Published Jul 26, 2009
Hi. I work the night shift in a Long Term Care Unit. I have a part time schedule but, I'm working the next ten nights to cover a coworkers vacation. I love my job. I love the residents and enjoy working with most of my coworkers.
A resident there whom I will name Dolly is extremely challenging. She is a diabetic, hypertensive, MS, and a former elementary school principal. She gets around on an electrical wheelchair. Her and her husband who lives in an apartment in the seniors village, eat out at resteraunts frequently, and she always asks for the sugary desserts and toppings. She picks and chooses how she will comply with her treatments. During the night, she experiences leg cramps and she says it's very painful. She calls for help almost every half hour and recently, she's taken up to yelling loudly instead of using her callbell. After report, I do an initial "round" and check on everyone to make sure they are there. The PSW delivers the briefs and towels to each room and we do two "rounds" to change briefs, security checks and monitoring. So, for the night shift, we intentionally see each resident four times. Should they need help in between, they call for help with their call badge. I also have paperwork, and "routine" meds to administer and other routine administrative type duties to do.
So, we see Dolly on purpose five scheduled times in the night. She requested that we come in a five in the morning to pull her crampy, painful leg. Dolly wont take pain medication. Dolly wont listen to the dietary staff when they remind her that she is a diabetic and perhaps she should chooze the diabetic deserts. She has very high blood sugars and has required short acting insulin. Dolly does like to use herbal medicines and when she first arrived she insisted that we rub Aloe Vera on her sore crampy toes. Then, she'd call five minutes later and ask for "Aloe Vera on her sore crampy toes and she's been calling all night and no one came to help her." It was as if everything I did five minutes ago never happened. I chalked it up to her MS cognitive deficits and she had a very poor memory. Dolly says a lot of hurtful things to us staff and about all of the staff. She says the call badge isn't working and that's why she ends up having to call out for help. If she had her way, she'd want the nursing station beside her bed so the staff could pull her leg and wiggle her toes every two minutes. She has a lot of unreasonable requests and when we are changing her brief, me and my partner wish we each had more arms to fulfill her requests. I really feel for her. I can only imagine how uncomfortable she is when she gets a leg cramp. Once she is sleeping, she sleeps very well. It's unfortunate that we have to wake her up doing our brief checks because she is a deep sleeper and her legs and feet don't cramp when she's sleeping. Once she wakes up she's itchy, crampy, painful, thirsty, and very forgetful.
Last night, she was yelling and woke up three other residents. I was already dealing with a resident way at the other end of the hall who has needs help to transfer to the commode because she's in a lot of pain. Dolly said she's been calling for hours and no one came to help her. I asked her what she needed and she wanted me to pull her leg and wiggle her ankle and toes. As I was doing that, I asked her to use her call badge. She said she didn't know how and it doesn't work anyway. Then she started yelling at me to pull her leg and scratch her back. At the time, I was already pulling her leg and I couldn't scratch her back at the same time. Dolly doesn't seem to even notice if her leg is pulled or her toes are wiggled.I don't know what else I could offer her. Every night I work, it's the same story. As we go on in the night, she's accusing us of ignoring her and not coming when she calls. She said to me "I wont be using the call badge." I was serious when I told her that she wakes up other residents when she yells and she said "you'd better come quickly then." This seems so unreasonable to me. I'm not sure what she's expecting. Tylenol might help ease the pain but, she wont take it. I've seen her legs cramp up and it does look painful. But, she wont take a muscle relaxer because that's "too many pills"
I'm asking for advice for the following:
Is there an herbal capsule or something she can take for leg cramps and neuropathic pain? She wont comply with her diabetic diet and I know that poor glycemic control could contribute to night time leg pain. She already has poor sensation because she can't feel us pulling her leg and wiggling her toes etc. She says so never sleeps at night but, she's snoring whenever we enter her room. We used to try rubbing the Aloe Vera gel on her but, the doc has discontinued it because she told him it didn't work anyway and she then she started asking the PSW's to insert it vaginally.
