nurses hide from high-needs pt

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Today I had a bariatric-size patient on med-surg floor. CA pt comes in for BSO. Large vertical abd incision dehisces and resists healing. Her health is not improving after a month in hospital and a short stay in ICU. She is very high maintenance. She needs to be toileted every 20-30 minutes (diarrhea) but she's unable to get to commode or bedpan without help. It's a 2 person assist (200+ lbs unsteady weight) but she doesn't want us using the lift. She's in constant pain "all over". She's got IV, central line, 2 nephrostomy drains, ilieal conduit drain, O2, and woundvac lines that she keeps tripping over and being upset about. She wouldn't ambulate so she ended up with DVT. Contact precautions because she's now got an infection. Also has a skin yeast infection in her folds because she can't shower or keep clean enough. Bedsore risk due to immobility. Edema isn't improving. Having trouble regulating body temp and needs a fan or a blanket brought to her on and off all morning. In short, she just needs alot of nursing care.

Today, as a student nurse, she was my patient. For the first time in this facility, I felt like I could not find my primary nurse or my aide. For my entire shift, I saw my aide once and then I swear she hid from me because I could NOT find her anywhere. After talking to my classmates who had her over the past few weeks, turns out they commented the same thing: nurses HIDE from this one patient. At one point my primary refused to get me pt's pain meds because nurse was "too busy", and she sent me to go beg help getting the med out of the Pyxis from another section's nurse. What was my pt's nurse doing that was so important? She wandered off to watch a new product demo at the other end of the unit when a vendor wandered through.

So, to use this as a learning opportunity, I had some questions:

Is there a good way of addressing it so that this pt gets the level of attention she needs? Was it a hospital policy issue (# pts per nurse) or something else? Is this common in some hospitals to treat a high-needs pt the same way as everyone else, not allowing for the extra attention she needs?

Any tips on dealing with pt when you can't get a helper but she's a 2 person assist -- but she throws a fit about the lift sling. She's also having explosive diarrhea, so even if I used the lift to get a commode or bedpan under her, I have no way by myself to lift this large woman off the sling enough that she can access the commode. She refuses to stay on the commode more than 5 minutes because commode is not bariatric-sized and pt states "it's too uncomfortable", so we'll get her back in bed, and 10 minutes later she starts asking for the commode again.

Any words of wisdom for me? Right now I feel disturbed to see a patient who needed care so much being avoided as the 'problem' patient. Was the staff at fault? Or where they good people just overwhelmed by the situation, and it's management's fault for not staffing things better?

If you were her primary nurse, is there anything you could do to improve her overall situation? Could you call a case worker or your supervisor to share concerns?

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Specializes in Med/Surg.

Welcome to med-surg, sounds like a typical patient on my unit. In my experience it is less the nursing needs of this patient than their attitude and unwillingness to cooperate with the staff that would be more the issue of people wanting to avoid them. We've had several patients on our unit referred to as "one-nighters" because they are mentally, physically and emotionally that draining. Personally I try not to do this as all people in the hospital need a nurse. To answer your questions:

1. It could be, sometimes theres not enough time in the day, and sometimes have to wait. It's easy to think that because you've spent 90% of your time with one patient and that patient and the one you've spent maybe 5 minutes with call at the same time to think that the one you've spent less time with gets first priority. Evidence based practice says we should use acuity based staffing, which takes into consideration the amount of time a patient requires rather than a number, that being said it isn't always feasible to do.

2. At some point this becomes less about wants and more about patient safety. If she is not safe to ambulate with one assist, you do NOT ambulate her with one assist. She either uses the lift or she waits for you to find someone. Why does she not like using the lift? Has it been explained to her that it is for her safety?

3. I think its easy to look at things with rose colored glasses and think that the system is broken and needs to be fixed, well it is broken but the solution isn't anything that can easily be fixed, the fact is everyone takes some blame in that situation.

4. I would leave a note to her doctor seeing if it might be possible to have her a higher level of care where the patient to staff ratio was less. Also consider a PT/OT consult to see if she might be able to improve her ambulation and care for her own hygiene, Wound care consult if not already done, Also see about getting her a bariatric commode, or fecal management system depending on the consistancy of her stool.

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She sounds like the kind of patient I avoid, yes. I do what needs to be done and will answer her call light the first 22 times but I won't cater to a non-compliant, demanding, reusing-to-consider-anyone-else brat. Not using the lift endangers others and she doesn't care. Being unwilling to ambulate earned her a DVT. Not wanting to use the bedpan ties up two staff to transfer her frequently. She refused to stay on the commode because she's too tender to take it.

Heck, yeah, I'm hiding from her.

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Specializes in Professional Development Specialist.

I kind of have to agree with Sue. As a student I generally took these pts. Often there was a significant psychological diagnosis to accompany the medical issues. As a nurse I don't ignore them, I definately tend to their needs. But there is some point where a certain amount of personal responsibility on the pts part is required. Caregiver safety overrides whether they "like" the lift or not, same with the bedpan. Sometimes people need to have limits set for them, even patients.

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Specializes in Med/Surg.

I agree, as much as I try to be with my patients as much as possible and see that every last one of their needs are met, the fact is that especially in med-surg there are probably a lot of patients that same primary nurse has that have much more life threatening needs and are possibly not able to vocalize them as easily. I understand and commend your desire to help this patient and ensure that all her needs are met, but please try not to be too critical of the nurses and other caregivers that are trying to keep their distance.

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As an aide, I wouldn't dare transfer with one just because I couldn't find someone to help. But i may make comments towards the patient about how difficult it is to find someone so frequently, because all of my other patients need me just as much.

A bit of "tough love" perhaps?

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You can injure your back when lifting or moving even a small, diminutive patient. Trying to do anything alone with this person, or even with only two people, could be catastrophic. I guarantee you if you hurt your back and are disabled, this patient won't be coming around to care for you. I would speak to the supervisors about the refusal to use a lift. There is no excuse for that and it is the responbility of the supervisor to assist her to see the light.

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You can injure your back when lifting or moving even a small, diminutive patient. Trying to do anything alone with this person, or even with only two people, could be catastrophic. I guarantee you if you hurt your back and are disabled, this patient won't be coming around to care for you. I would speak to the supervisors about the refusal to use a lift. There is no excuse for that and it is the responbility of the supervisor to assist her to see the light.

And you can bet your sweet bippy that because she is care-planned for two and you didn't folow it the facility will deny the ensuing workman's comp claim and write you up as well.

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I would not be hiding "from" this patient, I would be giving care "to" my other patients. Equally.

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It's human nature to avoid someone who refuses to do themselves any favors and puts the remainder on you..her nurse. As her nurse we are expected by most to cater to her every whim because we are afraid of being reported by said patient. Personal responsibility comes into play here and she needs to start taking some. The nurse taking care of her had a med-pass, doctors to talk to, notes to write, and a number of other patients to take care of. Sometimes in a 12 hour shift a vendor doing a demo is the only reprieve we get. Sorry for the rant but I have dealt with way too many patients who have refused to take part in their own care plan to the detriment of my other patients.

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With this type of patient I go in, do care, and get out. No more, no less.

I think it's funny that there can be 3 CNAs standing around the nurses station complaining about how bored they are, and as soon as you say you need a couple of them to help you with Mr. "So-and-So," they all of a sudden hear imaginary call lights and remember urgent tasks that need to be completed such as disinfecting siderails and scrubbing bedpans.

Go figure.

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I will quote a nurse that I work with.... "Does she have a pulse? Is she breathing? Then she can wait!":o

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