LTC Resident w/ OCD

  1. :trout:

    I'm the nurse for a resident with *severe* symptoms of Obsessive Compulsive Disorder. Her hospice social worker and I were discussing the resident's concerns, and I looked at the social worker's notes and discovered we had discussed "OCD Behaviors." This was a great revelation to me. I've got a colleague w/ OCD and she's *wonderfully* neat and organized and a joy to work with, and this lady's room is profoundly disorganized and messy and she's um ... "challenging" to work with, so I completely missed it.

    So ... what do I do now? I can't find that it's documented anywhere but in this social worker's notes. She's being treated with Seroquel which she hates because she says it makes her fall asleep in the middle of dinner so she's not eating well and she *is* experiencing weight loss (hence the justification for hospice - "general decline").

    My CNA's are like ... duh ... of *course* she has OCD and they laughed because it's so screamingly obvious if you do her personal care.

    Last night, I did some personal care for her and she burst into tears because I wrapped her feet with a towel the wrong way. I put the towel on the mattress first, and wrapped the towel over her feet, and she *needs* the towel put over her feet first, and tucked underneath them, and she told me through her sobs that it doesn't matter how the towel is wrapped and I could see it so clearly matters to *her* and I want to help. Making sure she has a towel available and that it is wrapped the right way is just the tip of the iceberg ...

    Her primary issue since I began working for her has been the inadequacy of help with her ADLs. We don't help her enough. I *get* it now, maybe. What she believes that she needs is help acting on her compulsions. She can't physically get a towel from the linen cart and wrap her own feet the right way and she can't physically arrange things in her room the right way and we keep rearranging her stuff and she hates her life and she hates us and she just wishes she would die.

    So ... I don't know where to start. Educate the patient? Educate myself? Fax my concerns to the psychiatrist? Tell my DON (whom I'm imagining would take me as seriously as I took my CNAs when they told me these completely unbelievable stories about her unrealistic expectations ... )

    oh help ...
    •  
  2. 9 Comments

  3. by   joprasklpn
    I would notify the DON and the dr. about what is being observed during her routine care and try and implement a plan of treatment for her before she gets very depressed. Sounds like she is having trouble adjusting to letting others help her.
  4. by   Alois Wolf
    I also work at LTC facility dealing with a similar population.

    Document, document document. I would bring up the medication being used for her issues. Is she bi-polar or manic? From what I read on wikipedia that drug is used as an "off-label" solution to OCD... as well as sleep disorders.

    I don't think you're really in the position to help her psychologically with her OCD issues... but I think it would be a good idea to try and coordinate with the Psych and ADL (ADL might mean something where you work...) to help set up a program so she can try to adjust, at her own pace, to not give into her compulsions as much.... if that's what she wants. I think if she was crying over it I think there might be a possiblity that other staff degrade her for her OCD tendencies which, if true, should be investigated and stopped immediately. There is obviously some stigma she associates with the behavior she participates in... all you can really do, professionaly, is support her and make sure she understands that even though she has these behaviors it doesn't make her a bad person. She shouldn't feel guilty or ashamed of an issue she is having. She can work through this, but she is going to need positive support from all staff. But like I said, you should definately go through the psych departmetn. Read her active treament notes if she has them and again document document document.

    PS It would never hurt to learn anything new about psychological disabilities.
  5. by   TheCommuter
    I work at a LTCF, and one of our patients had OCD when she stayed at our facility last year.

    The management and administration at my facility decided to take the path of least resistance with this lady: they had her transferred to a geri-psych facility so that they didn't have to deal with her issues anymore.
  6. by   SuesquatchRN
    First, find out if you can get her Seroquel changed to HS. And find out if she can be put on an anxiolytic.

    And sit with her and the social worker and go through every personal care event and make a list of how she would like it done. Get a copy placed into her care plan, and onto the cheat sheets the aides use. Post it above her bed. Make certain that everyone who deals with her has a copy of her list. Review it with her before care begins.

    She has no control over anything any longer. As a person with undiagnosed OCD I KNOW how important her rituals are to her sense of well-being. Yes, they mean nothing; yes, she knows they're ridiculous, hence her assertion that it doesn't matter; and yes, easing her anxiety is time-consuming. But if it can be done, it's worth it. She's, like, a human being, y'know?

  7. by   dream'n
    Suesquatch is right on the mark. Advocate for her...OCD can be miserable, and can go along with depression and/or panic. Perhaps the Seroquel is not the right medication for her, there are so many others that can be tried. She sounds as if she is declining due to mental suffering, which can be just as profound as physical. But the symptoms are treatable, so again advocate with her Dr., speak with the DON, see if they are willing to try and be more aggressive with medication/treatment plans for her. Don't be afraid to ask the patient which of her compulsions/rituals are important to her and careplan them. Even if they seem trivial or ridiculous to other staff members, they bring comfort and reduced anxiety for her. That would be nursing with compassion.

    Also, it is a misconception that OCD means someone is always organized, neat, or perfectionistic. Some with OCD can live in an unordered home, but have a pen (or book, etc.) that is out of place and it will trigger a compulsion. Or the ritual could be reading something ten times, or holding their breath for a certain amount of time, or washing their hands constantly, walking through a doorway five times, or wrapping a towel a certain way. Anyway, what I'm trying to say is that the rituals/compulsions associated with OCD can be as varied as the people that have them. So no, many times you can't tell who has OCD.
    Last edit by dream'n on Nov 13, '07
  8. by   SaraO'Hara
    We have one that is obsessed with her colostomy bag... always fiddling with it, emptying it, etc. We document the number of times per shift that she is continuously playing with the bag or her foley.
  9. by   nancyhlpn
    You have not mentioned medications. I have family members with OCD. Until 10 years ago, treatments were not very effective. Luvox and Lexapro work very well, and might be worth a try if the client has not tried meds in a while.
  10. by   SuesquatchRN
    Actually, any of the SSRI's are helpful.

