How could I have handled this better?

[RaziRN]

Okay, I know I'm probably going to be torn a new one for this but I need some advice on how I could have handled this situation better. I already feel like a *terrible* nurse because of it so please don't be unnecessarily rude.

So last night I had a LOL in with ARF. It was reported off to me that she was A&O x 3 and "mean as a snake." She already had one unit of PRBC's and needed a second unit. So I brace myself and go in to do my assessment. It was a struggle just to get a listen to her heart, lungs and bowel sounds. She kept pulling her covers back up and stating "Leave me ALONE." I did my assessment as quickly as possible even though I ended up having to put my arms and stethoscope under the covers while trying to keep this lady from grabbing at me with her nails. I also had to do a neuro-check on her as she was post-fall. She very reluctantly did the hand squeezes and let me assess her pupils but she refused to answer my orientation questions. I would ask her what her name was, where she was, what date it was and she just shook her head that she didn't know the answers. I think she knew the answers but just wanted me to leave her alone. She did ask for something for heartburn so I went to look if she had anything ordered and she had a scheduled dose due at 2100 so I informed her of that. I was especially hoping that my prompt response to her request for medicine would build some sort of trust as it usually does with my patients. They feel they can rely on you. Well, it didn't work with her. I also went ahead and informed her that I could not "leave her alone" as she was supposed to get another unit of blood. I was trying to fairly inform her of what to expect. She said "How was I supposed to know I was getting more blood tonight?" when I asked her if she knew she was supposed to get another unit. Again it was another litany of "Leave alone and why can't ya'll let a person rest.

Anyways, I come back later to give her her medicine. After some coaxing and reminding her that she had asked for Maalox for her heartburn I finally got her to take that. She refused her Megace, her Protonix and her heparin flush for her PICC line. I spent 20 minutes trying to reason with this woman. I used my best active listening practices so that maybe if she got things off her chest and actually had someone listen to her she would feel better. I explained the importance of the medicine she was refusing especially the heparin and how we wouldn't want the PICC line to clot off. I explained why I had to come in and bother her at night. She said "If I bothered someone so much at night I would feel guilty." I said "Ma'am I don't feel guilty because it's my job to take care of you." So we go back and forth like that for awhile. I tried to get to her arm to give her some Protonix but she kept pulling it back and stated "You think you're so smart, if you touch me see what happens." At this point I ask her one more time if she wants her meds and of course she doesn't and I go off to give my now late meds to my lovely, compliant patients.

At this point I'm thinking there's no way I'm going to get any blood in her. I might be able to hold her down while I hook up the tubing but there's no way I'd be able to get frequent vitals on her. So following my med pass I talk with the charge nurse and tell her what's going on. She told me to call the MD to see if we can get restraints or something to sedate the patient. I really don't want to restrain this lady because she was telling me how they restrained her earlier in her hospital stay and just the way she was talking sounded like she felt SO violated. But I call the hospitalist on call and tell him the deal, the patient's H&H which was something like 8.0 and 23. The doctor told me to document her refusal and to basically just document, document, document. I tell the charge nurse and she agrees. So I go back in with the patient and tell her that since she's refusing she won't get the second unit of blood and I ask her if I can at least unhook the blood tubing from her and get her regular IV fluids hooked up. Well, I got the blood tubing unhooked but she wouldn't let me hook her IV fluids back up. I then help her to the BSC.

So she ends up refusing to do her neuro-checks for 2400 and 0400. *Sigh* I document all of this in my narrative notes. At 0400 lab comes in and wants me to draw blood from the PICC line. I was busy trying to re-insert the NG tube of a patient who had just pulled hers out (small bowel obstruction). So another nurse says she'll draw the blood for lab and I warn her that the patient will be difficult and of course she was. I then go in there because the batteries in the patient's telemetry unit have died and literally me and the lab tech had to hold this ladies arms down just so I could do something as non-invasive as put batteries in the tele box and make sure her leadswere on correctly. All the while this ladies' yelling at us to leave her alone and let go of her. She was trying to scratch at our faces. So we finally get that done and I'm trying to talk the pt. into doing a neuro-check and she said "Don't you talk to me." and set her mouth into a grim line. So I leave her be.

I documented all of this to the best of my ability to CYA. But I'm not feeling comfortable about it. I'm afraid I might lose my job or worse my license for neglecting a patient. I know I documented everything but it seems flimsy and not good enough. I'm starting to question just how A&O this patient was because another nurse who had her previously told me she was confused. But I was reported off that she was A&O x 3. I wasn't able to get a good assessment of her orientation with her refusing to answer my questions. But she did remember that she had been restrained earlier in her stay. I'm thinking I should have just gotten orders to restrain her like the charge nurse suggested but I really hate restraining people.

