Verbally abusive patient, worried I could have handled the situation better - page 6

Let me start out by saying this is a little long winded, but it has been weighing on me and I have to get it off my chest, so bear with me!!! So, my last shift, I had gotten report on a male patient... Read More

  1. by   Creamsoda
    Maybe the only thing I would have added was, " sir you are discharged, but if you think you need to you can go to the ER". Sure it could be easier to just resign and let him stay once he had his coffee, but that would be reinforcing his terrible behavior. We can still give him the care he wants... but after he goes back through the ER. Sure its a pain, and a big waste of resources, but just because its a hospital, doesn't mean he gets a free pass. Anywhere else in society if he doesn't follow the rules, he has to live the consequences. He was alert and oriented. And assaulted you by throwing stuff at you. Which you could certainly press charges for.
  2. by   TriciaJ
    Quote from RestlessHeart
    At the risk of getting my "membership" here handed to me on a platter..Id like to ask something. Please keep in mind I am not and never was a Nurse of any degree. I do have great respect for all of you in the Medical Field. My Medical side is only extensive as far as the patient view because Ive been one way tooooo many times.

    Anyway... I digress. Just be gentle ok? Im curious about the fluid restriction and how that comes about. How is it decided and who decides how much of a restriction is applied? Does it mean ANY fluid? Is it "touchy" (where a little too much or a little too little can be nasty?)

    My twin has kidney failure and when she was hospitalized and later in a Nursing rehab prior to going home they had her on fluid restriction. But...here's the thing I never understood. She would leave the clinic / dialysis and almost immediately drink 2, 16 ounce bottles of Mt Dew. Mind you she is a raging diabetic that believes you can eat or drink anything as long as you take the insulin. UGH.

    Anyway....I appreciate any responses...just be gentle.

    Have a super day and I wouldnt wish the treatment the patient OR the nurse received in this matter on ANYONE!!
    Here goes. Your twin is a classic example of someone who is not following her prescribed treatment. "Raging diabetes" quite often leads to kidney failure. That means her kidneys can't get rid of excess fluid or do any of the other things that kidneys do, like help control blood pressure. The fluid restriction is to lighten the load on her kidneys and prevent all the other bad things that happen when our bodies are in fluid overload. One example is literally drowning when our lungs fill up with fluid and our hearts are unable to pump properly.

    When your sister gets discharged and promptly starts drinking Mountain Dew, she is taking in fluid and sugar that her body is unable to handle. ALL of her problems start getting exponentially worse. Her caregivers know that.

    One of the first things drummed into us in nursing school was a quote by Florence Nightingale: "Above all, do no harm." That means even if we can't make the patient better, we should at least not make him worse. The corporate bean counters and customer service gurus don't get that. They don't get that a pickle, or Mountain Dew or a cup of coffee can actually hasten someone's death and why nurses can never function like a concierge at the Hilton.

    Your sister is committing suicide the slow way. Nurses know that, even if it is not apparent to others. If you discovered her trying to hang herself, would you be nice and help her tie her noose, or be a mean sister and take away her rope? Think of nurses as the mean sisters.
  3. by   Creamsoda
    Quote from JKL33
    Kooky...

    Come on, you don't really mean that, do you? She'd already discharged the guy, after telling him that he may NOT treat staff that way.

    I'll take that for support, in a heartbeat. I would've brought him the coffee myself at that point, seriously.

    Yeah I didn't think the doctor is as evil as everyone is making them to be either? The way I understand it as written, doc told the guy to quit acting like an idiot and that yes he may go home if he wishes. Told him he is discharged per the patients wishes. Then while all that is getting ready to go, brings the guy coffee while he's waiting for a cab to help de-escalate the situation more. He's discharged, he can drink what he wants. I would have got the coffee too at that point.