    Ask me how I know.

  11. by   Callinurse
    This situation needs follow up on several different levels.

    First of all, so everyone else will know that she is OCD, it needs to be added to her Diagnosis profile. If her Seroquel has a qualifyer in the order "OCD manifested by .... " , that is sufficient to add it.

    I would also care plan her messiness. If she is unable to organize her area I would suggest making an agreement with her that the CNA will meet with her weekly to assist her with organizing her area. Give her the power. If the goal is to make her area more organized and clean it doesn't matter how its accomplished. She can just think its the weekly special time for her to be assisted. Its the fear of not being in control that is the worst. Take baby steps. Just having someone in there once a week with the purpose of "cleaning up" will help the situation for her and the facility.

    To me, with her statements of, "just wishing she would die !!!!!!", she is severely DEPRESSED. Weight loss also goes with depression. Tearfullness and crying are both possible indicators of depression. A good psych eval is in order. Remeron and Lexapro are both good antidepressant that also work well with poor appetite. I always suggest a non-psychotropic appetite stimulant prior to the psych approach but clearly she needs both.

    I would also look at all her meds. It might not be the Seroquel that is making her sleepy. Also check her night time sleeping. If she is awake at night or gets up very early she may get tired at that time because she doesn't have a good sleep routine.

    I have worked with a fair share of OCD patients. I have never worked psych. One thing that I always hear from the OCD patient is why they do what they do. In my experience 100% of them have a reason for what they do and have never had one yet say, "I know this seems silly but I want it this way." they always have a reason or justification. I would care plan the major ones to start with. Like others have suggested add it the to Cardex or the CNA ADL cheat sheets, so everyone knows who works with her can provide her with what she needs.

    I would also make sure she has consistent staffing as much as possible. The CNA's more than likely know her every special need. The more she has the same staff she won't have as many changes with people moving things or doing things differently and this could greatly effect her quality of life.

    I would also make sure the CNA's know how important it is for this resident to NOT hear anyone laughing at her.

    I would also request her primary MD to evaluate her. Maybe her labs need to be drawn again. Rule out any pain she may be having. Is she constipated???? Ask her when she was living independently how often did she move her bowels? Maybe she went twice a day or everyday. We usually don't get concerned until they do go on the third day. It can make a big difference in someones life "Constipation vs. regular bowel pattern". However, the key thing is her regular not ours.

    There are so many little things that could be effecting her.

    Does she get visitors? Are there any volunteers that can visit her just to read the newspaper or to help her write letters. Maybe she can start a journal. Get her mind off her problems.

    And, yes review yourself. You will find as you get more years under your belt that OCD patients are the same but very different.


    Here are a few good "reliable" links to check out:

    The simple but useful encyclopedia - Wikipedia:

    http://en.wikipedia.org/wiki/Obsessi...ostic_criteria

    National Institute for Mental Health:

    http://www.nimh.nih.gov/health/topic...cd/index.shtml


    The Mayo Clinic:

    http://www.mayoclinic.com/health/obs...sorder/DS00189

    The Obsessive Compulsive Foundation:

    http://www.ocfoundation.org/

    I keep my own care plan library on dx's, s/sx, etc that I have review over the years. I would suggest the same and update it as you learn. I keep mine on a memory stick that I spend 10$ at Walmart. One of my best investments so far. If I am at work and need to use it, I plug it in. If I am at home and want to update it, I plug it in.

    Hope this helps,

    Callinurse






    Quote from abooker
    :trout:

    I'm the nurse for a resident with *severe* symptoms of Obsessive Compulsive Disorder. Her hospice social worker and I were discussing the resident's concerns, and I looked at the social worker's notes and discovered we had discussed "OCD Behaviors." This was a great revelation to me. I've got a colleague w/ OCD and she's *wonderfully* neat and organized and a joy to work with, and this lady's room is profoundly disorganized and messy and she's um ... "challenging" to work with, so I completely missed it.

    So ... what do I do now? I can't find that it's documented anywhere but in this social worker's notes. She's being treated with Seroquel which she hates because she says it makes her fall asleep in the middle of dinner so she's not eating well and she *is* experiencing weight loss (hence the justification for hospice - "general decline").

    My CNA's are like ... duh ... of *course* she has OCD and they laughed because it's so screamingly obvious if you do her personal care.

    Last night, I did some personal care for her and she burst into tears because I wrapped her feet with a towel the wrong way. I put the towel on the mattress first, and wrapped the towel over her feet, and she *needs* the towel put over her feet first, and tucked underneath them, and she told me through her sobs that it doesn't matter how the towel is wrapped and I could see it so clearly matters to *her* and I want to help. Making sure she has a towel available and that it is wrapped the right way is just the tip of the iceberg ...

    Her primary issue since I began working for her has been the inadequacy of help with her ADLs. We don't help her enough. I *get* it now, maybe. What she believes that she needs is help acting on her compulsions. She can't physically get a towel from the linen cart and wrap her own feet the right way and she can't physically arrange things in her room the right way and we keep rearranging her stuff and she hates her life and she hates us and she just wishes she would die.

    So ... I don't know where to start. Educate the patient? Educate myself? Fax my concerns to the psychiatrist? Tell my DON (whom I'm imagining would take me as seriously as I took my CNAs when they told me these completely unbelievable stories about her unrealistic expectations ... )

    oh help ...

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