Am I overreacting?

Agnus · Dec 16, 2003

Certainly she has a medical MD? I would address this issue with him. Ask your questions of him.

I would also bring in the Psyc Doc who is treating her. Sounds like your staff need to be informed why she is there an not on a med unit.

It could be she is terminal.

I must ask you what do you think a med floor can do to keep her in bed that you can't?

I understand your frustration in feeling ill equipted to care for someone with serious physical illness.

My guess is the phyc issues are the overriding concern at this time. Putting her on a medical floor will not make her more compliant with care, will not make her stay in be.

If she is non compliant with her medical treatment document it. Keep the docs informed.

You know well that you cannot force complinance with a voluntary psyc admittance. You also cannot force compliance with medical care. Educate the patient and document it.

Then document, her responses. Document that teaching is continually reinforced and still no compliance.

Yep, she could throw an embolism. It is her right to choose behavior that leads to this.

Maybe that is why she is in psyc because she has chosen to ignore her medical treatment.

Trust me there is no floor that can more closely monitor this patient. She is not a candidate for ICU.

Can you get a sitter? If not ask a family member to sit with her. If they decline document.

Again there is nothing a medical floor can do for her to get her to cooperate that you can not. Sorry but she does sound like she needs psyc care.

PMHNP10 · Dec 16, 2003

Actually she has been here for about a month. She is definitely terminal with the CA being in her lungs and possibly brain. My only thinking is that if need be on a med floor they can put a posey on to help remind her to stay in bed...we would not without an act of God. It is diffucult to know what is going on in her mind because she doesn't communicate.

Bottom line for me is...if that were my mother, I would not want psych nurses who have been out of m/s for 10-30 yrs taking care of my acutely ill mom. I have only been out for about a year, so I am the most recently m/s experienced nurse. And don't get me wrong, I love my coworkers and think they are wonderful nurses but when you haven't been on a m/s floor for almost 3 decades, ethically I don't think you can competently care for this pt as well.

Agnus · Dec 16, 2003

This is legally not a valid reason to posey her.

A sitter or a family member at the bed side must be tried first.

Insufficient staff to monitor is not a valid reason to restrain.

I would definately ask for a conference with the docs. and staff and express my concerns about the medical issues.

It sounds like the intent is to treat her medical issues with palliative care. Treating depression in a terminal pt is part of paliative care.

Did the family admit her? It kind of sounds like they may have because they are overwhelmed. It sounds like a long term facility might be better for her. You might address this with them. Even if they perfer to take her home Hospice could be a huge help. Especially with the psyc issues. Personally I would like to see hospice involved what ever their decision. You might call for a hospice consult or eval. Even an informal one could be useful.

CCU NRS · Dec 16, 2003

I would do education with a twist of scaring her in to compliance. Be very stern about the fact that

You have a blood clot in you lower extremity. If you get up and walk around you could cause this clot to travel. If this clot travels it could go to you lungs or your heart and there it would clog up the system and cause you terrible pain and SOB and possibly death within a matter of minutes. This not anything to fool around with I understand that you have many other factors involved with your care and that you may feel that this is no big deal but if this clot travels and becomes a PE Pulmonary embolism you will be in a state of imminent doom which will cause you to loose all rational thought because you will know that you are dying because this is one of the symptoms of PE. It will cause extreme shortness of breath and you will instinctively understand that you are not going to be able to overcome this probelm and it is not a peaceful death. Fortunately it is an easily avoidable set of circumstances if you comply with treatment and remain in bed for the next 48-72 to hours and we give you blood thinner to assist the clot to move through your system without causing any damage.

longtermcarern · Dec 16, 2003

Our docs here are refusing to order bed rest for DVT, say that is what caused it in the first place. They order activity as tolerated.

On a personal note, having lost several members of my family to cancer, I fully believe what ever the patient wants to do is OK with me as long as it is legal :)

CCU NRS · Dec 16, 2003

Originally posted by longtermcarern
Our docs here are refusing to order bed rest for DVT, say that is what caused it in the first place. They order activity as tolerated.
On a personal note, having lost several members of my family to cancer, I fully believe what ever the patient wants to do is OK with me as long as it is legal :)

DVT can becaused by inactivity but if Pts are not recieving blood thinners and a DVT becomes a PE your facility with its policy of Activity as tolerated is going to pay a big price for not following proven protocols, I would think.

