Where’s the limit to accommodate a patient

[Lanimisses]

Hello, Im a very frustrated tx nurse…need advice as in my entire 10 year LTC nursing career this patient is really getting me. Long post by the way…first off I do believe in high quality care and respect all of my patients even the most difficult ones who yell at me, curse me and call me names…don’t bother me…I treat all my patients as if they are family even when they don’t like me which is fine. This one patient is the most difficult person I have ever dealt with shes so miserable and hates the world and just negative. She is very alert and has an arterial wound with lymph edema very swollen ble like  plus 3. Walks around all the time and only puts her leg up on wheelchair at waist level. That’s how she sleeps too sitting up because her bed is so cluttered. Her gets really worse and bigger with lots of slough…trust me when I say she controls the healing of her wound telling us how to treat her wound and is too particular. Very argumentative very sensitive shes fragile. Doesn’t listen to docs orders or wound specialist  refuses compression and elevating correctly…so it’s always swollen and has extremely sensitive legs so she won’t allow anyone to touch her leg. She is very non compliant with everything. And everything is well documented. She makes us put lidocaine jelly to wound bed won’t let us wash it off put lidocaine ointment on leg and wants us to apply extremely slowly with finger tip in one direction. Then has us cut up lidocaine patches in small prices as she feels for sensitive spots to place all over legs one by one and slowly. All while her leg continuously drains heavy serous fluid. When wrapping her leg she has us use like 6 packs of gauzes I have to make a dressing taped together with the product tape and stacks gauze over gauze and even tells us exactly where to place a stack of gauze. For her comfort…the dressing looks like a beehive around her leg and leaves it on all day. Even when cleaning her wound I can’t even wipe correctly I have to do small strokes in slow motion hardly touching wound. All of theres are all against docs orders but that’s what she wants. Also argues with docs and wound specialist saying she only uses aquacel ag and that’s it. Refuses debridement all types of debridement. She was getting treated with the aquacel ag for an entire year with no improvement. But recently settled by using hydrofera blue not the wound is stalled again. She’s allergic to all medication only pain pill she can take is dilaudid. Refuses to see psych. And take any psych Med. Refuses to go to hospital. I also spend 2 plus hours doing all this care while on my hands and knees to treat her wound all the bending because she doesn’t want to lay in bed and elevate and won’t allow anyone to hold her leg. and she refuses to do treatment early…demanding I do treatment at end of day while she prolongs treatment saying she’s not ready yet causing me to stay overtime every day. While doing treatment constantly criticizing about everything. She won’t allow anyone else to touch her leg just one other nurse. I get it I try to accommodate by going around her time and tell her when I leave. She don’t care and expects me to stay to complete her treatment I don’t know what to do. Department heads tell me to manage my time and work it out with her I tried and been trying for 2 years no change I don’t know what to do…all her behavior and noncompliance is documented…she controls everything and never listen to staff just her way everything very demanding  …I understand we need to  accommodate based on patient needs but we tried everything under the sun and my back is against the wall…she even checks to see when I’m here looking for me going to other nurses making sure they text me when I’m not there and grilling them about me and my whereabouts. It’s none of her business about where I’m at I’m just making sure she gets her treatment when I’m scheduled to do to for the day…that really bothers me. I have a lot of work to do a lot of time consuming patients who really need me and have 8 hrs to do so we always short staffed…I want to do the right thing so where’s the limit? 

[Tenebrae, BSN, RN]

My intital feeling is that for anything to work all nurses have to be on the same page.

Consistency. 

Negotiate a time with her to do her leg. 

Say something along the lines of 'I will be in and X time to do your leg'

If she procrastinates and time wastes say "I have to leave at X time, if we don't get started now, the next shift will have to do your leg"

Chances are at this point she will scream and yell and chest beat, tell you what a horrible person you are, yadayada yada ad nauseum". If she still doesnt let you get it done, you leave, hand over to the next shift and document the hell out of it. Eg that you gave multiple opportunities patient refused etc

Next shift go into them and say, "because we ran out of time to get your leg done I suggest we start at X time to make sure we get it done. If she repeats a behaviour, continue to impliment polite, pleasant boundaries. Reinforce that you want to provide her good care, her *** behaviour is not acceptable and you are done accepting it. Try though to reinforce that her behaviour is seperate from her as a person. I would suspect her self esteem is absolutely aweful. People like this take time, and like I said, you need to make sure all the nurses are on the same page or it will be like peeing into the wind/

No one has to put up with that behaviour and there is no minimum length of time you need to put up with it before doing something about it

[amoLucia]

A suggestion for those proposed compliances conversations is to have a witness present, preferably a UM, NP, doc, etc.

Like Tennebrae so wisely recommended is to document the wazoo out of each occurrence.

Is she being seriously care-planned? I'm guessing you're trying. Like is there any family involvement/awareness?

One major thing - I would INSIST that those tracking texting/phone calls to other staff STOP IMMEDIATELY! Its privacy invasive and time consuming for staff. I mean that the pt is counseled, and ALL staff are instructed also.

 

[Hoosier_RN, MSN]

I agree with what's been said. I justwant to add to get social worker involved.  This pt tracking your whereabouts is not correct in any way shape or form, and needs to be addressed from the MSW standpoint

[amoLucia]

^^^^ sounds like it's something like stalking to me.

[Olivelove20]

The patient sounds like she has been catered to because of her behavior (which sounds controlling and like an impetulant child throwing a fit) and therefore is in control. On a variety of levels this isn't acceptable. 

As others have stated, what you are doing/where you are is ZERO business of hers and that reporting of your whereabouts on/off duty should stop immediately.

If wound care is being performed that is not doctor orders, you are risking YOUR license. If she doesn't like/accept the orders as written, let the ordering physician know, document it and simply let the patient know you an ONLY perform wound care that is ordered and you have let the MD know the patient isn't happy with what is ordered but she can either do w/what the orders are until they are changed/contact the MD herself or refuse care. If she refuses, document it and move on. You said she is alert/oriented so if she refuses, that is on her.

If your nursing leadership isn't going to intervene and throws it back on your to work out, then continue to document but do NOT stay after work or allow this patient to continually manipulate/demand your time/attention. That is unfair to you, other staff and other patients. 

Two years is way too long for any of this to have gone on. It sounds like others have washed their hands of the situation knowing you would step in.

Either place limits without a lot of explanation, ask to not take care of her or find another job elsewhere. This situation has disaster written all over it and you may very well end up being the scapegoat when it all hits the fan if you don't set limits NOW. You are going to have to save yourself here.

[amoLucia]

Great advice by other OPs here.