When is patient education TOO much?!?

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Specializes in M/S, Tele, Sub (stepdown), Hospice.

Ok...a little background of this particular patient: She's a 50 something y/o female w/ hx of cervical cancer admitted for pyelonephritis. I get warned by the charge nurse that she's tough to handle (that's all the info I get) as I get handed my assignment.

I notice she's very particular & needs to control everything. She refuses to void in the hat (she keeps putting it on the floor). She refuses to let us to empty her nephrostomy tube (she empties it on her own...but at least tells us the amt - of course we don't observe it ourselves). She wears foot pajamas (yes...I repeat she's a 50ish y/o) & has lymphedema in her legs but she refuses to remove them to allow me to assess them.

Anyhow....she has a double strength Fentanyl PCA pump & her pain remains a 9 (even after I got the Fentanyl up'd from a standard concentration). She's also taking Ativan Q6 & complains that the MD didn't order it Q4 as "he usually does" & is irritated with me b/c HE didn't order it the "right way".

The next morning the MD writes an order for a sleeping pill as requested by the patient. The following night I have her again (yay me) & at about 9 p.m. she asks for her ativan & her sleeping pill. Now, I'm still a newer nurse & wasn't totally comfortable administering her ativan + sleeping pill while she's on a double strength PCA (& still requesting boluses). I understand she may have a high pain tolerance but it's my first time taking care of her (she's well-known on our unit) so I make the mistake of asking her "Did you want to take the Ativan first & if you can't sleep we can give you the Restoril?"....aaaaaaaand she goes on a tirade: "Well, why can't I take both at the same time.....I always take both at the same time when I'm here" I try to tell her that her Fentanyl, ativan, & sleeping aid have an additive effect & her immediate response is "Am I gonna die?!?!?" I tried talking her down & she told me that I scared her and now she doesn't want to take them both at the same time if at all. I tried explaining to her that I was just trying to be safe & NOT scare her. And then she told me "I think you give too much information....I've never had any nurse tell me that before". I WANTED to say "Really?!?! You've been in the hospital sooo many times & you have no freakin' idea that taking all these narcs, benzos, & sleeping pills won't have an effect on you?!?!?"

So.........days later, I'm still wondering if I did give her too much information. The hospital wants to us to educate our patients...especially the meds we are giving them. I didn't offer all this information to begin with, she kept asking & then when I tell her...she claims I scared her. Turns out one of the other nurses said she told her the same thing last time she took care of her (about spacing out ativan & sleeping pills).

In the end, I want to give safe care & not lose my license. I just hate that with someone like that, she can easily go make a complaint about me & say I scared her, etc. & I don't know where that will leave me.

Thoughts, advice...??

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Specializes in PACU, OR.

There are plenty of people out there who just refuse to be educated, even if it's in their best interests. Maybe because they're scared of other people ruling their lives, and consequently WILL NOT listen to reason, or maybe they're just too stubborn to listen to reason. At some point I suppose the best route is to let them go to h*ll in a handbasket on their own steam....:coollook:

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I hope you are documenting everything she is refusing to do or to allow you to do.

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Specializes in Emergency & Trauma/Adult ICU.

This is standard-issue manipulative behavior. This may be the first time you've seen this ... but it will not be the last.

Medicate within your order parameters and in accordance with your nursing judgement based on your assessment of the patient. Document frequently and at length and always include vital signs and a description of the patient's mental status and quality of respirations. Documentation of these assessment parameters will be your friend if/when you need to justify your decision to give and/or hold meds.

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Specializes in M/S, Tele, Sub (stepdown), Hospice.
I hope you are documenting everything she is refusing to do or to allow you to do.

Yes! I most certainly documented everything she refused!!

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Specializes in M/S, Tele, Sub (stepdown), Hospice.
This is standard-issue manipulative behavior. This may be the first time you've seen this ... but it will not be the last.

Medicate within your order parameters and in accordance with your nursing judgement based on your assessment of the patient. Document frequently and at length and always include vital signs and a description of the patient's mental status and quality of respirations. Documentation of these assessment parameters will be your friend if/when you need to justify your decision to give and/or hold meds.

So besides documenting her vitals/respiratory status....how do I deal with this type of patient directly?? I guess that's my main problem. I didn't know how to communicate with her. She was being totally unreasonable!!

She also asked me "How long have you been doing this?" & of course she just ate it up when I told her just less than a year... :uhoh3:

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Good. It is a shame to have to do so much cya charting but this is just the type to sue if anything goes wrong.

Give the info you feel is appropriate and if she is scared she is scared. She SHOULD be scared, the way it sounds! You might mention Michael Jackson in your next conversation.

;-)

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Specializes in Psychiatry.
I didn't know how to communicate with her. She was being totally unreasonable

Kill her with kindness. Don't let her know she is getting to you!