Agnus · Dec 16, 2003

I think this is multifacited. The pt. is termainal. She will die no matter if she gets an emboli or not. The DVT is likely secondary to her condition.

Is is more important that she does not die from a possible embolism or that she remain relatively comfortable. Her ability to move about is a comfort issue.

I know PE is not pleasant either. She is non verbal and has possible mets to the brain. It is unlikely you can educate her. You cannot stop the cancer and inevitable death. So what are your and the family's priorities.

Discover the family priorities and go from there.

PMHNP10 · Dec 16, 2003

Agnus said

This is legally not a valid reason to posey her.

A sitter or a family member at the bed side must be tried first.

Exactly what I suggested, but again this could take an act of God.

I would definately ask for a conference with the docs. and staff and express my concerns about the medical issues.

I work nights so I don't get to speak to docs, but again, I mentioned it to the day nurses, and I know they aren't feeling real safe with their licenses right now with a specific dimentia and frequent faller and borderline supreme and manic we have on the floor. I am actually officially on vacation until Christmas Eve so I'm not really making any suggestions to my coworkers for my benefit, but rather I'd like to continue working with them until I leave...they are sorta like a family to me.

Personally I would like to see hospice involved what ever their decision. You might call for a hospice consult or eval. Even an informal one could be useful.

I want to say this idea was rejected by the family--or certain members of anyways. Along these lines, I guess I am concerned about the family. I do not see them there, but know they brought her in; probably, as already mentioned to get a break. I have this concern the family might be seeking some money...call it my paranoid delusions. She is definitely going to lose the battle with cancer, but there is no money in that. Again I am not saying my word here is Gospel, but I get this funny feeling deep down. I couldn't even begin to explain--other than the paranoid delusions.

Thank you very much for your posts.

PMHNP10 · Dec 16, 2003

Originally posted by CCU NRS
I would do education with a twist of scaring her in to compliance. Be very stern about the fact that ...

Pretty much what I did and it made no dent...didn't bat an eye. She remained silent...and make no mistake about it, she is selectively mute, not catatonic. Her getting up might be her way of a suicide attempt, but like I said, it's so hard to read anything about her other than this poor lady is hurting mentally, not physically. I will be very curious what happens here.

PMHNP10 · Dec 16, 2003

Also, I should maybe add that the doctors in charge of her care actually brought in an 99 y/o lady for ECT. We kept her inpatient until about a day or so before she passed and sent a few volts of electricity through her until the end. God bless that lady, and damn those MDs who did nothing but fatten their pockets while making this poor lady delirious.

Again, thank you much everyone for your posts and listening to me vent a bit. They are very much appreciated.

caroladybelle, BSN, RN · Dec 17, 2003

Originally posted by Agnus
This is legally not a valid reason to posey her.
A sitter or a family member at the bed side must be tried first.
Insufficient staff to monitor is not a valid reason to restrain.

I would definately ask for a conference with the docs. and staff and express my concerns about the medical issues.

It sounds like the intent is to treat her medical issues with palliative care. Treating depression in a terminal pt is part of paliative care.
Did the family admit her? It kind of sounds like they may have because they are overwhelmed. It sounds like a long term facility might be better for her. You might address this with them. Even if they perfer to take her home Hospice could be a huge help. Especially with the psyc issues. Personally I would like to see hospice involved what ever their decision. You might call for a hospice consult or eval. Even an informal one could be useful.

I am an Onco nurse.

Onco patients frequently develop clotting disorders, especially after mets begin to develop.

Most onco DVT patients these days are not on much bedrest. If anything they are MAYBE on bed rest for first 24 hours of anticoagulation, if that. The theory is that bedrest causes them to clot more as well as develop other complications.

Is the patient being anticoagulated or not? If she is, they still ambulate after 24 hours. If she isn't, what difference does it make which floor that she is on?

In actuality, it is nearly impossible to legally restrain patients in many facilities and it matters little whether it is a psych unit or a medical unit. And if she is competent, she can refuse to stay in bed.

Also, the patient is terminal and being treated for depression. We cannot cure her cancer. Anticoags can be done on any floor. We can treat her depression. And she is on the correct unit for that care. How will it affect her depression to put her in restraints?

I also believe that Hospice care could be incredibly useful with this situation.

(I would love to also turf all of my medical patients whose problems originate w/psych-drug abusers, schizophrenics, borderlines, and bipolars to the psych unit. - After all, it has been over 10 years since I did a psych rotation. But none of UDs that I have dealt with will buy that reasoning, either)