Dolly says a lot of mean mean things to us and other staff. I really start to feel uncomfortable and each night, I regret asking her how she's feeling. I've recently been trying to keep the conversation at a minimum as to not encourage her to wake up and think of more mean things to say. How do I keep my sanity? How do I help this woman? I don't understand why she doesn't seem to want to be happy. I'm running out of encouraging things to say to her because she can really kill a conversation with her negativity. It's also interesting that she can remember how to use her call badge at 0555 each morning when the day staff is coming in.
I wish for her sake that she does get the six to eight hours of sleep she needs. I'm not a pill pusher but sometimes, analgesics do help. She'll take tylenol for a headache but oddly wont take a tylenol for her leg cramps. I want things to be positive because positive thoughts might help her outlook in general. She's in a vicious cycle with herself. I want to help her get out of her rut but sadly, I'm not very successful. Any advice or ideas would be greatly appreciated.
The patient's physician needs to be contacted with this information. Something is not right. There are probably other medications/thereapies she could try- one is a magnesium supplement, the other is along the line of anti parkinson meds- used for 'restless leg syndrome'.
newohiorn, BSN, RN, EMT-P
Can't help you with the behavioral issues but drinking a bit of tonic water can be helpful for leg cramps--I believe because it contains some quinine. Perhaps she would be amenable to that since it wouldn't be a pill. Both my dad and my husband use tonic water for leg cramps--with great success.
positioning may help, making the fob lower, so her legs can be in a semi-dependent position, letting blood flow.
agree about consulting pcp.
depending on how wet she is during bedcheck, maybe awakening her only 1 of the 2 times.
and as always, (always, always!!) document to extent needed (which sounds like a lot of writing, hoo boy).
As Leslie stated, make sure that everyone is documenting every trip into her room. If she is forgetting staff visits to the room, perhaps she is having dementia along with other issues, at the very least sundowners? The pcp needs to know these things so that appropriate action can be taken, and care can be adjusted accordingly. Just try to remain positive with each and every visit, and encourage all staff to do the same, as anyone receiving care can sense if the caregiver is not at 100%, and some take advantage of that, and for others it can cause anxiety which can lead to repeated calls. Hang in there!
Tait, MSN, RN
1. Sorry. :icon_hug:
2. Anyone who asks for aloe vera in her vagina has a screw loose. Sounds like she needs a thorough evaluation of her medication regime per her MD. (Maybe some psych/dimentia meds, Lyrica, quinine and a sleeping pill?...man I sound like a pusher...but I swear I am not!)
3. :icon_hug: I don't know what else to tell you, other than talking to her MD.
Sounds like you might be dealing with some anger issues; loss of control of her life could be part of the problem.
The quinine (tonic water) is a really big help for leg cramps...my MIL swears it's the only thing that helps. I wonder if you could just plan to spend a little extra time with her to talk? I know she's a downer, but maybe her escalating calls for help are the way she says "I'm scared".
The only piece of advice that I can offer, as a pediatric nurse, is to recall something that I used to tell camp counserlors when they were having tough times with certain campers, and I as the nurse couldn't find anythign physically wrong with them that I could treat..."The camper that you want to be around the least is the camper who needs you the most." I think you could easily insert "resident" for "camper" and realize that they do need you, physically, as well as mentally. Hang in there with Dolly.
my mil passed away this last October and she had ms. she was very young, only about 50 at the time she passed. she was always the youngest in the nursing home and was a lpn. the ms messed with her mind, she would say we hadn't visted in awhile and we were just there the day before. she would also say a family member that lived in FL was there yesterday. She was in a lot of pain due to the ms. the last month was the worst because she gave up. she could not move and was bed to chair. well she broke her hip (the family member of the lady across the hall witnessed the nurse dropping her when moving her with the lift) and everything went down hill, she stopped eating and everything. I have no adivse for you but this story reminded me of my wonderful mother in law!
CoffeeRTC, BSN, RN
Oye...this is a typical younger LTC patient.
I agree with all of the above...get the MD involved, document out your but and what about the rest of the IDT? SW, therapy, dietary, etc? They should be involved.
Get her hubby and what ever family she has involved too.
Sometimes having a meeting and getting a patient contract type of thing helps. She obviously wants more control in her life. Is this a LT or Short term placement?
Virgo_RN, BSN, RN
If she won't take pain pills, what about a patch?
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