Nurses: WWYD!?

[GLP1U5er]

You have a patient who has presented as immobile and laid for 3 days in their own mess. A year of investigations didn't explain their pain but in hospital it's discovered hip and pelvic fractures.

You know this patient has a long history of alcoholism and cannabis use. The fanily tell you they are not themselves, they make false claims of the past, sometimes are unkind to nurses and family but this is not them.

What would you think was the issue/ what would you think was needed?

I don’t quite understand what you’re asking.
Alcoholic/drug users are complicated to look after. What can be done often comes down to capacity. No one can force treatment/help/support on patients deemed to have capacity, alcoholics are often poorly compliant they frequently discharge themselves or don’t engage with services consistently. In my current role I come into contact with both they often intermittently engage usually when their condition is very acute and then stop for long periods when their conditions have slightly improved until their conditions are very acute again and then once starting to settle disengage it’s a vicious circle. Generally we work with them until they disengage once they do explain the risks step back until the next time.
“Unkindness” to nursing staff is rightly not tolerated especially if they have capacity. It’s not uncommon for any patient to have a one of episode of unkindness especially if stressed in pain etc. but consistent “unkindness” is totally unacceptable. The vast majority of us are trying to do our best in impossible situations. Staff have the right to refuse to treat patients who are repeatedly “unkind” and the patient should be clearly informed that their behaviour is unacceptable and what will be done if they continue.

I totally echo what @tiredwardsister says.

How were the fractures explained? Have they had a dexa scan? Pain can absolutely cause behaviour changes. Being in constant pain is miserable. I’d assume some MH issue and/or possibly undiagnosed neuro diversity if they are self medicating with alcohol and cannabis. What kind of support are they receiving?

The fractures are most likely to be caused by a fall. The patient had a long lie implying a fall or collapse. This person age has not been mentioned. He would be highly unlikely to had a fractured hip undiagnosed for a year. His orthopaedic surgeon would be able to tell if it was an old or new fracture.
Alcoholism is always a “MH issue” most very sadly have experienced significant childhood trauma but no one can force them to engage in a rehab programme. In my area where we have a high number of alcoholics and IVD users services are sadly very stretched support is offered but consistent willingness to engage is crucial.

Is this a homework assignment or are you posting details of an actual human whose private information doesn’t belong here?

So you would put your own needs for respect above the needs of a patient and the family telling you something is not right. That explains a lot. You're in a job to help people but only if they tow the line right? You wouldn't possibly consider that something more was going on to cause that behaviour.

abuse?

Op, are you saying you think the person may have alcohol related dementia and/or withdrawal?

Or do you just want to take your own frustrations out on some random nurses who happen to be on mumsnet and are trying to answer your question?

Has anyone said this? Your post has the vibe of someone who is angry and seeking an argument with someone rather than wanting to understand a complex situation. Is that going to be helpful for you?

Yes. And I can't understand how that wouldn't be something that is at the forefront of any nurses mind caring for an alcohol dependent person, Korsakoff/TD.

The derail along the route of NHS worker respect is frightening if that gets in the way of actually looking into the medical need and I'm horrified that this was the first response here. I absolutely believe in respecting nurses etc but you can't write someone off who is not in their right mind when you have been told this is not who they usuallt are!

Is that what would affect your response? A model homework answer vs how you would actually treat a patient?

I’d hope the patient wanted to engage with the offered help, because classically, alcoholics don’t want to.

Going into hospital means not drinking. Having adequate opiate pain relief means not drinking.

What setting is the patient in?
Have they had thiamine and librium prescribed by the doctors?
How are you expecting the nurses to act? They are only human and will have different tolerance levels of abuse and some will be better at dealing with it than others.
Btw it is for doctors to make such diagnoses, nurses can bring behaviours to the attention of the doctors, but they can't prescribe the necessary Medications.
If you are not happy with the care, it might be worth speaking to a more senior nurse and/or contacting PALS

Exactly what is the nature of the 'unkindness' here?
Absolutely everyone has the right to expect a level of respect when they are at work. Nurses are not exempt from this and it can be frequently incredibly hard to get alcoholic patients to engage with services. What would you LIKE to happen?

It also depends very much on the setting - what are they in hospital for? Nurses on a surgical ward and unlikely to be instrumental in alcoholism recovery for instance, bar signposting and referring on to relevant services. What has their Doctor said?

Hello, im sure this is a stressful time and hope youre ok. Your posts are reading a little cryptic or hypothetical and yet it seems clear this is a real and difficult situation.

Just so I understand. A person who comes to the hospital having been immobile and lying in their own mess. They have a history of alcohol and drug use and are still using? Even if not while in hospital?

The patient is being difficult and rude to the nurses and therefore the nurses and staff sre refusing or reluctant to engage with them but family and friends of thr patient are saying this behaviour is out of character and should be treated as a symptom not a behaviour issue. It could be alcohol related dementia or other neurological issue?

Literally one of the first things this poster did say (after explaining that they weren’t sure they understood your post) was about capacity, which suggests to me that they’re considering whether the patient has dementia.

