How do you deal with verbally abusive pts?

[Molly.RN]

Hello all,

Long time lurker, second time poster here. I guess this post is more of a vent / advice post since It's probably going to be long. I currently work in a SNF/LTC and we have this one resident who is notorious for her abusive behaviors. On our MAR we have to count her behaviors concerning being demanding, manipulative, slapping/hitting, and being verbally abusive to staff.

To paint a picture of her: On average she has ~350 of the above behaviors a month. She is incredibly (read: impossibly) specific about her medications and how the CNAs take care of her, and often keeps them in her room for 30+ minutes screaming abuse at them because she thinks there is a wrinkle in her brief. She is A/Ox4. On multiple antipsychotics and anti anxiety medications along with two narcotics for chronic pain. Her antidepressant has recently been stopped because she didn't like it. No psychiatrist will take on her case because of her behaviors anymore. She is on the last doctor at our SNF because she has "fired" all the rest. She has multiple physical ailments along with a generalized psych diagnosis of "anxiety." She has had ~90% of CNAs come crying out of her room by now.

First offense: She takes eye drops hourly when awake. She demands you come in exactly at 0600, 0700, etc to give her the eye drops. I had another agitated, confused patient I was trying to deescalate at that time and had to give her eye drops at like 0610 or 0615. I made a rookie mistake of telling her the actual time instead of just saying 0600 and she looks at me and asks if there was an emergency. I say yes, I needed to help another resident. Then she starts yelling at me, "NO! You come in here EXACTLY at six to give me my eye drops and I DON'T CARE what else is happening" etc.

Second: She takes a weekly medication and the routine for her is to go in at exactly 0515 to wake her up, have her take the medication at 0530, then come back in at 0600 and give her the rest of her medications (This weekly medication has to be taken a half hour before eating/other meds and she has to sit up for a half hour after to prevent GERD.) I don't take care of her all the time so I actually had messed this up about two weeks ago and she accused me of trying to kill her when I went in with her weekly med and her routine meds all together at 0600 since I didn't notice in time that day was her weekly med day. (FYI: The MAR doesn't specify that she can't take this med with her other meds)

Fast forward to two days ago. What had happened was she called in the CNA to tell me she wanted to take her weekly med at 0300 this morning. She has NEVER asked for this before and we have never done her med like that before either. Since I can't legally give the medication until 0400 at the earliest I didn't go in because I was trying to let her sleep, and frankly I didn't want to go in there and have her scream at me because I couldn't get the medication at the time she wanted she since had yelled abuse at me about messing up her routine with that weekly med before. She ended up calling around 0345 asking the CNA why I never came, so I went in there to explain and of course, the yelling and abuse starts immediately. I am there calmly trying to explain that she can't have it at 0300, why she wouldn't even want it at 0300 anyways, and why I didn't come in when she requested. But she won't listen to reason. She's yelling at me to do things for her like take her blanket off of her, telling me I'm putting words in her mouth, its her decision and not the doctor's when to take this medication, and how rude and disrespectful I am to not come in at 0300, and that she's been taking this medication FOR MONTHS at 0300, which just isn't true.

Basically, I was trying to calmly talk to her but it wasn't working. I will admit I became defensive but was still just trying to explain that I couldn't give the med at 0300 so why should I have gone in to wake her back up and tell her I couldn't give it at 0300 anyways. I do believe our supervisors have talked to her before but I don't know how long ago that was or how often they try to talk to her. She is demanding and manipulative like that nearly every shift every day.

How would you have approached this? Be more firm? Set more boundaries? Tell her you're going to leave until she can treat you like a human being? Tell her to stop being such a.... witch? Should I have gone in at 0300?

Even though it was two days ago I am still so mad and upset that I have been treated like this!

[canoehead, BSN, RN]

Go in when she's calm and explain that screaming makes everyone upset, and you're there to help her. I would add, "I can't think clearly when you yell." If she screams at you, you will walk out and return in 15 minutes. If that means she misses a treatment or meds are late, that's her choice. She can talk, vent, complain, argue, cry, but screaming and obscenities are a no go. Add that you will do your best to get things to her at the times she prefers, but it won't happen every time. You can't promise perfection, and she'd probably dislike a bunch of Stepford nurses anyway.

A care plan that everyone follows to deal with behaviors is ideal, but you can start with yourself. Warn your coworkers that there may be a ruckus the first day, but they may really like the idea and start doing it too.