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So besides documenting her vitals/respiratory status....how do I deal with this type of patient directly?? I guess that's my main problem. I didn't know how to communicate with her. She was being totally unreasonable!!

She also asked me "How long have you been doing this?" & of course she just ate it up when I told her just less than a year... :uhoh3:

So many of our pt.s come into our facilities with med profiles that should have killed a team of oxen, yet they take it everyday; and somehow survive to live and gripe another day.

You don't have to try to change, save or convert this pt., she has a disease that she feels entitles her to all the pain killers she wants.

Your job is to administer her meds as ordered, within the safe guidelines and nursing judgement you have.

You cannot treat her suspected addiction. You cannot treat her behavioural problems. You can only follow orders within reason; and document and communicate this pt.s signs and verbal cues.

It IS extremely frustrating to not be able to help this person.

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Specializes in Trauma/Tele/Surgery/SICU.

"You might mention Michael Jackson in your next conversation."

I almost spewed soda all over my keyboard when I read this it made me laugh so hard!

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Specializes in CTICU.

Am I the only person who feels bad for the patient? I totally understand awful manipulative patients you can't do anything right for ... BUT... my mother was terminally ill last year, and I took care of her for months.

I think we both got a bit like this lady - we were in and out of hospital and hospice often, and it was very annoying to KNOW what meds you (mom) needed, and to get a lecture from some nurse who doesn't know the patient.

People with chronic diseases get set in their ways sometimes because it's the only thing they CAN control.

Try not to take it personally, as although it's just a day at work for you, she has to live with this every day and it's not surprising patients turn into witches sometimes.

Personally I would have told her the same as you did, and and I am very straightforward (?blunt!) and would have said "I do not mean to scare you but it is my responsibility to ensure you are safe and informed". Then document document document!

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Ok...a little background of this particular patient: She's a 50 something y/o female w/ hx of cervical cancer admitted for pyelonephritis. I get warned by the charge nurse that she's tough to handle (that's all the info I get) as I get handed my assignment.

I notice she's very particular & needs to control everything. She refuses to void in the hat (she keeps putting it on the floor). She refuses to let us to empty her nephrostomy tube (she empties it on her own...but at least tells us the amt - of course we don't observe it ourselves). She wears foot pajamas (yes...I repeat she's a 50ish y/o) & has lymphedema in her legs but she refuses to remove them to allow me to assess them.

Anyhow....she has a double strength Fentanyl PCA pump & her pain remains a 9 (even after I got the Fentanyl up'd from a standard concentration). She's also taking Ativan Q6 & complains that the MD didn't order it Q4 as "he usually does" & is irritated with me b/c HE didn't order it the "right way".

The next morning the MD writes an order for a sleeping pill as requested by the patient. The following night I have her again (yay me) & at about 9 p.m. she asks for her ativan & her sleeping pill. Now, I'm still a newer nurse & wasn't totally comfortable administering her ativan + sleeping pill while she's on a double strength PCA (& still requesting boluses). I understand she may have a high pain tolerance but it's my first time taking care of her (she's well-known on our unit) so I make the mistake of asking her "Did you want to take the Ativan first & if you can't sleep we can give you the Restoril?"....aaaaaaaand she goes on a tirade: "Well, why can't I take both at the same time.....I always take both at the same time when I'm here" I try to tell her that her Fentanyl, ativan, & sleeping aid have an additive effect & her immediate response is "Am I gonna die?!?!?" I tried talking her down & she told me that I scared her and now she doesn't want to take them both at the same time if at all. I tried explaining to her that I was just trying to be safe & NOT scare her. And then she told me "I think you give too much information....I've never had any nurse tell me that before". I WANTED to say "Really?!?! You've been in the hospital sooo many times & you have no freakin' idea that taking all these narcs, benzos, & sleeping pills won't have an effect on you?!?!?"

So.........days later, I'm still wondering if I did give her too much information. The hospital wants to us to educate our patients...especially the meds we are giving them. I didn't offer all this information to begin with, she kept asking & then when I tell her...she claims I scared her. Turns out one of the other nurses said she told her the same thing last time she took care of her (about spacing out ativan & sleeping pills).

In the end, I want to give safe care & not lose my license. I just hate that with someone like that, she can easily go make a complaint about me & say I scared her, etc. & I don't know where that will leave me.

Thoughts, advice...??

OBTW, she had LOTS of nurses tell her about the same interactions, this little one is playin' with your head.

Get a troubling diagnosis; feel free to lay down and die and take everbody else in contact with you along for the ride.

The NEW America. Whoopee! Sorry to be so cynical, I'm just seeing too many 23 year olds with chronic pain and/or "anxiety disorders" that require MASSIVE amounts of narcotics/benzos and lifetime disability payments.

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