Depressed patient refuses positioning even though she is lying on her own bowel movement

Nurses General Nursing

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Hi everybody, I am still a nursing student and have encountered a big ethical issue in placement. The ward got an elderly lady about 80 who just went for hip replacement, she was also depressed and bereaved due to her daughter dying last week due to cancer. I tried my best to make her smile because she cried a lot. It was all okay until we spotted that she had moved her bowels and I could smell urine. When we tried to re position her to clean her, she kept shouting at us and said she didn't want to and that we were abusing her by forcing her to. I am aware it is our nursing duty to act beneficently and "do no harm" however I felt like we were disrespecting this lady's autonomy. I am confused what would be done in this situation because she technically lacks mental capacity, my shift finished and never got to find out what happened. I would like to know what everybody here thinks would be the ethical thing to do for this lady.

Specializes in Psychiatry, Community, Nurse Manager, hospice.

Treat her pain and wait for the moment when the effect of pain meds is greatest. Also, I would use an anxiolytic like ativan. Give care when both meds are peaking.

One thing that has not been mentioned is to find a rockstar nurse or tech at bed bathing hip surgery pts to help you.

Grief consult if there is such a thing at your facility. We have grief counselors, but we are a psych hospital. Not sure how common that is.

Specializes in PACU.

So many people have pointed out really good stuff here, (advocating, listening, grief counseling, competency.....ect.) so rather then repeat I want to add two things.

1. Yes, please do medicate pain and anxiety, but remember your assessments. Giving meds because of refusal to be cleaned, instead of because of pain is chemically restraining the patient in order to proceed. So makes sure your documentation shows that you investigated and are treating pain/anxiety.

2. I have often found that giving a patient two choices (both that I could live with) gave them autonomy back in a way that its me take care of them.

Example: Mrs Patient, you have moved your bowels and it's up against your skin. Would you like me to clean you up in bed or would you like to sit up at the bedside commode while we do this? or the: I can do this now, or I can come back in once the pain medication kicks in, which would your prefer?

I have been in this situation many times. First, make sure you are managing pain appropriately. Then, with assistance, gently turn and clean the patient. Don't get adversarial. I usually say things like: Please let me clean you. I respect that you don't want to be moved but I cannot leave you dirty. I know you'd rather be clean. You will be more comfortable afterwards. Thank you for being patient with us.

I try to be verbally and emotionally gentle.

The ethical thing is to clean her up and not allow her to lay in feces and urine. She is obviously not in the right state of mind right now.

Laying in feces and urine will cause skin breakdown and infection that could be deadly. It's a huge ethical issue to not clean her up.

I agree with this. We had a younger lady, of sound mind, who had less 'reason' to be noncompliant, who was worse than this on an ongoing basis. This resulted in a pressure ulcer that went to the bone and had tunneling. She threw a fit over wound care, everything. People allowed her to have her way because everyone was tired of her and her behavior and no one wanted to deal with her. I don't know what ultimately happened to her, but it could not have been pleasant.

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