    Though to be honest, I don't care if a patient is having a hissy fit, if they want to break all their restrictions, i am not going to stop them. You want cream and sugar with your coffee? Thats where I think OP maybe took things too personally. You just chart that the patient is not following restrictions. We can't force them. They want to fluid overload themselves while alert and oriented? Go right ahead, ill be at the desk when you go into flash pulmonary edema and code and will help you then because then its implied consent to save your sorry life. And I will continue to get as much overtime as I do because these people give us job security. =D
  4. by   Here.I.Stand
    @RestlessHeart --

    Fluid restrictions are prescribed for patients whose heart function (or in your sister's case, kidney function) is compromised too much to be able to handle unlimited fluids. In a nutshell, pt drinks excess fluids, fluids absorbed into the bloodstream; the blood volume increases, but the heart is too weak to keep up with pumping the extra volume/kidneys unable to filter all of that volume. The excess fluid leeches from the blood vessels, which causes edema. The big danger isn't cankles though -- it is pulmonary edema, which is like partial/gradual drowning.

    The restriction amounts are usually between 1 and 2 liters per day -- depending on the degree of heart failure. This is entered as an order/prescription as part of the medical plan of care.

    The OP's patient and your sister may not follow the recommendation and that is their right. However as health professionals, *we* can't be compelled to ignore the plan of care which compromises his/her safety. It's one thing if their family gives him bottled drinks from the store -- it's their legal property and we can't confiscate it. However, this pt threw a toddler tantrum because the licensed professional RN chose to follow the POC.

    He could possibly have been able to drink the coffee. If he got 2000 ml of fluids per day, he'd drank nothing overnight, and had 120 ml of juice with breakfast -- sure, he has room for a 240 ml cup of coffee. But was he limited to 1000ml per day, but he had juice with breakfast PLUS half his water pitcher is gone? Midnight is a long way off, and he will get VERY thirsty, because the nurse isn't going to procure drinks once he's had 1000 ml. So the OP was absolutely correct to check his chart first. Say that coffee put him to the top of the fluid limit, he had every right to be informed up front that staff couldn't bring anything to drink until after midnight. Unfortunately, instead of being reasonable he chose to act like a 2 yr old and throw things at the nurse.
    Last edit by Here.I.Stand on Sep 22
  5. by   Snels50
    What could you have done differently? Considered alcohol withdrawal in your differential. Big missed diagnosis by the doc.
  6. by   BSN16
    Quote from nursemike
    Sometimes our patients are having the worst day of their lives. They're frightened, they're frustrated, and acting out may be the one way they have of feeling like they have some sort of control. As much as it may not look that way, in our relationships with our patients, the power is disproportionately ours, and that can be hard to swallow for the one without the power. Indeed, we sometimes feel like we are powerless and have to kowtow to get those patient satisfaction score, which makes us want to act out a little, too.
    In times like these, it's very important to understand that people may be dealing inappropriately with their anxieties and stress because they just don't know any other way. Nor is it wrong to step away a moment, take a cleansing breath, and keep in mind that some of these people were probably jerks long before we ever met them, and will be long after they're discharged.
    I have had my number of patients and their families coping inappropriately. however i think this mentality is dangerous because it normalized verbal and physical abuse from patients. Yes they are in a stressful situation but no, this does not give them the right to treat staff this way. In my opinion throwing the cup of water and getting the nurse wet boarders on the line of physical assault whether intentional or not.

    OP i dont think you could have handled this situation much people. These patients are difficult and sometimes make us question why we became a nurse in the first place. Just remember that for every ungrateful angry patient there are a 100 appreciative patients in their place.
  7. by   Julius Seizure
    Quote from Kooky Korky
    So you would have given in to his babyish demands and not followed orders? That would leave you open to claims of negligence or malpractice I think because you handed him the coffee or whatever liquids.
    This doesn't ring true to me. Patients can refuse treatments. Are you saying that if I go to insert an NG tube on a patient and they say they don't want that treatment, that I am at risk of negligence/malpractice? Or if I offer a patient their enalapril and they say they don't wish to take their medication, that I am open to negligence/malpractice? I think not. If the patient refuses a treatment, then my duty is to educate, document their refusal, and update their attending provider on the patient's wishes. Not to force them to accept the treatment.
  8. by   JKL33
    Quote from Julius Seizure
    This doesn't ring true to me. Patients can refuse treatments. Are you saying that if I go to insert an NG tube on a patient and they say they don't want that treatment, that I am at risk of negligence/malpractice? Or if I offer a patient their enalapril and they say they don't wish to take their medication, that I am open to negligence/malpractice? I think not. If the patient refuses a treatment, then my duty is to educate, document their refusal, and update their attending provider on the patient's wishes. Not to force them to accept the treatment.
    Agree with you in spirit here, and I was thinking about this aspect of things when I've been busy writing about the AMA process.

