Large man wound care

leslie :-D · Dec 28, 2003

the snf that he's going to will probably order a psche eval. and any competent facility will make sure he's repo'd while in bed; and he'll be changed q4h/prn; and he'll be reassured but w/limit setting if necessary. good nursing care commands many interventions; avoidance is not one of them.

Tweety, BSN, RN · Dec 28, 2003

I've had several patients as you are describing and I feel your concern and frustrations.

I don't have any suggestions though. The dynamics of what he's going through is so complicated. He's angry, he's afraid, he's got control issues, he's in pain, he's in denial on and on. Probably underneath it all is a lot of fear.

Bottom line is though that he's making his own choices here. You can only take care of him the best you can, teach him, set limits as to what is an isn't acceptable behavior, ignore rude and nasty comments while you're doing his care, leave the room when he is very inappropriate, etc.

Also, supervisors should be rotating his care daily so people don't get frustrated and then refuse to care for him.

Good luck. He's lucky you care.

CseMgr1, ASN, RN · Dec 28, 2003

I had the same type of case when I worked in Home Health several years ago. This patient had a nasty abdominal wound which tunneled to hell and back. He was also a diabetic and as non-compliant as they come. The house he lived in was in an upscale neighborhood, but filthy and nasty on the inside. He had a large dog, who he INSISTED having on his bed, while dressing changes were being done...until he made my aquaintance. I refused to do his care, until he made that dog stay down off the bed. While I didn't win any popularity contests with this guy, the structuring that I did made him realize that he was going to have to behave..if he was going to get the care that he needed.

After I stopped seeing him, the word started getting around that he was physically manipulating his wound...to keep the nurses coming. He had become so difficult that more and more nurses refused to see him, and he was finally discharged from our agency. He later died. A pathetic human being.....

Agnus · Dec 28, 2003

I think we all realize this fellow craves attention. I have no doubt the reasons behind it are complicated. All his behaviors are attention seeking. The wound, incontinence, etc are ways to insure he receives attention.

Perhaps if the need for attention were addressed directly. That is some arrangement were made to see that this man got undivided attention focused on him as a person. Not focused on his wounds or physical care just him as a man. Maybe this would reduce the need to self destruct his body to get the attention.

He is probably feeling unappreciated and unloved. Somehow a way needs to be found to show him these things apart from the attention given to the physical.

I know probably not much help but maybe stimulate some of our creative juices here.

Jay-Jay, RN · Dec 28, 2003

I had a wound care case that was somewhat similar. He was a diabetic with Stage 4 pressure sores on his buttocks. He refused to stay in bed and allow them to heal. He was up in his wheelchair most of the day. We were doing Acticoat on the ulcers. It was a MASSIVE dressing. Took a minimum of 1 hour, if you knew where everything was, how to gett him from bed to chair, etc.

He did not have a/c in his townhouse, so when the weather got really hot, he would dump a glass of water over his head, and sit in front of a fan. Of course that would wet the dressing, and cause the wound to macerate and deteriorate even further.

He eventually moved away, and continued to receive home care in his new location. A short time later he died.

The horrible tragedy of it was his son, who was also diabetic, and his main caregiver, ALSO died a short time after his dad. I don't know the details, but suspect that once his dad was gone, he lost his will to live, and let his BS get out of control. (He also had Ca. of the prostate, but it was in remission, as far as I know.)

Sometimes there isn't ANYTHING you can do.... People make their choices, and that's it. You do your best to convince them of what they need in order to heal, but if they won't listen, and co-operate, there's not a lot you can do.

zacarias, ASN, RN · Dec 28, 2003

Thanks guys...

I'm a pretty caring guy and I just wish there was something we can do.

I appreciate all your comments and encouragement and stories. At least I know I'm not alone. And for the first poster, clearly I'm not avoiding the issue; My posts clearly states I wish to do the best I can for this man.

I agree he's an attention seeker and needs to be addressed as a person. Unfortunately, I do give him more attention than most nurses but it's not enough. Also, he's SO huge and non-compliant/demanding that we don't have the staff and time to give him excellent care where his wounds are concerned. If we put him in one of those arjo things, he'd die of a coronary because of anxiety. Also with his sleep apnea, docs would hurl before giving the guy lorazepam.

I just am beginning to think that sometimes there are people that we will run across that are screwed, for lack of a better term.

Thanks for listening.

CseMgr1, ASN, RN · Dec 28, 2003

Originally posted by Jay-Jay
Sometimes there isn't ANYTHING you can do.... People make their choices, and that's it. You do your best to convince them of what they need in order to heal, but if they won't listen, and co-operate, there's not a lot you can do.

AMEN. I wonder just how many billions$ of taxpayer money have been flushed down the drain, because of this very issue, too.

BarbPick · Dec 28, 2003

Originally posted by earle58

the snf that he's going to will probably order a psche eval.

That is what is missing. SNF have little time to invest in his nonsense. They have taken care of worse. He will be put on as much medication as needed to stop him from shooting himself in the foot. The last resort for these people are colostomies to stop skin breakdown.

Hellllllo Nurse, BSN, RN · Dec 28, 2003

zcarias-

I feel for you. I've had plenty of pts like this in my time- even some really skinny, tiny ones who were just as difficult to turn and transfer as the big ones, r/t their manipulation of the situation. These pts can just suck the life out of their caregivers.

When I've had these pts who stop you in mid turn/transfer to ask questions, etc. I've told them "Turning/transferring someone is like swinging a sledge hammer. You get prepared, and then you just do it. Stopping in the middle is not possible. One or all of us will get hurt. So, we're going to do this now. Ready? one-two-three...."

When I've had a pt who rings the call light every 5 mins for some bs request, I say something like "Mr. X, before I leave, I want you to make sure you don't need anything else." (Do a quick scan to check that anything he might need is within reach). "I am not able to come in here every five minutes. Now, here's your water/call light/pillow/whatever. (I often use touch at this point to reassure the pt. Touch their hand or arm and smile) I will come back and check on you in approx 1/2 hour."

As for the rest of it- be kind, and polite, but firm. Always get help for transfers, no matter what. Make sure the bed and chair brakes are locked. Look him in the eye to acknowledge him.... and set limits!

Say things like "Mr. X, I have other pts waiting for me. We've got ten minutes to do xyz. If you're not ready/finished in ten minutes. We'll have to stop and finish later."

Doing these kinds of things has helped me to care for this type of pt without going crazy. It's still really wearing on a nurse!

If a volunteer can spend time w/ him during the day and provide some diversion, it might be helpful.

Rotating staff assigned to this pt, and sticking to the assignment helps a lot, too. So does venting, here.

germain · Dec 28, 2003

I was thinking, god, this guy sounds so familliar, then I realized that we work at the same hopital. I know this guy too, as an HA, all I can say is strength be with you and thank you so much for taking the extra time with the poor soul, even if his needs are bottomless. He is hte worst of the worst, in terms of need. Youre a great nurse. keep at it and give yourself a pat on the back.

ktwlpn, LPN · Dec 29, 2003

Originally posted by germain
I was thinking, god, this guy sounds so familliar, then I realized that we work at the same hopital. I know this guy too,

Can you hear the music? It's a small world after all,it's a small world after all,it's a small world after all...it's a small small world.....