What would you have done? I had to stay over after report to finish my charting as I was way behind and I noticed that the nurse I reported off to was also having a hard time with the patient and that it took four people to hold the pt. down to give her her vitamin B12 injection. But the nurse did manage to get her hooked back up to her IV fluids and flush her PICC line. Maybe I should have just been more stern with the pt.

*Sigh* I don't know. I'm still new to all this and hoping I didn't screw up royally. Any constructive advice? I just feel like I handled this all wrong. God bless you if you read all of this.

[netglow, ASN, RN]

Well, it sounds like you did try. You know what they say, the lid to the jar always comes off easier when someone else takes a crack at it (That's only because you did all the preliminary "wearing-down") :)

[Fribblet]

You can't help someone who doesn't want help. You did the right thing. As long as the patient has not been declared incompetent, they can refuse any and every treatment.

You were right to document the crap out of everything and to try and educate this woman to the best of your ability.

IMO, the nurse who restrained the patient to give the B-12 injection should be worried. If the patient is not incompetent, refuses a shot, and is held down and given it anyway, that's assault and battery.

Don't worry. You did exactly what you should have done. Always remember to cover your own ass.

[April, RN, BSN, RN]

You are not a terrible nurse! It sounds like you did the best you could. In fact, you had a lot more patience for this patient than some other nurses would. You tried therapeutic conversation, you explained everything that needed to be done and why, you notified the doctor, your charge nurse was aware, and you documented everything. Patients have a right to refuse treatment. It was difficult to assess her mental status but she's not critically ill so it sounds like there was no urgent need to force treatment on her. She was combative and you needed to protect your own safety as well as hers. I don't think you need to worry!

[Bella'sMyBaby]

Sounds to me like you did your Best......Nothing more you could have done.....You handled the Situation MUCH Better than I would have.....I'm so Sorry you had to put up with such a Nasty Old Bat....... :hug:

[misschiatia]

Absolutely, you did the right thing. Where I practice even dementia residents have the right to refuse(LTC, not hospital).The day we stop respecting the rights of the people we care for is the day we are in this job for the wrong reasons. I do think that some social worker or case manager somewhere needs to have a conversation with this lady about why she signed herself into the hospital if she does not want treatment. And if she did not sign herself in, maybe we need to start a conversation with family about whether or not we are truly honoring this woman's wishes. Hospice was created for a reason.

[mustlovepoodles, RN]

You can't help someone who doesn't want help. You did the right thing. As long as the patient has not been declared incompetent, they can refuse any and every treatment.

You were right to document the crap out of everything and to try and educate this woman to the best of your ability.

IMO, the nurse who restrained the patient to give the B-12 injection should be worried. If the patient is not incompetent, refuses a shot, and is held down and given it anyway, that's assault and battery.

Don't worry. You did exactly what you should have done. Always remember to cover your own ass.

Absolutely~! It alarms me that there is all this talk of holding this woman down, restraints, etc. No wonder she feels persecuted and violated--she is!

My first reaction is that perhaps this woman is having some kind of psychiatric event or perhaps drug or alcohol withdrawal. I once had a woman call the sherriff on me at 3am to tell them she had been kidnapped and was being held hostage. DTs soon followed.

OP, I think you handled this as well as you could. If this woman wasn't declared incompetent by a judge, then she has the right to refuse treatment even if her refusal could harm her. The only thing I would have done differently is I would have contacted the charge nurse and MD sooner. It was clear from early on that she was not going to comply with treatment. No need to beat a dead horse. Document your brains out, call the MD, and otherwise continue to observe. You do not have a right to even touch her for vital signs if she is telling you NO. If she is in her right mind, and so far there is no reason to think she's not, you could be held for assault and battery. You don't want to go there.

[RaziRN]

Thank you everyone for your replies.

To the poster that mentioned hospice: The day shift had told me that they had brought the family and doctor in to try to convince this lady she needed treatment and why. The doctor told her "We can't leave you in here to die" or something to that effect. Anyway, the lady said "Just let me die!" So maybe that is what she wants or she could just be saying that in an effort to be left alone. The fact that she doesn't eat and weighs something like 35.6 kg would suggest that perhaps that is what she wants. Maybe she's depressed. I don't know her life history. Maybe her husband died recently and she doesn't feel she has much to live for? I don't know.

To the others who mentioned assault and battery: I was thinking that the whole night. If this ladies' competent and doesn't want to be touched and we touch her, legally it's battery. I too was uncomfortable with all the talk of restraints, etc. I was so torn that I was either going to be accused of neglect with this lady or assault and battery. It really wasn't a very good situation.

I'm just hoping my documentation was thorough enough. I tend to be my own worst enemy and I just want to be a good nurse. I never want to fail my patients, though I know sure enough that I probably have at some point. Thank you again for your responses, they have made me feel a little better about the situation. Hopefully this lady can get things straightened out with her family about her wishes, etc.

[CrazierThanYou]

I'm not a nurse, just a new student but I couldn't help but think, why on earth is this woman even IN the hospital??