How do you handle non compliant patients??

Ariesbsn · Nov 5, 2007

Sorry you had a stressful bunch of firsts all in a row.

The first thing you need to do is put yourself in your patients shoes. He is hungry. Hunger and pain will drive a person to do things that don't make sense to someone who has a full belly and doesn't hurt. Being frustrated and angry are natural, but also be sympathetic.

Just for kicks and giggles, on your off time put yourself NPO, get in bed, and do nothing but lie there and watch TV or read. See how long you can go before you have to eat. One of the things that may surprise you is that if you have nothing to do but watch lousy TV, you may find yourself unable to concentrate on anything but how hungry and thirsty you are.

OK, now on to the patient situation.

The first thing I would have done was to ask the patient to explain to me his understanding of why he wasn't suppose to eat and the consequences of that behavior. Then, if he knew why he wasn't suppose to eat and what could happen if he did, I would ask why he had someone sneak in food. Next, I would turn to the attorney and the medical doctor, look at them with the biggest, most innocent eyes, smile and say:

"I'm so glad to meet you both! So you are a medical doctor. How wonderful! Are you on staff here? Mr. X you do know that since Ms. T isn't 1. a staff doctor here and 2. not your doctor, I can't legally follow her orders, don't you? However, Ms. T, since you are a medical doctor, maybe you can do a better job of explaining to Mr. X how hunger never caused physical harm to a patient, but eating with symptoms such as his has. Oh, can you also explain to him how as a nurse, although I do sympathize with him being hungry, as long as one of our doctors writes orders that are safe, I am bound by law to carry out those orders. If he isn't totally bored with the conversation by this point, could both of you discuss the legal ramifications to the nurse and doctor of allowing a patient to do something harmful? While you all are having your discussion, I need to go report this to the charge nurse, the nursing supervisor, and the doctor."

Then I would talk it over with your charge nurse, I would also look up the results of his tests that morning, and then page the doc. What happens next kind of depends on your facility. In ours, I could tell the visitors to leave and that they weren't welcome back. I could also institute the rule that unless he is receiving care, his curtain is to remain open at all times. I would also fill out an incident report.

One of the things you will learn, in time, is to use that kind of b.s. of "my friend is a lawyer/doctor" to help you.

Ruby Vee, BSN · Nov 5, 2007

sorry you had a stressful bunch of firsts all in a row.
the first thing you need to do is put yourself in your patients shoes. he is hungry. hunger and pain will drive a person to do things that don't make sense to someone who has a full belly and doesn't hurt. being frustrated and angry are natural, but also be sympathetic.
just for kicks and giggles, on your off time put yourself npo, get in bed, and do nothing but lie there and watch tv or read. see how long you can go before you have to eat. one of the things that may surprise you is that if you have nothing to do but watch lousy tv, you may find yourself unable to concentrate on anything but how hungry and thirsty you are.
.

i don't think the issue here is that the op is unsympathetic to her patients. the issue seems to be that the patient knew he was supposed to be npo (hence he was "guiltily hiding something behind his back") but just didn't care. i know it's uncomfortable, boring and miserable to be npo for a test -- even worse when you have to drink golytely and $hi+ your brains out -- but most patients will manage to perservere in the interests of ultimately getting diagnosed and getting better. i think the issue here is that the patient wanted what he wanted when he wanted it and the op isn't quite sure how to deal with that.

i'd explain to the patient that his test will have to be cancelled because he's been eating, and he'll probably have to stay in the hospital an extra day (if this is true) and the test will be rescheduled. he'll need to be npo the next time, too! if he wants to refuse the test, that's his right. but if he wants to have the test, he'll need to comply with the prep.

it's not going to help this time around, but at least you'll know what to do the next time.

ktwlpn, LPN · Nov 5, 2007

QUOTE>

The first thing you need to do is put yourself in your patients shoes. He is hungry. Hunger and pain will drive a person to do things that don't make sense to someone who has a full belly and doesn't hurt. Being frustrated and angry are natural, but also be sympathetic. Just for kicks and giggles, on your off time put yourself NPO, get in bed, and do nothing but lie there and watch TV or read. See how long you can go before you have to eat. One of the things that may surprise you is that if you have nothing to do but watch lousy TV, you may find yourself unable to concentrate on anything but how hungry and thirsty you are ENDQUOTE>>>>>>You've got to be kidding,right? I'm sure this patient had IV fluids on board -he wasn't dying of thirst or even very uncomfortable........................... QUOTE>.The first thing I would have done was to ask the patient to explain to me his understanding of why he wasn't suppose to eat and the consequences of that behavior ENDQUOTE>>>>>>Always good advice-very important to ask the patient to explain back at you the rational behind his treatment so you can document his actions........................................................... As for the rest of this advice-I would not discuss this patients care in front of any visitor due to HIPAA-I would have asked the visitor to step outside and had the above conversation ,assessed the pateint and then I would have gathered all lab reports and studies available and called the doc. As for telling visitors they are not welcome,leaving privacy curtains or doors open-I believe this also is a violation of the patient's rights.The visitor was a victim of the patients manipulation-whatever she was.My advice-NEVER be intimidated by a visitor/family member no matter who or what they say they are.Remain professional and deliver care to the best of your abilities-they may be a clerk at the 7-11,not really a doctor or lawyer...You can't MAKE a patient be compliant-you educate until you are blue in the face.That's all you can do.And try not to get frustrated-it's not your fault you are dealing with a fool.

