How do you handle non compliant patients??

fultzymom · Nov 6, 2007

Educate and document. That is really the only thing that you can do in this type of situation. Also let the doc know right away that he is being non-compliant and the education you have done. Then, your documentation will back you up.

I understand your frustration. It sucks when people come to us for help, then when we try, they refuse to listen. Unfortunately, they have the right to do that.

Leslie

MQ Edna · Nov 6, 2007

I work at a place that has a lot of clients who by their nature... are just difficult. That is one of the things I really appreciate about working at a place that cares for people who have mental/physical disablities because it teaches one very important thing: patience.

You might get very angry and upset with someone for doing something that seems absolutely logical to you in your mind, but I think (and I'm not flaming you! I've totaly been where you are!) that it's one of those situation where you just really have to explain to him why he can't eat/drink anything. Document, of course, but sometimes I've found that that saying, "you catch more flies with honey than vinegar" is absolutely invaluable in the healthcare field.

I used to have one client that was on NPO status and it was my job to make sure he kept it... well this individual has been known to be violent if he didn't get his way and was considered a PICA, so I had to follow him everywhere, including the bathroom. The dreaded question... no demand.... was asked about 3 in he morning, "I want something to drink... NOW!" and I turned white as a ghost. I really was not prepared to have to put someone in a PRT in case things got violent.

I went to my supervisor and told her the sistuation and she knew just as well as I did that this was a red alert kind of situation because this particular ind. was like a hurricane when he didn't get his way... she told me to handle it and proceeded to go on lunch.:angryfire I had never been so upset with anyone in my entire life (and I proceeded to write her up for it afterwards.)

Everything turned out okay in the end though... I had just told him firmly but nicely, "You can't have anything to drink or eat for another 8 hours, if you do you wont be able to see the nice lady nurse in the morning. If you promise not to get angry (I wanted to say "kill me") I will make sure that the trading post gives you extra fries tomorrow at lunch.

I really didn't think he was going to fall for it because the population I work with doesn't really understand, "later" all too easily. But when he looked up at me with the glint he gets, I knew it had worked.

"Lady nurse? Red Hair?...." he proceeded to turn over and tell me to get the F out. I hapilly obliged.

The next morning when the nurse came... it was a male...

all the blood drained out of my face and onto the floor. My supervisor walked by and proceeded to tell everyone around her (like the knight in shining armour that she thinks she is) that since the building was so short of staff that she was going to stay for OT. I put a smile on my face and told her "suchandsuch is readly to get his bloodwork done... it's time for me to go home (which it was), can you take him to the nurse please" in the sweetest tone I could muster.

She looked at me weird for a second and then said, "Okay".

I clocked out, started my car and posted out for another department latter that day.... and this is a true story.

PS:The situation did not end well for my supervisor. He went off, like I knew he would, in the prescence of the male nurse. She ended up running down the hall away from such and such and the male nurse later told me that though nothing happened in the end and that he had no idea that anyone could run so fast in such high heels....

PPS: suchandsuch did get his extra fries that day (becaue it was free double lunch day).

Kanani_Ikike · Nov 6, 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.

I let 'em have it. I tell them, and I quote, "If you are not going to comply with the MD orders, then why waste our time?" Yes, I say exactly that. I get so tired of people coming in and doing what they want, then if they don't get better, they point fingers. If I were you, I would've said that. And wouldn't have given a darn about the "doctor" or the "lawyer" sitting there. That's when I would have said something like this, "Then your "doctor" should know better, and tell you're lawyer this (while spelling my name) is how you spell my name." You did nothing wrong. While you may not want to be as crass as I can be, you don't let them intimidate you, either. As long as you're doing what's best for the patient, then you're in the right.

I get so tired of people trying to undermine us and tell us how to do our job. If you don't want help, then why come to the ER? Oh, let me guess, you probably want a quick fix. They always say they're either having abd pain/nausea or chest pain. The test always come back negative, but they get to harass us for 2-3 days. Can I have my "pain and nausea" medicine now, blah, blah, blah!!!!!

Oh, sorry.....................Sorry to rant like that. But you are doing fine.

MQ Edna · Nov 6, 2007

I let 'em have it. I tell them, and I quote, "If you are not going to comply with the MD orders, then why waste our time?" Yes, I say exactly that. I get so tired of people coming in and doing what they want, then if they don't get better, they point fingers. If I were you, I would've said that. And wouldn't have given a darn about the "doctor" or the "lawyer" sitting there. That's when I would have said something like this, "Then your "doctor" should know better, and tell you're lawyer this (while spelling my name) is how you spell my name." You did nothing wrong. While you may not want to be as crass as I can be, you don't let them intimidate you, either. As long as you're doing what's best for the patient, then you're in the right.
I get so tired of people trying to undermine us and tell us how to do our job. If you don't want help, then why come to the ER? Oh, let me guess, you probably want a quick fix. They always say they're either having abd pain/nausea or chest pain. The test always come back negative, but they get to harass us for 2-3 days. Can I have my "pain and nausea" medicine now, blah, blah, blah!!!!!
Oh, sorry.....................Sorry to rant like that. But you are doing fine.

