uncooperative residents

[glucas985]

Lately I've been noticing that the residents in my nursing home aren't our regular crowd. We have been getting a lot of residents that are between 45 and 60. I'm not sure if there's a way I can put this that doesn't sound heartless or completely insensitive. This younger set is very uncooperative. They actively do things that are detrimental to their health. Many of them are continent but will not ask to be toileted or given the bed pan and refuse it when it's offered, choosing instead to go in their brief and be changed. They refuse all medications. They refuse to be tapped even though their skin is actively breaking down. They refuse meals and eat only snack foods they keep in their rooms that were brought in by family members. They refuse their RNP many that were capable of walking when they first arrived do not even get out of bed. They instead choose to ring their bells constantly for secondary things like help finding their remote, having me flip through channels to find a show, dig through their drawers for snacks, moving things around on their bedside table, etc.

Their families are terrible. Half of them think it's our fault they are in such sad shape and the other half are mad because we aren't legally able to force the resident to do anything that would help them.

[VivaLasViejas, ASN, RN]

Ah, the younger resident. ~sigh~ So many issues, so little time. But no less deserving of compassionate care than any other segment of the nursing home population.

I'd be willing to bet that most, if not all of them have psych issues along with whatever medical illnesses have forced them into a nursing home at such a young age. And when you look at it from their perspective, who WOULDN'T have a problem with having to live with people old enough to be your parents---some of whom are demented---and where your freedom to crank up your stereo, smoke cigarettes (or other substances), and do whatever else you want is severely curtailed? No wonder they have an attitude!

This is a time to undertake some root-cause analysis. Besides the above, what other parts of their lives are broken? So many of these young residents have horrible family dynamics, as you've discovered. The "kids" are usually in their 20s and 30s, and they've dealt with these dysfunctional parents for many years so they can be hostile, even abusive. They are also often the caretakers because Mom or Dad hasn't taken decent care of her/himself. Meanwhile, Mom/Dad has developed emphysema, severe diabetes, heart failure, and/or more than a little depression over the years, and THEY are angry at being "put in a home".

This is when you need to enlist the help of the resident's doctor, the facility social worker and the resident care manager to get them the necessary services that may help them live their best life under these changed circumstances. Request a psych eval if they're exhibiting symptoms of psychological distress or mental illness; see if alternative activity programs can be started to get them out of their rooms (Baby Boomers are usually not big fans of bingo or card games).

Try to give them as much space and as much freedom as possible to do age-appropriate things, e.g. listen to Steppenwolf on an iPod or have the occasional Corona on the patio if their physician agrees. Most of all, show them that you understand that they are middle-aged adults and their needs are different than those of the traditional nursing-home resident, and work together with your interdisciplinary team to address their underlying psychosocial needs and meet them as well as possible.

[MomaNurse]

I understand your frustration, but viva is speakin my language! Steppenwolf and corona? Ummm yeah!

You will have to set some rules with your younger patients. Boundaries that you will not let them get away with pushing. You are responsible for upwards of 50 patient's health and safety, not working in a hotel. If they can't be bothered to be continent, you shouldn't have to be bothered to clean someone who can do it themselves. And I'll be dipped if I'd flip through channels for them! The good part is you're in a facility. Talk to the activities staff. They should be interviewing each resident for activity preferences. Suggest a movie night with current movies. Junk food within reason can be served. Naturally you want to get with the manager and psych to see if behavior modification is appropriate. Like, call me once for something you refuse to do for yourself and you can't go to movie night. And make sure you praise, praise, praise when they do anything independently or don't call you for stupid stuff. You would be surprised, and sickened, at how well it works.

[vampiregirl, BSN, RN]

I've also encountered an increase in younger patients. I think unfortunately there is still a stigma attached to long term care care, and many misconceptions.

I also agree with Viva, many of these resident's probably have mental health/ psych issues that may need addressed. And if they didn't come in with them, residents of LTC are certainly at risk for depression...

As for some of the "behaviors", sometimes I find that it is embarrassment that causes the resistance (toileting, TAP, etc). Some of them respond well to being more involved in their careplans and helping develop their own schedules because it gives them more control over their lives (which truly they have so little of in a LTC). Others simply don't care - or just give up.

I've also encountered the food issues that the OP mentioned, and that is one area that is driving me batty right now. These are the same people who need the nutrition they aren't getting from junk food. And the family members who provide the junk food are the same family members who are upset d/t their loved ones lack of progress in getting stronger or other medical issues r/t their food choices. Even more frustrating is when the family members and even the resident have the cognitive function to understand the rationale/ education when we try to explain the importance of nutrition. Sadly, I've had resident's tell me that is how they ate at home. When you try to help the resident figure out a plan to enjoy their favorite foods in moderation...

I think person centered planning is a little step in the right direction towards dealing with many of these issues. That can be tricky though, trying to balance what the facility is really able to do (with the current staffing models).

I think this topic is great for discussion. I know I'd love to hear some ideas and approaches that have worked for others:)

[KRSLPN, LPN]

Regarding meals and snacks. . .i find it very frustrating to see a resident roll up to the table, take a look at the slice of roast beef, mashed potatoes, buttered carrots, dinner roll and butter and chocolate pudding, pick up the dish of pudding, take a couple bites and push themselves out of the dining area and head, immediately, for the bank of snack machines in the hall.

When I observe them at the snack machine, I approach and ask, "are you coming back to the table to eat your lunch?", to which I get the following reply, "I don't want that garbage". I then ask if they would like a sandwich or even a bowl of cereal. They shake their head "no" and roll down the hall with the newly purchased "noon time meal", which consists of chips, cookies, and a bag of M & Ms.

When I bring up what I just observed to the supervisor, I get the following response, "it's their right".

It is incredibly frustrating to observe this scenerio over and over again. A BIG problem I see in LTC is that nowadays, to avoid "upsetting" a resident, they lump everything as "their right" and basically the residents do whatever they want. I believe this is also a product of the younger residents as opposed to some of the older residents behavior.

[ktwlpn, LPN]

You'll burn yourself out by personalizing these issues. These people are in LTC because of years of poor life style choices over the years-we can't fix them and even if we could the damage is done. We provide appropriate,healthy choices and acknowledge their right to choose. They still deserve to be treated with dignity. They may have psych issues that have been undiagnosed/untreated ,we can help with that but they may still refuse tx. Careplan and document. One of the worst things I see is a nurse browbeating a middle aged non-compliant patient over their diet. They are adults,treat them as such.

Same with refusal of meds and tx-you take a minute to explain what you need to do and why and when they refuse you accept it in a non-judgemental way. Offer choices-sometimes they may only mean "not right now, but later" Ask them when? Allow them to feel in control-you'll be surprised how much their compliance approves.