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?
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.
I've been called to review an elderly gent; recent stroke and now living in a nursing home. The nurses think he needs reviewing because when he goes for a cigarette and they don't give him one he gets verbally demanding.
It takes him 10-15 minutes of hard work to get to the nursing station; there is no chair for him to sit in while he waits for a nurse to come by and when they do they simply refuse him a cigarette and leave him to make his way back to his room.
They want to know if I can arrange to give him something to cut down the verbal behaviour. My answer:
1. A chair
2. Some attention
3. A cigarette
Why is it that unless it's a medical/nursing issue, people do not get attention to their needs? It annoys me no end when we clearly identify someone's wants, needs and desires - then fail to address them and wonder why they're acting out all verbally.
I am not comfortable with responding to basic needs requests with increasing levels of anti-psychotic
It's even worse for me when they have medical/nursing care needs that aren't being met.
This is an LTC facility - it's his home - most likely completely against his greater desire and certainly not like being at home.
Giving anti-psychotics for someone who is 'grumpy' instead of meeting their needs isn't the treatment I'd like to see my parents receive and is probably in part causing him to be more agitated.
Santa Claus update: Santa Claus continues to refuse medications (ref. Seroquel at 0600 for me, and many other doses). Santa has made disturbing statements to my noc CNAs, saying "I sliced my brother's throat and my laywer got me off," "i broke my sister's leg and now she's permanently disabled," and he has implied situations of "getting away with it" to me. There was an order written to schedule a family meeting with Santa and the Social Worker here. I'm going into work tonight, and what I wouldn't give to see him somewhere else where he can have a 1:1. I can take demanding residents, but someone who is demanding donuts, cake, and stating that he doesn't understand how a place like this doesn't serve breakfast at 5am when everyone else is sleeping, and not even thank you for bringing him something to eat is beyond me. I hate to say this, but I hope he is gone or leaves soon.
If the pt is refusing medications then there's little point in reviewing any efficacy of a medication regime. But there may be a benefit in reveiwing why he's reluctant to accept them. Very often it's because they don't want them to have the desired effect - ie taking the edge off / slowing down.
However, if he wishes to continue to do that then he has to also take a responsiblity for his behaviours.
The 'claims' of violence may be psychotic in origin; they may be personality driven attempts to intimidate. Either way I'd tell him I had no wish to hear such stories, true or not.
If he continues to be abusive to staff (by announcing these stories) then I would tell him that staff will not be able to attend to his needs.
Behaviour always serves a function or purpose. If you can resolve the purpose then the behaviour stops.
Often you get an increase is negative behaviour when you challenge it - cos they want to keep using it so try to force the issue - but holding fast will always result in them seeking a new behaviour. Whether that is a good or bad behaviour will depend on him and the "care" given that leads him to the decision.
Sounds like the guy could do with some specialist mental/behavioural interventions.
try giving the dose at night just before going to sleep so the side effects are less disruptive to him. We have a guy like that gets a loading dose at 8pm and goes to sleep in the morning gets a smaller dose and is balanced because of it. He also has a supportive sister (a real angel) who helps.
Santa update #2: The last I heard, Santa was on a 2 week "trial period" where if his behaviors continue, and he keeps refusing medication and treatment, that he will mostl likely be sent to another facility. The 3-11 nurse at my facility told me that telling him the Seroquel is his "tranquilizer" or "calming pill" often helps him to take the med. For me, it has worked this week. He only refused me 1/4 days. He has been staying in bed 90% of the night, which is good. I hear he is still verbally abusive to the 7-3 shift, but I am not sure in what way. I think he has one more week of review before a decision is made.
Specializes in LTC, Disease Management, smoking Cessati.
Does he have pain? My dad would get that way and we would ask him if he was in pain, he said no, but if we gave him his pain medications he would calm right down. Just a thought. Sometimes even alert people can't describe pain they feel it different. My dad was alert and sharp up to the end but could never tell you it was outright pain.
I've been called to review an elderly gent; recent stroke and now living in a nursing home. The nurses think he needs reviewing because when he goes for a cigarette and they don't give him one he gets verbally demanding.
It takes him 10-15 minutes of hard work to get to the nursing station; there is no chair for him to sit in while he waits for a nurse to come by and when they do they simply refuse him a cigarette and leave him to make his way back to his room.
They want to know if I can arrange to give him something to cut down the verbal behaviour. My answer:
1. A chair
2. Some attention
3. A cigarette
Why is it that unless it's a medical/nursing issue, people do not get attention to their needs? It annoys me no end when we clearly identify someone's wants, needs and desires - then fail to address them and wonder why they're acting out all verbally.
I am not comfortable with responding to basic needs requests with increasing levels of anti-psychotic
It's even worse for me when they have medical/nursing care needs that aren't being met.
This is an LTC facility - it's his home - most likely completely against his greater desire and certainly not like being at home.
