Mondays

I work every Monday. I don't mind working every Monday; in fact, it gets the week off to a productive start. What does bother me is what goes on--or does not go on--with my patient all weekend when there are no nurses there.

It's certainly not abuse, and couldn't be defined as neglect, either. It's just that SL is not getting as good of care as she should. When I get there Monday morning her lips are coated with "gunk". Her limbs are tight; I don't think her mom does range-of-motion all weekend. Her mom doesn't get her up in her wheelchair all weekend, after having wrist surgery--more than a year ago (she's been OK's by the doctor--months ago--to resume every activity, including lifting, that she did before the surgery. Besides, there's a lift she could use)! SL's back is red; thankfully there have been no open areas--at least not yet. But it's clear that she doesn't get repositioned regularly. Her hair is very greasy, and while her body odor is not terrible, it definitely falls into the category of "funky and unbathed for two days."

I feel bad for my patient; those basic nursing cares--oral care, repositioning, getting up, and so on--are necessary health-wise as well as comfort-wise. I think we have a duty to make our patients comfortable, no matter what their level of alertness or mental status.

It also bothers me because performing these very basic nursing cares--oral care, repositioning, getting a patient up in her wheelchair, and so on--are so important to preventing potentially dangerous complications like mouth sores, skin ulcers, blood clots, pneumonia, and so on. My patient is only in her 20's, and I think that's why she's been able to fend off these complications . . . at least so far. However, it's not a given that she'll be able to resist complications indefinitely! Her respiratory status is poor to begin with, and she had a UTI a few weeks ago. Performing these cares and basic tasks would probably take less than an hour, at the most, every day. Yet her mom doesn't do them.

Today, shortly after I arrived, SL was wet. She was also moving her legs kind of like riding a bicycle--very UNcharacteristic for her. When I changed her, I noted that her peri area was extremely red, almost raw in some places. Obviously it was very painful when her urine touched those areas. I washed the area off with a soft cloth and left it open to air for about 15 minutes, and the redness was dramatically decreased. I told her mom I'd done this, hoping that she would leave her bottom open to air when she was in bed later in the day. Before I left, I positioned SL on her side, with her brief open, to get the pressure off of her bottom and leave the area open to air. I told her mom I'd done this, too, but got the impression her mom was unhappy, because later she'd have to remove the pillows and reposition SL on her back again.

The other nurses and I are in a tough spot. SL's mom DOES change her brief whenever she is wet or has a BM (although there is often some BM in the cracks {sorry!} when I change her the next time she's wet and do peri care). She DOES give SL her meds and formula on time. She just doesn't do the basics that she probably feels are "extras" . . . but nurses know are part of basic good care. We do all the teaching we can . . . we all reinforce what the other nurses have said. But if we "push" too hard, SL's mom gets defensive and is less likely to listen to us.

But I can't say that SL would be better off in a long-term-care unit . . . although if she was there, she would get much more stimulation, PT, etc. Maybe. Depending on staffing and how good the particular staff members were. We have absolutely no basis for "turning her in" to social services or even calling the doctor about it. SL's mom has successfully kept her at home for more than 20 years--who are we to question what she does???

All we can do is teach why it's important, and give the care WE know is the best we can give. When I put her arm braces on before I leave, I know they'll be on at least a few hours until her mom gives her meds later in the afternoon and takes them off. When I position her on her side, I know she will be that way for at least a few hours, too. When I give peri care I know she will have no BM on her skin until she has another BM, usually not until the next day. When I clean her mouth and lips, I know she is refreshed for at least a few hours.

Although it's all I can do for her . . . some Mondays it feels like it's not quite enough.