have you ever had a pt that you cant tolerate!???

Virgo_RN, BSN, RN · Jul 23, 2009

Behavior modification strategies are not quick fixes. They take time and consistent repetition. If the undesired behavior *always* results in her not getting what she wants over an extended period of time, she will change her behavior.

It's like a vending machine. If you stick a penny in there and get your favorite candy bar, you'll keep sticking pennies in there. If sticking a penny in does not work, you will use whatever currency works.

However, in behavior modification, the undesired behavior will often get worse before it gets better. It's called an "extinction burst". That's because what has always worked is no longer working, so the person will try harder and harder to make it work before finally trying something else. Also, if the person even has one success at using the undesired behavior to get what they want, this reinforces the undesired behavior even more than consistent reinforcement does. It's called a "random" reinforcement, and random reinforcement is very powerful. Even caving in just once to her tantrums will undo all the hard work that has been done up to that point.

Back to the vending machine. Say you've tried the pennies and it's not working, so you put the quarter in and it works. The next day you decide to try the penny again, and it works. Both the quarter and the penny have worked, but you want to hold onto your quarters and spend your pennies. So, what are you going to try first, every time? Yup, the penny. Even if the penny doesn't work and you use your quarter, you'll still try the penny first because it did work that one time, and there's a chance that it might work again.

By caving in to her demands when she behaves the way you've described, you are reinforcing that behavior. The only way behavior modification is going to work is if *everybody* caring for her responds in the same way, every single time, over an extended period of time. That means telling her that you will not do X, Y, or Z so long as she is carrying on, and that when she is quiet and under control and will ask nicely, you will fulfill her request. And yes, you have to do this every single time, and so does everyone else who cares for her. Her behavior will most likely get worse at first, and she will throw more intense tantrums for longer periods of time. But with consistent denial of reinforcement for that behavior, and positive reinforcement for the behavior you want to see, she will eventually change her behavior.

You may want to have a meeting with all staff who will come into contact with her and make sure that everyone is on the same page with this, so that she will not be getting reinforcement from one or two individuals for her undesirable behavior. This would be detrimental to the efficacy of any behavior modification efforts.

luvbug · Jul 24, 2009

I have one like this and she is so particular about everything, she will only deal with me as her nurse when absolutely necessary. She actually will call the other nurse at home. I think it is because she coddles her more than I do. I mean, i am nice to her, but I don't overly indulge her. anyway, while in clinic, she will come out of her room repeatedly to "just ask a question." and she doesn't care if we are in the middle of a conversation with another patient or anything, she just starts talking because she is the only patient in the clinic you know. Arrgh! She drives me so nuts I can hardly stand it when I see her name on the schedule. :banghead: thanks for letting me vent about this one, I know it is hard to understand just how much she makes me mad without being there...

sasha2lady · Jul 24, 2009

ohhh thank you virgo...the things you just mentioned have never even been brought up by the psych NP who follows her and she has met w/ me a few times about her. she just adds meds which dont work. yesterday she was much better minus one episode. the other night after she was so terrible i came home and woke up in the middle of the night thinking about her and things were just running thru my head...and bam it hit me!..the 3 P's...polyuria, polyphagia, polydipsia......diabetes! now...i know this has nothing to do w/ her behaviors but for some reason this thought came to me out of nowhere and i started piecing things together....(ps..did i mention this pt is HUGE! LIKE a ton of bricks huge)..so the next day at work i decided to check her bs...which was over 500 all 3 times i checked it...called the doc got orders for insulin etc...and she was upset about the levels. after a while ...she was ok and we talked about it and all was well. Still....this wont help her actions. What we were told to do w/ her is when she is at the desk or whatever...acting out ..we are to push her back to her room and tell her we will come back when she gets herself together and quits carrying on.....this occasionally works but it works less more than most. Plus..one thing that does worry me is that even though she is so with it....if she doesnt get her way...she starts accusing the staff of being mean to her etc etc....and im afraid that if she tells that to the right person we all might be in trouble even though we are not mean to her in the least bit. I will definantly bring up your points with my cnas and fellow nurses at work and do my best to implement it full force....if nothing else at least on my shift. I chart on her nearly every single night ....over a page at least. Its rarely less than that. Sometimes I wonder if she is trying to test me ......for the simple fact that shes good during the day most of the time and on 3rd but not on my shift when im there....if another nurse works....shes fine. I dont get it? the psych NP told me that she is like a colicky baby who cries and yells just to tire herself out....I didnt buy into that for a second and I didnt hesitate to tell her that until she has been on my shift for 8 hrs listening to it and dealing with it then that wasnt a fair assumption .....anyhow...thanks again virgo and all who reply.