[doodlebuttRN]

Canoehead nailed it. You can't control or change her behaviors, and you have to give meds as scheduled. When she starts yelling, I would calmly tell her that I am not going to stay here and be yelled at, I have other patients, and I will be back in __ minutes. (Do follow through and come back when you say). If she wants to talk calmly at that time we can. If not, it is her choice to continue being abusive, and her choice to make her meds or whatever late. Some residents are just like this, and you can only make the choice to not get sucked into her nastiness by refusing to stand there and be abused.

Of course, document everything, as I'm sure you already are. And above all, don't take it personally (not that I think you are, it's just hard with some residents who hurl nasty insults at you day in and day out to NOT take it personally after a while).

Best of luck to you

[FolksBtrippin, BSN, RN]

Is there counter transference going on? Is there anything about this patient that reminds you of someone in your life, past or present? If so, acknowledging that might bring the insight you need to break out of your reaction to this patient.

If you have this kind of problem with a lot of patients, it may be something else.

Either way, if you're willing to change the way you respond and think about the situation you can break yourself free from feeling victimized and mistreated.

To answer your question more specifically, I would listen to the patient's concerns and address any problems regardless of how rudely they were brought to my attention. So my response to her yelling "are you trying to ******* kill me? I'm not supposed to take this med until 5:00!" Would be to check the record and the pharm guidelines to see if I do in fact have it wrong. If I have it right then I would explain to the patient why she's taking that med at this time. If i had it wrong, i fix it.

Now, If the patient is just hurling insults and not actually trying to tell me anything pertaining to her care, I'm not going to respond to the insults. For example, "you're a fat pig, why don't you drop dead?" No response to the actual comment is needed. But I would assess for pain and anxiety. I would offer any prn anxiolytics.

I worked in outpatient psych and earned the trust and respect of some pretty volatile patients this way. They usually didn't actually hurt my feelings, but once in a while I'd hear something that stung. It's amazing how far listening to a patient's gripes can go. It's also pretty interesting that ignoring the mean stuff while taking care of the problem seems to help patients feel real remorse when they are capable of doing so. Not saying this lady is.

Edit: I would avoid the whole leaving the room and coming back in 15 minutes thing unless you really need the time yourself. You could get into a dynamic where you are just in and out of her room all day as she plays the edge. Better if you can feel/appear unaffected by her yelling.

[Been there,done that, ASN, RN]

There is nothing staff can do to change her behavior. She has been rewarded for her outrageous behavior and it will never cease. Administration is aware and allowing the staff to get beat up because:

A) They are money hungry and want that Medicare payment.

B) They don't know they can evict her.

When she fires the last doctor, administration will be forced to call checkmate.

It's not the patient beating you up, it's administration.

[MidLifeRN2012]

PRN around the clock and don't take her abuse. Give her her meds within the hour when they're due or per policy and treat her no different than anyone else. Make it clear you won't stand for her abuse and walk away if safety isn't a concern. I work in inpatient psych and this is par for the course with some patients. You need to develop a thick skin to deal with these people sometime. Does she have family who can intervene with changing her behavior?

[Molly.RN]

@MidlifeRN2012 No she doesn't have any family come. Sometimes she has visits from a catholic priest.

[Pat_Pat RN]

@MidlifeRN2012 No she doesn't have any family come. Sometimes she has visits from a catholic priest.

Gee, I wonder why.

[Pangea Reunited, ASN, RN]

I don't even try with these types, anymore. I figured out a while back that there's nothing I can do that hasn't been done before. I just go about my tasks with them in a flat, matter of fact way. I don't go out of my way to please or displease them. If they scream and whine and want to talk to someone in charge, they can.

[Been there,done that, ASN, RN]

@MidlifeRN2012 No she doesn't have any family come. Sometimes she has visits from a catholic priest.

Perhaps the staff could kick in for the cost of an exorcism.

[Boomer MS, RN]

Perhaps the staff could kick in for the cost of an exorcism.

Ha! I like this idea. :-))

[dudette10, MSN, RN]

Agree with those who say just do your job and get the hell outta that room as fast as you can. I had one EXACTLY like this in acute care for two days this week. She took up a ridiculous amount of everyone's time, including the doctors. Eventually, I would just leave the room as she was going on and on and on and on about how ****** the care was.