herecomestrouble · Nov 5, 2007

Aries I loved that response.I usually resort to"that's nice" and then continue on as if they had never mentioned that they were a Dr,lawyer or whatever.I like the idea of turning it back on them.

classicdame, MSN, EdD · Nov 5, 2007

you will come across many non-compliant patients. There are varying reasons, but the main responsibility you have (as I see it) is to be sure YOU have taught and documented what the patient should know. Ignorance of outcomes is not the same as stupidity. At least ignorance is curable.

teeituptom, BSN, RN · Nov 5, 2007

I had a patient that was admitted Saturday evening about an hour before shift change. He came to the floor fromt he ER about 1800. He was admitted with abdominal pain, nausea, vomiting and supposed GI bleed. He was NPO. He had stated he had coffee ground emesis at home so they dropped an NG tube in the ER and only got out "green stomach contents" according to the ER nurse. So they pulled the NGT. When he came up to me he was in a lot of pain and extremely nauseous, but no vomiting. We medicated him and then I left. I had the same patient yesterday. He went down for an abdominal US and an upper GI with small bowel follow through. All day he complained of nausea and pain. His belly was distended and firm. He also kept asking to eat. I kept explaining to him and his wife that he was NPO and couldn't eat anything.
At about 1700 yesterday I was going in to check my IV's and his curtain was closed. When I opened the curtain he hurried to shove something behind his back. I realized he had a bag of chips and next to him a sandwich! I asked if he was eating and he hung his head down and said "yes, I am, I'm sorry" I just told him that there was a reason he was Not allowed to eat and that if he wanted to be non compliant that was his business and we can't force him. Sitting next to him was some other lady, who I assume brought in the food because it was food we can't get in our cafeteria. He quickly introduced me as his friend "the attorney" and that her sister was a "medical Dr" HMPH!
I wanted to tell him that when he starts vomiting again not to bother calling me for anymore zofran!
How do you handle things like this? I am still in my 1st year of nursing and this weekend was a HUGE lists of FIRSTS for me.
First patient fall (mom in bathroom with the 22 year old patient, she tripped over her own foot as stated by her) First patient to pass out on me, literally in my arms in the bathroom and now my first patient to go against the rules (That I know of at least! LOL!)
It was not a great 3 days.

This too will soon come to pass

The little problems in life actually are not a problem at all

All problems are actually little problems

Altra, BSN, RN · Nov 5, 2007

Whatever the visitor's profession is/was is irrelevant. It makes no difference if he/she is an MD, an attorney, a garbage collector, a ballerina or the President.

The important fact of the situation is that your NPO patient has not been NPO. I would have reminded the pt. why he was NPO and advised him that I would discuss with his MD the implications of his potato chip indulgence - delaying tests/diagnosis/treatment, etc.

Excellent response, as always, from Ruby.

steelcityrn, RN · Nov 6, 2007

All you can do is educate,then notify the physician. Can't force anyone to do anything, even if its for their own good. I have been accused of being "pushy"in the past, all for the concern of the patient. I have learned its not worth it. Let the doc know about it, the patient may just be presented with a A.M.A.

woody62, RN · Nov 6, 2007

A year ago this past July, I spent twenty-one days in ICU, with an NG tube down my nose. The first week and half, I really was out of it. But once I came around, I was terrible thirsty. I would have traded my one and only child for a glass of orange juice. If I hadn't been so sick, I would have walked over and gotten a glass of it, even knowing it was not good for me. It is always easy to complain about the noncompliant patients. It is and entirely different story to be in their shoes.

Woody:balloons:

RheatherN, ASN, RN, EMT-P · Nov 6, 2007

The first thing that came to my head when i saw the topic, didnt even see the whole thing..

DOCUMENT DOCUMENT DOCUMENT..

thats school talking!!

-H-

Hope ur days get better!!!

nyapa, RN · Nov 6, 2007

Continue to educate your client, document everything and inform the relevant ppl.

We have an episode where a patient continually gives his own insulin, against the orders. He will give himself a long acting medication, when a short acting medication is due, and will sometimes give the former twice. I really wish the medicos would do something about it, but they don't. There is no sense talking to him - we all have explained that our registrations are on the line, but he is right no matter what! So all we can do is document! And he refuses to give us his insulin...