The Ointment in the Daughter's Purse
Mrs. L is a 78-year-old resident with a Stage 2 pressure injury over her coccyx. Her care plan calls for repositioning every two hours, including a 30-degree side-lying position. She has osteoarthritis in her left hip and rates the pain 7/10 when turned onto that side; she refuses that position and asks to be left flat. Her daughter visits at 10:00 PM, brings a tube of over-the-counter antibiotic ointment, and says, "Just put this on the sore and skip the turning tonight - she needs her sleep." The resident is settled and drowsy. The licensed nurse is on break. The resident is alert and makes her own decisions.
1. What do you do about the ointment and about the turning before the nurse returns?
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The ointment: no. It is not ordered, it is not in the care plan, and applying a topical to a pressure injury can mask signs of worsening or irritate the wound. I thank the daughter, take the tube, and tell her I will give it to the nurse - I do not put it in the resident's drawer and I do not apply it.
The turning: I do not simply skip it, and I do not force it. A 7/10 pain score is information, not an obstacle to bulldoze. I offer the turn in a way she can accept: prop her at a 30-degree tilt with pillows rather than a full side-lying, try the right side first, time the turn around whatever pain medication is ordered and working, keep movements slow and quiet, and offer small shifts and heel offloading if she still declines.
If she still refuses, that is her right as a competent resident. I document the refusal with her words, what I offered instead, and the time, and I report it to the nurse the moment she returns - pain that blocks repositioning needs a nurse's assessment, not an aide's workaround. I never chart "turned q2h" if it did not happen.
2. How do you answer the daughter so that she feels heard without agreeing to anything unsafe?
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Acknowledge first: "You're right that sleep matters, and you're clearly trying to look out for her."
Then be clear without arguing: "I can't put this on - it isn't ordered for her, and only the nurse can apply a treatment. I'll hand it to her nurse tonight. And I can't take her off the turning schedule; those turns are what keep the sore from getting worse and protect the skin around it."
Then offer what I can do: "We can make the turns quiet - pillows for support, timing them with her pain medicine, and I'll tell the nurse her hip is hurting so it can be looked at."
What I avoid: promising to skip turns, debating the daughter's judgement, discussing anything about other residents, or speculating about whether the sore is healing. If she pushes, I say the nurse can talk with her about the plan and offer to arrange that. The resident's own wishes are the ones that count, and if the daughter and the resident disagree, that goes to the nurse.
3. What do you report and what do you write in the record at the end of the shift?
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Report to the nurse, verbally, before end of shift: the refused left side-lying and the pain score, that the pain is blocking repositioning, the daughter's request to skip turns, that the daughter supplied OTC ointment and it is at the desk for the nurse, and what I did instead (positioning used, times).
Chart objectively, with times, e.g.: "10:15 PM - resident declined left side-lying position; states left hip pain 7/10. Repositioned supine with pillow under right hip, heels offloaded. Daughter present at 10:00 PM; provided OTC antibiotic ointment, given to RN."
What stays out: "daughter refused turning for resident" (the resident is the decision-maker - record her refusal, not her daughter's), "noncompliant," any assumption that the skin is unchanged, and any note implying turns were done that were not. If the skin looks different, describe what I see - color, size, drainage - and say the nurse was notified.