    I just want to point out that it can get sticky very quickly, and possibly when you least expect it. Wisdom and a good understanding of the risks of non-compliance are important in the day-to-day handling of these situation. I mean, it sounds pretty rational to simply document a NGT refusal and let it go, and not be overly worried about liability. As long as your patient doesn't aspirate feculent material overnight, for example...

    In cases where those types of serious possibilities seem to be on the table, I think every measure should be undertaken to ensure the patient understands (education provided by both nurse and ordering provider) and the refusal and acknowledgement of such very clearly documented.
  9. by   Julius Seizure
    Quote from JKL33
    Agree with you in spirit here, and I was thinking about this aspect of things when I've been busy writing about the AMA process.

    I just want to point out that it can get sticky very quickly, and possibly when you least expect it. Wisdom and a good understanding of the risks of non-compliance are important in the day-to-day handling of these situation. I mean, it sounds pretty rational to simply document a NGT refusal and let it go, and not be overly worried about liability. As long as your patient doesn't aspirate feculent material overnight, for example...

    In cases where those types of serious possibilities seem to be on the table, I think every measure should be undertaken to ensure the patient understands (education provided by both nurse and ordering provider) and the refusal and acknowledgement of such very clearly documented.
    You are absolutely right. It is more than just "document the refusal and move on." Education is critical - and real education, not the "I said it so I could document that I educated".

    Sometimes the refusal will also mean that a new care plan needs to be made - probably a good time for a pow-wow with the provider, nursing staff, and patient.
  10. by   Sour Lemon
    Quote from Ruby Vee
    The "customer service pendulum" has swung so far that we're now happily providing patients with liquids, foods, options that are medically contraindicated. And it seems that many of us nurses don't see the problem with just giving the patient whatever he asks for. That's good customer service, you see, and it obviously trumps good patient care for many nurses. Or maybe it's "give him what he demands so he'll shut up and my shift will go more smoothly."
    I'm in the "just give him the coffee" group ...and yes, it's to shut them up so my shift goes smoother. I used to try a little harder, but then I realized something. These patients don't stop. They just don't. When you don't give them what they want, they ask for the charge nurse. When the charge nurse won't give in, they want the supervisor. In the end, the original nurse is undermined and the patient ALWAYS gets their way from someone up higher in the chain of command. I've made the mistake of wasting hours of my time dealing with these sorts of issues in the past, but never again.
    I spent nearly an entire 12 hour shift going back and forth with a patient who wanted to go outside for "fresh air" (cigarettes). Policy was that if a patient left the unit, they were discharged AMA ...but that was not acceptable to my patient so she just kept whining, begging, causing huge scenes and contacting anyone who might be able to overrule me. Fifteen minutes before my shift ended, she was given permission to go outside for "fresh air" by the director. I wanted to SCREAM. I could have done that 12 hours ago and actually had a good night.
  11. by   debiklages
    Attached Images screen-shot-2017-
  12. by   debiklages
    Attached Images screen-shot-2017-
  13. by   CCUNURSE1
    I say ignore the "you could have handled it better, self riotous people". There will ALWAYS be non compliant pts, hateful pts, or those that just don't give a crap about their own health. If they don't want to change...they won't. And most often, the nurses take the brunt of it. If you had given him the coffee and whatever else he wanted, he would have bullied you the rest of the day; plus, you could have possibly endured the wrath of the physician that ordered the fluid restriction. At the end of the day, remember that you did your best and your other patients didn't suffer because of the erroneous time you spent with someone who didn't want to be helped. Been there, done that...have the emotional scars to prove it. At the end of the day, he would have left anyway.

close