I want this pt showered...and a bunch of other questions...

lamazeteacher · Jan 1, 2009

We have a resident who hasn't showered in months. He stinks so bad, at one point the smell saturated all the way from his room, down the hallway, to the nurses' station. He also hasn't been taking his medications, he refuses them. I cannot stand it anymore..someone has to do something about this man's hygiene. I don't have him most of the time but when I do, I am really bothered. The psych hospital was asking me to do a skin assessment on him, but he gets really agitated when we get near him. He told me to go to hell and stop bothering him tonight so I just backed down. He is "lds conserved"...what does that mean? CNAs have tried to lure him into the shower room with snacks, we've given him IM haldol, it's like it had no effect on him...he's growing crusts on his hair, and his roomate is complaining because of the smell. What can we do for this man?

"Conserved" means the court ordered his placement where he is. It is involuntary.

His physician needs to leave an order for twice weekly total bed baths under sedation, or find another roost for that "pole cat". Administration of your facility needs to be told that the risk of other "residents" having a nosocomial ("hospital acquired") infection from wafting shedded skin, or in in case anyone touching the guy handles anything else before sufficiently handwashing. Get the Infection Control Committee involved in this. They have to respond.

Frequent reminders to that MD if there is failure to attain minimal cleanliness, from administration is needed. If all else fails, report the situation to the Public Health Department. Peeeeu!

pagandeva2000, LPN · Jan 1, 2009

When I was an aide in psych, I remembered occasionally being told by the nurse that after sedation and placing the patient in restraints that we were to do a full bed bath. I don't know if orders were placed since I was not a nurse back then, but it sure as heck was better for the others that were exposed to that guy.

Now, as a nurse, I would be documenting off the yang yang, with names of doctors, charge nurses and supervisors that I contacted about the situation as well as the patient's behavior when being approached about showering. Something would have been done within a week!! It is an infection control issue, for sure! Yuck-mo!

WickedRedRN, BSN, RN · Jan 1, 2009

I would get a social worker involved. We had a similar resident in a LTC. The smell was so bad in the hall the DON would come down and complain abt the smell, but we were told we could not "force" a bath on anyone. It was her home and her right. The best we could do was clean linens and odor control for the air around her.

Sorry this isn't much help, but I know how frustrating a situation this is.

eldragon · Jan 1, 2009

We had a patient in our LTC facility who was also diagnosed paranoid schizophrenic, and refused to take any meds. He was a diabetic and while he let you check his blood sugar, he would't allow insulin to be given. He was a pain, but also a stroke victim and therefore had some physical issues that caused him to rely on help.

We did the best we could by him until he was moved to a private care home, by his choice. I'm pretty sure that situation didn't work out long either.

Sometimes patients find one or two employees they grow to trust and perhaps that is your best bet with this man. Otherwise, as suggested before, sedate him and scrub him because state won't care much about the details of why he stinks, just that he's not clean.

Perhaps he needs to hear that he will be sent to another facility if he doesn't shower. Whatever it takes, the man has to be cleaned up.

pagandeva2000, LPN · Jan 1, 2009

We had a patient in our LTC facility who was also diagnosed paranoid schizophrenic, and refused to take any meds. He was a diabetic and while he let you check his blood sugar, he would't allow insulin to be given. He was a pain, but also a stroke victim and therefore had some physical issues that caused him to rely on help.
We did the best we could by him until he was moved to a private care home, by his choice. I'm pretty sure that situation didn't work out long either.
Sometimes patients find one or two employees they grow to trust and perhaps that is your best bet with this man. Otherwise, as suggested before, sedate him and scrub him because state won't care much about the details of why he stinks, just that he's not clean.
Perhaps he needs to hear that he will be sent to another facility if he doesn't shower. Whatever it takes, the man has to be cleaned up.

That is so true! The State on one hand speaks of client's rights and autonomy; on the other hand, will say that nursing was neglectful in caring for this person and that someone should perform a miracle. Totally unrealistic, but they are not empathetic. Also, the families of other patients will start barking, especially the room mate. I know I would.

