Disrespectful patient

jdub6 · May 30, 2016

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."

To be fair to the OP (and i agree this wasn't appropriate behavior on the part of the nurse) i have worked for 3 systems, none of which have provided any kind of psych training for inpatient med/ surg RNs. In fact most inpatient and ICU nurses i worked with were well aware they had no idea how to handle psych patients and dreaded getting them.

Also, why are so many assuming this pt has autism? Certainly that kind of behavior could be autistic but generally a dx of autism would be found out in the ED (esp since the pt had mom there) and included in the admit report or h&p. And i would expect this to have been diagnosed by age 20 in someone with this level of behaviors.

In any case, while it sounds like this interaction didn't go well, i think this is a great example of why inpatient staff should receive the kind of training many ED staff receive in crisis intervention etc-if the hospital wants to send this stuff to the floors they need to provide training to the staff. Also, i am curious why, if this pt was felt to be a suicide or self harm risk, there was no sitter? If this pt had a legit psych issue there should have been a 1:1 plus other precautions (limited visitors, no dangerous items like drawstrings, etc). This nurse was left to figure out how to handle a totally unfamiliar condition on their own from the sound of it. I probably wouldn't have handled it the same way but i don't know that the OP was malicious, just uninformed.

OP i am curious what your coworker who was assigned the pt after you thought of all this.

Libby1987 · May 30, 2016

Mental health experience seems essential for working ED, or anything healthcare these days, but even basic people skills would have had a better outcome.

psu_213, BSN, RN · May 30, 2016

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.

We have a psych facility nearby. If the pt. is not medically stable, they will not/cannot accept the pt. In my experience, if the pt. has so much as a hangnail, they will not accept the pt. as medically stable.

psu_213, BSN, RN · May 30, 2016

jdub6 said:
Also, why are so many assuming this pt has autism?

I may be wrong, but I don't think anyone is assuming he has autism. I do think that people are trying to offer other possible explanations for the pt's behavior other than him being a brat, jerk, etc.

OCNRN63, RN · May 30, 2016

As a former certified psych. nurse, I have to be honest: your conduct was inappropriate and not only escalated the patient's agitated behavior, but made things more difficult for anyone who would have had to evaluate him later, e.g. physician, social worker, crisis intervention worker, etc. Not only that, but you angered his mother, who could have been an ally.

People who are suicidal don't behave in textbook manners; they present in many forms. And just because he didn't take an OD this time doesn't mean he won't OD to get that girl's attention the next time...or the next. It sounds like this kid is very impulsive and most likely has a personality disorder. The last thing people like that need is someone hectoring them over all their shortcomings.

This was definitely not a therapeutic interaction. Perhaps you should do some research on how to handle suicidal patients in the ED. When you learn better, you do better.

catebsn25 · May 30, 2016

OCNRN63 said:
As a former certified psych. nurse, I have to be honest: your conduct was inappropriate and not only escalated the patient's agitated behavior, but made things more difficult for anyone who would have had to evaluate him later, e.g. physician, social worker, crisis intervention worker, etc. Not only that, but you angered his mother, who could have been an ally.
People who are suicidal don't behave in textbook manners; they present in many forms. And just because he didn't take an OD this time doesn't mean he won't OD to get that girl's attention the next time...or the next. It sounds like this kid is very impulsive and most likely has a personality disorder. The last thing people like that need is someone hectoring them over all their shortcomings.
This was definitely not a therapeutic interaction. Perhaps you should do some research on how to handle suicidal patients in the ED. When you learn better, you do better.

I agree... My thoughts were some type of Axis II pt and possibly Bipolar I D/O, currently manic.

OP, try to meet the patient where they are. Instigating them by insulting their behavior during an acute psychiatric episode is never a good idea. And your opinion on their mental illness is completely irrelevant. Unfortunately sick patients are sometimes rude. If you can't accept that and learn to not take these things personally, nursing might not be for you.

Maevish, ASN, RN · May 31, 2016

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.

Because that's what you get on Med/Surg. :cheeky: It's a psych ward (and so is every floor to a degree) unless you're "super sick" and have proven yourself to be so. There's always been at least 2 legit psych patients on any Med/Surg floor I've worked on...:singing:"that's the way it is:singing:lol

xo

Maevish, ASN, RN · May 31, 2016

hwknrs said:
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.

