Patient refusing meds, combative

[Trubie]

Hello all!

New grad here.... on my first day of orientation at LTC.

Ran across a situation where a patient was very agitated and combative, refused to get up for the day/get dressed/receive peri care (incontinent).

She was also refusing meds. She had a PRN order for xanax, but she wouldnt take it. Of course the CNA's did not want to leave her sitting in messy briefs (she had a roommate, as well as skin breakdown issues).

What should the nurse do in this situation? The nurse who precepted me handled it in a way that I felt very uncomfortable with. What would you do?

[morte, LPN, LVN]

sounds like a case for ABH cream......do wear gloves, lol.

[nurse2033, MSN, RN]

I sneak the med into ice cream or something the resident likes.

I find this unethical, although none of us were there and don't have the full picture. The patient has the right to refuse a medication. Forcing or sneaking are just about the same thing. If it is something they really need, then another mode of delivery must be sought. If the patient is at all rational find out what the problem is. I know there is a lot of work to be done and time is money, but it might just be quicker to satisfy her issue or come back later. I would carefully document the refusal of care. One good way to do that is to say to the patient "is there anything I can do or say to get you to (insert desired outcome here)". Then just document, move on and try again later.

[sillyang]

I agree that it is wrong to force the meds on the patient, they have a right to refuse. I too would try later, and I'm not one to "trick" the patient it won't help in the long run. Be sure to document situation (facts) and notify the physician. I would ask the doc for a UA order too. Something is causing the agitation.

[sziq1]

call the doc and get an order for iv meds to calm her down ie. ativan/haldol. she obviously was not able to make decisions on her own. You could also call the family or POA if one is available and see if that helps.

[CapeCodMermaid, RN]

wow..all y'all don't work in Massachusetts. IV meds? The woman is thrashing about and you want to start an IV? Neither IV Ativan nor Haldol are allowed here in skilled facilities. IM? Again trying to inject someone while they are agitated is quite risky.

Wrist restraints?? I like having my license thank you very much and would never do this. If the resident is going to harm herself or others, I'd call the doc and get a section 12 to the hospital. Otherwise, who cares if they bathe or dress?

Security?? We don't have any. It's usually me.

[SuesquatchRN, BSN, RN]

I find this unethical, although none of us were there and don't have the full picture. The patient has the right to refuse a medication. Forcing or sneaking are just about the same thing. If it is something they really need, then another mode of delivery must be sought. If the patient is at all rational find out what the problem is. I know there is a lot of work to be done and time is money, but it might just be quicker to satisfy her issue or come back later. I would carefully document the refusal of care. One good way to do that is to say to the patient "is there anything I can do or say to get you to (insert desired outcome here)". Then just document, move on and try again later.

We deal with a different population that do you, nurse2033. I understand the concept of informed consent. Understand that we have 38 chronically ill people, some of whom have no more capacity to consent than a cucumber, and some on their way to that state combative and violent /s provocation. If it is a choice between having a CNA assualted or sneaking the Zyprexa into an ice cream I am choosing the latter.

[VeronicaWileyRN]

Without knowing if this patient has a diagnosis of Alz, dementia or other mental health diagnosis, it depends if you have to hide the medication. If you have a patient with dementia, then you may have to hide their medication, but if you have a patient with mental health diagnosis, you need to do some investigating. Why are they really upset? Do they have a UTI? Do they want to get up latter in the morning, etc? I had a patient who was alert, but he didn't want anyone to come clean him up on third shift. He just wanted to be left alone. We tried alot of ways to get him to let us clean him up and sometimes he would corporate and other times NO. You just have to keep working with the patient and family.

[sziq1]

wow..all y'all don't work in Massachusetts. IV meds? The woman is thrashing about and you want to start an IV? Neither IV Ativan nor Haldol are allowed here in skilled facilities. IM? Again trying to inject someone while they are agitated is quite risky.

Wrist restraints?? I like having my license thank you very much and would never do this. If the resident is going to harm herself or others, I'd call the doc and get a section 12 to the hospital. Otherwise, who cares if they bathe or dress?

Security?? We don't have any. It's usually me.

I obviously would not try to put an IV in someone who won't sit still. I am talking about in an acute care setting like a hosptial where more often than not they already have an IV. I don't know what you guys do in the nursing homes but I would rather not have my patient sitting in urine for days on end while it is breaking down her skin. Maybe that is why we get people from nursing homes that have terrible skin breakdown all the time...

