Verbally abusive patient, worried I could have handled the situation better - page 9

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   NurseMom2016
    Quote from ufgatorjax86
    Hi guys. I am still a nursing student now, and I want to know how would you document this after you educate the patient regarding fluid restriction and given him the coffee?


    Like: "Pt understood the ramification of extra fluid in his body after I educated him on fluid restriction. I gave him a cup of coffee at 0800."
    I am just trying to learn how you document certain situation. Thanks!
    In this situation, I charted everything specific that I remembered him doing, including quoting some curse words in there that were said. I chatted one big long note after he left, with a rough timeline. Like:
    0815 called to pt room by charge RN, states he asked her for a drink and then started cursing loudly when told she would check with primary RN. Upon entering room to speak with pt, he politely asked this nurse for cup of coffee. This nurse stated "let me check your chart to see how much fluid you are at as you are on a fluid restriction." Pt then began to curse and yell loudly again, also shoving bedside table forcefully at this nurse. This nurse then left room to return in no more than 5 minutes to allow him to calm down.
    0825 returned to pt room. This nurse educated pt that he has already had 400 ml out of his 1000 ml for the day. Pt became agitated, yelling at this nurse, said "you are a f***ing liar, I haven't drank sh*t." He then threw his fork, empty cup, gown, tele box, and wristband across the room and continued to yell and curse directed at this nurse. Charge RN was notified of problem and security was called."

    That's something like what I charted in the beginning of my note. I always document some of the things that I can clearly remember them saying (and usually I "censor" the words too, although I know some nurses don't). I think thoroughly, objectively documenting pt behavior like this could help you later if it ever came up again. I also later documented that "pt stated several times 'get me the f*ck out of here", also that he stated he wanted to stay after he got his drinks and what I told him. That way if you have to look back on it in 3 years, you have a pretty clear picture of what happened, and so does anyone else reading it.
  2. by   NurseMom2016
    Quote from Fiddleback
    Some people brought up his "rights". Well, the OP has a right to not be verbally and physically abused. The other patients and their families have the right not to be subjected to this sort of thing or be afraid. Where is the concern for their rights.
    This is a classic example of a behavior issue. In the facility I work in there is no way we would reward his bad behavior by giving in to him. Rewarding bad behavior guarantees more bad behavior.
    Thank you. In all the comments, you are the first I think that has looked at it this way. I understand he has rights as a patient, but what I'm getting from a lot of the other comments is that I don't have a right to leave the situation when I'm being verbally abused. It's like we are expected to bow down to this kind of behavior and accept it as part of our job-well we shouldn't! If he would have calmed down after a few minutes of being alone after I left the room the first time, this would be a whole different story, but he didn't. He was completely calm when speaking on the phone and to the officer. But me and the physician, pct, and charge nurse? No way. The officer saw that behavior too.
    Looking back now, I am glad this patient could not ambulate completely independently, or he might have been coming up to the nurses station doing who knows what.
  3. by   Emergent
    Quote from TriciaJ
    Nope. You cannot say what he understood. You can only say what you did and what he did, using patient-centred language: "Pt was provided with extensive and repeated teaching re necessity of fluid restriction. At 0800 was given coffee at his insistence."
    Be sure to include: 'Pt said "You f-ing b---h, get me coffee right now!". Then pt threw water across the room getting me wet, continuing to use profanity. Charge nurse and Dr Jerk notified. Dr Jerk arrived and brought pt coffee after writing discharge.'
  4. by   Julius Seizure
    Quote from TriciaJ
    Great note. But you'd have to lock yourself in a closet and turn your phone off to chart all that without several interruptions.
    Haha! I was thinking that too! I nearly fell asleep writing it (that explains the typos). I vaguely remember that I meant to say something about how it might be TOO thoroughly charted
  5. by   TriciaJ
    Quote from NurseMom2016
    Thank you. In all the comments, you are the first I think that has looked at it this way. I understand he has rights as a patient, but what I'm getting from a lot of the other comments is that I don't have a right to leave the situation when I'm being verbally abused. It's like we are expected to bow down to this kind of behavior and accept it as part of our job-well we shouldn't! If he would have calmed down after a few minutes of being alone after I left the room the first time, this would be a whole different story, but he didn't. He was completely calm when speaking on the phone and to the officer. But me and the physician, pct, and charge nurse? No way. The officer saw that behavior too.
    Looking back now, I am glad this patient could not ambulate completely independently, or he might have been coming up to the nurses station doing who knows what.
    Actually I think most of us keep in mind what other patients are experiencing and we do think you have the right to step away when you are being subjected to a torrent of abuse. Maybe we didn't do a good job of conveying that, but I think most posters here get that there was no saving this situation.

