incapable, helpless, unmotivated, unteachable pts who are unable to cope with life

[FireStarterRN]

I got floated to Med-Surg yesterday. I had a patient in her 50s who had originally come in with a blood sugar in the 600s, had been on an insulin drip originally, then transfered to med-surg.

The doctor came in and ordered her discharged. Supposedly she had been receiving diabetic teaching. This woman obviously was an utterly passive personality. To make a long story short, it took me all day to get her out the door. She could give herself an injection just fine, but she really seemed unable to learn the information. She had a history of being 'noncompliant', I'm told. The CNA told me that the woman was so helpless that she would call to have her pop can opened for her.

I didn't have very many patients, but I had the most frustrating exersise in futility I've had in a long time. I tried to explain the difference between NPH and Regular, the sliding scale, and the rest. Everyone at the nurses station kept hearing the latest chapter in the boring story. Then after hours of this I finally called the doctor after hours of this and told her that there was no way this woman could learn this. I suggested Lantus as a simpler insulin, and he said that he had to order NPH because of cost. He ordered home health and said that we "can't live her life for her". I finally got the patient to understand that, at the very least she should take the NPH in the morning and evening, and that perhaps homehealth could get her to understand the rest.

Then her husband picked her up in the front of the hospital, he wouldn't come in to pick her up. He had an old ramshackle pickup with a bunch of junk in it. He didn't say a word and wouldn't get out to help my patient who is quite obese and needed a stool they keep in the truck to get into the truck. She attached the stool by a string to the door handle so she could pull in up into the truck after she got in. I noticed a siphon hose on the floor of the front seat, among other things, I think that's how he fills up the truck with gas. They looked like characters out of Steinbeck's Grapes of Wrath. It was the most heartbreaking scene I've witnessed in a long time, one of utter poverty of spirit.

Very frustrating and sad...

[sdre]

I suggest consideration of the effects of low literacy in both Canada and the United States as an issue in this type of situation.

As educated persons, we consider the information we are giving patients is effective in helping them to manage health conditions.

I suggest the following research paper as useful:

How Does Literacy Affect the Health of Canadians? by Burt Perrin

http://www.phac-aspc.gc.ca/ph-sp/phdd/literacy/literacy.html

The Partnership for Clear Health Communication (PCHC) also provides information about improving our approaches in giving health information.

National Patient Safety Foundation, 132 MASS MoCA Way, North Adams, MA 01247

http://www.p4chc.org/

Regards from Canada

Sharon

[country mom]

I'm a Certified Diabetes Educator. Most inpatients simply cannot process all that information during their hospital stay. They're not lazy, incapable or unmotivated. Bottom line, they don't feel good and they're overwhelmed. The most I usually aim for is to get those very basic survival skills down before they leave. If they're going to be homebound, get them a referral to home care. If not, get them a referral for outpatient diabetes education. That's where we dissect all the issues they're dealing with and break it all down into pieces of information they can understand. You simply cannot teach a newly diagnosed person with diabetes everything during the inpatient stay- get them an education followup.

[sarahdeez, BSN, RN]

Sorry but I have to take a different position. I was diagnosed in 1990 as a Type 2. My doctor and nurses taught me what to eat and how to manage my diabetes. For the next two years, I ignored my disease and ended up in the ER several times. I was labeled as non-compliant. And to make matters worse, a non-compliant nurse. When someone is first diagnosed with a life altering chronic disease, they generally do one of two things. They accept it or they do not. And this patient sounds like she has not. The fact that she does not open a can of soda has nothing to do with things. She is faced with a disease that is going to alter her life. You do not know her situation, the support she gets or doesn't get, her personal situation. It is very easdy to give up and wash your hands of such a patient. It is much harder to determine her situation and why she is acting the way she is. And to work out a plan to help her.

Woody:balloons:

You must really be the most understanding person in the world. I am wonderful to my patients and am known as a softie in the ER but, but have a hard time truely believing in them like you seem to. I hope you work in an area where you get to utilize those impecable understanding skills alot. I would say you'd eventually get jaded but... with 27 years I guess you wont. You seem kinda idealistic to me (maybe i giveup to easy) but it is inspiring to know that there are people who feel the way you do.

[tooy10]

I am an RN traveler doing dialysis in an inner city chronic dialysis unit.

I routinley have pts. come in for tx. under the influence of all kinds of drugs and etoh. The vast majority of these pts are IDDM, Morbidly hypertensive and run K's in the 6's.

These pts have been given and MASSIVE AMOUNTS of education.

I am not kidding! Daily I talk to people about loss of life and limb.

The pervasive response is, I know I know I know and then the glazed vacant look comes over the face.

I am on my 3rd extention at this clinic.

After the first contract I came to understand that the best I can do is feel good about what I offer, humane, compassionate care despite a total lack of compliace with tx.

It has been the toughest place I have ever worked.

But,,, I'm still there.

[CHATSDALE]

problem with newly dx patients you are trying to educate them while they are still in the denial state

best solution as stated in other post follow up education is absolutely necessary

[woody62, RN]

You must really be the most understanding person in the world. I am wonderful to my patients and am known as a softie in the ER but, but have a hard time truely believing in them like you seem to. I hope you work in an area where you get to utilize those impecable understanding skills alot. I would say you'd eventually get jaded but... with 27 years I guess you wont. You seem kinda idealistic to me (maybe i giveup to easy) but it is inspiring to know that there are people who feel the way you do.

