Probably a stupid question, but what do you think about this?

[miko014]

Hi all

My unit has a pt who has been there for a little over a week and has no desire whatsoever to leave. She is young, came in with abd pain. Denied drug/etoh use on admission, but tested positive for cocaine. Was very grouchy for a couple of days, but is now chipper, goes down to smoke (even though we are a smoke-free hospital now...they aren't enforcing it very well so I can't prove that she's not), goes to the gift shop, walks around all over the place. Has a double lumen PICC.

Here's the issue...every time she comes back from "smoking", her pump is always beeping downstream occlusion. She knows that the PICC needs flushed. It's always a really ahrd flush, too, you have to really work with it to get it to go. But it will run fine after that. The pt claims that it's because the external part of the PICC is in her elbow and it gets kinked off when she's walking. Uh huh. It's pretty obvious that she's doing "something" while she's downstairs. So what would you do? I'm pretty sure the docs confronted her about it yesterday and she denied it, but she wasn't my pt. I just had to flush it once when her nurse was off the unit.

[TazziRN, RN]

Of course she has no desire to leave, she has a direct route to shoot up! She needs to be tested again, since she should not have had access to cocaine or anything else since admission. She definitely would not be a candidate to go home with the PICC in.

[SCRN1]

We had patients like that and the doctor wrote an order that the patient is not to leave the floor. When the patient decided to leave the floor again, they were told the could but would first have to sign out AMA and not return. This patient decided not to sign it and went back to the room and sure got "well enough to go home" quickly after that. Guess since they couldn't get their "fix" in the hospital, they decided they'd just go home so they could get it their previous way.

Would you believe we had a patient once who actually rubbed her own stool into her surgical wound, knowing it would become infected? Her doctor had cut her off from getting narcotic prescriptions, so she came up with this idea to get admitted again and get the drugs in the hospital. She finally admitted what she did when she was confronted with her wound culture showing e. coli.

[Antikigirl, ASN, RN]

I would perhaps get social services involved to see if they need to help her find a facility to help her quit her addiction, and if she is unwilling...then the MD should consider discharging her.

Sadly we can not stop people from doing what they are going to do outside the hospital, but we can limit it within. This person sounds like they are doing well enough to have home services or go to a clinic to have whatever needs to be done via the picc line done. That is our responsiblity...her cocaine use or other habits are our concern, but not responsiblity. We can't hire a guard for her outside the hospital.

Document fully the state she is in after going to have a 'smoke'. Eyes, tremors, energy level, mentation, general attitude, VS with temp, gait, spontinaity...and if she complains say it is normal to take these after someone leaves the floor (heck I do!). Document ONLY what you see, do not assume or lead...factual info and only that! Have other nurses do the same. This will document trends in a factual mannor and perhaps lead to some clues!

Also a UA should be done, or even tox screen daily.

I would also be leary if the picc was not working properly that it either needs to be changed out, or d/c'd. That will be up to the MD, and maybe things can switch to oral medications, IM, SQ... OR a good IV starter can get in a line now...especially if she is hydrated now? (may not be any good veins...but typically there is one there for one with great skill and tallent!).

[Antikigirl, ASN, RN]

Would you believe we had a patient once who actually rubbed her own stool into her surgical wound, knowing it would become infected? Her doctor had cut her off from getting narcotic prescriptions, so she came up with this idea to get admitted again and get the drugs in the hospital. She finally admitted what she did when she was confronted with her wound culture showing e. coli.

We had a pt that had an colonostomy and would take the waste from that an actually inject it into their abdomen to get into the hospital~!!!! I don't know how it was done (getting needles and all), but it was done. After three times of this..they were finally released again, and found a few days later home dead from the infection because they started it up once they got home! What a horrible way to go, and what a waste!

[miko014]

I know she likes the PICCs - she has nothing to stick, it's a direct route for her to have access to her veins. As far as documentation, she must not be doing very much of whatever she is doing because she coems back up happy and with food and very chit-chatty. But she has a hx bipolar and doesnt take meds regularly, so it's hard to tell mood wise with her what's really going on.

I think she has MRSA in her blood now (not sure, but I think I overheard one of the docs say that yesterday) - big surprise. But they have told her she can't leave the floor - she does anyway. She sneaks out and sneaks back in. The last time she was my pt, the docs where going to check "one more thing" re: her abd pain and then try to d/c her. It didn't happen, unless it happened today (I'm not there today so I don't know).

She denys that she's using and refuses being set up with rehab resources, so I think once d/c her, that's pretty much it. I know they won't send her home with a PICC.