The Refused Turn: Pressure Injury Risk Against Uncontrolled Pain
Mrs. Chen, 84, is post-op day 3 after surgery to repair a broken right hip. She weighs 98 lb, has thin skin over her sacrum, and the care plan says reposition every 2 hours. When you enter at 2:00 p.m. to turn her onto her right side, she grabs the rail and says, "No. It hurts too much. Leave me alone." She is pale and her face is drawn. Her last pain medication was at 12:30 p.m.; PRN pain medication is ordered but is given by the nurse, who is in a staff meeting. She has not been repositioned since noon.
1. You cannot force her, and she cannot stay flat on her back all shift. What do you do first?
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Believe the pain, and do not force the turn - but don't abandon the goal either.
- Treat the refusal as a reportable change. Guarding the rail, a drawn face, and a flat refusal in a woman who has been cooperating is not naughtiness; it is information.
- Get the pain question to the nurse now. A staff meeting is not a reason to sit on a request. Tell her: "Mrs. Chen is refusing to turn, says it's too painful, PRN was last given at 12:30."
- Unload the sacrum within what she will tolerate. A pillow tucked under her left hip to hold a slight tilt (about 30°), heels floated off the mattress, head of bed lowered as tolerated. That takes weight off the sacrum without a full roll onto the operative side. Coach her to shift her own weight.
- Come back sooner - try again in 20–30 minutes, after the nurse has addressed the pain.
Why: the care plan says every 2 hours because turning relieves pressure. A tolerated tilt relieves some pressure; a forced turn on a three-day-old hip repair risks injury and ends her trust in you. Pain control is the nurse's call and has to come first.
2. Two hours later she is still refusing and the nurse has not come. What are your options, and what is the line you cannot cross?
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Escalate - don't improvise and don't fake the record.
- Go find the nurse in person. If she is still unavailable, tell the charge nurse or the nurse in charge of the unit: prolonged pressure plus uncontrolled pain plus a missed repositioning interval.
- Keep doing the parts that are yours: comfort measures, small shifts, checking the skin each visit, keeping her clean and dry, call light within reach, checking on her at least as often as the care plan says.
- Chart exactly what happened: "1400 - refused turn to right side, states 'it hurts too much.' Pillow tilt applied and tolerated. Nurse notified 1405; no response, charge nurse notified 1600."
The line you cannot cross: you may never chart that she was turned when she was not. A false entry hides the exact problem the nurse needs to see, and it is your name on the chart.
Also not yours: deciding she can lie on her back all shift, digging a pain pill out of her bedside drawer, or telling the family the staff "forgot" her.
3. What observations turn "she refused" into a useful report to the nurse?
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Report the whole picture, not just the word no.
- Color and expression: pale, drawn face - new since your last check?
- The pain itself: is it escalating, or the same as before the PRN?
- The hip: any drainage on the dressing, any new swelling or warmth, any change in how she looks overall. Take and report vital signs if your facility assigns that to you.
- Intake and output: how much she has had to drink, and when she last urinated.
- Time last repositioned, and whether she was turning with help yesterday.
Why: a resident who tolerated turns yesterday and now will not be touched may have uncontrolled pain, a bleeding or infected wound, or something new. You are not deciding which. Your value is the specific, timed observation - "she refused" tells the nurse almost nothing; "pale and drawn, won't let anyone near the right hip, dressing dry, PRN at 12:30, no repositioning since noon" tells her where to look.
Write it the same hour, and put her words in quotation marks.