Plz Help. Can't Deal with Obsessive Pt.

[MichelleDawnLPN]

I'm very frustrated. I don't know what expectations to have and what interventions to implement with a resident in our LTC facility. This patient has Parkinson's disease and suffers with delusions and hallucinations. She is not being treated for her mental disorders. She refuses meds and mental health professionals have minimal contact with her. I feel the issue is not being adequately addressed but that is another matter.

This woman believes she is receiving radiation from the facility. She thinks we are trying to poison her and that her bed and lounge chair give her electric shocks so she often refuses to get into bed and spends several days/nights in her wheelchair.

She makes strange requests all the time. For example: she wants her clothes hung on hangers and aired out by the window to blow off radiation before she puts them on, she wants her head and limbs wrapped in towels if she gets into bed (to prevent the electric shocks from getting her), when meals arrive she may send you down to the kitchen 3 times with different requests (i.e. get me milk instead of juice, this smells funny), she wants her cares done in a very specific order and a different facecloth used for her eyes compared to the rest of her face, she wants her teeth brushed by dipping the toothbrush in mouthwash followed by peroxide, she wants her blanket folded a very specific way and hung over her rails just so... it goes on and on and it is mentally EXHAUSTING. The simple act of putting a blanket on her bed can take 5 minutes before you understand what she wants.

I need some advice. I am not a psych nurse. Should I be doing all these things for her or does that just feed into her delusions? Should I be taking the time to do origami with a bedsheet or do I just fold it how I would any other sheet and lay it across the foot of the bed. Do a replace a perfectly good just-opened yogurt with a new one because "it doesn't look right" or do I say no. (And if I say no to these things how do I tell her? I mean, if I say, "there is no poison in the yogurt, it is safe" or "there is no radiation in this room you don't need to be wrapped in towels" it starts an argument whereby she starts defending her delusions.)

I feel like I am being manipulated into being the crazy one! When is enough enough? It obviously causes her anxiety when I refuse and she will start to cry or become rude.

I'm out of my depth here! I'm a part-time LPN. I've asked my supervisors for a care plan and direction but they are not helpful. The general response is, "just do what you can do to keep her happy."

[Whispera, MSN, RN]

She refuses all meds? Even those for her Parkinson's? I'm wondering if the doctor could prescribe something for her psychosis (the paranoia and delusions) and you could give it to her as part of her Parkinson's treatment (psychosis can be part of Parkinsons). IF she is willing to take Parkinson's meds.

Can she be served foods that are sealed and opened only in her presence? Sometimes that helps people with fear of their food. The same thing goes for medications. Sometimes patients will take medications that are individually packaged and opened in front of them while they won't take meds from a med cup.

You aren't going to change what she's thinking by talking to her about it. She's truly scared. I think it could be partly mental illness and partly worry about giving up power as she faces the reality of her illness and its future. She probably knows her prognosis isn't good and is trying to maintain some control over her environment, so she asks for things that are unreasonable to those who care for her. They are reasonable to her. Couple the need for some control with disturbed thinking and you have a tangled web.

Can she communicate with you and talk about what's going on? Maybe she'd be willing to make some compromises, such as "Mary, I'll fold your sheet as you like but won't wrap you in towels. The towels could get tangled up and be very uncomfortable." Maybe you could put towels under her head and limbs instead of wrapping them around her? Before meals arrive, ask what she wants, and tell her there's just not enough time to send things back and get new things all the time. Give her input into what happens to her, but remind her you only have so much time to care for everyone. Let her keep some power. Ask her what's most important for you to do to help her each shift, while letting her know you want to help her but can't do everything. She might surprise you and be reasonable if she feels she has more control.

Don't argue with her delusions. That won't help a bit. They are very real to her. Imagine how terrifying it would be if you thought radiation was going to get you? Imagine how terrifying it would be to be progressively losing the function of your body, along with having a whole lot of pain related to it. Maybe she needs someone to talk to, about her concerns. Is there a counselor who can visit patients, just to talk, and not to be all medical?

[MichelleDawnLPN]

Thanks Whispera. She doesn't refuse all meds, but she is very aware/particular about what she will take. Psych meds are out of the question. She won't take anything unfamiliar.

Even if something is sealed she will still insist it has been tampered with. We never open things unnecessarily.

I think you have some great points about 'give a little, take a little'... it's just so frustrating not having a team approach. Everyone seems to have a different idea about how to treat her and the nurse managers are disengaged. There is no consistency!

Thanks for the feedback!

[Whispera, MSN, RN]

In your spare time (I know, that's a ridiculous concept), observe her as she interacts with others. Try to think about how she's behaving when she's with you and what the reasons for the behavior might be. Keep your emotions out of it, because they'll cloud what you're thinking. Try to detach as you observe, but keep your mind open to possibilities. Consider what you see her do and say. Maybe you can get to the root of her behavior.

[MichelleDawnLPN]

Thanks Whispera. I will. She acts the same way with all staff, but does much better with other residents. I definitely think the feeling of loss of control is a big issue here. The problem is, when I try to act collaborately with her, give her more choices, etc. she only gives me snarky, sarcastic responses. Again, I think if everybody was on board with the same careplan we'd have much more progress.

[Whispera, MSN, RN]

...then get 'em on board! That might mean you have to develop a care plan and have some sort of meeting with everyone to talk about it. It could be no one wants to have the same care plan because it's complicated to get it done and no one wants to do it herself...

Your patient needs someone to advocate for her, to do for her what she can't do for herself...

[MichelleDawnLPN]

I'd love to do this but I'd definitely be stepping on toes. I am an LPN and only work 2 shifts/week. It's a large government facility with about 2 dozen full time nurses on our unit including a nurse supervisor and patient care cooridinator. It is the RNs who work full-time days who are supposed to be creating the care plans. I will however reiterate that I think we need to address this issue with a thorough care plan.