    If I didn't say this before: I don't think anyone could have handled this better.
  6. by   Julius Seizure
    Quote from NurseMom2016
    Thank you. In all the comments, you are the first I think that has looked at it this way. I understand he has rights as a patient, but what I'm getting from a lot of the other comments is that I don't have a right to leave the situation when I'm being verbally abused. It's like we are expected to bow down to this kind of behavior and accept it as part of our job-well we shouldn't! If he would have calmed down after a few minutes of being alone after I left the room the first time, this would be a whole different story, but he didn't. He was completely calm when speaking on the phone and to the officer. But me and the physician, pct, and charge nurse? No way. The officer saw that behavior too.
    Looking back now, I am glad this patient could not ambulate completely independently, or he might have been coming up to the nurses station doing who knows what.
    I've read this entire thread, and I didn't get the sense that the majority of people felt that you had no right to leave the situation. Granted, not many people explicitly addressed it but I think most would agree that you have no obligation to stand there and take that kind of verbal abuse. You did the right thing by saying that you are leaving and will come back after he has had a chance to calm down.

    I think even the "I would just give him the coffee" crowd would agree that you don't have any obligation to stand there while he screams profanities at you.
  7. by   ufgatorjax86
    Thank you for your reply. So it is totally acceptable to charted the whole details or it is depending on the hospital policy? If it happened to me, I would prefer to chart the whole events (including his profanities, throwing stuffs to me, etc) in case it gets back to me.
    This is a great learning opportunity for me, because it might happen to me someday and that way I know how to handle this. Thanks!
  8. by   TriciaJ
    Quote from ufgatorjax86
    Thank you for your reply. So it is totally acceptable to charted the whole details or it is depending on the hospital policy? If it happened to me, I would prefer to chart the whole events (including his profanities, throwing stuffs to me, etc) in case it gets back to me.
    This is a great learning opportunity for me, because it might happen to me someday and that way I know how to handle this. Thanks!
    You're right. It really is best to chart as much of it as you can and use quotes when necessary. Because this is exactly the kind of person who will complain to the powers that be that he wasn't shown any compassion. And we now know he can be perfectly reasonable when he wants to be, so he can present himself credibly.

    Just make sure all your statements are objectively written: what you saw, heard or did.
  9. by   Ruby Vee
    Quote from NurseMom2016
    I have read through each one of your comments. I am very thankful for those of you who are supportive in how I handled the situation, and very thankful of the constructive criticism I have received. However, there is one point I don't think I did enough justice to in my original post: that this man had been educated numerous times. It was documented throughout the chart. The physician had even said that she had spoken to him at length the day before while he was still in icu. So yes, he had the right to refuse following the order of the fluid restriction. But when does that make it appropriate to behave like he did? (He was also sitting 100% naked in his room during all of this, his gown went on the floor with the other stuff he threw).
    Within the two hours this was going on, the physician, security guard, charge nurse, the tech, and myself witnessed his behavior, along with him saying numerous times "get me the hell out of here." The physician and I agreed that yes, it could have been related to withdrawals, but at that point I don't know if he would have let me give him any Ativan through his IV, as he had already began to pull off the tape to get them out himself.
    Also, I think the patients and family were thankful he left as well. They had heard him numerous times overnight yelling and cursing through the walls. The patient next door was an elderly woman who had just been put on inpatient hospice the day before, with a good bit of family in the room with her.
    One other thing: where I work, the physicians normally do not put in an actual "discharge order" for pts leaving ama. The pt signs the Ama paper (or refuses to), then leaves, and we document.
    Looking back on this, I think this guy was at the end of his "sober period" of being in the hospital, and probably needed a fix of whatever drug of his choice.
    Let me make this clear as well:
    I think giving him the coffee, fluid restriction or not, would have solved the immediate problem, but not the problem that would have inevitably arisen 20 min later.
    I agree with you. You did the right thing.
  10. by   Ruby Vee
    Quote from kiwinurse18
    There's this really great article called "care goes in, crap goes out". Worth a read. Basically the patient is the centre. Nurses, doctors, family, friends are all in outer circles and the patient is allowed to dumb their crap out to their support.

