"problem patient"

TazziRN, RN · Apr 15, 2007

In many states it is actually illegal for a non-licensed person to refer to oneself as a nurse

**canoehead, BSN, RN** · Apr 15, 2007

A CNA is a nurse's aid- that's why the NA part stands for "nurse aid"

If he is allowed to refuse baths he can make his own decisions, and I would imagine he can make his own decisions about dietary intake too. You can refuse to provide junk food, but if he gets it he can eat it. I second the person who said tolet him sign out AMA. What is the point of keeping him in there if he is unwilling to maintain the plan of care if he's not forced? He can't stay on 1-1 supervision his whole life.

Home Health Columnist / Guide · Apr 15, 2007

Name changed to reflect status.....

Im having major issues right now with a patient that I do multiple 1:1's with. Heres the HX:
Pt came in almost comotose from being noncompliant with his DM. He also has a HX of multiple heavy recreational drug use to the extent where his liver is shot and his mind is that of a teen (hes about 27). He is constantly hungery and extreemly verbal about his "misgivings" that the Dr.'s give him (the restrictions on what he can and cannot eat). He has been here since 2/11 and will stay here untill a custody hearing can be arranged and he can be admitted into an assisted living facility.
The reason why he is a 1:1 is because he was constantly in the kitchens (we have 3 on the 65 bed unit) and is a flight risk.

Back to OP question: how to best manage pts behaviour.

I suspect this patient is on psych hold until competency hearing is held as danger to himself from self care neglect and overeating with suspected medical condiiton causing severe food cravings.

What words/advice can we provide to help sitter deal with pt escape while emptying urinal, changing bed..... I had pt in 4 pt leather restraints and they managed to escape each shift so despite careful eye it DOES happen.

morte, LPN, LVN · Apr 15, 2007

well, i had suggested locking the kitchen doors...comb. locks and see that all appropriate persons have the comb....if this wont work....if your institution could use the wonderguard/watchmate system they could electronically lock him out of the kitchen....

banditrn · Apr 15, 2007

Nurse2b(and that's what it say's guys, geez!) There is an obscure disorder of the hypothalmus, I can't recall what it's called - but the person never feels like they are full.

RunningWithScissors · Apr 15, 2007

might get into trouble for this, but really if he is his own man, let him sign out AMA, really hospitals are not prisons. If he's pinked you have a different situation but really you are not a guard, there is only so much you can do - Sometimes people make choices we dont agree with, and you have to let them do it

I am in 100% agreement here. Look, if it requires 1:1 to keep this guy's diet on track, come on, what do ya think he's going to do when he gets released??? Medical management is NOT prison, people have the right to eat themselves into a heart attack if they choose...as long as they're not eating sharp objects and glass, etc.

There HAS to be more to the story, I doubt even medicaid would certify a hospital stay that long just for dietary management and some minor rectal complaints.

TazziRN, RN · Apr 15, 2007

Nurse2b(and that's what it say's guys, geez!) There is an obscure disorder of the hypothalmus, I can't recall what it's called - but the person never feels like they are full.

That's what it says now. I give her credit for changing it.

purple1953reading · Apr 15, 2007

I think he number one issue is lack of control over his own body and circumstances. If he is already a ward of the court, or has an appointed guardan, and his affairs are all handled by somebody else, the only control he has is over his own body and the food he consumes. HE is rebelling and will continue to do so until the problem is worked out. I had an alcoholic who drank himself to death, n pulmonary edema, cardiac faliure, put on 100plus pounds of fluid. We kept him in a private locked unit on CCU in front of the desk,on Ativan drip, Diprovan, (you name it he got it.) and so forth. Had him for months till he became mind clear enough to function. HE immediately wanted old habits. Was in 30s Had had a good job, etc. but chose to drink. WE treated him for 4 months in unit, transferred to skilled, his family went n and literally carried out urine and booze soaked furniture from his apartment, and fixed it up. HE lost over 130 pounds while there of mostly fluid. and eventually sent home, considered rehabilitated. RIGHT? NO was back n 4 months , comatose, same thing.