Since he obviously was with it even if he was mentally ill, there's no excuse for behaving that way to you. You handled it poorly, now that I look back on the OP, but it will hopefully be a learning experience for you.

You can show that you won't tolerate that kind of behavior without belittling him or telling him off. If a patient is screaming and cursing at you then just stand there until they're done if you have time. If you don't, speak loudly enough for him to hear you over his own yelling, tell him that you'll be back in a few minutes and maybe he will have decided what he needs you to do by then.

I mean it. This guy has probably been a little jerk all his life because his mother allowed it. If he truly does have a mental disorder he still proved that he can obey commands and is with it enough to be a smart alec about it after the fact. My little sister put on a huge performance for over 3 years getting my parents to believe that she was bipolar because it gave her an excuse to act like a brat.

You're not going to educate him and undo everything his mommy has done to/for him over the years so don't try. It's a pain in the a**, but if you make it a point to come back when he stops making a fuss, he'll get it. You have to at least act like you're on the same team so he doesn't have any excuse to fly off the handle. I've had situations similar to this and my method has worked (they were like this guy who could turn it off and on at will), it just takes some patience and when you're already busy, that can be difficult.

Just because he may be mentally ill (to a degree) doesn't mean you have to stand there and take it. Be professional, do your job well, and let me tell you that one of the best feelings in the world is to get a patient like this to cooperate with you. #winning :smokin:

xo

jdub6 · May 31, 2016

Maevish said:
I mean it. This guy has probably been a little jerk all his life because his mother allowed it. If he truly does have a mental disorder he still proved that he can obey commands and is with it enough to be a smart alec about it after the fact. My little sister put on a huge performance for over 3 years getting my parents to believe that she was bipolar because it gave her an excuse to act like a brat.
You're not going to educate him and undo everything his mommy has done to/for him over the years so don't try. It's a pain in the a**, but if you make it a point to come back when he stops making a fuss, he'll get it. You have to at least act like you're on the same team so he doesn't have any excuse to fly off the handle. I've had situations similar to this and my method has worked (they were like this guy who could turn it off and on at will), it just takes some patience and when you're already busy, that can be difficult.
Just because he may be mentally ill (to a degree) doesn't mean you have to stand there and take it. Be professional, do your job well, and let me tell you that one of the best feelings in the world is to get a patient like this to cooperate with you. #winning

This is a great response to the OP.

As i said before i feel the OP and others in her situation is at a great disadvantage as more and more psych/ behavioral issues come to med surg floors but the staff receives none of the education in crisis intervention, therapeutic communication etc that others have had in ED/psych.

So thank you for sharing how you would have handled a pt with psych labels who is also behaving inappropriatly as i think that was the OPs question. I know i always appreciate tips on how to handle difficult behavior .

jadelpn, LPN, EMT-B · Jun 1, 2016

Zelda, RN said:
Have you ever heard of borderline personality disorder? Far worse (in my opinion) in boys than girls, it usually manifests itself in manipulation - and is not going to change thanks to a lecture.
And it doesn't matter what the drug screen said: if he wants to kill himself, that's cause for alarm.
Things I would've done differently:
- Walked away from computer and got on pts eye level - pull up a chair, crouch by the bed, whatever.
- Said, in a non-confrontational way, "I want to help you, but I can only do that if you answer my questions".
- If pt refused to talk, I'd turn to the mom, and get what I could from her.

And in some order sets, patients have things that are taken from them upon admission, one of which is a cell phone.

With that being said, this patient needed an alternate level of care, and/or to be seen by behavioral health.

No one can assume that this patient's suicide ideation was not "real". Or the motivations behind his admission.

Just because you would not "allow" your child to act in such a manner doesn't mean that everyone else has the same parenting techniques, or techniques to deal with bad behaviors. And if we are talking a personality disorder, it does take a sense of "ignoring" inappropriate behaviors, and redirecting.

I have heard many a nurse make the "bad parenting" and "I would kick that kids butt if he were mine" and "he was not serious, just wanted attention" stuff. Makes for some juicy nurse's station gossiping. Now that we all are good with the perfection of our own parenting of our stellar kids, lets start telling our patient's parent how to improve. Not.

Remember, people who have personality disorders and acting out behaviors, are more than likely(in my own opinion only) trauma survivors. Behavior is how they cope. Hurts my heart, but we are there as a nurse, not as a interventionalist, or a behavior modification therapist.

Separate yourself and your own ideals from your nursing practice. Best thing you could do for your career.