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!
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
How would you have approached this? Be more firm?
Verbally abusive patients can expect to have no face-time with me until they are ready to stop the verbal assault. I simply exit the room or situation and inform them I'll return when they'll stop cursing/name-calling/etc.
Some exceptions include the very demented and/or psychotic.
"I'm sorry that I wasn't available to bring your eye drops at 0600. I am here now, would you like them now or do you want to wait until 0700 for the next dose?"
Saying "I'm sorry" and attempting to reschedule an HOURLY medication will just feed into the problem!
Saying "I'm sorry" and attempting to reschedule an HOURLY medication will just feed into the problem!
That's why two and only two acceptable choices are offered: take med now, or wait until the next scheduled dose.
0600 is no longer an option, as it is now 0610. Take the offered dose of refuse it. Rescheduling is not an option. It is now or never, and the next dose is due at 0700.
The "I'm sorry"? We can make that part optional. :). But the wording was intentional. "I'm sorry I wasn't available" is not the same as "I'm sorry I didn't come when I was supposed to". Point is that I don't mean to convey that I as the nurse did anything wrong by bringing the med at 0610, but it is unfortunate that you had to wait ten minutes. I suppose. Eh. Sorry not sorry? :)
Specializes in Mental Health, Gerontology, Palliative.
A patient told me to "shove it up my ass" last week when I was giving them their meds.
I looked them in the eye and said "they wont fit, now taking your pills". Patient looked at me and opened his mouth and took his pills. Now that patient has dementia so there is a certain give or take with them usually i end up having the same conversation the next day and the next day
As for an alert and orientated patient. Who IMO sounds like she has some fairly massive axis 2 issues going on. First of all I would get the backup of my line manager.
Secondly I would impliment a fairly strict behavior management plan
1. meds will be given as charted at 0800 1000 1100 1300 etc
2. Make regular times in the day to give patient a chance to make any requests express any concerns
3. If the patient is being verbally abusive, advise them that staff will ensure they are left safe, they will leave the room and come back in for example 30 minutes. If patient becomes verbally abusive again repeat process. Let the patient know that it is not ok or acceptable to be verbally abusive to staff and that if this behavior continues, staff will leave and come back in 30mins and again and again if necessary.
4. Role model appropriate behaviors, consider use of DBT or other such therapy in terms of helping the patient regulate their internal distress.
5. Consistency, consistency, consistency. Everyone needs to be on the same page in dealing with this person.
jadelpn and a couple other posters hit the nail on the head. A multidisciplinary care conference -- which always included a&o pts when I worked subacute rehab -- needs to happen, and a behavior contract needs to be implemented.
Re: counting/documenting, yes that should be done. Like KatieMI said, you can track trends and see deviations from baseline which can clue you in to problems e.g. UTI, which can cause AMS. My thing with this plan is that it is not an intervention. It's only part of your assessment data.
So now, what do you do? For everyone's mental health, remember it's not about you. She's not being ugly bc you're bad nurses/CNAs; she's being ugly because she is ugly. (Yes I know she probably has mental health issues not being properly treated, possibly a personality d/o which to my understanding needs a treeatment plan beyond meds.... but you can't medicate ugly.)
Boundaries, boundaries, boundaries. Be kind, but firm. You and the CNAs don't deserve a hostile work environment. "I am here now. Are you going to take the med, or is this a refusal?" "I am not legally permitted to give this med outside the abc00-xyz00 time window. Next time the physician rounds, you can ask him if permanently changing the time is a possibility... but for now, this is when I am legally permitted to bring it." "I wish I could physically split in half and be in two places at once, but I can't. We can promise we will try, but we cannot promise on-the-dot med times." "It is not okay to speak to me/her/him that way. I will come back when you've collected yourself; I will peek back in x minutes." (Part of what the contract can address is meds: you are not going to hold onto them indefinitely until she controls herself. She can take them, or refuse them and will be documented as such.)
Sounds like a lady we have. Only recourse has been to firmly tell her that we will not be spoken to like that and we will leave the room and come back in 15 minutes. Wash, rinse and repeat. As she is A & O x 4 and perfectly capable of understanding the consequences of her actions I see no issue with this approach as long as she is left in a safe position. Sometimes she will decide to behave appropriately after a re-approach, sometimes it takes several rounds of "I'll be back later" before she decides that being verbally aggressive is just not getting her what she wants. When the behaviors mean her meds are either late or missed altogether, she is of course given the option to take them or not and her frequent refusals are documented and reported to the MD. That of course adds to the paperwork, but you do what you gotta do to CYA so document, document, document and update that MD and document some more.
She is also now care planned for 2 CNA's at all times for the CNA's safety as she is fond of making false allegations. No care for her without a witness so needless to say staffing issues sometimes makes her wait a little longer as there is rarely a time when 2 staff are available the moment she wants her pillow or blanket readjusted. An "emergency" care conference made her aware of the need for 2 staff to assist her at all times and that it is solely because of her behavior that this happened. It is now a situation of choose the behavior, choose the consequences.
I really have no patience with that stuff when they're A+O. If they've got dementia and are acting out I don't mind (unless they do something to me that leaves a mark lol) cause they can't help it.
If I've tried everything I can and I'm still not meeting their expectations (and they're still yelling at me) I talk calmly over them and explain that I will do my best, but that I am responsible for another patient as well. Usually they say I never told them anything of the sort, but then I say that I had said it while they were yelling at me so that's why they didn't hear me. If they keep it up I cluster my care like no one's business and get in and out because I don't need to be around that nonsense (plus, we can see them in the cameras and heart monitor screens).
I realize that people are sad, lonely, frustrated, etc when we see them in hospital, but I don't personally feel that that warrants verbal/physical insults and rude behavior. Most of my terminal cancer patients and trauma patients (both in immense pain, usually) aren't rude and are generally pleasant even though they feel like crap warmed over. The entitled ODs that come in are way worse than most and I just don't feel the need to break my back to reach an unattainable goal when it leaves me sour and not able to care for the other patient who is usually REALLY sick.
People think that just because we are nurses that we have to take behavior (by sentient, adult patients) that would otherwise be a crime outside of work. I don't believe that and people kissing their you-know-whats when they act like that is what has made them like that in the first place.
Making a schedule helps, but things happen, you get busy, someone starts trying to die, and that just frustrates them more. You can't please some nurses and you definitely can't please some patients.
No face-to-face time should be spent unless she agrees to behave like a human being. She's on a lot of meds, but I know people on a ton of psych meds and they don't behave irrationally as a rule, so that's not an excuse unless she's not had them titrated properly. Psychotic or not, she's A+O. No excuse.
Should I have gone in at 0300?
TheCommuter, BSN, RN
102 Articles; 27,612 Posts
Some exceptions include the very demented and/or psychotic.