Psych pt. in long term care

[abooker]

I have new nursing home resident with a looooooong history of unstable interpersonal relationships. She has the usual physical problems you'd expect in LTC - mobility, ADL's, multiple meds, some dementia ... but the primary problem is IMHO her difficulty coping with being in a nursing home.

I know it's a huge adjustment - Nobody says; "Hoooray! I get to say goodbye forever to most of my independence and most of my posessions!" Most of our newbies withdraw for awhile, then gradually adapt.

My new resident is not like most. She's been deeply involved in all the activities since Day 1. She expresses extreme fondness for a staff member, then later describes that same staff member as completely worthless. She does the same thing with herself. She complements herself on her beauty and her talents, then later says she feels ugly and worthless. She binge eats, and she hides liquor that her family brings in her room. (She's limited to one drink per day since she's on lots of meds and is a brittle diabetic, and we're supposed to keep it locked up in the med room).

Today, she told me that she knows how to commit suicide by using her insulin. I told her I'd *definitely* be keeping my med cart locked, and we both laughed, but there's truth in all humor.

The root of this lady's problem, as far as I can determine, is that she isn't getting everything she wants all the time. She doesn't appear to see this as unrealistic, but as more of a communication issue. She seems furious at her family, friends, society, and me for not "getting" what it is that she wants and needs and deserves. Clearly, we're all morons, but she loves us anyway.

My problem, as far as I can determine, is that I enjoy working with this lady and I don't want to lose her. Unfortunately, we've had to send her out to hospitals several times. Once, she ended up on a behavioral health unit. She's now asking me to set up several outpatient appointments for her to see various doctors, even though we have the same kinds of doctors that visit the facility. I believe she plans to elope - get out of the building and convince some ambulance crew or transport van driver to drop her off at her house. She's incontinent and almost total care, so home health can't take her back. Her family is physically and emotionally unable to provide the 24/7 care she needs.

Our social worker has suggested that maybe LTC is not the appropriate environment for this lady, and maybe she needs to live out the remainder of her life on a psych unit. I didn't even know there were places like that - long term care psych?

I'm meeting with the social worker and perhaps the family on Monday, doin' the "care plan" thing. Any suggestions for goal-setting here? Resident's goal is to go home; family's goal is to keep her from going home; my goal is to get her to accept the fact that she *is* home, and the social worker's goal is to send the resident somewhere else. I have no idea how to advocate for this lady, or if a psych unit could take better care of her than I can. I'm afraid for her, because some of the psych patients can be a danger to self or others, and this lady has an amazing capacity to find someone's emotional buttons and push them.

Help?

[FFN BehUnitMgr]

I work in a nursing home that specializes in behaviors, just an FYI there are many of us out here!! Sounds like your lady could possibly have a personality disorder~ and is very much manipulative. Personality d/o are tough. She could very well be managed with behavioral plans, and it could be possible a behaivor unit is the place for her. Are you sure she doesn't have anything acute medically going on? (uti/uri) Those are two biggies that make our residents "cycle" sometimes. Good luck with her!!

[abooker]

There don't appear to be any acute problems. She's been evaluated for lots of things, as she has been to the ER three times since Mother's Day. Good to know there are LTC behavior units out there. I was thinking she'd be sent back out to a hospital where staff are trained to deal with acute problems, and they'd release her to a nursing home, who'd send her to a hospital, who'd send her to a nursing home, and she'd spend her final years as a human ping-pong ball, at least until the dementia gets her.

My facility has a locked "memory unit" and all the staff here are trained to deal with Alzheimer's-type dementias. Her issues are different. "Therapeutic lying" does *not* work with her!!! :)

Good to know there are folks out there who know what they're doing when trying to provide a home for people like her. Thank you.

[nanacarol]

Has she had a true psych work up? If so, what is her diagnosis? Is she on any medications that may contribute to her outbursts? What contributed to the family admitting to the LTCF? When she is communicating from a reasonable place does she express insight? Why is the social worker seemingly advocating against the nursing team in developing a realistic stay in place plan ( each time a patient is moved to a new environment some resiliency is lost)? Just questions to be considered. nanacarol

[Thunderwolf, MSN, RN]

I would bet money the issue is Borderline Personality Disorder from the behavioral symptoms described.

Hugs.