Advice on difficult resident/vent - sorry for length!

[evilolive, BSN, RN]

I need advice on a resident who is currently on my floor. I also need a 1-2 part vent about this resident!

Bit of background, I work on a 32 bed unit, mostly LTC and some short-term rehab. We have "Santa Claus" in one of our rooms (named for his white beard). This man's baseline is to be a royal terror. He is not physically abusive, but he often times gets agitated, is EXTREMELY needy, and can at times be verbally abusive. He complains when he can't get a cup of coffee at 2am, when he has his PA on, when his heels hurt, and how he cannot sleep. All of the staff, including myself as the Supervisor RN on 11-7, have been more than accomodating to this man. The trouble is, I can't figure out a way to get him to calm down or quiet down. He is supposedly HOH, and is overly disturbing to the other residents in his room and throughout the floor. He gets very loud and wakes everyone up around him. If I ask him kindly to keep his voice down, he gets worked up. He gets louder.

We have tried so much to get this man stable emotionally/mentally. We've had success with ABHR gel in another hospice resident, and have begun administering that PRN with no effect. He takes Seroquel 25mg QID and q4 PRN. No effect. He gets 0.5 of Ativan at HS. No effect. I am at my wits end with this man. Even my ADON agrees that he is hard to handle. And she usually thinks everyone has a UTI or has to be saved!

Part two of my story and vent deals with a resident across the hall. He is in his 50's, here for rehab secondary to a TMA of the right foot. I heard this man yelling last night, which is not his norm. I go in and hear him cursing like a sailor. He is sick of the guy across the hall, wants to beat him over the head with his cane because he "has no respect for anyone else." He is tired of PT deeming walking down the hall and walking up a few stairs "rehab." He is an A+Ox3 guy who is stuck on a floor of nut jobs and sickies. I really did feel for this guy, he told me he didn't belong here and that he thought he should write to the paper to get them to investigate why someone in his state would be placed at my facility. I had no clue how to respond to him. He apologized and told me it was nothing against me.

So basically Santa Claus is causing an uproar all day every day with his demands and inconsolability, and it's really starting to grind on my other residents. I'm trying to come up with ideas to calm Santa, but I can't think of much else. It's almost impossible to do a 1:1 with him, we don't have that kind of staffing or time. How can I console my A+O gentleman despite the fact that I agree that he doesn't belong in this unit?

Thank you for listening

[WoofyMutt80]

It sounds like it is time to get a meeting organized with the RN's, other care staff, ADON and "Santa" family or guardians (if he does have family, I dont know!) and put everything on the table and bring all the charts and nursing notes. Also as I learned when I was a CNA/HHA some older people can be hard to please and they have some inner turmoil which results in displaced anger. I had one lady who was a crabapple and she would be beligerent and yell at every little thing I did. Also all the appliances in her house where at least 50 years old and not up to code and when there was a smell of gas, and the fire dept came, they told her the stove had to go and she insisted there was nothing wrong with it and not to move it! The stove was violating the fire codes! She was ****** cuz she had to be evacuated from the house and it was a fiasco! Also one day I went to vaccuum the living room with this broom vac that has to be 40 years old and it fell apart! She gave me the riot act for breaking the vac and I said I would be glad to bring my own broom vac since this one is in bad shape! And she insisted there was nothing wrong with it!

[RochesterRN-BSN, BSN, RN]

Have you had a psych consult done on him.......they may be able to take a look at his meds and see if there is room for any changes or increases. Depending on his age, weight, liver and renal function, etc. --They might be able to increase his Seroquel at least the HS dose--25 is really pretty low, and maybe the Ativan to 1mg. Has he ever been on Remeron?...Sounds like he really is difficult but you really may find it helpful to have his meds looked at by a geriatric psychiatrist and also he/she might be able to help you with some suggestions with a behavioral plan. Now you said he is really difficult all day and eve right? Not just in the evening? Curious as to is there is any sundowning going on.

I find keeping these kind of patients busy and being consistant with how he is handled by all the staff--nurses and aides is important. Sometimes being creative is helpful.....thinking outside the box. You know? Like with women it is common to give them washcloths and small towels to fold, sometimes it helps calm a female patient who is aggitated...brought on by lack of occupied time.......sometimes with the men you have to be creative as well. Boredom and lack of feeling needed can cause patients to become irritable. I remember a patient that was cranky often and I read in his chart that he used to be an engineer or something......so I decided to take tubing...oxygen or IV tubing will work......take off any sharps like the spike for an IV tubing......and I knotted the H*** out of it, and said to him......"I have a problem here and I wondered if you could help? I need to use this tubing and I am just so busy and can't seem to get it unknotted. What do ya think? Think you might be able to fix it for me?"

We had him in a geri-chair where we could all keep an eye on him and he was not a safety risk as far as using it to harm himself.....he was harmless, just grumpy. Well he got that thing undone, and an dhour or two later I approached again and he didn't remember that he had done this so it worked again and he sat quietly working really hard at that and was so proud every time he got it untangled. It was really quite cute. But that was thinking outside the box......men sometimes will even like to do the folding. or sort paper for you......it's amazing how making them feel needed and giving them a job helps..........so yes this stuff doesn't always work but I figure its worth a try.