Giving anti-psychotics for someone who is 'grumpy' instead of meeting their needs isn't the treatment I'd like to see my parents receive and is probably in part causing him to be more agitated.
I agree except that I also think the meds can definitely help. Chair, cig, attention, and meds.
Santa update #2: The last I heard, Santa was on a 2 week "trial period" where if his behaviors continue, and he keeps refusing medication and treatment, that he will mostl likely be sent to another facility. The 3-11 nurse at my facility told me that telling him the Seroquel is his "tranquilizer" or "calming pill" often helps him to take the med. For me, it has worked this week. He only refused me 1/4 days. He has been staying in bed 90% of the night, which is good. I hear he is still verbally abusive to the 7-3 shift, but I am not sure in what way. I think he has one more week of review before a decision is made.
I wonder if someone on Days is provoking him. I'm sick to death of how some staff talk to patients. They have been trained by, apparently, a sadist with no insight into human behavior. They don't know even the first thing about how to talk to patients, how to recognize illness. They take it personally when a patient is difficult or ugly verbally. They respond in kind. Outrageous, maddening, abusive.
I agree, I think many people are fed up with him and might respond in non-productive ways. For a little while I thought I had a breakthrough with him on Wed. night - we talked for a half hour, he was crying, and basically told me he was very depressed, hadn't seen his wife (who is on an Alzheimer's unit somewhere in the state), told me his kids don't come to see him anymore, can't go outside/hates feeling like a prisoner doesn't like being alarmed, etc. I gave him some hugs, a kiss on the cheek, and got him some food to calm him down. I did a nice long note on the situation. I felt bad for him, truly.
An hour later he was demanding me to get him food immediately, and even stated to me "I don't care if it inconveniences people, I want my food when I want it." I learned in the morning that his daughter has come before, many times, and the last time she came she left in tears because he apparently told her she was no good, worthless, etc. He will either barrade her with negative comments, or refuse to get OOB when she comes to visit. I have no idea where his son is. I also learned that the dtr. doesn't want to take him to see his wife because she's afraid his behavior will upset her too much or be too hard on her.
Last night he wanted food, so I obliged and got him a sandwich from downstairs and a drink. He said he had questions for me and I thought "oh boy." He was asking me about "hostice" aka hospice and I told him the basics of what I know. He asked me about going outside and I told him I honestly don't know what the house protocol is for going outside since I work 11-7 and the situation has never come about. He repeatedly kept asking the same questions, despite me telling him numerous times that I did not have any answers for him. He also wanted to know why he could not get a fried fish plate or a Wendy's double bacon cheeseburger at 2am. I reminded him of the time, and he said "well the time doesn't matter!" I was almost going to offer to bring him in something special next week, but I don't want it to become a habit and expect it on a daily basis. After finding him wandering at a very inconvenient time (just pronounced a death) he just had to tell me that I didn't answer any of his questions. Then he has the balls to ask if he's an inconvenience. I just have to grin and bear it even though I am just mentally/emotionally drained by his demanding behavior.
And as a quick addendum, he is not in any chronic pain as far as I know. He wears a fentanyl patch 24/7 and has MS as needed. I frequently ask him if anything hurts and he denies it.
It's also funny because he's on a NAS diet, realizes this, and still wants his burger or ask for the sub he thinks he has in the fridge (then gets ***** about when I tell him he has no food in our fridge). I understand the pt's right to refuse, but how does this work in terms of dietary requirements?
Last Santa Update: He was supposed to be transferred today to the same facility where his wife! He was beginning to refuse meds again.... I am just glad this headache will be over, and I hate to say that about my residents, but he was just irritating everyone. It will be a whole new week!
So besides him being locked indoors and unable to go outside, has meals only at set meal times, being kept away from his wife and then being overdosed on opiate pain meds - we've no idea why he's grumpy?
I don't think you mentioned what his original crime was that he's currently incarcerated for?
Mr Ian
340 Posts
I've been called to review an elderly gent; recent stroke and now living in a nursing home. The nurses think he needs reviewing because when he goes for a cigarette and they don't give him one he gets verbally demanding.
It takes him 10-15 minutes of hard work to get to the nursing station; there is no chair for him to sit in while he waits for a nurse to come by and when they do they simply refuse him a cigarette and leave him to make his way back to his room.
They want to know if I can arrange to give him something to cut down the verbal behaviour. My answer:
1. A chair
2. Some attention
3. A cigarette
Why is it that unless it's a medical/nursing issue, people do not get attention to their needs? It annoys me no end when we clearly identify someone's wants, needs and desires - then fail to address them and wonder why they're acting out all verbally.
I am not comfortable with responding to basic needs requests with increasing levels of anti-psychotic
It's even worse for me when they have medical/nursing care needs that aren't being met.
This is an LTC facility - it's his home - most likely completely against his greater desire and certainly not like being at home.
Giving anti-psychotics for someone who is 'grumpy' instead of meeting their needs isn't the treatment I'd like to see my parents receive and is probably in part causing him to be more agitated.