Therapeutic Communication

Shifting from LTC to inpatient psych hasn't proved to be much of a challenge, but I do find myself needing to approach my residents/patients/clients in a different way. For starters, the majority of our interventions and planning begin with "approach in a calm, non-threatening manner", which is a given. What I hadn't anticipated was the absence of touch.
While an elderly demented patient might benefit from a warm hand on the shoulder as you gently guide them out of the garbage and into the sensory room, your average schizophrenic will tell you directly, "don't touch me", if you're lucky.
At 0600 yesterday, as I began my final rounds administering the synthroids and checking the blood sugars, I gently woke the lofty dutch woman whom has enjoyed her 23 days at the all-inclusive resort we call "gero". She was quivering and tearful, and I asked what was wrong. She was up for discharge, and was frightened. She had been slowly weaned from her 4mg of klonopin, and the cymbalta did not work. So far, it appeared as if the zyprexa and trazodone were helping her a tiny bit; the panic was less frequent, she was sleeping (although she denies this) and an axis II dx was being considered.
I asked her if I may sit down. She said yes, and began to talk more than she has in the past three weeks. She is lonely, the staff had decided early on. She states she is unable to enjoy any hobbies or outings with friends, she just can't concentrate. She denies SI, although there is a hint of a passive death wish. She laughs when she tells me her house is "very, very clean". She wonders if a pet might be a good idea. She is picking at her gown, the sheet, the edge of the paper souffle medicine cup. Tears are welling up in her eyes. I feel detatched. On the one hand, I want to reach over and hug her; on the other hand, I wish she'd just snap out of it. Call bells are going off, bed alarms are screaming, and I have to go tape report. She has until monday to decide if she's going partial or if we have to 304 her to a more long-term program. She doesn't belong with the psychotic patients, she is just wound too tight. I've seen much worse. Why is she here, and why for this long? Meanwhile, Mr. OCD with diabetes insipidus in the next room has taken himself to the bathroom, urinal in hand, to try his luck at the spring water in the porcelain reservoir. She can tell I'm distracted, and I hate that I am. I acknowledge her concerns, state that I am needed to tend to some urgent matters at the moment, and tell her we can discuss this more after breakfast. I forgot I wasn't going to be there at that time. After I took care of the risk-for-water-intoxication gentleman, I returned to let her know I'd stop by at the end of shift instead. She reached out and grasped my hand. I was taken aback, in a big way. People don't touch here. Unless we're wrestling someone down, but that's another story. I didn't have time to sit with her. She began to plead with me. My heart went out to her, yet I had many other (more important) tasks to tend to. There are limits to be set, boundaries to enforce, levels of caring that one has to be careful not to breech. This is mental health, not a nursing home, and... well, shit. What do you do? In the hour that followed we started an IV, sent one patient medical, did two bladder scans and a straight cath, and documented all the 1:1 and chemical restraints.
I did return to tell her I was off, I hoped she would participate in group, and ensured she contracts for safety. She wasn't paying attention, because she needed 2% milk, not skim, she preferred cranberry juice to apple, and she needed to know why all she ever got was decaf coffee and tea. Did she have to sit at this table with those people, why aren't they allowed to eat in their rooms, and what inane craft did they have planned for today? Did her son call yet (make sure she gets it), did that social worker ever bother to schedule the family meeting, and make sure I get the wet towels off the floor and change her linens. And by the way, her toast was cold.
Axis II, indeed.