My patient is going to get a pressure ulcer and there's little we can do to stop it. How do you handle situations like this?

[wernicke, BSN, RN]

The patient is in her late 90s and is here for rehab following an accident. She has absolutely zero cognitive deficits-sharp as a tack. She also has no diagnosed psychiatric history. Her medical history is surprisingly minimal, and her prognosis is great once she completes rehab. I'm willing to bet she will make it to 100 at least. However, she is at high risk for a pressure ulcer because of a behavior. 

She is absolutely insistent on sitting on the bed pan for as long as physically possible, even when she does not have to go. She is mildly incontinent of urine but only ever wore menstrual pads for this at home. It is worse due to her current situation. She has briefs, and our call bell response time is usually about 1-3 minutes (not bad given our ratios; everyone's a team player, even the director of the facility will answer call lights when making the rounds). She denies urinary urgency. 

She states that sitting on the bed pan makes her feel prepared. She has no fear of involving staff in her care, as she makes very frequent use of her call bell. 

I think she is struggling emotionally with needing what she considers to be a diaper. She has, however, refused all psychiatric consults including psychotherapy. Attempts to bring up the subject gently or casually have failed as well. 

She has been educated ad nauseam and in many different ways that she is placing herself at very high risk for a pressure ulcer, and what the consequences of an ulcer would be. She has also refused any and every intervention, even those strongly focused on her dignity. We have thought about taking the bed pan away as an option but the ethics of that are quite thorny. After all, since she is a totally competent adult, that would be paternalism. 

I am documenting, documenting, documenting so legally I think we are in the clear. It's just the ethics/morals of the whole thing. I hate seeing someone set themselves up for so much pain and a worsened prognosis. 

[NurseBlaq]

Have you tried putting her on a bowel training program? Don't take it away completely but set limits and stick to them. Continue to document. Does she have next of kin you can bring in for a family meeting? I think that would be necessary for not only educational purposes and family support, but you can have a familial presence. Be sure to explain the risk of her behaviors including, and up to, the worst case scenario regarding pressure ulcers. It will protect the staff, the facility, and insurance billing if she does develop a decube.

[TriciaJ, RN]

When a behaviour makes no sense, despite much instruction, it makes me wonder if everyone is barking up the wrong tree.

The clue is that she frequently uses the call light and states she wants to be "prepared".  I think it's a control issue and a need for frequent interaction.

Is the lady ambulatory?  Would it be appropriate to take her for frequent walks?  This will provide staff interaction and skin recuperation time.  Replace the "teaching" sessions with something more positive.  I really don't think the issue is her fear of incontinence.

Good luck.

[marienm, RN, CCRN]

Tricia is probably right but if continence/preparedness is actually the concern, could she use a Purewick?  Or if she is able to ambulate, up to the commode every 2-3 hours while awake. We have patients who we don't allow to use bedpans because they NEED to get moving. The M.D. will place orders to this effect. 

[JKL33]

Interesting post. I like to read of nurses thinking through patients' individual situations like this instead of it always being about whatever the protocol is.

In the interest of discussion, though, I am not sure it is quite this simple:

8 hours ago, wernicke said:

We have thought about taking the bed pan away as an option but the ethics of that are quite thorny. After all, since she is a totally competent adult, that would be paternalism. 

I would think of this in terms of autonomy vs. nonmaleficence. There are actually a lot of common nursing situations where these same two principles oppose each other. 

My thinking would be as follows: Patients do have the right to make their own decisions. Others are not obligated to help them facilitate/carry out choices which are solidly known to be harmful to themselves or others. There is a second aspect here (I think?) - which is that it's one thing to have a patient refuse something wherein doing it anyway would constitute medical battery. We would not go against their wishes in that situation. It is different thing to give a device to someone knowing that they are going to misuse it in a way that is widely known to be significantly harmful. I do not believe that we have an ethical obligation to participate in or facilitate the latter.

I would not find it paternalistic to have just stated that this device is not used that way because it has been shown to be harmful. We are not authorized to use this device that way. Then hold the line. If necessary I would provide information on manufacturer's instructions for use, sourced information from professional specialty organizations, regulatory agencies, etc.

Then segue into brainstorming other options. I know she has rejected other options at this point but people often do that when their preference appears to still remain an option.

[DesiDani]

Like Tricia asked, is she ambulatory? If so can she use a BSC?

[FolksBtrippin, BSN, RN]

Is she able to use the menstrual pads she uses at home? 

I also agree with JKL33 that you aren't obliged to allow the bedpan. 

And if she can ambulate, that would be my focus, to just get rid of it entirely. 

[NurseLy, BSN, RN]

I think it’s totally appropriate to tell a patient they can not sit on a bed pan constantly. 

Just a thought - when I worked rehab, we absolutely did not use bedpans. It did not matter if the patient was a 2 assist, required a transfer board, used a lift, etc. 

We had to tell the patient it was part of their therapy program to use the restroom how they would when they are home. The more they practice transferring with whatever their new deficit is, the easier it becomes. 

[wernicke, BSN, RN]

Happy update-she stopped this behavior! 

Turns out she had a traumatic experience with incontinence in a healthcare setting. She was able to work through it, and the traumatic situation was very preventable so we were able to assure her that it would never happen here (not going to go into specifics for privacy but let's just say some people were possibly burnt out and definitely shockingly unkind at the other facility). She's a lady who likes to have her makeup just so, and everything in its place, etc. So the combo of a bad experience plus her personality led to this behavior. 

We very rarely use a bed pan-only for people who cannot be ambulated and for whom a Hoyer is painful. It's a way to preserve dignity as cognitively intact people are often very upset at the idea of having to "wet themselves in a diaper", as one once put it. She is now ambulatory with help. 

[lmichelle25, BSN, RN]

I'm glad to hear she's not still wanting to sit on the bed pan. Before I read your last comment, I was going to agree with the other posters who suggested telling her you can't keep using the bed pan because it's more of a risk at this point. I make it a point to NEVER use the word diaper when referring to a brief or depends. I've heard other nurses and techs say it occasionally, but I try to call them underwear or depends (usually whichever I hear the patient call them). We're on a pressure ulcer prevention kick at my hospital, so no briefs in bed, but if patients specifically request them, then we can make a note and allow them. We also have mesh panties, like the ones in post partum, and menstrual pads, so we can make due if a lady likes using those instead. I'm sure a rehab is totally different with your supplies, but I'm glad you recognized the possible outcome and worked to stop it before it happened. We've gotten people (mostly being cared for at home) who turned septic and died because of horrible pressure ulcers. 

[Hannahbanana, BSN, MSN]

Sounds like all’s well that ends well, so bravo. Great work in figuring out why this lady did what she did.

One small cavil: the term “pressure ulcer” has been out of use for many years. This is because you can have a very serious pressure injury without any visible skin damage, only to have big underlying wound c necrosis become apparent later. I know it’s still called the NPUAP, but they recommend the term “pressure injury” to alert people to the unseen damage that could be there. 

[amoLucia]

Please define NPUAP. I know what you're talking about, but the exact abbrev ...

This post has struck a very deep chord with me. I could write a book about my descent into involuntary urinary 'incontinence by default' that I acquired while as a pt in a rehab facility. Maybe ...

Also, just know that a Purewick would most prob NOT be an option for this lady. BTDT.