The 2:00 AM Turn: Refusal, Pain, and a Pressure Injury
Mrs. Okafor is 84 and was admitted six weeks ago with a stage 2 pressure injury over her coccyx. Her care plan reads "reposition every 2 hours, alternate side-back-side, float heels." It is 2:05 AM. You turned her onto her back at midnight, and she is due to go onto her left side now. She has arthritis in her left hip and had her last PRN pain medication at 9:30 PM. She says the left side "burns" and that she is not going to move, "so leave me alone and let me sleep." She is fully oriented and has the right to refuse. She is also incontinent of urine, and her brief is wet. The charge nurse is on break.
1. It is 2:05 AM and Mrs. Okafor refuses to turn onto her left side. What is your plan, and what do you say to her?
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Start with the part she has not refused. Her brief is wet, and urine sitting against a coccyx wound is worse than a missed turn. Say: "Let's get you dry first - I'll be quick." That is care she is likely to accept, and it is also the reason you are in the room.
Then name the problem out loud, without arguing: "I know that left hip burns when you lie on it. I'm not going to force you."
Offer real alternatives, not a lecture:
- A 30-degree tilt onto her back with a pillow wedged under one hip - it takes pressure off the coccyx without putting her full weight on the sore hip.
- A small shift rather than a full turn: pillow under the left knee, heels floated off the mattress with pillows.
- A 15–20 minute window: "I'll come back at 2:25 and we'll try again."
- Ask the nurse about the PRN pain medication. The nurse decides whether a PRN is appropriate; you do not.
Why: the care plan's goal is offloading the coccyx, and there is more than one way to reach it. The turn is a means; a healed wound is the end.
2. She refuses everything, including the brief change. What do you do, and what do you document?
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Do what you can without a fight. An oriented adult can refuse. You do not turn her by force and you do not threaten. You can still:
- straighten the bottom sheet and remove any wrinkle or plastic under her,
- float her heels with a pillow if she will allow it,
- leave the call light in her hand,
- check back at 2:25 as promised.
Report it now, not at 7:00. Contact the charge nurse (pager or phone if she is on break). A stage 2 wound plus a flat refusal is a skin-integrity risk the nurse needs to know about tonight. The nurse may come in, renegotiate, medicate, or revise the plan.
Document only what happened:
- "2:05 AM - repositioning offered; resident declined left lateral, stating left hip burns. Positioned supine, pillow under left hip, heels floated. Brief change declined."
- "2:25 AM - re-offered; declined."
- "2:30 AM - charge nurse notified."
Do not chart "turned q2h" or "repositioned per plan" if it did not happen. An accurate refusal record protects her and protects you; a false one hides a wound that is getting worse.
3. The next aide says, "You can't just let her refuse - that's neglect." How do you explain the balance?
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Both things are true at once, and the exam tests whether you can hold both:
- Resident rights: an oriented adult may refuse care, including repositioning. Physically forcing her is battery, and threatening her is not allowed either.
- Duty of care: a refusal does not end your obligation. It changes it. You keep offering, you reduce the harm you can reduce (dry surface, heels floated, brief change, a 30-degree tilt), and you tell the nurse, who owns the plan.
Pattern matters. One refusal on one night is a note. Every turn refused for three nights is a care plan that no longer fits and needs the nurse, and possibly the provider, to revise - around pain control, a specialty mattress, or timing.
Say it plainly: "I didn't let her refuse. I offered, she declined, I did what she would allow, I called the nurse, and I wrote exactly that. If we force her, that's abuse. If we stop offering, that's neglect."