I started my career, as a nurse, working nights on a general med-sur unit. There wasn't much opportunity to interact because most of the patients slept thru the night. And those that didn't, wanted pain medication, which I gladly gave them, to relieve their pain. I moved on to a Burn Unit, on evenings, where I and another nurse, as well as an aid were responsible for all the care and dressing changes for eight to ten patients, varying in age from 12 to 68 years old. I lasted eight months before I was transferred to our general ICU. You would think there, since most of our patients were either comatose or unresponsive and tubed, there would be little interact. And their family members were restricted to visiting for ten minutes every two hours from 8AM to *PM. But I was one of the strange nurses. I believed patients were capable of hearing and understanding everything that was said around them and to them. Unfortunately, every year I had to have a patient demonstrate this to the house staff, who persisted in talking about patients around them. That is, until one of their patient's woke up and repeated what they had heard. A lot of house staff learned that lesson the hard way.

I have been in three car accidents in my adult life. And in each one, I was badly injured. In the first one, I suffered a closed head injury, with a fracture to C4. I was out of work for more then six months. The second one, I was hit by a big rig, and suffered multiple fractures to the left side of my body, as well as a closed head injury. This accident left me unable to ever return to bedside nursing. Between the first two accidents I worked as a staff nurse, an assistant head nurse, a head nurse, a public health administrator and a hospital administrator. I move to Florida and spent nine years working as a major case manager dealing with WC claimants and liability injures. I also worked staff relief on weekends during what we called 'season.'

I've worked in ERs, ICUs, transplant units, medical units, surgical units, to name a few places. I more then likely had the wool pull over my eyes several times but I would rather that happen then short shift a patient or his family. I have been threatened by family members with a gun in ICU. I have had a client appear at my door with a gun in his hand. I have had a client tell me I was lucky he couldn't afford the bullets or I would be dead. I have even been picked up and tossed thru a glass wall by a patient's son, a patient I was discharging from ICU AMA. I also have numerous letters from family members thanking me and others for helping their loved one make it thru his/her illness or injury or surgery. And I have letters from patients thank me and others. I've kept them all. I have even gotten letters from a family member thanking me for helping their loved one to not be afraid when dying-something I do not understand, since all I did was be there.

I am not a saint nor am I a sinner. I have always attempted to treat patients and their families like I would want myself or my family treated. And at times I had to face very angry, very troubled people who have been somewhat irrational and unreasonable. I've tried very hard not to allow my own anger to overcome me, that just makes the situation worse. I taught for a short time and I attempted to impart this to my students. One can attempt to hide their emotions and feel they do quite well but a patient and family can pick up on one's feelings. If you have negative feelings, no matter how hard you try to hide them, you don't succeed, you just think you do, believe me. I know when nurses have been angry at me, frustrated with me, when I was a patient. And a lot of them prided themselves on their professionalism. I learned a long time a go, if I felt anger at someone, I need to get it resolved. And if it took professional help, I got it.

Today it is much easier to say the patient only spends a short time in the hospital and he/she has to be taught everything. And if they will not learn, pass over them, go on to someone who will. If you do that, that patient will end up back in your hospital, on your floor, sicker then he/she was the last time. And if you keep repeating the cycle, they will come back until they die. Then no one will have to worry about teaching them any more. And if they are on medicaid, your tax dollar will no longer be wasted, will it?

Woody:balloons:

[MaryAnn_RN]

We have several like this in the Nursing Home,buzz for every little thing instead of doing it themselves,lie like a stone and nearly give the nurses a hernia trying to move them when they are perfectly capable of moving themselves. When it is explained to them that they could do so much more to help it's as if you are insulting them! I think some of them think that ,just because they are paying to be there,we should run around doing everything for them.

We also have the really unmotivated ones who just don't want to be here anymore,very heartbreaking,and soul destroying.

We get bariatric surgery patients like that, won't lift a finger to help themselves

[Iconoclast]

I work in Southern Appalachia and I see A LOT of pts like those described by the OP. They are either completely or functionally illiterate and very "backward" (no offense intended, can't think of a more PC way to say it) I frequently have patients that have no electricity or running water in their home. Incest is not uncommon, alcoholism, marriage and childbirth in the early teens is the norm. Generation after generation. Add to that the loverly fact that we are now the meth capitol of the US, and I often feel quite hopeless.

When I feel that way, I tell myself that in all likelihood they are going to forget or ignore any/everything I tell them, so I try to just get ONE thing to count. Maybe my 20 year old DKAer that I seee twice a month will NEVER "get" or comply with her tx, but maybe something I say will get her out of the abusive relationship she is in. Bad enough to be 20 and in the shape she's in, but she and her kids are routinely beaten. Cops and social workers try, but the effect is always temporary. My position now is: "Have a twinkie, but leave the bastard." sigh...I dunno. Sometimes, the best you can do is the best you can do.

[november17, ASN, RN]

I remember reading this thread the first time around. It's funny how even 6 months can make a difference in my perception of patients.

Is it possible the patient was suffering from delerium? The "hyper" signs of delerium are very obvious - Pulling at lines, assaulting staff, yelling, etc. There is a "hypo" side to delerium as well which is a flat effect, signs which mimic depression, listlessness.

I'd certainly think that someone who a short time ago had a BS of 600 could be suffering from it. Her decreased cognitive skills could easily be misinterpreted as what you just described.

Maybe she's mentally very sensitive to delerium? Couple that with ongoing medical problems that require frequent hospitalization (different environment, etc), and it seems like there might be something going on there that is obviously being undertreated. Dunno...Just thought I'd throw that out there.

[edowhitetop]

Sometimes patients can be extremely difficult - but that is part of the job. Just be glad you are on your side of the relationship.