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Insight Dialogues: What Would You Do?

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Let me start off for those of you who don't know me:

I work at a LTC facility that is run by state. This facility cares for individuals with mental and physical disabilities. The population ranges from profound to slight mental-retardation. Behaviors range from PICA to SIB to over violence. (Not all of them have these behaviors of course.)

Recently I was given an in-service, or "Insight Dialogue" asking me what I would o in a particular situation. Now I'm curious as to how you would react in the situation given:

(NOTE: I'm not quoting word for word, I'm just rebuilding a similar scenario.)

It is time for an individual, that you were assigned to, to take his shower. When you approach the individual to tell him this he asks you if it would be okay to smoke a cigarette first. You don't see a problem with this so you go outside to monitor the individual while he smokes his cigarette. Before he lights it, however, you notice that he has urinated himself. You ask him to come back inside to change and wash up before he smokes his cigarette. He insists on smoking his cigarette and this request causes the individual to become agitated. You know he has a history of violence toward staff when he does not get his way. What do you do?

The correct answer may or may not surprise you. It didn't really surprise me... but then again I've been working at this place for about 3 years now... nothing... and I mean nothing phases me anymore lol.

sharona97, BSN, RN

Specializes in IM/Critical Care/Cardiology.

Ask a co-worker for back-up. If policy neccesitates the pt to return "inside" after urinating on himself, safety first. Did h/she know they had urinated? Was it gently discussed? Safety first IMO.

I'd let him smoke first then go in for his shower. Safety first - is it necessary to make a huge deal out of incontinence?

steph

joprasklpn

Specializes in pediatric and geriatric. Has 19 years experience.

I would think he could smoke his cig. first. Pee pants won't kill him and why agitate him.

Hmm... will having urinated himself cause more of a threat to his health than further agitating him, Sharona?

(thanks for deleting the answer . . .I was just going to tell you that so we could discuss it further and see what other folks think).

steph

(thanks for deleting the answer . . .I was just going to tell you that so we could discuss it further and see what other folks think).

steph

yerp no problem

sirI, MSN, APRN, NP

Specializes in Education, FP, LNC, Forensics, ED, OB. Has 30 years experience.

Looks like to me you've already given in for one request and with the hx of the patient, why not give in to the second? Unless there are other unseen issues involved here.

You figure on one hand... here is the individual sitting in his own water... outside..., dirty as he is because he hasn't taken his shower yet... in the elements...

But on the other hand... if he doesn't get his nicotine fix he might start yelling or he might tell the supervisor that you hit him (this has happened before... and it happens all the time) or something bad like that.

Also take into consideration that if the individual is allowed to smoke his cigarette there is a chance that other staff on grounds will see this individual with urine on his pants... maybe some supervisors! How would you explain yourself?

sirI, MSN, APRN, NP

Specializes in Education, FP, LNC, Forensics, ED, OB. Has 30 years experience.

What outside elements?

A couple minutes cig isn't going to be detrimental to his health (and, I'm not talking about nicotine and health-related issues - I'm speaking of time taken to smoke causing health concerns as they relate to urine-soaked trousers).

sharona97, BSN, RN

Specializes in IM/Critical Care/Cardiology.

Hmm... will having urinated himself cause more of a threat to his health than further agitating him, Sharona?

I guess I misunderstood your "situation". You mentioned that you asked the pt to come in before smoking the cig. No, of course I don't think that incontinence is worth the hassle of agitation, but that wasn't expressed in your question. That is why I asked if it was discussed and brought up the policy issue....maybe more info needed to be given. I gave a response to the info given with concern for your safety as you OP did say the patient has a hx of violence, I've never worked in your work setting, but I would think there are times when back-up with violent patients would not be uncommon.

So, let s/he smoke and then proceed with shower hopefully without event!

Better answer for you? I read your answer and totally agree with it, document and CYA. Same as anything else,eh?

sharona97, BSN, RN

Specializes in IM/Critical Care/Cardiology.

You figure on one hand... here is the individual sitting in his own water... outside..., dirty as he is because he hasn't taken his shower yet... in the elements...

But on the other hand... if he doesn't get his nicotine fix he might start yelling or he might tell the supervisor that you hit him (this has happened before... and it happens all the time) or something bad like that.

Also take into consideration that if the individual is allowed to smoke his cigarette there is a chance that other staff on grounds will see this individual with urine on his pants... maybe some supervisors! How would you explain yourself?

Good question, how would you?

(NOTE: I'm not quoting word for word, I'm just rebuilding a similar scenario.)

It is time for an individual, that you were assigned to, to take his shower. When you approach the individual to tell him this he asks you if it would be okay to smoke a cigarette first. You don't see a problem with this so you go outside to monitor the individual while he smokes his cigarette. Before he lights it, however, you notice that he has urinated himself. You ask him to come back inside to change and wash up before he smokes his cigarette. He insists on smoking his cigarette and this request causes the individual to become agitated. You know he has a history of violence toward staff when he does not get his way. What do you do?

Sit upwind.

hahaha Sharon, you're right. Please I didn't mean any offense. Everyone answered correctly. I was just playing devils advocate. If staff came up and questioned it I would simply tell them what happened.

Sit upwind.

*snort*

I let him have the cigarette. If a supervisor questions the wet pants I say, "Yes, they're wet. He wanted his cigarette. We're going to take care of that as soon as he's done." "Oh, I should insist that he change first? Well, he weighs 230 and he'll try to hit me. Would you care to get him to change?"

That might be one reason I don't hold jobs....

sharona97, BSN, RN

Specializes in IM/Critical Care/Cardiology.

hahaha Sharon, you're right. Please I didn't mean any offense. Everyone answered correctly. I was just playing devils advocate. If staff came up and questioned it I would simply tell them what happened.

I knew you were holding out!;)

*snort*

I let him have the cigarette. If a supervisor questions the wet pants I say, "Yes, they're wet. He wanted his cigarette. We're going to take care of that as soon as he's done." "Oh, I should insist that he change first? Well, he weighs 230 and he'll try to hit me. Would you care to get him to change?"

That might be one reason I don't hold jobs....

That's the right answer. If the supervisor insists on you changing him that minute she would be in the wrong... and anything resulting from that decision would be on her.

I knew you were holding out!;)

:devil:

They do that at my job hardcore though. Even if you get the right answer they try to convince you that you're wrong... they are a little more intimidating about it than I am. Their theory is that they want to make damn well sure you know what your supposed to do in any given situation. our policy and procedures fill up two shelves in every unit. They are insane..... they have everything listed from what color bus do individuals ride if they smoke to what to do if one has a paper cut... to what you should do in the case that an ind. is trying to eat their own... well never mind.

But yeah.... I love my job none-the-less. And the population is great. You really learn how to deal with people... but you become less tolerant of people who don't live there who should "know better". I remember one time my supervisor got in trouble for wearing a shirt that said, "Stupidity is not a crime... you are free to go."

God.... someday I'm going to write a book about that place. There already is one out called "Hard Candy" but it's... kinda sad and depressing. Mine would be about the quirks of working in a developmental center.

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