Skin Breakdown on the Patient Who Refuses to Turn

[moosie_poo]

I have a larger patient who refuses to get out of bed, refuses my coworkers and I to turn him Q2 hours and has what looks to be a Stage 2 pressure ulcer which is rapidly progressing to Stage 3. I believe he does not have the mental capacity to understand the importance of his Q2 turns. So my question is how do you handle the situation? He already reported one nurse for turning him after he said no (as well as for her not bringing him a popsicle even though he was told multiple times that we were out until morning). Do you turn the patient against his/her will, knowing that it is the thing that would be best for him/her? Or do you acquiesce and allow the skin to breakdown further, allowing the possibility for greater infection, run the risk of a lawsuit or other disciplinary measures that may result from not turning a patient who is unable to reposition independently? The patient is in DKA and is retaining a lot of fluid. He has blood clots in his legs. He is unable to lift his arms to grasp a cup of water. What do you do?

[FolksBtrippin, BSN, RN]

I think it needs a team discussion. Everyone needs to be on the same page, no matter what you all decide.

More info to get: what are all the possible barriers to pt accepting being turned? You have identified mental capacity to understand importance of turning. But there are almost definitely more. Is turning uncomfortable or painful? Is embarrassment a factor? Is the pt depressed? Suicidal?

A pain med or anxiolytic or possibly even an antipsychotic might help.

We know he likes popsicles. Many intellectually disabled people can be persuaded with incentives. This is always preferable to doing procedures without consent.

In the end, you may have to turn him against his will. But try everything else first. Educate him. Bribe him with popsicles. Get his favorite people to tell him he needs to turn. Get the family involved. Grt everyone on board first and get an order.

[KatieMI, BSN, MSN, RN]

Unfortunately, doing anything physical with a human being against his/her will, for whatever intentions, MIGHT be qualified as battery.

So:

1). Document, document, document. Every 2 hours, verbatim.

2). Team meeting as above. Education, bribery, etc., but NO pressing and NOTHING done against his will. Get family on if it is on board.

3). Request psych evaluation for "ability to make his own medical decisions". It needs to be evaluated and signed by 2 M. D.s, one psych and another usually primary team.

4). If qualified as "unable" to do so, can be psych /pain medicated to docility >> problem solved

5). If not, go back to 1). That would be unfortunate, but that's his life and his way to live it. Pain consult might be appropriate, as well as a device which decreases need in turning like Clinitron bed.

[ruby_jane, BSN, RN]

Unfortunately, doing anything physical with a human being against his/her will, for whatever intentions, MIGHT be qualified as battery.

So:

1). Document, document, document. Every 2 hours, verbatim.

2). Team meeting as above. Education, bribery, etc., but NO pressing and NOTHING done against his will. Get family on if it is on board.

3). Request psych evaluation for "ability to make his own medical decisions". It needs to be evaluated and signed by 2 M. D.s, one psych and another usually primary team.

4). If qualified as "unable" to do so, can be psych /pain medicated to docility >> problem solved

5). If not, go back to 1). That would be unfortunate, but that's his life and his way to live it. Pain consult might be appropriate, as well as a device which decreases need in turning like Clinitron bed.

^Perfect.^ Is there family involved? If so, I would make a special effort to make sure they know you're doing your level best and that their family member is not accepting the care. That and your excellent documentation may protect you.

[xoemmylouox, ASN, RN]

When our patients refuse things like SCDs or turning, we require they sign a refusal form. Now if he is deemed incompetent, then it is a different situation. So start documenting well, get everyone on board, see how this situation has been handled in that past, and keep trying.

[ruby_jane, BSN, RN]

and keep trying.

^that, too.^

Because at some point you may be asked what you did and documenting that you tried daily is going to look a lot better than "Well, I tried somewhat and then just documented a previous refusal."

[KatieMI, BSN, MSN, RN]

I had one time family stating that patient "was not talked enough into thinking about it". I won't give any details because the case was a really, really big deal, but that statement died almost upon arrival when about 250+ nursing notes came in light, each of them stating that the intervention in question was duly offered, explained and rejected.

[Meriwhen, ASN, BSN, MSN, RN]

Unfortunately, if the patient is competent and refuses to reposition themselves or let themselves be repositioned, there's nothing you can really do. As long as they're determined to be competent, they have the right to make their own healthcare decisions...even the decisions that may be detrimental to their health.

Keep trying, use any (legal) trick that you can to get them to cooperate, and document to high hell each time there's a refusal.

[cardiacfreak, ADN]

Have you considered a specialty bed?

[moosie_poo]

We currently have him in a HillRom Total Care P500. I believe he has orders to be transferred to a different bed for aggressive pulmonary toileting.

[psu_213, BSN, RN]

Unfortunately, if the patient is competent and refuses to reposition themselves or let themselves be repositioned, there's nothing you can really do. As long as they're determined to be competent, they have the right to make their own healthcare decisions...even the decisions that may be detrimental to their health.

Keep trying, use any (legal) trick that you can to get them to cooperate, and document to high hell each time there's a refusal.

I agree. And make sure that each time, it is documented that the RN educated the importance of being turned and the risks of not being turned (i.e., pressure ulcer leading to increased pain, infection, possible death). If the pt becomes septic, more than just "pt refused" is needed--someone will ask "yes, but did the patient know what could happen to him if he refused?"