Eleanor walled herself in and us out

Nursing, Jun 1997 by Zimmerman, Lorraine

Breaking through her stony silence would take some fancy teamwork.

THE DAY THAT ELEANOR WAS ADMITTED TO OUR TRANSItional care unit, I had no idea that she'd eventually challenge just about every assumption I'd made in 10 years of nursing-and reward my efforts with so much progress.

When I first entered her room, she greeted me in a flat voice: "Where are my I.Vs? I can't live without my I.Vs."

Eleanor, 63, had been an insulin-dependent diabetic patient for many years. She was now recovering from surgery to remove a grapefruit-size uterine tumor. Fearing a malignancy, the surgeon had explored her abdomen extensively. Fortunately, the tumor was benign.

Afterward, Eleanor had developed gastric paresis and couldn't eat a thing without vomiting almost immediately. She'd been dependent on total parenteral nutrition (TPN) for weeks.

Her abdominal incision, which ran from just below her breasts to just above her pubic hair, had dehisced and was tenuously held together with four retention sutures; the cavity was packed with antibiotic-soaked gauze.

But impressive as her wound was, it was her face that captured my attention. Expressionless, waxen, with a few strands of lank gray hair clinging to the damp forehead, this face told me that Eleanor had built an emotional wall to defend against the onslaughts her body had endured.

An old-school Minnesotan, Eleanor valued people according to the amount of hard work they could do. Because she was sick and weak, she judged herself worthless.

She spent what little energy she had repelling our efforts to help her. Every attempt we made to talk to her was met with stony silence or clipped monosyllables, and she refused to address any of us by name. We tried to deal with her rebuffs professionally, but she was starting to wear down the staff's enthusiasm.

Real home cooking

To rebuild a sense of her self-worth, we turned to Eleanor's family for clues about her past, hoping to find some small task she could succeed at. They told us she'd worked as a cook at the same restaurant for over 30 years. It was a mom-and-pop establishment with an emphasis on "real home cooking" Eleanor had been expert at preparing every item on the menu, her sister told us. Armed with this information, I mentally gritted my teeth, adopted my most nonthreatening expression, and invited her to join the residents' baking group.

I explained to Eleanor that the group had a hankering for pie, but the woman leading the group didn't have a clue about baking one. Eleanor glared at me with her steely blue eyes. "Can't roll piecrust no more," she snapped.

"Prove it," I shot back. To my surprise, she nodded. Grabbing her wheelchair, I wheeled her into the activities area.

And there she sat, as rigid and unresponsive as the rocks that line the north shore of Lake Superior. I retreated into the nearby conference room and attempted to distract myself with paperwork. The minutes crawled by.

I was just about to give up and escort her back to her room when I heard her say, flatly but firmly, "If you don't quit workin' that flour, it ain't gonna be fit for the dogs. Give it here." With deft moves, she rolled out the crust, separated it carefully from the table with a spatula, and placed it in the tin. "There you go," she said. "It ain't so hard when you know how."

Although she remained expressionless, she was sitting straighter in her chair, giving me a glimpse of the woman behind the wall.

Despite my entreaties, she refused to participate in any more baking groups. After this single show of spirit, Eleanor retreated again.

At this point, her care team had just about despaired of ever seeing her eat normally again. We even had to administer her medications intravenously (I.V.very attempt at using the oral route triggered vomiting.

Eleanor was never without an emesis basin, which she perched under her jaw like a third chin. This was the only hint of pride we saw: her fear of "making a mess" by vomiting on herself.

Taking a team approach

Eleanor's surgical wound was slowly healing, but her spirit wasn't. So we organized a care conference with her physician and other team members. We invited Eleanor and her family too, but they declined.

We started the meeting by taking inventory of Eleanor's progress-and made some interesting discoveries. For one thing, the physical therapist reported that Eleanor could manage a pivot transfer with one nursing assistant. Yet in the unit, two assistants were still doing lift transfers at her insistence-Eleanor told them she was too weak to get from bed to chair any other way.

What's more, the occupational therapist who'd been working on Eleanor's upper-extremity range of motion reported that Eleanor could now reach across her body to the opposite side rail. Yet the nursing assistants were going into her room in pairs around the clock to turn her, assuming that she was too weak to participate.

To our chagrin, we realized that Eleanor's lack of progress reflected a breakdown in communication between team members. By compartmentalizing her small gains, we'd unwittingly encouraged her to remain dependent.