    I get it. It gets hard sometimes. Especially when their non compliant and disrespectful. But nobody WANTS to be in hospital. Maybe he's like it all the time. Or maybe you're meeting him on the worst days of his life and he's filled with nothing but fear. You're gonna get crap dumped on you, so it's important you have your own support that you can share that with. Maybe a little more teamwork and education. Some people might disagree with me, say there's no excuse for certain behaviours but I just don't believe patients you meet in hospital are a true representation of themselves usually. And for every awful one, you'll get one who is sorry they're "wasting" bed space. You just gotta hope the balance is there.
    Hospitalized people are still pretty much the same person they are outside the hospital. The verbally and physically abusive ones don't miraculously become kind, gentle folks just because they're discharged. I don't believe this "you're meeting him on the worst day of his life" crap. He's a donkey behaving like a donkey.
  11. by   Ruby Vee
    Quote from TriciaJ
    Nope. You cannot say what he understood. You can only say what you did and what he did, using patient-centred language: "Pt was provided with extensive and repeated teaching re necessity of fluid restriction. At 0800 was given coffee at his insistence."
    Or even better: Patient was re-educationed re: fluid restriction. As he is already 250cc over his fluid restriction, coffee was not given and patient education re: fluid restriction reiterated."
  12. by   spunkymoo
    You were in a no-win situation. Who is to say if you gave him the coffee he wouldn't be pulling the same thing half an hour later? There are sick patients who want to get well, better that they have the bed.
  13. by   canoehead
    Quote from Been there,done that
    Any patient has the right to refuse a doctor's prescribed treatment. YOU had no right to refuse the patient's request. It's a hospital, not a jail.


    This is not about you, it's about the patient. You basically bounced out a patient that was not ready to go home, that even rescinded his own discharge and was visibly too weak to manage his own care... because your feelings were hurt.
    Disagree.

    if the patient wanted a rope to hang himself with, would I provide it after discussing the pros and cons?

    Giving fluids over the limit would have exacerbated his condition. I would do the education piece, especially ways to make a little fluid go a long way, and told him he makes his own decisions. I'd get the coffee up to his fluid limit, then start using ice chips for the last 50cc. I won't be involved in a decision that will hurt him. He's free to get up and get the coffee himself, have relatives bring something in, or call for delivery. I don't interfere, but I'm not helping him go against doctors orders.

    He wanted to leave AMA when he couldn't demand and receive, fine. I'll remove medical equipment, call the doctor, and the patient can dress himself and take himself down to the cab. (That approach has kept a few confused patients in my ER long enough for meds to kick in) If he's too weak to move, I guess he's stuck (and not safe to go home alone anyway.) Again, he can problem solve his way out by calling for outside assistance, and doing that will show he can care for himself, so chart carefully. Yelling and cursing would indicate an inability mentally, to work things out. Don't approach him as an adversary, be a person that wants to help, but refuse to assist in a bad decision. Keep going over options that might make the stay tolerable, and put the responsibility for physical action on him.
    Last edit by canoehead on Sep 24

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