you could call into his room every minute and a half and ask him what he'll be needing next and bug him for all the details of what that will be like. Call back each minutes and a half to confirm.

Antikigirl, ASN, RN · Mar 31, 2005

At my facilty we have these hourly check lists we sign when we go into a room. It has time, reason, and signature. I would emplore you do start one up (or make one) and put it on a clipboard inside his room (we keep ours near the doorway).

When I have patients that do this, I almost automatically do this...and that way not only do I have proof to the probelm documented on a regular basis (to show a doubting doc/admin/family)...but I can also guage when the probelm is at its worse! I also document when family or friends visit (and sometimes when they call) sometimes anxiety with family causes increased need for socialization and general needs. It is actually interesting to see the changes when a family talks to a patient, especially if they are new!

We ask our families not to visit if they can help it for at least one week when they arrive, but they can call. They don't have to of course, but we find that if the patient gets use to the routine and facility at first without the stressors of family and memories of the way their life was before they got there, it goes a heck of a lot better for all involved! Sounds harsh, but it really does work!

heron, ASN, RN · Mar 31, 2005

All the suggestions I've read sound good. I just have 2 to add. First, is he already on any psych meds? Neuroleptics such as haldol can cause a wierd symptom called akithesia ... a very unpleasant internal sensation of needing to move all the time ... being unable to lie down and then immediately getting up again is typical of this. We have treated this with either cogentin or benadryl. Also, once the behavior has been documented, you then have a little "ammunition" for sitting down with the patient and the family and working out a behavior plan. We used to use a plan that included assigning one caregiver per shift and establishing a reasonable schedule for checking in on the pt. With good documentation you stand a chance of enlisting family support. Never forget, even paid caregivers get to set limits! Heron

Demanding Patient

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