Alert & Oriented Patients Who Pee and Poop on Themselves

[All4NursingRN]

My co-workers and I are noticing a surge of young relatively healthy patient who are willfully incontinent. They have no structural bowel or bladder problems and are a & o x 3.

We are a surgical unit with mostly stable post-op patients.

Last shift I had a 40 something year old woman who was a few days post-op. I went into her room and she told me she had to urinate, so I told her I could grab a bedpan really quick but she insisted that she would just go directly into her diaper I then told her to press the call bell when she was done, instructed the PCA that the patient in room 2 will go to the bathroom and may ring the bell. I gave report to my colleague and went on break.

When I came back from break I went to ask the patient if she wanted to be washed up and she said yes and as I cleaned her she said she needed to urinate again and commenced urinating on herself again while I was cleaning her.. she then chuckled and said she was urinating on herself all night and when I asked why she didn't ring her bell to be changed she just smirked and did not respond.

I have had multiple patients like this.

I had another patient again a/o x 3 who would defecate on herself and then ring the call bell. One of my co-workers puzzled said... " I dont' get it, if they have the presence of mind to know when they are soiled why can't they also ring the bell for a bedpan"

Again none of these patients have had a bowel/bladder issue with incontinence?? None of them have expressed a feeling of incontinence, they just seem to not really be bothered.

Somewhat unrelated but .. another patient I had who was a 25 year old new mom post c/s who was ambulating to and from the bathroom independently a few days post baby had a terrible odor that was filling up the hallway in front of her room. I went in, introduced myself and asked to look at her c/s incision (as that I thought it was infected and that was where the odor was coming from. It wasn't the incision, it was her lady parts!

I asked her if she would like to wash up (because everyone at the nurses station was aghast with the stench:barf02:) and would like a basin with soap and water to wash up at the sink. She refused insisting that the PCA come wash her up in bed, the PCA was on break so I washed her up myself as she refused to sit up out of bed, all the while her complaining that no-one understood how she felt giving birth and eating snacks.

Her mother and boyfriend just sat in the room amongst the stench with straight faces

Again, I understand being hospitalized and having surgery is rough, but days after the surgery some patients seem to regress or be depressed and refuse to be cared for properly??

Has anyone experienced this?

[smf0903]

Yes! We have had ambulatory patients, a/o, the whole shebang just go as you are describing. We had one such patient who vomited from the bathroom (yes, they were IN the bathroom when they started puking) and proceeded to walk back to bed...my guess is that they were walking/puking/turning their head side-to-side all the while because it was an unbelievable mess literally on every inch of that room. Not 2 hours later one of the other RNs walked into the room to pass a med and the patient says "Oh, don't slip!" Patient decided instead of calling for assistance-or walking to bathroom as they had been doing-they'd just stand up and urinate all over the floor.

We seem to go in streaks with people who lose all function when they come through the doors of the hospital, I honestly don't know why that is. I do think that the almighty patient satisfaction plays some role. Some patients literally need you to be firm and adamant with them about getting up and/or doing some things for themselves. I refuse to let someone lay in bed because they don't feel like doing a, b, c. Sometimes you just have to tell them to get up and get to it. Period. No favors are ever done by letting patients lie around getting weaker, etc. But therein lies the problem as patients get pretty ticked when you insist they get up, they work with PT, they participate in their own care.

And yes, it's primarily been in the age-range you posted.

Just curious, why was the 40-something wearing diapers if they were continent?

[All4NursingRN]

i believe the patient requested the diaper and the day shift RN put it on as she requested. The patient had a new ileostomy which was leaking from the bag down into the patients perineal area (as the ileostomy was located below the umbilicus) so it was messy. I think the patient just didn't want to be bothered going on and off the bedpan which I understand is very uncomfortable but still...

[KatieMI, BSN, MSN, RN]

There are multiple patients who demand home care just in order to be wiped and cleaned every day because that's what "they always do for me while I am in hospital". As well as multiple people in the nearest Walmart who walk around looking (and smelling) like if they didn't wash themselves and change their clothes for weeks.

Truly, for some of them even the simplest life tasks are big hurdles. They cannot afford $10 for clothes in Goodwill, leaving alone gas for car to get there, if they have a car. They exist in drug-induced stupor most of the day, and when they accidentally float out of there, they just cannot muster enough energy anymore. They cannot drag laundry baskets down to basement and out of there. They are morbidly obese, so they just do not have hands long enough to reach and wipe themselves. And, I would say, in poorer area there are plenty of such folks. But the rest... I am lost at why they would do that.

[Emergent, RN]

Have you ever watched the Hoarders show? There is a segment of the population that has no ability to be clean and tidy. Talk to paramedics sometimes to see what they encounter when they go on their runs. There is a lot of filth and squalor in this world.