We cannot force our ideas on others, and the doctors aren't really the ones who have to deal with him, so they can afford to make compromises. BUT HE WILL always take a mile, so to speak. IN his condition, he must be state subsidized, or independenly wealthy, and have been a problem for them before. SOMEWHERE In that mess in a legal issue that is at the brunt of all. EITHER MEDICAID OR Social services or somebody have dealt with him for WAY TOO LONG, and nobody wants to do it, so they just put him there, and let somebody else do it for awhile. They will have to hold a competency hearing, and then it will probably only get worse for the patient. |||

HE needs to have some sort of control over his own diet. The thing to do it to bring him a menu like everybody else gets but lists choice he can exchange in his dietary confinements, and let him plan his own diet this way. Have the dietician come in and explain how the exchange works. THEN if he doesn't, perhaps, eat all of one meal, make sure that is noted, to add to calories for a snack later. ALSO I would schedule his SNACKS every two hours between meals and see to it that he gets to choose 1 of maybe 3 choices for each time. HE NEEDS CONTROL. AS for baths, simply limit the choices, NEVER ask When do you want to take your bath, or are you ready for your bath. Simply ask Do you want to take your bath now, or after breakfast. OR do you want to take your shower when you get up before breakfast or at night before you go to bed. HE needs an established routine, that he gets to make choices in.

I know this is more easily said than done. I have handled these kind of patients. The reason they are addicts, alcohol, drug, food whatever, is they have no self control. We have to teach them that. IT IS HARD!! Patience is the name of the game. I would also suggest that instead of them assigning a nurse in there for the whole shift. that you be allowed, to change patients with somebody. BUT again, he may react better to the same person over and over. IT just depends on the patients reaction. THE state should not be paying for medical care for this patient, but his blood sugars are life threatening, and that, therein is the problem, NOBODY from social services to doctors want to be responsible for discharging a patient with those levels. Hope things improve, talk with the suprevisor, and have her establish guidelines that are followed by ALL of his care givers.

crissrn27, RN · Apr 15, 2007

https://allnurses.com/forums/f8/im-uncertified-medical-assistant-217447.html

Had to post this for nurse2b. It is the ongoing discussion (here on allnurses) of the non-licensed persons calling themselves nurses. Not picking on you just trying to educate!

As for your problem pt, I've had many of these when I was in LTC. If he is not competent then when the heck is the legal issues gonna be wrapped up? I agree with whoever said your hospital will not be getting payment soon for this pt, regardless of the kind of insurance he has. Have you guys tried activities such as TV/VCR, books to read, etc? What about meds if his behavior warrants it and Tx hasn't worked?

TraumaICURN · Apr 15, 2007

Would it be possible for you to place your chair so that it is by the bed, yet close to the door? Or just place the chair closer to the door so that if he does get up, he will have to walk infront of or around you to get out the door??

You should never let a psych pt come between you and the door anyway!

Cattitude · Apr 15, 2007

Nurse2b(and that's what it say's guys, geez!) There is an obscure disorder of the hypothalmus, I can't recall what it's called - but the person never feels like they are full.

Hey, the "2B" was not there last night :uhoh3: . We're not THAT petty:lol2:

https://allnurses.com/forums/f8/im-uncertified-medical-assistant-217447.html
Had to post this for nurse2b. It is the ongoing discussion (here on allnurses) of the non-licensed persons calling themselves nurses. Not picking on you just trying to educate!
As for your problem pt, I've had many of these when I was in LTC. If he is not competent then when the heck is the legal issues gonna be wrapped up? I agree with whoever said your hospital will not be getting payment soon for this pt, regardless of the kind of insurance he has. Have you guys tried activities such as TV/VCR, books to read, etc? What about meds if his behavior warrants it and Tx hasn't worked?

Thanks for posting the link for her. I don't want her to feel picked on, just trying to show her the way. Better for her to learn here I think then to "get it" from someone out there. This site can be invaluable in learning things BEFORE becoming a nurse. I wish it had been around when I was in school.

casi, ASN, RN · Apr 15, 2007

I myself am an occassional binge eater. I find that I feel constantly hungry. What I have found is that I'm not hungry because I'm hungry, but because I crave flavor in my mouth. What I have found that helps is constantly chewing gum. It alleviates the cravings and the hunger. Maybe try a sugar free gum on him.

Also make sure there are activities for him to do to keep him occupied. Spending 2 months in a hospital room when you don't need it would drive anyone to eat out of boredom.