You’re clearly angry but even with the limited information you’ve posted here it is clear that this is a complex situation which would need careful assessment. You’re not going to get a reliable response on mumsnet, speak to the medical team.

I’m not a nurse, just a passing reader wondering why someone has posted a situation which, if it is real, shouldn’t be on mumsnet!

Or perhaps I’ve misunderstood and you’re not a medical professional, in which case that wasn’t clear from your post.

It depends on what you mean, no one should be abused at their work and nursing staff take a lot from patients because they know people in pain find it very hard to be measured. There’s a point when “unkind” becomes unsafe though.

The patient needs a full assessment but if they have capacity and either don’t want assessed or refuse to work with nursing staff carrying out that assessment what do you think staff should do? They literally can’t force people to accept assessment or treatment other than in very specific circumstances.

I like anyone else am entitled to not be abused by my patients and their families. I have worked in A and E for 20+ years and fully understand how frustrated people get when they are not getting the analgesia/answers/tests /beds/bring seen/ or even sandwich filling they want. I have dealt with 100s of complaints and listened to countless upset and angry patients and families. Usually peoples anger is directed at the system rather than the individual nurse and most people calm down if they know someone is listening and trying to help although you need to understand everyone is working in an overstretched system the individual in front of you can not make huge structural changes.
But there will always be those who continue to abuse us regardless either physically I’ve had knives and guns pulled out on me, I’ve been pushed punched chased spat at and had chairs thrown and I’ve also experienced high levels of verbal abuse this is unacceptable. I and my colleagues have no hesitation in calling police and security and refusing to treat someone who behaves like this.
40+ years of nursing I have been frequently praised my patients families and colleagues for “going above and beyond” for those who I care (literally) for but I and everyone who works in the NHS is entitled to draw a land in the sand when it comes to abuse and say enough is enough we cannot treat you if this continues.
I genuinely hope you resolve your concerns and this person fully recovers but I would strongly advise that you try and work with the staff rather than against them. You will never get the best out of anyone by being abusive. All hospitals have a zero tolerance policy on abuse, all have security guards, and they will not hesitate to get the police involved who are usually very sympathetic to staff and many will even get a court order to keep you away if they feel this is the only way to protect their staff.

Doctor and with that history I would expect an assessment for Korsakoffs/alcohol related dementia. And a capacity assessment for every decision.

I deal with a population with a high level of alcoholism and self neglect and it's fairly common for me to diagnose Korsakoffs in someone previously considered 'impulsive' or 'chaotic'. They generally do not have the skills to care for themselves but can be very convincing.

OP@GLP1U5er your initial post was cryptic and your updates haven’t made the situation that much clearer. Are you feeling that your relative hasn’t been treated correctly since admission to hospital ? Have you been able to speak to a dr and make them aware of the situation, do they have an acute illness or infection on top of chronic problems that may be causing change of personality ? A heavily alcohol dependent person would generally need meds prescribed to help manage withdrawals.Not all staff have the skills and knowledge to treat addicts or those with challenging behaviour within an acute setting …but it can be a fine line between accepting that unwell, confused patients can show abusive behaviour (not though their own choice) versus some patients ,who have the capacity to know better ,behaving badly towards staff. It sounds like you are worried staff are presuming the latter? I had to visit someone with dementia in hospital recently and sadly the ward staff seemed to have no clue as to how to reduce likelihood of negative reactions from the person I was visiting or how to de-escalate situations , even to the extent of grabbing items off them. Equally , staffing levels in some areas are appalling and its no surprise that care is compromised, and I wouldn’t want to be NHS ward staff these days.

In my hospital we have a clear algorithm for treating patients withdrawing from alcohol, this policy details very clearly what medicine needs to be prescribed/offered and when.
Ive worked in numerous hospitals and in the case of an alcoholic and or drug user withdrawing and displaying challenging behaviour most staff in an acute medical setting are pretty quick to ask for expert input from MH teams.
But these things are often very complicated patients if they assessed as having capacity are entitled to confidentiality, families often have their own concerns/ options about what they think needs to be done which may not match with the patients.

Honestly the first thing me and my team would do is 1) bath him. Wash him up and begin assessing his needs 2) drugs based on the dr’s orders WHICH may include stout. Detox protocols include the extra Vit. 3) Referral to D&A counselling 4) Physio to maintain mobility and if socially appropriate the in hospital day program for mental stimulation.
Concurrently would be family history and a visit to his home. Either family or home support would tidy up the home.
Rule out other medical issues.
Transfer asap (medically stable) to a long term respite bed discharge from there.
Most likely 101 other things, I worked in a tiny remote village, hospital admissions were whole community involvement. MN wouldn’t like the whole town involvement but we’d get meals on wheels and food bank sorted plus daily phone check ins.
Oh and if too nasty to staff security guard 1-1. while in hospital.
Sadly I’ve done this too many times it’s pretty routine.

This doesn't make much sense lying 3 days in faeces and urine with these injuries means pressure sores big time