See... IMHO, the patients health overrides everything else. Even if he is an complete jerk for not following orders, it is only harming himself to be doing so. Just because someone does not follow orders, does not mean that are wasting anyones time. He doesn't want to be there anymore than you want to deal with a difficult patient. He's ill... maybe by no fault of his own... maybe by all the fault of his own and if he's not doing something that he should be doing all you can do is advocate for his health and strongly insist that he does not continue whatever it is he should not be doing. EXPLAIN to him why he shouldn't be doing and describe what could possibly happen if he doesn't comply. You should never make a patient feel bad or act like you're rubbing their nose in it because they made a mistake. We are all human and I have had the 'privilege' of being on NPO status on more occasions that I would like to disclose and I hate it. You have no idea how many times I was tempted to just steal something out of food cart while I was in the hospital.

You're all professionals and you're right, you shouldn't be told how to do your job by someone who isn't in your field... but IMHO i must reiterate, the patient's health overrides ALL pride and personal feelings/frustration.

FireStarterRN, BSN, RN · Nov 6, 2007

I would advise you to try to educate the patient thoroughly as to exactly why they should be NPO, and then chart, chart, chart. Patients have their rights to refuse care. Then, move on to the next patient. You also should inform the doctor and chart that you did so, that leaves the problem in his or her lap. You aren't going to change everyone's life during one hospital stay. Don't take what they do personally.

As far as them trying to impress or scare you by mentioning the profession of the visitor, just smile and say "Oh, how nice" or "Oh, how interesting", and don't be drawn in any further than that. Just be polite, don't let them push your buttons.

rn undisclosed name · Nov 6, 2007

I've had a non-compliant pt who was not NPO. He was relatively young with a really bad pneumonia. Already been intubated and self extubated himself though he didn't remember doing that. When I had him I couldn't get his O2 to less than 10 L via high flow nasal cannula. Well the day before he was going for his possible thoracotomy he received a get well basket which was essentially junk food. He was diabetic and kept on eating even though he wasn't supposed to. Well, I had him the next day when he was going for his surgery. He was actually more compliant and stayed NPO the day he was going for surgery. But I told his cardiologist, attending, pulmonologist, and thoracic surgeon how he was the day before. They all laid into him. Pt was not too happy with me. The attending told him he was in the hospital to receive care and he prescribed a particular diet for him and if he was not to follow his orders he could just be discharged. BTW, I spent the prior day educating him as to why he needed to keep his sugars under control and it was well documented.

I understand he was stressed out and people eat when stressed but I also have a job to do and can not just let people eat. Really it has nothing to do with being unsympathetic or unempathetic. You're taking up a bed and you're in the hospital. Sorry that doesn't give you a license to eat. You're in the hospital and not a hotel. How is insurance or medicare going to like it when they see a pt had to stay in the hospital an extra day because they were just so hungry and they had to eat before getting a test. Yes I have had to be NPO before and been on a clear liquid diet. Yes it does suck but if you want to be diagnosed and start feeling better you just need to do some things. If you don't want to be treated quite frankly you don't need to be taking up a bed that someone who wants to get well can have the use of.

MQ Edna · Nov 6, 2007

I've had a non-compliant pt who was not NPO. He was relatively young with a really bad pneumonia. Already been intubated and self extubated himself though he didn't remember doing that. When I had him I couldn't get his O2 to less than 10 L via high flow nasal cannula. Well the day before he was going for his possible thoracotomy he received a get well basket which was essentially junk food. He was diabetic and kept on eating even though he wasn't supposed to. Well, I had him the next day when he was going for his surgery. He was actually more compliant and stayed NPO the day he was going for surgery. But I told his cardiologist, attending, pulmonologist, and thoracic surgeon how he was the day before. They all laid into him. Pt was not too happy with me. The attending told him he was in the hospital to receive care and he prescribed a particular diet for him and if he was not to follow his orders he could just be discharged. BTW, I spent the prior day educating him as to why he needed to keep his sugars under control and it was well documented.
I understand he was stressed out and people eat when stressed but I also have a job to do and can not just let people eat. Really it has nothing to do with being unsympathetic or unempathetic. You're taking up a bed and you're in the hospital. Sorry that doesn't give you a license to eat. You're in the hospital and not a hotel. How is insurance or medicare going to like it when they see a pt had to stay in the hospital an extra day because they were just so hungry and they had to eat before getting a test. Yes I have had to be NPO before and been on a clear liquid diet. Yes it does suck but if you want to be diagnosed and start feeling better you just need to do some things. If you don't want to be treated quite frankly you don't need to be taking up a bed that someone who wants to get well can have the use of.

What was done to try and stop the kid (probably older than me anyway) from eating all this junkfood?

rn undisclosed name · Nov 7, 2007

What was done to try and stop the kid (probably older than me anyway) from eating all this junkfood?