You also have never worked on a psych unit because holding people down and giving them an IM injection is not an uncommon thing. You would not do this by yourself but in other settings we have plenty of help, such as other staff members or security officers. Now I doubt that I would hold someone down for this reason but if they are a threat to themselves or someone else I have no problem doing that. I also value my license...

[SuesquatchRN, BSN, RN]

I don't know what you guys do in the nursing homes but I would rather not have my patient sitting in urine for days on end while it is breaking down her skin. Maybe that is why we get people from nursing homes that have terrible skin breakdown all the time...

Yeah, you nailed us. We don't mind if they sit in their urine for days on end while their skin breaks down.

[Nascar nurse, ASN, RN]

I obviously would not try to put an IV in someone who won't sit still. I am talking about in an acute care setting like a hosptial where more often than not they already have an IV. I don't know what you guys do in the nursing homes but I would rather not have my patient sitting in urine for days on end while it is breaking down her skin. Maybe that is why we get people from nursing homes that have terrible skin breakdown all the time...

You also have never worked on a psych unit because holding people down and giving them an IM injection is not an uncommon thing. You would not do this by yourself but in other settings we have plenty of help, such as other staff members or security officers. Now I doubt that I would hold someone down for this reason but if they are a threat to themselves or someone else I have no problem doing that. I also value my license...

Stepping in & trying to douse the flames you are sure to get..

1. This is the long term care thread & while we welcome comments from nurses from all walks of life the most relevant comments would be expected by those that do understand what goes on in LTC and the regulations we are obligated to abide by. What may be common practice on a psych unit (holding down for an IM) WOULD get me fired in LTC. Those not familiar with LTC may not understand the rules we have to follow.

2. CCM..nor anyone else would ever propose that we "Have patients sitting in urine for days on end while it is breaking down her skin". It is simply the point of picking your battles. If they don't want to change, toilet, eat, etc...I'm not gonna fight with them. It will only serve to wind them up more, make them even angrier and risk injury to both the resident, nearby residents and the staff. Unless that resident is endanger of immediate harm it is best to walk away and leave them alone. Send a different staff in (with a different approach) in 20-30 minutes & often times the resident will be more cooperative. Again, we do not leave our residents in urine for day on end and we do not send them to you with skin breakdown because of it. Please understand just how insulting this comment is. Some in the LTC industry have become amazed at just how many skin breakdowns must occur on the ambulance ride over to our facility because it seems the hospital has no recollection of the skin ever being broke down when they came to us in the first place.

[Forever Sunshine, ASN, RN]

I find this unethical, although none of us were there and don't have the full picture. The patient has the right to refuse a medication. Forcing or sneaking are just about the same thing. If it is something they really need, then another mode of delivery must be sought. If the patient is at all rational find out what the problem is. I know there is a lot of work to be done and time is money, but it might just be quicker to satisfy her issue or come back later. I would carefully document the refusal of care. One good way to do that is to say to the patient "is there anything I can do or say to get you to (insert desired outcome here)". Then just document, move on and try again later.

I find this necessary. This is LTC. There are patients you could try again later and later and 3 days from now, they will still refuse care. It is a DANGER.. to themselves, to the staff caring for them, and to other residents, to let them be combative.

In the ER or ICU you might be able to restrain a patient and give these meds by IM or IV. But in a nursing home, we sometimes have to resort to ice cream and juice.

[CapeCodMermaid, RN]

I obviously would not try to put an IV in someone who won't sit still. I am talking about in an acute care setting like a hosptial where more often than not they already have an IV. I don't know what you guys do in the nursing homes but I would rather not have my patient sitting in urine for days on end while it is breaking down her skin. Maybe that is why we get people from nursing homes that have terrible skin breakdown all the time...

You also have never worked on a psych unit because holding people down and giving them an IM injection is not an uncommon thing. You would not do this by yourself but in other settings we have plenty of help, such as other staff members or security officers. Now I doubt that I would hold someone down for this reason but if they are a threat to themselves or someone else I have no problem doing that. I also value my license...

You might want to invest in a flame proof outfit. This is LTC not the hospital. We are not allowed to tie people down like you so frequently do in the hospital. We do not have security. I DO work on a psych unit. 90 % of the residents in my building have a psychiatric diagnosis. We are still not allowed to inject people willy nilly with antipsychotics.

We do not let people sit in urine for days. Since we are not allowed to be forceful like you are in the hospital, we have to find other ways to deal with these behaviors.

And don't go there with the skin thing. My residents' skin is well cared for. They don't have any skin breakdown until I have to send them to the hospital for something. THEN they return with multiple open areas since apparently you all in the hospitals don't believe in a turning program or preventive skin care.