Non Compliant Wound patient

[Katwel]

I am a home care nurse and have been involved with a wound care patient that is so noncompliant.....My 40 something paraplegic female was found to have a large stage IV wound on her sacrum. This patient has failed to go to wound MD appts, doesn't follow direction when it comes to keeping pressure off her wound and keeping area clean and dry. She will be seeing a new Wound/Plastic surgeon his week, but since I have seen her she has develped two stage II wound in adjacent areas. The patient is in the social work system, has to cg 12 hours a day, but clearly needs to be in a nursing home for more consistent treatment. How do you deal with a patient who clearly doesn't get it and when your consistent teaching goes on deaf ears. I am very frustrated and don't know how to deal with this sad women.

[Nascar nurse, ASN, RN]

You can lead a horse to water but you can't make em drink!

Document & let it go...it's really your only choice

[VivaRN]

1. DOCUMENT. I learned this in a documentation seminar recently, you also have document that you told the patient the consequences of refusal (informed patient that lack of follow up may result in further disability or death, pt. verbalized understanding) so they can't say "I didn't know that was going to happen"

2. Is she mentally impaired? If you feel she needs to be in a nursing home I would communicate with her primary MD so he/she knows what's going on even though the patient doesn't go to appointments. Perhaps the two of you can work out a plan.

I would give the plastics surgeon a heads up as well. If she's going to be admitted for surgery, it's important they have this backstory so she can be discharged to the nursing home. Your input is important! Pick up the phone and communicate with others involved in her care.

Good luck, this situation is never easy.

[flyingchange]

Just wondering, is this person choosing noncompliance because she wants to die? It seems glaringly suicidal...

[himilayaneyes]

Document, document, document. Document all the education you give her and her refusal of treatment. You can't make someone value their own life. She clearly doesn't value her life....perhaps she is ready to go. Just do the best you can. And if you feel that the patient isn't competent enough to care for herself..then you should get the md and social services involved.

[Katwel]

Honestly, I think its more of a case of her depression and her way of controlling the things. She has never talked about how she can't deal with things just that she has so much going on right now in her life that she can't cope, but I feel like she isn't really able to see what is good for her, one minute she tells me she is happy to see the Plastic surgeon and have something done, the next day I visit, I see her bed saturated, dressing off her wound and she seems unable to comprend the seriousness of the situation.

[lilykiss6]

have her see a psychologist, cuz she seems mentally unstable

[NotFlo]

You can lead a horse to water but you can't make em drink!

Document & let it go...it's really your only choice

I totally agree, as frustrating as it is, this is what you have to do. I know a patient in an inpatient setting that was in almost the exact same circumstance. This person was incredible...if you went in that room and said up they said down, if you sad the sky's blue they said it was purple, they seriously would not do ONE thing asked of them. Many people like this will also enjoy your frustration and distress and they are master manipulators.

Eventually I had to realize if it isn't bothering them I'm not going to let it bother me! As long as I was doing everything I needed to do regarding educating (falling on deaf ears but still) and documenting there was nothing else to be done.

[Pepper The Cat, BSN, RN]

You can educate. You can encourage. You can't force them to comply.

I had a pt with Parkinson's Disease who needed to go on thickened fluids because of swallowing difficulties. He hated thickened fluids. He (and his wife) asked what would happen if he drank regular fluids. I provided him with the info and he made his choice. He continued to drink regular fluids and developed aspiration pneumonia which lead to his death. It was his choice. He decided that living on thickened fluids was not something he could do. Perhaps your pt is making a similar choice? She has decided that she can't live with the regime of drsg changes, etc that a Stage IV ulcer requires. Maybe not the choice we would make, but its her choice in the end.

[Katwel]

Your all so right, and deep down, I know this but, its so upsetting when you try to do things for patients and want a positive outcome, it just makes you feel like you failed. I will continue to do what I can, and of course continue to teach, but I know we can only provide the information and hope that in the end the patient makes the right decision.

[grannyrn65]

I have gotten the impression, from your two post, that she is non-compliant because she is over-whelmed, by a variety of problems. And that she is caught between wanting to help herself, wanting others to take over, and ready to give up completely. Is there by any chance, a case manager assigned to her? If her care is funded because of a W/C claim or a liability settlement, she would likely have one. This would be the first person I would approach. If not, involve her primary care and wound specialist, which may be more difficult. In all likelihood she is going to need inpatient surgery. As an inpatient social service and nursing can become involved in discharge planning, including discharge to a rehab center/nursing home. I realize you will have to give up the patient's care but everyone needs to consider what is in her best interest and not their employer's.

GrannyRN65

[LoveANurse09]

I see these pts all the time as inpatients. Multiple wound debridements, antibiotics,sepsis,wounds vacs,skin grafts. It never ends. These patients are so depressed that they just don't care anymore. Psych consult might help her, but she still has to comply and you just can't force that, sad as it may be.