nurses hide from high-needs pt

[CeilingCat]

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?

[PostOpPrincess, BSN, RN]

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.

I often wonder why it becomes our responsibility to fix someone who did this to him/herself.

But, being the nurse I am, I wouldn't put up with her attitude.

She doesn't like the lift?

Too bad.

I like my back more....

I won't even tell you the other rules that would've been given to her up front.

But....

That would be me....

[crystalchen]

I suppose she was having diarrhea? If so I would call the team and put a rectal tube in her, which is both good for her skin and for the staff on the floor.... I had a pt before, similarly, refuse to use a lift because she had a bad experience before. I could imagine this is hard to take care of her, someone who does not appreciate your help at all. I like the quote by the previous post, and in reality, it is so true.

[TigerGalLE, BSN, RN]

I suppose she was having diarrhea? If so I would call the team and put a rectal tube in her, which is both good for her skin and for the staff on the floor.... I had a pt before, similarly, refuse to use a lift because she had a bad experience before. I could imagine this is hard to take care of her, someone who does not appreciate your help at all. I like the quote by the previous post, and in reality, it is so true.

You took the words right out of my mouth. FLEXI-SEAL!! STAT!

She still needs to ambulate and be active. But getting up to have loose BMs every 20 minutes and needing 2 people to get her up. This just isn't possible on a busy medsurg floor. Not everyone is a candidate for a flexi-seal, but she sounds like she needs one for sure!

Tiger

[sistasoul]

I have had patients like this. Not the same scenario but just real needy people. A lot of ETOH detoxers are like this. They often med seek, are manipulative and are demanding. These people are the least sick of my patients but take up the most of my time. I know it sounds mean but sometimes I would just walk away and tell this person I will be back later when they start the "demanding" behaviors. Sometimes people can just not be satisfied. I fully understand why a nurse would "hide" from a patient. As nurses we simply do not have the time to deal with this. Especially when the patient could be doing things to help herself. Unfortunately, these type of people can be quite common and when the nurse has been catering to them all shift and cannot get his/her work done and management comes down on us for the overtime we are said to lack time management skills. And if we don't cater to these types of personalities they complain to the higher ups about the "mean nurses".

[Kim, HHRN]

I had a patient like this a few weeks ago. She was morbidly obese and asked to be put on the bed pan every 5 minutes. It was totally nuts. Her son was hunting us down constantly and I was avoiding him like the plague simply because I had a patient across the hall who required my care and assessments more because she had a bladder irrigation. That took A LOT of time and required a lot of work in order to avoid clots. So obviously the patient with the irrigation got most of my time and attention simply because her issue was a much higher priority.

I think my biggest pet peeve are those patients who sit on the call light for things that are not a high priority and truly believe they are the only patient on the floor. These are the same ones who answer negatively on hospital surveys. These are the same patients who are noncompliant and really don't care if anyone else is harmed, that simply just want their way. These are the days that I really do wish I was not a nurse.

[sistasoul]

I had a patient like this a few weeks ago. She was morbidly obese and asked to be put on the bed pan every 5 minutes. It was totally nuts. Her son was hunting us down constantly and I was avoiding him like the plague simply because I had a patient across the hall who required my care and assessments more because she had a bladder irrigation. That took A LOT of time and required a lot of work in order to avoid clots. So obviously the patient with the irrigation got most of my time and attention simply because her issue was a much higher priority.

I think my biggest pet peeve are those patients who sit on the call light for things that are not a high priority and truly believe they are the only patient on the floor. These are the same ones who answer negatively on hospital surveys. These are the same patients who are noncompliant and really don't care if anyone else is harmed, that simply just want their way. These are the days that I really do wish I was not a nurse.

I totally agree with your second paragraph. So true. I know how you feel.

[Kim, HHRN]

I totally agree with your second paragraph. So true. I know how you feel.

Lol, seems like we were on the same train of thought......:)

[wooh, BSN, RN]

Sometimes in a 12 hour shift a vendor doing a demo is the only reprieve we get.

Not to mention, often that demo is REQUIRED for me to know how to use a piece of equipment and do my job.

Absolutely agree, there comes a point where you have to set limits. And often, the way to do that, is to be unavailable for every single little thing. If I was just in the room 10 minutes ago, sorry, you're going to have to wait, because I have a load of other patients that need attending to as well. I'm not going to reward you for being non-compliant with safety issues, especially if it means punishing my compliant patients by not being able to attend to their needs.

I have limited time, and I will make sure you get everything you NEED but it might not be what or when you WANT.

[scoochy]

I'm "in" for "HIDE & SEEK." I'll hide, for sure, in all honesty!

[kcochrane]

Let's look at this logically. I usually have 5-6 patients. In a eight hour shift that equates to about 10 minutes an hour for each patient with figuring in report at the beginning and end of the shifts. Add in needing to talk to the Dr., pharmacy, charting, taking off orders, stocking rooms and helping your other staff members. Doesn't leave much time, does it? So you do the most important things and some things slide. Its very possible that paitent wasn't being ignored, but that the nurse was just making sure each patient was taken care of equally.

[Medic/Nurse, BSN, RN]

:sofahider :sofahider :sofahider :sofahider :sofahider :sofahider :sofahider

Count me in with the "hiders". As long as the are infinite NEEDS/WANTS/DEMANDS and finite resources - there will ALWAYS be certain items that WILL NOT be done. Sad - perhaps. Also, just a reality.

Not sure of the various issues at play here - and I'm gonna bet my license on the fact that there are many. I think there are some amazing responses from our regulars and others - I'll just add - maybe a PSYCH consult and treatment plan is called for and needed. To the OP - careful of drawing a line and judging staff - someday it will be BUT FOR THE GRACE OF GOD, GO I. You will find situations that will test you assuming you make it to a nursing role. You just will - so, be careful of being too hard on others.

Practice SAFE!

:angel:

[Moogie]

I am sure this woman finds the lift and the commode to be very uncomfortable and if she's having persistent, explosive diarrhea, can anyone blame her for wanting to use the bed pan every five minutes? No one wants to sit in his/her own feces.

I would point a finger of blame at administration for not transferring this woman to a facility that is better equipped to care for obese patients. If a facility does not have lifts or commodes that are comfortable for obese patients with mobility issues, they should transfer her to a place that has such devices. Ceiling Cat, as you pointed out, this woman is not getting better. Obviously the hospital cannot adequately care for her and she shouldn't be there. Administration is not doing right by her to keep her there and not doing right by the nurses in expecting them to risk back injury transferring her.

As the prevalence of obesity continues to rise, this will become an issue that is paramount to many institutions. Still, if they can't care for the patient and it's evidenced by a poor outcome and failure to heal, she should be in a facility that can accommodate her.

I agree with Sue and Caliotter3---if a nurse gets hurt trying to transfer her alone, the institution will NOT support that nurse in a worker's comp claim. They will weasel out of it and try to put the blame onto the nurse.