medical abuse?

ChristineN, BSN, RN · Oct 16, 2013

What was the medical rational for the in and out cath? Sometimes when you have pts that are not able to give consent, such as your dementia lady, there are treatments that are medically necessary that need to be done. However, you should try to ensure that the pt is as comfortable as possible. You can try distraction techniques for example, but sometimes, especially in a pt with advanced dementia comfort measures may not seem very effective. Hang in there, I know it can be an awkward experience for a student. I encourage you to talk to your instructor about what happened

loriangel14, RN · Oct 16, 2013

I have been in this position several times. Sometimes you just gotta do what you gotta do.We will do in and outs for urine specimens.

Pondmud · Oct 16, 2013

I think the context surrounding why she was straight-cathed is important. What if she were retaining urine, and they didn't want to go with a continuous catheterization because 1. they hope to resolve the problem and return her to continence, or 2. they suspect she is at risk of pulling the tube and thus cause herself serious injury?

Now - Hopefully whoever ordered the cath considered all other alternative. Also hopefully, they did everything they could to manage the pain (pre-medication, lidocaine jelly, etc.).

The other element to this is your reaction to the patient's experience of the procedure and the pain it caused. While you don't want to harden yourself, it's also one of those things that you'll have to do, like being a parent and taking your kid to get a vaccination. They will cry, and maybe tell you they hate you, and maybe be a little scared of nurses and doctors - but ultimately, aren't you preventing a bigger harm? I won't say it becomes less uncomfortable for you. Maybe the discomfort becomes familiar, and you draw your own lines between what is ok for the greater good, and what is ethically distressing?

jadelpn, LPN, EMT-B · Oct 16, 2013

If the patient is demented to the point of not remembering what you are doing, then be sure that there's consent from someone other than the patient. Sometimes, this also means that a family member is present to help calm the patient while the procedure is being done.

This is something that needed to be done. And if short term memory is an issue, then i am curious about the patient's behavior 5 minutes after. Did she completely forget that the procedure ever took place? Or was she still crying and complaining of pain? If she was still crying and c/o pain, then something else may be happening with her that is causing the distress and pain. Would warrant further investigation--anything from yeast, does her peri area have open areas, is there some sort of bladder issue that may be present--lots of things. It is an uncomfortable procedure, it is invasive, and if this should have to happen again, an alternate plan for family support. There is even a thought that with a toileting program for the day--literally putting the resident on the toilet every 2 hours may get you a sample, not a clean catch, but at least a sample.

There are a lot of things that we do as nurses that are uncomfortable to a patient. The only thing you can do is to make the procedure as comfortable as possible. And let the patient cry, say owwww, whatever it is that releases that tension for them.

Altra, BSN, RN · Oct 16, 2013

If the patient is demented to the point of not remembering what you are doing, then be sure that there's consent from someone other than the patient. Sometimes, this also means that a family member is present to help calm the patient while the procedure is being done.
This is something that needed to be done. And if short term memory is an issue, then i am curious about the patient's behavior 5 minutes after. Did she completely forget that the procedure ever took place? Or was she still crying and complaining of pain? If she was still crying and c/o pain, then something else may be happening with her that is causing the distress and pain. Would warrant further investigation--anything from yeast, does her peri area have open areas, is there some sort of bladder issue that may be present--lots of things. It is an uncomfortable procedure, it is invasive, and if this should have to happen again, an alternate plan for family support. There is even a thought that with a toileting program for the day--literally putting the resident on the toilet every 2 hours may get you a sample, not a clean catch, but at least a sample.
There are a lot of things that we do as nurses that are uncomfortable to a patient. The only thing you can do is to make the procedure as comfortable as possible. And let the patient cry, say owwww, whatever it is that releases that tension for them.

As the OP relates this experience, it appears to have occurred in an acute care setting. Obtaining a urine specimen now as opposed to several hours from now can be important in starting antibiotics or obtaining other UA or urine electrolytes data so that the patient can be treated in a timely manner. And like other bedside nursing procedures, specific consent is not obtained for catheterization -- it is covered in the general consent to treat.

Pondmud · Oct 17, 2013

There may be a consent to treat, implied agreement as evidenced by the patient consenting to be admitted to the hospital; but upon admission don't we all have our patients sign a Patient's Bill of Rights, reminding them that they have the right to refuse treatment as well?

It's so much cleaner when someone is 5150'ed, and to a lesser end-stage dementia, and a much, much lesser degree delirium... OP, is this your struggle? Or is it a more basic human pain of observing someone else in pain?

Esme12, ASN, BSN, RN · Oct 17, 2013

NOt really.....sometimes as nurses we need to perform procedure for the patients best interest. I tis under the general consent and if the patient is exhibiting signs of infection with increased agitation/confusion and a UTI is suspected...a in and out cath is indicated and is usual and customary.

It is for the benefit of the patient....elderly that are confused/children will scream...NO NO NO!!! But the decision has to be yes yes yes....we are not being brutal we are doing what is necessary for the patient. The intent is not assaultive....it is a necessary evil to help them heal and they can't understand it.

Nursing isn't always black and white....and not everyone needs a psych hold for treatment.

loriangel14, RN · Oct 17, 2013

NOt really.....sometimes as nurses we need to perform procedure for the patients best interest. I tis under the general consent and if the patient is exhibiting signs of infection with increased agitation/confusion and a UTI is suspected...a in and out cath is indicated and is usual and customary.
It is for the benefit of the patient....elderly that are confused/children will scream...NO NO NO!!! But the decision has to be yes yes yes....we are not being brutal we are doing what is necessary for the patient. The intent is not assaultive....it is a necessary evil to help them heal and they can't understand it.
Nursing isn't always black and white....and not everyone needs a psych hold for treatment.

Well yes, a child will scream when an IV is being started but it still has to be done.

LPN709 · Oct 17, 2013

It's funny I had the exact same situation when I did my clinicals in the hospital. The only difference was I was the one putting in the catheter and it was indwelling. My first catheter ever. I felt so bad because she started crying. But when I put the catheter in and so much urine came out I had to clamp it...and after I unclamped it ever MORE came out...I knew she had to feel so much better with the catheter. I didn't feel so bad after that lol I promise you, it's normal to feel bad but ultimately your doing the right thing for your patient. You'll quit feeling bad eventually...especially when it saves someone's life!!! :)

KelRN215, BSN, RN · Oct 18, 2013

No, it's not abuse. The patient was demented. Demented elderly people are much like children in this sense. I had a child today who cried and kicked and screamed when I gave her a shot. She's too young to rationalize the need for it while this lady is too cognitively impaired. Specific consent is not required for straight cathing. Obviously if a cognitively intact adult says "you're not cathing me", you don't cath him (I had this situation in my life three years ago... intern comes in and says "we're going to put a foley in you". I say "no you're not." She says "well we need really accurate I&O" and I say "I'll pee in a hat." And the matter was dropped for a few minutes. And then I got transferred to the ICU and those interns also decided that I needed a foley. I could hear the nurses arguing with them from my room saying "this is a normal 26 year old, she can use the bathroom". Needless to say, I didn't let anyone near me with a foley cath.) but this isn't that kind of situation.

MunoRN, RN · Oct 18, 2013

I think we're confusing situations where signed consent is needed vs where only verbal consent is needed. Consent is actually required for straight cathing even though signed consent is usually not required. Consent is required for each time we draw labs and even give medications as well, it just doesn't have to be in writing. The only exceptions are where the patient is incompetent to make medical decisions or where a Physician has declared medical necessity in place of consent.