Disrespectful patient

[hwknrs]

Tonight I got a 20 y.o. pt from the ED who came in saying he tried to harm himself by benzo OD. A&O drug screens neg. I went to his room to check vitals and get his admission history done. He was talking to his friend and did not stop to respond or even acknowledge that I had entered. he complained that he wanted to be released ASAP in the AM and that he didn't even have his cell phone charger with him. When I asked for his emergency contacts he sighed and rolled his eyes at me then went back to talking to friend.

Then mom came in from the hall. Pt then started playing with his cell phone and would not make eye contact. Just incredibly rude and snotty. I asked him to please put his phone down, show some respect and make eye contact so we could get this done He rolled his eyes & sighed ugh fine is that better. At that I told him it looks as though he has a lot of growing up to do and said that this is unacceptable behavior how he is acting towards me. I reminded him that he is here because of a choice he made and not to get smart with me as I'm trying to help and it's not my fault that he's here. His mom then told me that I shouldn't be talking to him that way that he just tried to kill himself (which he really didn't) and I should be more understanding. I said that's what I'm trying to do my job and no matter he still should not be so rude. It's not ok for him to be talking to me like this.

Then pt started screaming at me sayin you ***** you don't know and punching himself in the head. I stood back and watched and said this is pathetic how you are acting this is terrible behavior. Other staff heard him screaming & security was called. I then left the room and family requested another nurse and acted as though I was in the wrong. What do you all think? I just felt that his behavior was awful and inexcusable- needed to be brought to his attention that this is not the way to behave.

[Extra Pickles]

I have a nephew who's autistic and for the most part you described how he is a lot of the time and it's not that he's being rude by not making eye contact it's because he finds it very uncomfortable. He will also not put away his Gameboy and refuse to talk to you if that's where his head is at in that moment and you telling him that it's rude isn't going to mean anything to him. He also rolls his eyes and my sister hates it but she picks her battles with him and that's just something she puts up with so she can work on other things.

If you kept at him the way you kept at this patient my nephew would also start hurting himself, he does that when he gets really frustrated and for him it's punching himself in the arm or the leg, not the head. But don't you see what you've done here? If my sister were that patient's mother she would have eaten your face for a snack and then reported you to administration in a heartbeat! She has enough trouble getting people to understand this poor child without a nurse playing Miss Manners with him. I'm not saying this patient was autistic but your behavior toward him was only going to make the situation worse, could not possibly have made it better. You'll be lucky if you don't get an HR reprimand; that mother might just not be done with you yet.

[DTWriter]

I feel for you, OP (fist bump?); however, it was not the time to give a lecture. At that moment, he needed to be "babied" - or should I say pampered? Nah, babied. Yep, he needed to be babied. He just probably tried to kill himself. At that moment, any lecture you try to give would go in one ear and out the other ?

In the end of day, what is more important: preaching to the unteachable or protecting your license?

[NotAllWhoWandeRN, ASN, RN]

Anna Flaxis said:

Because some of the responses I was reading had the appearance of making the assumption that this happened in the ED.

While the OP's behavior would be inappropriate in any setting, ED RNs usually receive training in caring for the patient experiencing a psychiatric emergency, while RNs on the inpatient unit often do not. That has been my experience, anyway. The U.S. State in which I practice has a requirement for all staff who work in the Emergency setting to receive this training on a yearly basis.

All hospital systems I've worked for have included basic de-escalation techniques in case of violent or potentially violent patients. None of them use the word "pathetic."

[Laurie52]

ShaneTeam said:

Huh. Looks like it depends on where you work.

Where I work, if the county MH person can not make it to assess them at that time, usually over 5 hours wait time, the patient is admitted to ICU. But, our hospital is a small, rural hospital. They would never admit someone who is a suspected OD to the med/surg floor.

BTW, I am actually surprised the patient didn't knock you out, OP.

Just curious, why admit to ICU if asymptomatic?

[ShaneTeam]

Laurie52 said:

Just curious, why admit to ICU if asymptomatic?

The 1:1, plus if they started tanking. The floor had a census of 8:1, while the unit is closed half the time. The board just felt it was safer. Then they would be assessed by the county mental health agent in the AM, then either sent to the state hospital in the back of a squad car, or sent home, promising not to do it again.

The life in a small hospital.

[Christy1019, ASN, RN]

elkpark said:

Actually, we don't even know that. It takes time for ingested substances to show up in urine. The client may have taken an overdose of benzos too recently for them to be registering in his urine yet. I have talked to lots of people over the years who took an overdose, immediately (or, at least, quickly) regretted it, and told a family member or friend or called 911 her/himself. Those people often test negative in the ED, because not enough time has passed for the drugs to show up in a urine drug screen.

Or, as Purple noted, he may have been found and stopped before he actually swallowed the pills. That doesn't make him any less dangerous.

^This!! I was just about to post this. I've had tons of overdoses/suicide attempt pts come in over the years found with empty bottles of pills, unconscious, but negative drug screens. It doesn't make the situation any less serious.

OP, you've received valuable perspectives from many posters here, I truly hope that this gives you a chance to reflect on the situation and perhaps approach this differently in the future. Dealing with psych pts can be exhausting sometimes, but when we signed up for nursing we didn't expect it to be easy. I wish you the best, and please take the time to fully read all of the responses you've received here.

[Anna Flaxis, BSN, RN]

NotAllWhoWandeRN said:

All hospital systems I've worked for have included basic de-escalation techniques in case of violent or potentially violent patients. None of them use the word "pathetic."

Where did I say they did?

[Tenebrae, BSN, RN]

DTWriter said:

I feel for you, OP (fist bump?); however, it was not the time to give a lecture. At that moment, he needed to be "babied" - or should I say pampered? Nah, babied. Yep, he needed to be babied. He just probably tried to kill himself. At that moment, any lecture you try to give would go in one ear and out the other ?

In the end of day, what is more important: preaching to the unteachable or protecting your license?

Its amazing how often an unteachable patient/family become teachable when they get spoken to with a modicum of respect.

My rule of thumb? if you wouldnt tolerate being spoken to in a similar manner, dont do it to patients or their families.

[ixchel]

emtb2rn said:

I don't understand why the pt was an admit to med/surg. What was the dx? If anything, a psych facility/unit for the si would've been much more appropriate.

Easier said than done. We have one psychiatric facility in the state my hospital is in. We don't have a psych floor. We don't have anyone inpatient for psych (no MDs or NPs). We don't even have anyone on consult for psych.

My opinion? We should be shipping psych out. But we don't always. We do nothing helpful on medical floors. Our sitters have better psych experience than anyone.

[Been there,done that, ASN, RN]

hwknrs said:

I was hoping the mom would back me up and help remind him of basic manners. This has worked in the past but not this time. I know if my child was acting this way I would be embarrassed and definitely tell them to knock it off.

He is not a child. He is an adult patient with a psych issue. That you exacerbated.

I would simply chart.. unable to complete assessment, patient uncooperative at this time. Cannot FATHOM why you thought it was time to teach "manners".

At least he punched HIMSELF in the face, instead of you.

[sarah-ortho-boss]

OP: You really should've held you tongue this time. He may have been snotty, but you did escalate him to another level. This wasn't the right time for a confrontation.

[Adele_Michal7, ASN, RN]

sarah-ortho-boss said:

OP: You really should've held you tongue this time. He may have been snotty, but you did escalate him to another level. This wasn't the right time for a confrontation.

True! In my 7 years I've learned that trying to get that last word in, or even reason with, a patient, rarely produces a positive outcome.