Junebugfairy · Jan 2, 2009

i am getting my rn now :) when i was a cna at a ltc facility, we had this one particular little lady that refused to shower. she went for months without showering, it was baaaad.

i tried treats(not a diabetic or on a special diet), movies, etc.. finally, i caught her watching the coca-cola vending machine, and got my idea.

i told her "i'll give you a coke if you will let me give you a shower." she said yes!! haha... they finally started giving her coca cola..

i guess if 'treats' are not working, and since it is a 'psych' patient, sedation may be an option to consider. hygiene is a big deal, and his skin cannot be in good condition

SunnyAndrsn · Jan 2, 2009

Something I wanted to warn you about, if and when you do get that order/sedation to get this man cleaned up...

We had a resident who was A&O, but refused to get out of bed and shower. He stated too much pain. We offered to pre-medicate, use the hoyer to transfer, you name it, all sorts of things to get this guy in the shower. I don't even want to discuss his toileting issues.

Anyway, the CNAs finally convinced him, they got him in the tub because he couldn't sit on the shower chair, and chunks of his skin fell off on his feet. The skin underneath was new, red, and raw and now we have foot treatments to do BID. He often refuses those as well...

Lots of other skin breakdown issues do to his lack of cooperation with positioning, lack of cooperation with hygiene, etc. We document qshift, as do the CNA's in their forms, if he allows us to shower/bath, change his sheets, positioning, etc.

We have a resident who hasn't showered in months. He stinks so bad, at one point the smell saturated all the way from his room, down the hallway, to the nurses' station. He also hasn't been taking his medications, he refuses them. I cannot stand it anymore..someone has to do something about this man's hygiene. I don't have him most of the time but when I do, I am really bothered. The psych hospital was asking me to do a skin assessment on him, but he gets really agitated when we get near him. He told me to go to hell and stop bothering him tonight so I just backed down. He is "lds conserved"...what does that mean? CNAs have tried to lure him into the shower room with snacks, we've given him IM haldol, it's like it had no effect on him...he's growing crusts on his hair, and his roomate is complaining because of the smell. What can we do for this man?

lamazeteacher · Jan 2, 2009

Quote from PaganDeva's first post on this thread:

Something would have been done within a week!! It is an infection control issue, for sure!

Bravo!!

I can't believe the things I'm reading here! How could a facility allow their patient to lead such a deteriorating existance? Yes, obviously this patient is schitz - probably "simple" schitz, and terribly frightened of contact with water, others, who knows what.

Sedation, preferably of the anti-schitzoid variety, synergized with an anti anxiety drug is the humane thing to do, and lots of it, unless he had COPD and is of advanced age. You would need to bring a MSW in to plan for future care, but only when the bad odor subsides and things are settling down into a routine of regular hygiene, without zonking the guy with meds that make him somnambulant.

After the gentle, warm bath with exfoliative components in the soap, using soothing sounds and an approving voice, I'd recommend some acupuncture afterward, for more long lasting effects of the anti anxiety and anti psychotic meds. Keep warm blankets on him afterward, and after several of those "medicated" baths, a shave and a haircut you may find someone with whom you can work.

I really don't understand how nurses educated in psychiatric illness cannot see the pain suffered by patients like this, even if staffing is extremely short and one less shower/bath seems pretty OK at the time. In LTC are there locked units? If so, that is the ICU of mental illness.

I'd imagine this man was on one - if not, on conservatorship, if that patient escaped and became a victim of violence or a car accident, the conservator could make a case against everyone involved in his- uh- care.

I know administration would scream about extra expense, but this man warranted 1:1 care until stable. By stable, I mean receiving sufficient medication to be able to have psychotherapy and behaving more appropriately.

Our streets wouldn't be inhabited by walking critically mental ill shadows in the dark, if once they were remanded for care, they got some. The staff on that unit really could use Inservice Education regarding appropriate steps of care for people like the man described. First off, I'd recommend asking them to describe their reaction to the patient; and what special conditions are needed for him, since telling him to shower is ineffective.

eldragon · Jan 2, 2009

That is so true! The State on one hand speaks of client's rights and autonomy; on the other hand, will say that nursing was neglectful in caring for this person and that someone should perform a miracle. Totally unrealistic, but they are not empathetic. Also, the families of other patients will start barking, especially the room mate. I know I would.

I think it's important to note that the patient is living in a facility at least partly because he can't make responsible decisions regarding his life and health. Therefore the facility is responsible for making those decisions for him and for providing shelter, food, medical care and bathing, amongst other things.

I work in a LTC facility and many of my patients would refuse to get up every morning if they could. Many would prefer not take showers, and fight all kinds of care related to toileting and being fed, but the facility is responsible for making sure the patient is cared for, combative or not.

