Have you ever had one patient ruin your mood for the entire day?

[kristine_bean, RN]

I had this patient today that just made me feel like the most incompetent nurse. That's my button. I usually handle myself really well when it comes to emotions. But when I feel bad about myself because I feel like I can't do my best in this situation. I can't help it, I get emotional. So lets get to the story...

This patient was in a severe accident and has had multiple surgeries to reconstruct his left extremities. The last time I was his nurse, there were several orders to question. The patient remembered being told one thing, but the orders said something different. His surgeons office was called, message was left, follow up fax was also left. No response was received that day and I didn't have him as a patient again until today almost a month later, they ended up with clarifications but the next nurse probably got the credit in the patient's eyes. A month ago, his dressing to his left hand was to go untouched until the next follow up appointment. This time around, I got in report that he went to his appointment 2 weeks ago and the nurses have been changing his bandage without an order. This patient is very involved in his own self care and most likely told the nurses that the doctor wants us to change the dressings now. I can only presume that. I walk in the room hoping to see a dressing, take it off, clean the wounds, and redress it the way it was. But I walk in the room and the dressing is not there. He had just taken a shower and apparently was allowed to have it washed in the shower. Now it is sitting open to air and I have nothing to look at. So I ask the other nurses I was working with if they knew how it was being dressed. No one knew. My next option was to ask the patient. So I did. He was perplexed that I didn't know. I explained, we don't have an order. So I don't know what we're supposed to be doing. You are involved in your own care, so tell me what has been done the last several days and that's what I'll do. He tried to describe a piece of hardware I was totally unfamiliar with. He said it came from the ER. I went to the ER, no one knew what it was. I came back to him and asked him to describe it with different words and maybe it would click. Finally another nurse said, I think I know what you're talking about, she went to the ER and finally the patient said yes that's it! We had what we needed. As I'm applying the dressing and following his instructions, he's grilling me saying "how is it there are no orders for this, I brought papers in from my appointment and no one else has questioned this before, just you. In my head I thought, well they were probably communicating but no one told me, someone should have asked for an order between then and now, so situations like this didn't occur. I honestly don't remember how I responded. He was just very demeaning in his tone. The remainder of the day I was very busy with my other patients too, I tried to make it back in the room before he went to physical therapy to change the leg dressings as well. I came later than I hoped because I was pulled in a million directions. When I got there is was too close to his appointment time so he wanted me to wait until after. Then I got an admission that needed a lot of attention and I ended up telling him I wouldn't have time to do it and night shift would have to follow up. He didn't like the night nurses doing it apparently so made the choice to wait until the nurse tomorrow morning came on, and thank god it wouldn't be me. 30 min before end of shift I was drawing up an antibiotic for another patient and he is at the nurses station, and asks for a pain pill. I say I'm in the middle of something and I can't get it at the moment but I will when I'm through with what I'm doing. He replies "Come on, you have GOT to be kidding me!". I mean clearly, this guy did not approve of me and the way I had handled him the entire day. I just felt aweful and was so unhappy all day because of his attitude. I've had patients who are just plain mean to everyone and for some reason I can handle those guys, piece of cake. But this guy is different. He has that favoritism type of attitude like only one or two people can do a certain thing right. He seems very passive aggressive too.

In hind site, I may have been able to find specific details on his dressing change in the nurses notes or called one of them at home but it's not something I thought of until after the fact. I did end up requesting specific dressing change instructions from the provider. So then I'll be the only one who looks bad and anyone else who comes along will know what to do.

[jadelpn, LPN, EMT-B]

You need to stop thinking along the lines of "looking bad". There was not an order for a dressing that was being changed. I would have called the provider right then and there for an order. It is all fun and games until this patient has an issue with healing and/or function and "blames" it on the dressings and lack of an order. He may be involved in his own care, but you need to have specific orders for a complex dressing change post op. Additionally, all of his dressing could be changed at once, especially if he had just gotten out of the shower and the leg dressings were intact, but wet.

As far as pain management, you may have asked your charge nurse to medicate him for pain if you were caught up in another patient's meds.

There is no need to get emotionally invested in what you believe a patient thinks of you or have it ruin your day to the point you are perseverating on it. Seems to me he doesn't think too highly of the night shift either. You are talking about a multi-trauma, multiple surgery, complete change of life for this patient. Pain meds, some trauma, lots of things can make this patient less than baseline as far as mood, behavior, etc. and that this all leads to a complete sense of no control.

I would be 100% sure that you have ALL the orders that you need for this patient. That you go in and assess for pain within the parameters that he can receive pain meds. And maybe a wound consult to be sure that he is doing as much as he can independently, as that is goal--function. I would also think about asking for social work consult, as depression after trauma is a real thing.

Don't let outside influences reflect on your nursing practice. At the end of the day when this patient tips over the edge and decides to pursue a lawsuit over the trauma or some other such thing, YOU will be the one who got the correct order--and that is proper practice. That the patient can be cranky (and full reconstruction of their extremities, and who wouldn't be) can be at least addressed--by the social work aspect of things. And I would pop a note to risk management as well as the case manager. Some of the statements that he is making would warrant a bit of an extra watch.

[kristine_bean, RN]

Thank you for your reply. Unfortunately I work in a rural hospital with very few resources. We don't have a wound nurse, charge nurse, risk management team. We do have a social worker though, thank goodness. As far as getting a doctors order right then and there, looking back I may have been able to get the ER doctor to assess and order a dressing (the only doctor that is available in person). His provider while hospitalized though, is a nurse practitioner who honestly doesn't know what needs to be done with this patient. Our hospital has two MDs that look at the admission and either decide to take the patient or pass them off to one of our PA's or ARNP's. The other nurses and I have all looked at each other and scratched our heads wondering why they passed this one off, because his care is not straight forward and is quite complex. Had he been assigned to an MD, these problems wouldn't even have arisen. The order should have come from his hand team originally. I attempted to contact them, again with no response. I actually have applied to a larger hospital with more access to resources because issues arise quite frequently where I feel like I don't have the tools or people available to do right by the patient. Its hurt my self esteem quite a bit because though I know I'm not at fault, It makes me feel uncomfortable, puts my license at risk, and not only does it make me look bad, it makes the hospital look bad. You're right though, I shouldn't let this patient get under my skin, I am a little too sensitive. It's something I've been working on. Just needed to vent and get some feedback.