New to the community and one good question.

[extremenurse4u]

Greetings everyone!!

Here is my background and then I have a good question about a resident of mine. First, I am mother of 5, married to wonderful husband and been in nursing as an LPN since 2000. I was a CNA for 5 years. I am currently attending Excelsior for my RN. I have been working at the same LTC since 2009. I absolutly LOVE my job. I am a night shifter. It saves tons of cash by not having to pay for day care and also, I am not a morning person at all!!

Okay so when it comes to LTC, I will not say by any means I am perfect but; I do know a few things. My residents come first, I treat them as if I were the resident or if they were my family. When I go to bed, I like my teeth brushed, my bottom clean and my bed organized. So I insist my residents are treated as such. I have a great floor staff. I am not above a CNA; I will hold the cheeks while somone wipes. Its all about caring for my patients. I am an advocate for them. I will speak up and do what I can to make them comfortable. The unit I work on its mostly swing bed/TCU. They are here for rehap after hip or knee replacements or after significant illnesses. Some are hospice. At night, my census is 42 when full. Needless to say, I am very busy but I love it.

So now my question. About a month ago, a new resident was admitted from the hospital with a new dx of end cancer. The granddaughter signed the DNR and enrolled her into hospice. The problem? This poor little lady ( I mean tiny maybe 80lbs ) does not speak a word of english. The family does not speak english. In the begining, the family was visiting pretty often and a translator was used (via phone). The resident is mute; does not speak at all and would not communicate via translator. She lays in her bed and that is where she has been. The family has stopped coming. She barely eats; pushes most foods here way. There has been many many attempts to communicate with her but nothing has worked. We only know what little history came with her medical records. She does not appear to be confused or have any dementia. She knows how to use a TV and luvs luvs luvs TVLAND. She will sit and point and laugh for hours. I have figured out she likes to eat bites of food and likes pudding. She will not take any kind of medication. She will push your hand away if you attempt to get a blood pressure or anything. Recently she has been having more pain; not sure where. She moans and is unable to be still in her bed. She covers her eyes with her hands and cries. Attempts to give her any kind of pain med has been pushed away. Well, I was off for a few days and came back to work and found that she on a pain patch. I asked the nurse that I was working with and she said she got the order the night before because she was in a lot of pain. I asked how can we do that? She refuses all other meds why is the patch okay? The nurse really didnt say much except that she wasnt in pain now and that its our job to make sure she is not in pain. Which, I see her point but the resident refuses all other meds...she doesnt want anything. So my question is; isnt it forcing her to take the pain med by putting the patch on her? And also, it really hasnt worked; she is still moaning; which makes me wonder if the moaning is related to pain or just a behavior. There is so many what if's with this one resident and I feel like no matter what we do; its not gonna be enough and its not gonna be right. I hate it. I feel like I should be doing more for her. I have researched her culture; tried to find someway of communicating with her and nothing...i mean nothing works. Very frustrated.

[Here.I.Stand, BSN, RN]

Do you know through the use of a medical interpreter that she is aware of everything that she has refused, and has stated unequivocally that she does not want narcotics administered? Or has she simply pushed pills away? Is it possible that she is completely A&O but doesn't want to be given anything that she can't ask about? ("What's that oblong pink one?")

I'd be very concerned if she is showing verbal or nonverbal sx of pain and not being helped (not to mention it's a huge JC ding!!). She was moaning, unable to lie still in bed, and crying--all classic nonverbal pain sx.

Cultural awareness is great, but it won't help you communicate with her if you're not fluent in her language. That's why even bilingual staff--anywhere I've worked anyway--need to be certified as a *medical* interpreter to have healthcare conversations w/ the client and family. And especially since she has the dx of terminal cancer, pain is going to be an issue. She is only going to have more of it as the disease progresses, and she can't go through a death from cancer with no pain control. I mean I get respecting the resident's autonomy, but 1) she has to be able to say something like "I do not want narcotics to control my pain; I want to be completely awake and alert and free from narcotic s/e's, AND 2) she has to have the ability to rescind that request at any time, if/when her pain gets past what is acceptable to her.

Also a note about enjoying the TV--pointing and laughing doesn't indicate a lack of cognitive deficits. She could sense that responding to the classic sitcom's laugh track with her own laughter is the socially correct thing to do. It's kind of like when doing a neuro check, how we are not to demonstrate the command we want the pt to follow, e.g. "Hold up two fingers" while holding up two fingers--the pt could be imitating us, which a toddler can do, but not necessarily be processing the instruction.

Has there been a care conference recently?

[Here.I.Stand, BSN, RN]

I was thinking about this post today; I was getting sleepy when I wrote it. It sounds like I was talking out of both sides of my mouth, but my point was that you don't know if she's oriented or confused without someone interpreting. If she's nonverbal (I think I missed that initially) I'm leaning more towards a cognitive deficit, but I haven't assessed her myself.

My other thought today was that actually a patch sounds like a really good idea. She clearly needs pain control, and this way she gets it without the distress of being given pills.

And welcome to AN! I'm a mother of five too :)

[amoLucia]

I was thinking care conference too. I hope that her family is on board with knowing her status just so that they're not surprised. Even with the language barrier they should know and perhaps they could intervene.

Some kind of pain management is nec for this little lady. We wouldn't let a pet suffer.