Difficult Post/CVA Patient

  1. Hi All;

    This is the first time I've posted here. I'm an RN in Washington who recently accepted a job as an RCM in a long-term care facilty so I'm still in the middle of my learning curve. I have a new resident that I'm finding very difficult and frustrating, she won't eat (doesn't like the texture), won't keep her dentures in (so we could upgrade the texture & does not have any visible sore areas in her mouth), spends all of her time when in her wheelchair yelling that she needs to go back to bed. She is barely working with therapies and that is only because they are willing to put up with her yelling at them the entire time. I'm open to any suggestions on how to better work with her because at this point I'm totally frustrated & just don't know what to do for this woman. Her family & significant other are very supportive and try to motivate her but so far that isn't working either. I have worked with difficult patients before but this one has me stumped!! :angryfire Any help would be greatly appreciated!

    Kamara
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  2. 10 Comments

  3. by   AlixCoastRN
    First off, welcome to the RCM world. I've been doing it for about 5 years now and still love it - despite the paperwork and regulations. I actually got to do dressing changes and draw stat labs on someone today!
    Now to your resident - I would suggest you rule out a medical cause for the yelling: she may have a pneumonia, a UTI, or some other infective process going on. Check out her other diagnosis - review her labs from the hospital in comparison to what has been done recently at your facility.Does she have thyroid problems: if so, check her TSH. Find out from the family what her usual pre-stroke routine was at home and try to care plan to follow that as much as possible. Is she in pain? Sometimes yelling can be an indicator of pain. If she is on meds that need monitoring for theraputic values, you may want to get some labs to make sure all the levels are good. In what part of the brain was her stroke? That may be a good clue as to what is going on.

    Good luck and let us know how she does.
  4. by   shygirl
    Hi,

    Did anyone do a depression scale on this patient? Sometimes after a stroke patients are depressed. Chemical imbalances are to blame. Is this patient getting any type of therapies? O.T. or P.T.?

    Are there any family members that you could talk to to find out what type of foods this person is used to eating?

    Just some ideas???

    Shygirl
  5. by   VivaLasViejas
    I'm not an MD, but it doesn't take a medical degree to figure out that this woman is depressed.......and PISSED OFF!! Look at what she's dealing with here: her whole life has changed, she's lost her independence, she can't take care of her own personal needs, and she's in a nursing home. For goodness' sake, please look into getting her on an antidepressant, then arrange for some psychotherapy........she needs help!!

    BTW, I know how hard being an RCM can be......I was one for a year and a half, and I just about dropped dead from sheer exhaustion. Best of luck to you---you're going to need it.
  6. by   robin_mds_nurse
    Has she been assessed for pain? I often find that to be the cause of yelling, poor po intake, refusing therapy, etc. ~Robin
  7. by   CapeCodMermaid
    Could one of all y'all tell me what an RCM is?
  8. by   VivaLasViejas
    Quote from CapeCodMermaid
    Could one of all y'all tell me what an RCM is?
    RCM=Resident Care Manager
  9. by   kamara23
    Thanks to all for your quick replies! I had actually considered & started looking at and implementing some of your ideas. The other problem for this lady is her doctor isn't very responsive which makes her case even more challenging. Anyway, thanks to all & I will be looking at all of these ideas. What a great site!!

    I like being an RCM so far but I know what you mean about exhaustion...I find I'm working many more hours than I thought I would....very challening stuff so far. We are due for survey anytime so we'll see if I survive it. :wink2:

    Have a great week everyone!!

    Kamara








    Quote from mjlrn97
    I'm not an MD, but it doesn't take a medical degree to figure out that this woman is depressed.......and PISSED OFF!! Look at what she's dealing with here: her whole life has changed, she's lost her independence, she can't take care of her own personal needs, and she's in a nursing home. For goodness' sake, please look into getting her on an antidepressant, then arrange for some psychotherapy........she needs help!!

    BTW, I know how hard being an RCM can be......I was one for a year and a half, and I just about dropped dead from sheer exhaustion. Best of luck to you---you're going to need it.
  10. by   studious
    Quote from shygirl
    Hi,

    Did anyone do a depression scale on this patient? Sometimes after a stroke patients are depressed. Chemical imbalances are to blame. Is this patient getting any type of therapies? O.T. or P.T.?

    Are there any family members that you could talk to to find out what type of foods this person is used to eating?

    Just some ideas???

    Shygirl
    Sounds good to me, depression is very common is cva patients, not to mention the new environment, has anyone tried taking her into a private room and just talking to her as a person, instead of expecting her to comply with orders. She is not in control of anything that is happening to her, and must be very scared, loss of independence, strange faces. We have a lady who wants to go back to bed all the time, we let her as this is her own choice. She no longer shouts, she smiles more often than not????? everyone is different and handles their illness in a different way. Who are we to dictate what they should be doing. It is frustrating, you want the very best outcome for your patient. Do what she asks of you, and she may come around eventually, once she gets used to you and her new environment. Let us know how you go.
  11. by   Antikigirl
    There is also the fact that most CVA patients struggle with the fact that they see their own mortality, and really don't like it! (who would???). They feel that they should basically assume a 'old person' role in life...and may have seen their own family members lying in bed waiting to die. I have dealt with this a lot, and I find if I talk to my residents about their experiences with their parents or grandparents I see into a bit of why they act as if they just gave up!

    Rule out medical reasons for behaviors with the Physician (well let them rule it out, you just communicate as much as you can), get the family involved in talking with the physician often, and see if you can find some underlying issues about her thoughts of age, being in a facility, feelings of helplessness, hopelessness, powerlessness (ie the reason we have those Dx's!) and try to implement things that may help these feelings one at a time...sometimes even little things help a ton!

    Also remember that the patient is the one in control too...it hurts to have to remember this sometimes when we think "no, that is not helpful to have her lay in bed all the time"...but the patient runs the show if they are mentally capable of making their own choises. They have a right to lay in bed, not eat if they don't want to and so on...catch 22 to say the least..that is why I hunt so hard to find the underlying issues starting with their thoughts of the present and visions/memories of the past experiences!

    Good luck to you!
  12. by   knockandhello
    Quote from shygirl
    Hi,

    Did anyone do a depression scale on this patient? Sometimes after a stroke patients are depressed. Chemical imbalances are to blame. Is this patient getting any type of therapies? O.T. or P.T.?

    Are there any family members that you could talk to to find out what type of foods this person is used to eating?

    Just some ideas???

    Shygirl
    I totally agree with the above .Depression!

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