I really wanted to remove the food from the room but I'm not sure if I'm entitled to take something away from someone that belongs to them. I knew he would be going to the ICU after his sx so I had his family take all his belongings home which happened to include this food.

Kanani_Ikike · Nov 7, 2007

See... IMHO, the patients health overrides everything else. Even if he is an complete jerk for not following orders, it is only harming himself to be doing so. Just because someone does not follow orders, does not mean that are wasting anyones time. He doesn't want to be there anymore than you want to deal with a difficult patient. He's ill... maybe by no fault of his own... maybe by all the fault of his own and if he's not doing something that he should be doing all you can do is advocate for his health and strongly insist that he does not continue whatever it is he should not be doing. EXPLAIN to him why he shouldn't be doing and describe what could possibly happen if he doesn't comply. You should never make a patient feel bad or act like you're rubbing their nose in it because they made a mistake. We are all human and I have had the 'privilege' of being on NPO status on more occasions that I would like to disclose and I hate it. You have no idea how many times I was tempted to just steal something out of food cart while I was in the hospital.
You're all professionals and you're right, you shouldn't be told how to do your job by someone who isn't in your field... but IMHO i must reiterate, the patient's health overrides ALL pride and personal feelings/frustration.

Oh, I understand what you're saying. But, after I've have educated and begged them to comply out the wazoo, enough is enough. I can't be in there all shift explaining over and over again and the patient still does what they want. After a while, you have to go on and chart thoroughly. With 8 patients, I cannot babysit any of them. And especially a grown, sane person. If he is still going to insist to be non-compliant after all of my efforts, my patience has run out. In my opinion, he didn't really want help. If he did, why didn't he do as told. I'm sure the OP did all the education, begging, jumping through hoops, all that. And the man still didn't want to act right. He even tried to antagonize her. There is a limit for everyone.

MQ Edna · Nov 7, 2007

Oh, I understand what you're saying. But, after I've have educated and begged them to comply out the wazoo, enough is enough. I can't be in there all shift explaining over and over again and the patient still does what they want. After a while, you have to go on and chart thoroughly. With 8 patients, I cannot babysit any of them. And especially a grown, sane person. If he is still going to insist to be non-compliant after all of my efforts, my patience has run out. In my opinion, he didn't really want help. If he did, why didn't he do as told. I'm sure the OP did all the education, begging, jumping through hoops, all that. And the man still didn't want to act right. He even tried to antagonize her. There is a limit for everyone.

Yeah, that is a pain in the butt. And I understand what you're saying. There is a point where we just have to say... okay, it's right to refuse treatment or something like that... but sometimes I wonder if some nurses (and I am in no way implying anyone on this thread is one of them) give up before even really trying.

abbaking · Nov 7, 2007

This thread reminds me of a situation when I was new grad on the med-surg unit. The Pt. was to be NPO at midnight for some sort of upper GI procedure/ surgery. I politely informed the Pt. that they were to have no food or drinks past midnight in preparation for the following mornings prodedure. The pt seemed to accept the information well, but the family members were confused. They asked appropriate questions and I answered them to the best of my ability. I thought the situation was over. FAR FROM IT. During my rounds (about 30 minutes after i had spoken with the family), 4 Large guys cornered me in the hallway and began using very foul launguage and threats to me and my life. All because there mom (my pt) could not eat after midnight and that I was a %#&$! To make a long story short, I contacted security via Code Grey (keep in mind my life is being threatened by 4 dudes), requested a different patient, and was escorted to my car at the end of my shift. (By the way, a coworker had told me that those guys were waiting for me in the parking lot to "Take care of me".) Since then i have learned that if a patient or a family is going to be non-compliant, document everything (CYA), inform the patient or family of the possible consequences of their actions, and discuss the situation over with your charge nurse. :devil:

MQ Edna · Nov 7, 2007

This thread reminds me of a situation when I was new grad on the med-surg unit. The Pt. was to be NPO at midnight for some sort of upper GI procedure/ surgery. I politely informed the Pt. that they were to have no food or drinks past midnight in preparation for the following mornings prodedure. The pt seemed to accept the information well, but the family members were confused. They asked appropriate questions and I answered them to the best of my ability. I thought the situation was over. FAR FROM IT. During my rounds (about 30 minutes after i had spoken with the family), 4 Large guys cornered me in the hallway and began using very foul launguage and threats to me and my life. All because there mom (my pt) could not eat after midnight and that I was a %#&$! To make a long story short, I contacted security via Code Grey (keep in mind my life is being threatened by 4 dudes), requested a different patient, and was escorted to my car at the end of my shift. (By the way, a coworker had told me that those guys were waiting for me in the parking lot to "Take care of me".) Since then i have learned that if a patient or a family is going to be non-compliant, document everything (CYA), inform the patient or family of the possible consequences of their actions, and discuss the situation over with your charge nurse.

jebus... I just thought of a intersting possible outcome of that.

If nurses were allowed to carry pepper spray... and you sprayed them... would you then have to treat them? lol... I mean... you can't really deny anyone treatment... lol...