Patient refusing meds, combative

Specialties Geriatric

Published

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?

Specializes in medsurg, everything in LTC.

:nono:To sziq9:

Your remarks are highly offensive to those of us that take pride in the care provided. Like some of the others have mentioned, if you have not worked and are not aware of LTC regulations and settings, this is not the post for you. I also have sent residents to the hospital with intact skin and had them returned with pressure sores. At the moment in my facilty we have 1 in house acquired PU, and this person is terminal. All of our residents get incontinent care, get out of bed daily and our CNAs are very attentive to skin issues, they know that they increase everybody's workload.

I have worked in both hospital and LTC settings, tipically in the hospital the care was focused on the admitting diagnosis, everything else was an afterthought. In LTC we take care of the WHOLE person, including the families, not the Dx.

This is the main difference.

Both settings are difficult and challanging and we need understanding and respect for all, especially if you have not walked in someone else's shoes.

Apologizing might help.....

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Specializes in LTC, home health, critical care, pulmonary nursing.

Is the resident normally A&o x3, or are they demented, is this agitation thing common for them or is it new onset, do they have consent from the responsible party and a physician's order to covertly administer meds? The only thing that the resident really "has" to do, is not sit in urine. 99% of the time, letting her cool off, coming back in 15 minutes with a different staff member and a gentle approach with the assurance that she does not have to get OOB, she will most likely let you clean her up. If she doesn't want to get up, get dressed or take her meds, she doesn't have to. That being said, depending on the circumstances, you may need to investigate whether or not this is AMS and bears further evaluation.

I'm kind of surprised at all the replies that jump immediately to injectable antipsychotics. "Agitation" and being combative with staff is not an indication for IM haldol in the LTC setting. Due to the fact that the woman is refusing to get OOB, she isn't a danger to others. As for the incontinence thing, see above. Haldol is a terrible drug in the elderly. Usually, they get PRN haldol and then they fall, when really if we had let them have some freedom they wouldn't have been "agitated and combative" in the first place.

If she doesn't want her meds today, she doesn't want her meds today. Make sure the doc and family are aware. If this person is normally A&O, it's totally inappropriate to sneak them in her. The demented are another ball game entirely.

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Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

I have worked both in the hospital and in LTC...let's get real. We all do what we have to do. Yeah, it is probably unethical to "slip" someone their medications, but what is more unethical to me is a nurse who stands by and allows the resident to suffer, and yes, when they are combative, and acting out, in some way they are suffering. Hold me down and inject me???? That is a laugh. That causes me more agitation and suffering than what I am already going through and maybe somewhere in my agitated and demented mind I will remember what you did to me and I will never trust you again. I may not remember why, but I may know that you did something to me that was not right and that I could not understand. And when the state surveyors come in and read all that stuff you have documented, then there may be a problem with the use of a chemical restraint, not to mention the potential for injury to me. Tie me down? Can't happen in LTC, not without the nurse dancing through fire...now realistically just give me my glass of coca-cola (or whatever you can get me to drink or eat) laced with a little ativan or Xanax (either one- I'm not picky) and get me interested in something else after I have calmed down. The next step would be to take my situation to the interdisciplinary team to care plan my "special needs". This is just my opinion on the whole situation...

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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...

while i dont find your post offensive, it is somewhat under informed. I have the experience recently of them dcing IM ativan on a patient, used rarely, but needed when it happened. She was up in her wheel chair, ranting and raving, very restless....at least she cant get up and walk......the fear was that she would throw herself out of the chair and onto the floor.....this is what she and we are going to go through now, that out of fear of the state, her appropriate/needed medicine has been disallowed......

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Specializes in MDS/Office.

Has this patient been assessed for pain?

Many behaviors are pain related.

:twocents:

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I do whatever I can to get the medications into them. I try to use every trick in the book I know that I have seen re-approach etc, try to find out what is ticking them off....bad nurse good nurse. Then if I have to I call the family to inform them of the situation and that we are continuing to try our best to get the person the care they need. Usually before the family member shows up in all cases I have seen (but don't forget I've only been practicing nursing for a little while) the patient gets what they need. But I am definitely not a stranger to a patient so agitated that they attempt to bite/scratch.

The CNAs are very good for skin care where I work actually, and I wish I could be there but I am responsible indirectly for the care of so many residents, I don't see all their coccyxs etc. unless they tell me its really bad, I advise them on preventative measures and usually that works unless its bad enough that it needs a temporary dressing and usually the skin care issue is resolved pretty quickly. We have very few wounds, and our wound care nurse who is full time is excellent. I find what you say offensive, because I worked in acute care and there were MORE wounds. The bottom line is why don't us nurses understand each other? I find in acute care the nurses have less time for turning/positioning and its sad.....its not necessarily their fault, I see these nurses try but they don't get there at least every 2 hours to turn, they work their butts off and have a lot of critical situations in between, its not right, we need more nurses....everywhere

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I see this thread is from '10. I certainly hope that all the people who replied are either in retirement, been enlightened on how wrong it is to drug people against their will ~ even demented older people, or are being chemically restrained themselves. Reading this thread made me ill. Would you people do this to a combative child, or is it just older adults who you think it is ok to abuse? I do wish that I never work with any of you who think this is ethical or moral.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Welcome to Allnurses.com! Thank you for resurrecting this discussion from a seven-year slumber. The topic is still relevant in the present day.

I see this thread is from '10. I certainly hope that all the people who replied are either in retirement, been enlightened on how wrong it is to drug people against their will ~ even demented older people, or are being chemically restrained themselves. Reading this thread made me ill. Would you people do this to a combative child, or is it just older adults who you think it is ok to abuse? I do wish that I never work with any of you who think this is ethical or moral.
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Specializes in LTC.
I see this thread is from '10. I certainly hope that all the people who replied are either in retirement, been enlightened on how wrong it is to drug people against their will ~ even demented older people, or are being chemically restrained themselves. Reading this thread made me ill. Would you people do this to a combative child, or is it just older adults who you think it is ok to abuse? I do wish that I never work with any of you who think this is ethical or moral.

I wish you the best with combative and agitated patients. Chocolate + Xanax =

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Specializes in LTC and Pediatrics.

Wow, I am thinking you do not work LTC. Sometimes it is their routine meds they fight against. Yes, sometimes we have to crush them and put the meds in applesauce or pudding to see of they will take their meds that way. Yes, we may have an order for Xanax or Ativan for when they get this way. All the places I have worked, you are to try non-pharmaceutical ways of calming first. Usually at least 3 different interventions and these need to be charted for PRN doses..

You can not compare a child having a meltdown to an adult having a meltdown. Why? A child you may be able to convince them to let you hold them or you place them in a safe place for them to finish that meltdown. You can't do that with an adult. Many times when they get combative and agitated, they are also trying to get up. Sometimes forgetting they can't walk, well then they end up on the floor. Now it is broken hip time and you will have your facility, and the state breathing down your neck. So this becomes a safety issue.

At the same time you are going to be checking any med changes and get a UA for a possible UTI. WE will also try leaving and returning about 20 minutes later and see if things have changed.

We don't go for the drugs as a first resort. We go to them as a last resort and they most likely already have PRN orders for these. This is not abuse on any level.

Okay, getting off of my soapbox.

I see this thread is from '10. I certainly hope that all the people who replied are either in retirement, been enlightened on how wrong it is to drug people against their will ~ even demented older people, or are being chemically restrained themselves. Reading this thread made me ill. Would you people do this to a combative child, or is it just older adults who you think it is ok to abuse? I do wish that I never work with any of you who think this is ethical or moral.
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