case manager taught me a gem about families

[SNB1014, RN]

so, it was the morning after the "incident". I was caring for a 85yo man in icu step down who has BP that hovered 80/50 and we had finally gotten his a-fibb rate controlled. but he was now diagnosed with pneumonia. he had a hx of dementia and couldn't catch a break.

well, as you all know, sometimes it is a great triumph when you get a sickly,confused elderly man simply out of bed into the chair. I wanted an award!! It took a lot of coaxing to do this. he was on multiple IV antibiotics and had tubes and wires everywhere.

then he daughter came in to visit. normally, i enjoy families, I enjoy their help, their perspective and teaching them about our plan for the day or giving updates on loved ones.

all his daughter would say is "DAAAADDDDDDD, why aren't you walking? Has he walked? You know right before he came in , he went with me to the grocery store! I can't believe you wont let him walk!"

She repeated the same concept, different anecdotes and phrases, for around 15mins at change of shift. urghhhh. I tired to explain that when he walks, his 02 goes down to 86%, his feet hurt so bad he won't move them, it took 15mins to get him from the edge of the bed to the chair, he has pneumonia so bad I can hear him without a stethoscope, we had to have him in trendelenberg AND a bolus of NS just to maintain 85/55 bp. I said I was more concerned about his heart and lungs than him walking down the hall at this point.

Oops. Family didn't like that.

So in the am, I saw case management, and she must have overheard me discussing this with my charge and she chimed in:

"well, families focus on what they can understand. they dont understand afibb with RVR, pleural effusions, vanc. troughs, the seriousness of low potassium. walking is a measurable, concrete indicator of how her dad is doing. she couldn't care less what the number on the monitor says because she doesn't know what it means. when dad comes in being able to do certain things and now he cannot or refuses to try, its terrifying for families. They focus on what makes sense to them. "

A-Hahhhhhh!

I now saw the daughter wasn't trying to give me the riot act over walking him, but she wanted me to understand this is NOT dad's baseline. that he is 85, but normally he is strong.

So i made sure first thing after case management interjected, that I put in a request for pt/ot.

When I told the daughter that later in the afternoon that as long as he was hemodynamically stable (i say, "as long as his numbers look good....") pt/ot in addition to myself will be working on getting him as ambulatory as possible, but to please be patient because when our older folks get sick, it takes them longer than you and I to get back into fighting form."

she seemed happy with that answer, and therefore so was i :-)

[meanmaryjean, DNP, RN]

Excellent post! We are having this same discussion on another thread regarding NICU parents who focus on weight gain to the exclusion of all else. It's because weight is the ONLY number / concept they understand for the most part.

[NurseDirtyBird]

This is very enlightening and I'm really having a "duh" moment right now. Makes perfect sense. I work in rehab/LTC, so of course this kind of thing comes up all the time. Also in different forms: "Why isn't she on the medications she was taking at home? She took this every day and was fine," which could mean, "Now she's not on this med and look at her!" Or the doctor tells them they can't go home on certain pain meds, so the family convinces the pt. to not take pain meds at all, thinking they'll get to go home faster.

This really reinforces the idea that patient education includes family education, and that means putting things in terms families can understand. Thank you for posting this!

[Altra, BSN, RN]

I understand the point. However ... it does not take a medical professional to understand that when a person is sick they're not going to be doing the same things that they normally do at baseline. Ask a lay person to picture an average healthy adult who normally takes his/her dog for a short walk every day. Now assume that adult is generically "ill" on a particular day. Might they skip the walk? Does that seem "terrifying" ... or just kind of logical and expected?

The majority of patients & families do make these simple, intuitive connections and cope appropriately. We seem to work ourselves into a frenzy and feel personally insulted by the minority who need a little extra education and a little extra redirection.

[classicdame, MSN, EdD]

Good for you OP!

[VivaLasViejas, ASN, RN]

What a great piece of insight! Thank you for sharing....I'll need to remember that the next time I have to deal with a family member who seems unreasonable.

[TheCommuter, BSN, RN]

Great post, OP. This leads me to my next comment: the importance of the acronym 'K.I.S.S.' (Keep It Simple, Stupid).

We, as nurses, should take the utmost care in using the simplest language possible when educating families and providing explanations because our healthcare jargon is just going to frustrate people even more.

Even the simple phrase "The x-ray is negative" is often misunderstood by families and can be reworded to a much simpler "The x-ray shows that your mother has no broken bones!"

[Sun0408, ASN, RN]

I love K.I.S.S, it really works great for the families as well as pts. I wish more PCP would use it,it would really help with the gap..

OP, great read, thank you

[AWanderingMinstral]

I love K.I.S.S, it really works great for the families as well as pts. I wish more PCP would use it,it would really help with the gap..

OP, great read, thank you

I was thinking THE SAME THING when TheCommuter weighed in. MDs are guilty of this too...and get to walk out of the room in 5-10 minutes and possibly not return for 24 hours.

[mclennan, BSN, RN]

Case managers rock

[boogalina, ADN, ASN, BSN, MSN, LPN]

Yes! I totally understand what you mean about the human tendency to try to come to grips with a scary present by trying to reference where things were in the past. It's a big adjustment to have a family member in the hospital, let alone the scary, scary ICU. People need time to absorb reality, and nurses like you to help explain what's different, while acknowledging what the family member is trying to communicate. Logic kind of flies out the window in the face of the shocking reality. . .

[NurseDirtyBird]

I understand the point. However ... it does not take a medical professional to understand that when a person is sick they're not going to be doing the same things that they normally do at baseline. Ask a lay person to picture an average healthy adult who normally takes his/her dog for a short walk every day. Now assume that adult is generically "ill" on a particular day. Might they skip the walk? Does that seem "terrifying" ... or just kind of logical and expected?

The majority of patients & families do make these simple, intuitive connections and cope appropriately. We seem to work ourselves into a frenzy and feel personally insulted by the minority who need a little extra education and a little extra redirection.

You're correct, most patients and family members do make logical connections and cope well.

The majority of patients who cope well don't cause issues with care. The "frenzy" is because the family members in question are a hindrance to providing care. The OP was pointing out another way to look at the situation and reminding us that it's a cue to provide education instead of taking it personally and going on the defensive.