TheCommuter, BSN, RN · Jul 24, 2009

To answer the OP's question: yes, I've had patients that were difficult to tolerate. I am not necessarily obligated to personally like my patients, be fond of them, or enjoy their company. My main duty is to provide basic nursing care for them, keep them safe, and deal with any changes in condition in a timely manner.

NurseCubanitaRN2b, BSN, RN · Jul 24, 2009

Sasha why did your facility admit her? Since she came with that pattern I don't see why they would admit her. Well admissions admits her, they don't have to deal with her so that could be the answer right there. Let nursing staff deal with her, who cares, this woman is $$$$ anyway. Sarcasm of course.

sasha2lady · Jul 25, 2009

well....they take whoever and whatever.....she came in with a medicare pay source at the time....something had happened at the place she was at before i think...and there ya go. we got her and she stayed. they have taken worse than her though.....but luckily they went back to where they came from. she has done this from day one! I think ive had alot of patience with her...i do what Im supposed to do as her nurse and ive went out of my way to be nice to her. My aides get soooooo sick of it....several have threatened to quit but I told them there is probably one or more of her in any place they'd go to....so now..when its too much...they walk out of the room and go back in a few minutes when she tones it down. this is one of the ...no....make that the MOST selfish person I think i have ever met in my entire life. She does not care that anything is going on with anyone else or what staff has to do for all our pts.....its all about her her her her...all the time. Her hubby will come in and SPOON FEED HER!!!!!!!!!! we have told him that this is going to create a big problem but he doesnt listen......probably b/c he has the golden option of leaving after she starts her whining.

nursenow · Sep 15, 2009

I have to be honest; I have had a few patients die and I am glad they were no longer around. And their families. Even though we did everything we could for them while they were alive it was a relief when they died. Recently, while recieving report I was told ---- had died on my day off and the nurse telling me that smiled. We never said anything else but her message was clear.

NurseCubanitaRN2b, BSN, RN · Sep 15, 2009

I've had that happen, boy would I wish they were gone, but to another facility, never death. Even though they may have been horrible as a patient and had some horrible family members, I'd still never wish death on them. I know nobody else here does too, you're just glad that the person or people are gone.

nursenow · Sep 15, 2009

I've had that happen, boy would I wish they were gone, but to another facility, never death. Even though they may have been horrible as a patient and had some horrible family members, I'd still never wish death on them. I know nobody else here does too, you're just glad that the person or people are gone.

Yep, Up to now I have never wished death on anyone but have been mighty happy they were gone. I would have been just as happy if they had just transfered to another facility.

Fiona59 · Sep 16, 2009

Oh gawd, yes.

I left LTC to go to acute care to get away from long term patients. Now with the bed shortage in LTC, we are having our beds blocked by seniors waiting for a LTC bed. Usually the family is far worse than the patient.

The sad thing is the patient ratio is way better in hospital than LTC. They just don't understand that once they hit LTC it won't be 4 patients to one nurse and they will have to wait even longer than they do with us.

softstorms · Sep 16, 2009

WOW.. We have both long-term care and short term rehab-acute care. Before you all start laughing...Yep! one side of the facility is long term care and the otherside is rehab-acute care! Yes we take a lot of people on our acute care/rehab side that we as nurses know will never go home and never be re-habed LOL. Forgive me now...we call them Jumpers. They are at the desk, watched 24/7...because they have dementia and will jump up and fall at any time!!!!! End stage people, 89 years old, but brought here for "re-hab". At the same time...we are doing IV's on multiple pts. and taking care of people who are going thru chemo and getting TPN. I think it takes away from the pts. who need the care..both the long term dementia pts. and those acute care pts.