Oh and another thing I have found helps some is puting a radio in their room with some old music on....something they like that may calm them, or for some a book on tape/CD. So give these things a try and see if they help....and I really would have those meds looked at. I think he could most likely handle more Seroquel. Good luck and keep your chin up.

[Whispera, MSN, RN]

I agree with psychRN--a psychiatric consult is definitely called for. Is there a psychiatrist that oversees psych meds for your patients? Lots of times general practitioners don't really understand psych meds, but a psychiatrist would. I can see lots of appropriate med changes that might work!

I like the helping out psychRN recommends. He could fold papers for mailing? insert things in envelopes? sort socks? anything he might have done when he was younger might interest him. sometimes elders like to color too--do you have coloring books and crayons?

[CoffeeRTC, BSN, RN]

We get folks like that too that cause so much anger, resentment and sleepless nights for the other residents.

Is Santa a hospice pt? Can they be called?

I think a psych conult is def in order...The pp had great suggestions. What about having him wear an amplfier or have a hearing test done? Does her realize how disruptive he is? Can you bring him out of his room at night?

We have a few like this and man...they run you ragged and all the other residents loose sleep and start to make those type of threats..

[WoofyMutt80]

Has he been evaluated for Alzheimers or Dementia? I agree with PsychRN, he is on low doses of meds.

[achot chavi]

Is your facility the best place for him? If he is bothering everyone , he might need a different sort of place. I am sure you thought of the psych consult on your own. If he gets too agitated- capable of hurting himself or others- please give him something to calm down.

Why cant he get a cup of coffee at 2am?

[evilolive, BSN, RN]

Well apparently he must have had some kind of psych consult yesterday (unbelievable night, didn't even have time to look at lab results or consults..), they did change some doses of meds around. He's now on Seroquel 25mg TID and 50mg at HS. They put him on 7.5mg of Remeron daily. He seemed to have a low key night, so that's a plus.

To answer some of the questions, Santa Claus is indeed a hospice pt. He was seen by them yesterday, which probably explains some of the changes. He can get a cup of coffee at 2am, but it's just a p.i.t.a. to be honest. We have to go unlock the kitchen, try to find some instant coffee and styrofoam cups (or clean mugs) which can be elusive at times. I might try to pocket some Sanka packs to hide upstairs. I sometimes think that the caffeine probably wouldn't help him try to fall asleep, which is his main concern on my shift.

We'll see how he is this weekend, I'm going to try to get to know him a bit more to figure out some of his interests the next chance I get. Sometimes his mind is only on the fact that he seemingly "does not know what is going on" and thinks everything is a "conspiracy." Either that, or his mind tells him to speak like a robot (he has done this as well, short one word answers in a robotic monotone, then an hour later converse normally, and go back to robot mode when day shift comes on).

I really want to thank everyone for your input, it has given me some good ideas.

[RochesterRN-BSN, BSN, RN]

Wow...sounds like some psychosis there.....some dellusional thinking......this may be delerium.

Funny that the meds were changed as they were. I actually talked to the Psych NP at work today for some suggestions and to ask about the meds.....

He said that, assuming no medical problems that would contrindicate, he thought the Seroquel could go up but that 100 is the most a geri should get at one time-- (considering we give much larger doses to young medically healthy really ill psych patients) and i asked about Remeron and he said that was a good idea-- I also mentioned the suggestions I gave with the tubing and finding things to fill his time and make him feel useful.........he actually told me there is a philosophy he learned about that is basically the same concept and they have a website and all sorts of resources-- Its called the Eden Philosophy--

here is a website with its philosophy-- if you try it let us all know if it helps!!!

http://www.mcauleyplace.org/eden/

Good luck!!!!

[achot chavi]

Wow...sounds like some psychosis there.....some dellusional thinking......this may be delerium.

Funny that the meds were changed as they were. I actually talked to the Psych NP at work today for some suggestions and to ask about the meds.....

He said that, assuming no medical problems that would contrindicate, he thought the Seroquel could go up but that 100 is the most a geri should get at one time-- (considering we give much larger doses to young medically healthy really ill psych patients) and i asked about Remeron and he said that was a good idea-- I also mentioned the suggestions I gave with the tubing and finding things to fill his time and make him feel useful.........he actually told me there is a philosophy he learned about that is basically the same concept and they have a website and all sorts of resources-- Its called the Eden Philosophy--

here is a website with its philosophy-- if you try it let us all know if it helps!!!

http://www.mcauleyplace.org/eden/

Good luck!!!!

We've got one geri with Schizophrenia taking 250mg Seroquel a day. And its fine (for him)

Thanks for the website connection.

[Whispera, MSN, RN]

Seroquel is often used for its side effect of causing sleepiness, in those who need it anyway. So, biggest dose at bedtime can be a good thing.

[achot chavi]

Exactly we give the am dose of 50 mg, then the pm dose at 8pm of 200 mg. When he doesn't take it--- OOOOh Watch out- paranoid city!!!