I think we see a lot of that type of person in the hospital because they have a disproportionate amount t of health problems. Often they are less than average in intelligence. Then add in the fact that we do have a system that is highly enabling of its weaker members.

We have well-meaning social workers, teachers, healthcare workers who don't want to hurt anybody's feelings and correct their antisocial behaviors. The regulatory bodies often mandate this type of enabling. It's no wonder that these hapless people settle into their lives of allowing others to do for them, even to the point of becoming like infants.

[NurseSpeedy, ADN, LPN, RN]

I have had many patients like this. One was sitting up in the chair, waiting for lunch, and my aide walked in and I hear, "Let me help you to the commode" followed by the patient, "No, I'll call you to clean me up when I'm done". The aide stormed out and said, "I walk in there, she haunches over straining over the chair, s******g herself and refuses to use the toilet! She doesn't do that at home!" Apparently, she had been doing this since shortly after being admitted.

There was also the prisoner who refused to use the urinal or bedpan after orthopedic surgery. He would just announce every thirty minutes, "I (fill in the blank) the bed".

As for the new mom post c-section....yuck. I had one on a Wednesday morning and couldn't wait until Friday morning when I was allowed to shower. I was also the type to want to walk the halls less than 8 hours after surgery and demanding a discharge at 48 hrs. I had other ways to annoy the staff but being stinky or pain med seaking was not one of them.

[Ddestiny, BSN, RN]

This doesn't work all of the time, but when I worked post-surgical and had patients that would ask for help with things that it seemed they should be able to do (i.e. wiping their own bottom), I would come at it from a casual "oh, you're needing help with that. Okay, who has been helping you with this at home?". Typically they'd been independent prior to hospital though I do specifically remember one gentleman who looked down a bit embarrassed and said "no one, I would just shower after every bowel movement" because his body habitus did not allow him to reach back that way. That was a bit of a wake-up call to me and I didn't give him push-back when he would request that help in the future (poor guy was having diarrhea so we helped in that area a lot). His situation was not where he could be hopping in and out of the shower all day long with his many stools.

For those that didn't get help at home previously, I'd ask who would be helping them at home with [insert bodily function]. Usually independent, fairly-young and/or middle age adults do not want their family members helping with personal cares. In the case of people asking for Depends when they're capable of getting up, I think it's appropriate to ask "So, who's going to be changing these for you at home? Your parent/spouse?" Granted with many of these situations there may be an element of mental illness that causes them to not care, or maybe they aren't even living at home independently but in some kind of assisted living situation.

For those that would say "I can do it, but I want you to do [whatever task] while I'm here" I'd explain that we need to see them acting independently in order to feel comfortable sending them home without some kind of assistance. I like the phrase "show me what you can do" ... getting up, walking, etc.

Some patients respond to being told that bedpans are only for patients that are unsafe to get up to either the bathroom or the BSC (i.e. too hypotensive, strict bedrest prior to surgery, etc). For those that didn't like that, I'd insist that they get out of the bed and sit on a commode or a bedside chair when/if the commode spilled so I could change the sheets. This kind of sends the message that they might as well get up anyway. (It helps if they haven't already had their sheets changed while inhabiting the bed lol)

With mid age and older folks that didn't want to start working towards recovery (i.e. previously independent pts that are POD 3+ after abd surgery and still absolutely refusing to walk, participate in PT, etc) and if all other education failed (including describing the normal timeline of when we do our first walks, types of PT, etc), then I would say to them in a very concerned way, "oh no, you're just really not progressing well. If that doesn't change we'll have to start looking at what *nursing home* you want to go to until you're well enough to go home. You're not safe to go home if you can't even walk". I didn't pull that one out often but it typically had the desired effect because even the most resistant patient seems to want to go home of their own free will.

I also gave a few talks to some particularly unpleasant patients that didn't like being bothered to perform ADLS "because they hurt" and would get snippy with nursing staff who "just want to hurt me"..... I'd tell them that if they put half of the amount of energy that they put into resisting our recommendations, into actually taking the steps needed in order to get better, then they'd already be home by now. "The nursing staff's purpose is to keep you safe, avoid complications and get you home ASAP. Getting up and returning to independence is not comfortable and for that I'm glad to help medicate your pain. Laying in this bed is going to make your pain that much worse, while simultaneously putting yourself at risk for blood clots and pneumonia." Sometimes it's easy to make the nursing staff "the bad guy" but drawing this mental diagram that we really are on the same team, has been helpful in my experience.

But some people are resistant to all of the tricks in the book to help them become more independent.....and then you're just glad for those days off. =)