One of our patients is a 70 year old woman who is 99 percent with it but she lost power of attorney to her daughter, and her daughter is now keeping her in the nursing home, against her will. One thing that got this poor woman was the fact that she had very poor personal hygiene. In fact, the woman reeked when she was admitted and stunk up the room so badly within the first few days that the whole room had to be emptied out and the carpet steam cleaned. All her personal items had to be cleaned also. Now she doesn't stink. But she still can't go home. Sad but true. Sometimes not bathing is enough to lose your personal rights. (She also had 17 dogs inside her house).

So I suppose it's an indicator of overall mental health.

lamazeteacher · Jan 2, 2009

Quote from post of eldragon today

"70 year old woman......lost power of attorney to her daughter, and her daughter is now keeping her in the nursing home......... within the first few days that the whole room had to be emptied out and the carpet steam cleaned .........(She also had 17 dogs inside her house).........indicator of overall mental health.

________________________________________________________

Right you are! Her calls for help were finally noticed by her daughter, who may have gotton POA through the court (the only way I know of to "lose it").

17 dogs are not a responsibility a rational person takes, unless they run a kennel. The expense alone might have been against the patient's own best interest. At 70, walking that many dogs isn't realistic. I'm almost 70 and get OOB walking my one dog, who is also a senior.

So the daughter was overwhelmed and placed her mom. Soon some kind of MSW report should be forthcoming soon about their relationship, what other responsibilities the daughter has, what housing they have that might make it reasonable for her mom to remain at home with nursing supervision and care when the daughter isn't there.

We are all afraid of losing self control (which it appears that mom has done), and aging imposes unwanted limitations on our activities. Due to their not wanting to look at all that, or relationships that went "south" long ago, many people don't plan with their children about what might need to have done in situations that prohibit their continuing to live as they always did. (Thread about that is "would you put your parent in a nursing home".)

Lack of personal hygiene is one of the the first indicators of mental illness, along with s/s demonstrating the loss of touch with reality. Sometimes denial makes families turn away and hope for the best (actually it's more like: dig hole in sand and insert head). Then a parent's odor, behavior is reported to an Adult Protection Agency with limited staff and in that crisis, a decision to put her in protective custody is made. The daughter is told she can be POA.

No one wants that to happen to them, and I so adamantly oppose my own placement such as you describe, that I've told my adult kids that they'll be disinherited if they do that to me. However, they need to see me frequently so that an incidious change doesn't become a crisis, leading to placement. Plans need to be made for impending physical or mental illness (frequent falls, senility, loss of ability to perform own ADLs, gait difficulties, etc.)

**By the way I just read an article stating that new research indicates that frequent falling in type II DM patients can be caused by malfunction in the hypothalamus......**

Anyway, this 70 year old woman stayed on the unit several days creating filth that no one thought to encounter before then - how come? You've pretty much indicated that, like it or not, facility routine for rising, self cleansing, etc. must be followed. Why did this woman not have a bath of some type within 24 hours of admission?

Regression is also a sign of mental degeneration,/depression; and child-like refusal to do as one is told indicates that. What is done to discourage that, where you work. Do the doctors receive that information in a timely manner? Are activities done - (arts and crafts, singing, exercise, etc,) that indicate which direction is being taken by patients?

It's so important to assess that early and have staff/physician alerted, so a plan of care will be instituted that will produce an optimal outcome.

southernbeegirl, BSN, RN · Jan 2, 2009

get that man some IM Geodon stat! lots of it, lol.

seriously though, what a situation! since he is involuntarily admitted, i would get the Social worker and the ombudsman involved. this is detrimental to his care. i dont remember which poster said it but this is one of those cases where if you do nothing...you are neglecting him, if you do something...you've broken his rights. but with him declared incompetent, i would think you are at bigger risk of a case of neglect by NOT bathing him.

i dont envy you and your coworkers. keep us updated please!

moe1802 · Jan 2, 2009

NOTHING!! He has his rights. Only if he is a threat to himself or others can you do something. I had a lady who didn't take a shower for two years. I told the doctor and the famly.

She lost it every time we tried. As long as you let the doctor and the family know and document it, you are all right.

This lady took two showers before she died ( I gave them) when she was to the point of being unconscious and

not able to fight. She was agreeable to both of them.