psych pt in ltc facility

  1. I m hoping you psych nurses can give me some pointers.I work in LTC as a float nurse.We have a middle aged left sided CVA-w/c dependent resident with a 15 yr hx of bi-polar.He is also extremely manipulative-from what I have read I believe he would be dx as borderline.He is a sad case but has caused himself many of his problems at the home.He sets himself up to be the adversary and there is always an issue with someone-dietary,soc,services,the don....I am new to the unit-and am floating in that building.He has a schedule for getting his meds and this is care-planned and he well knows it.The first morning he does not present himself at his appointed time for meds and is then supposed to get his after the med pass is through.Nurse on the other unit comes over and pulls me in the med room to give me a heads up and then gets into a verbal confrontation with him.Later on I went in his room and shut the door-I talked to him for a few minutes and I believe that I set my limits and conveyed my own philosophy regarding nursing care in the LTC ....without really directly contradicting other staff I let him know that I am not what I consider to be an old school nurse-set in my ways and controlling like so much of our staff is....But I made it clear that I would not get involved in any of his on-going issues with other staff....So far it seems to be going well-If I need him to leave the area at the desk because I am busy or have a privacy issue I just ask him to excuse me and he leaves.I chat when I can-as I do with all of my residents-share fresh fruit,play music....I treat them as I would want my family treated-and I treat them all like they are all my friends....I believe that I am working FOR them -in THEIR HOMES....Now-am I his newest victim? My supervisor says to me "I see he treats you as a friend-Sometimes a cold shoulder is best with him" Well- I had heard lots of stories about him-most of the admin makes it clear that they can not stand him....But I am determined to treat him fairly and honestly and yes-friendly as long as he does the same with me....He is an educated man-and is interesting to chat with-which as I said I do this with everyone He knows his rights and has had no problem calling in the proper authorities when he needs to and I see nothing wrong with that.Our DON and the head of soc.services are controlling and rigid and what they say goes.And I don't approve of the way many of our residents have been handled....but I like me job and I think that on the whole we are providing good care to a segment of the population that really needs it....But I have no psych experience-and in an LTC we are limited to the therapies we can try anyway....My goal is to make the days as pleasant for all of my residents while getting the job done.........Am I his next victim? What can I do to keep things going smoothly with him and myself out of hot water with management?
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  2. 10 Comments

  3. by   autumn-moon
    Well, my advice, as a newbie nurse, but with many yrs. of experience in the psych field....

    Sounds like you are doing great! I too, run up against some of the same stuff with the "more experienced staff" on my unit. Maybe I'm just new and naive, but I have found that it's best to be honest, set clear, reasonable and enforcable limits, act in a professional manner and treat the pt. in the same way you would expect to be treated yourself....with respect and kindness. Also try to promote appropriate behavior and self-reliance with praise and positive reinforcement (AND by modeling these behaviors). I think your discussion with this patient was right on!

    And just as a heads up....You do want to respect a pt's privacy, but I'd be careful about closing the door when 1:1 with a pt. who has psych. issues. Their perceptions can sometimes be very different than yours and with no witnesses present, you could be leaving yourself open to all sorts of accusations.
  4. by   Orca
    And just as a heads up....You do want to respect a pt's privacy, but I'd be careful about closing the door when 1:1 with a pt. who has psych. issues. Their perceptions can sometimes be very different than yours and with no witnesses present, you could be leaving yourself open to all sorts of accusations.
    Excellent point, especially when dealing with an opposite-sex patient. In situations when I have to talk with an opposite-sex patient confidentially, I make sure that I use a consultation room with a window in the door. No way am I going into a situation like this in a secluded spot with poor visibility (such as the patient's room with the door closed) without a same-sex employee with me. It just isn't worth the possibility of unfounded allegations.

    Better safe than sorry.
  5. by   Louie18
    Whenever you have a question such as yours, to put yourelf in the bed. (meaning YOU become the patient)
    Now, a left sided means he is a rt sided hemi with possibly NO or minimal speech. Either way, wether he can talk or not, the man is going nuts and all of you afford him stimulation. Take it as that and NOT PERSONAL and things will turn around for all of you.
    But, keep giving him stimulation only AT YOUR CONVENIENCES.
    See if you can get his family to take him out to party or something.
    Stop and think how you would feel?
    NOW, imagine taking care of a quadraplegic. And think how you would feel as a quad?
    Louie
  6. by   ktwlpn
    Update-I have made out fine when I've been on that unit-so far though I have not had any emergent situations to deal with.That will be the true test.His family has had their fill,too....The bi-polar dx pretty much took care of his relationships with them before the CVA.His speech is not affected at all....In the past it seems as though he has been very willing to step into a dependent role but then manufactures conflicts or aggravates them....I had not considered the 1:1 with the door closed and will be mindful of that in the future.The housekeeper was working in the other end of that room and 2 of his room-mates were present.Privacy be darned-I guess I just wanted to talk to him out of earshot of staff members that he has issues with....He is mobile in a wheelchair-just slight limited use of his arm/leg.He can even transfer on and off the commode independently.He is involved in an organization that works with the disabled-maybe they can get him out of LTC....while he still has most of his mind...(Louie-yeah-putting myself in that bed would be just a little beyond the call of duty:chuckle ...Thanks everyone.....
  7. by   Noney
    ktwlpn
    Keep up the good work. You could be the person that makes a difference in this man's life.
  8. by   Louie18
    You think it would be to his benefit, set him up for a short bit in jail.

    I'm Louie (and I'm serious as a heartbeat here)
  9. by   Noney
    Louie

    What's up with you today?

    Explain this post to me, please.

    Noney
  10. by   Louie18
    To have had nurses assaulted by the type patient you speak of. That is against the law. If pt was not sane when he did it, have him incarcerated and triaged appropriately.
  11. by   snoogans
    Some of my LTC bipolar are very manipulating. Until you figure out for yourself what this person is all about... listen to the other staff and take all into consideration and make your own nursing judgement.
    One of my ladies was forever accusing one nurse of being horrible to her. Turns out after talking with other staff she wasn't given her 10th cup of water in 5 min.
    Some ltc psyche esp bipolar (some don't even have a clue what they ate for B.F.) will tell a different story 10 times over of the same situation.
    Bipolar is very misunderstood and compounded with a CVA. Poor guy. good luck
  12. by   ktwlpn
    Our major problem is the staff has had no real training in dealing with psych paients...He acts and staff re-acts over and over...I have had to withdraw a bit-he just demands so much attention and he deserves his share but not at the expense of the rest...If he is not able to get into an independent living situation(with the assistance of an organization that works with the dis-abled) I really hope he looks for other placement-I feel that our social services,administrator don,adon and supervisors just are not capable of working FOR him because they ALL dislike him intensely...so they work against him...He is NOT incompetent and I think is capable of more freedoms and he is being denied them....THings like public transportation for the handicapped.In our state one is evaluated by PT at a local well known rehab...He has been delared suitable and safe for the services provided but the MD refuses to allow it-so if he goes out via the "short bus" it will be AMA and he was told he "will have consequences" What does that mean? If he goes out we would not be responsible if something happened-would we?What happens in other LTC facilities? We are seeing more and more younger people with no mental disabilities at all....Don't they have the right to some freedom? He was denied his own computer-admin said we would not be responsible for that...whatever...It's always something...

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