Irrational patients

Pangea Reunited, ASN, RN · Apr 24, 2016

That sounds like a normal patient, to me! Sadly...

I usually cycle through a bunch of approaches before deciding which one to go with. It's different every time. If it's a young, strong guy who's just a jerk, he might get some firm limits set and a cocktail (after I get an order). If it's someone elderly and confused, I might respond with sympathy and lots of attention while they wear themselves out. I also tend to ask the family (or nurse at the transferring facility) what works. That's my shortcut.

roser13, ASN, RN · Apr 24, 2016

Have you ever been taught that some patients' states of mind/levels of awareness can be static? Have you ever heard of Sundowners' Syndrome?

Have you ever been taught that a sudden change in personality can be a sign of a physiological change? UTI? Sodium level?

I find your post more than a little disturbing. And no, I have never told a patient to "cut the crap and stop being nasty," nor do I recommend it as an effective way to communicate.

elkpark · Apr 24, 2016

Sounds like delirium.

Smilie0809RN · Apr 24, 2016

This woman was fully alert and oriented. She even told me at the beginning of the shift that she had previously been rude with other staff members but that someone told her it's ok because being her age and being sick she can say and do whatever she feels like.

And I didn't tell her to cut the crap but I have never in my life had anyone demean me like she did. I was just curious how others handled this type of situation.

elkpark · Apr 24, 2016

People can be alert and fully oriented and still be delirious. That's part of the "beauty" of delirium. And the waxing and waning that is characteristic of delirium can make it difficult to spot -- but being an older individual hospitalized with pneumonia puts her at v. high risk for it.

Whispera, MSN, RN · Apr 24, 2016

Sounds like delirium to me too, especially since it happens at dark-times.

There's more to it than her just being a twit.

Something I've done with twits is to say, "I'll leaving now. You cannot talk to me like that. I will be back later when you are calmer." Then I walk out and do come back later.

roser13, ASN, RN · Apr 24, 2016

This woman was fully alert and oriented. She even told me at the beginning of the shift that she had previously been rude with other staff members but that someone told her it's ok because being her age and being sick she can say and do whatever she feels like.
And I didn't tell her to cut the crap but I have never in my life had anyone demean me like she did. I was just curious how others handled this type of situation.

My point is that "others" may have handled this situation from a different standpoint than you appear to. Sun-downers may be "fully alert and oriented" during some shifts. Nursing assessment must take all potentials into account.

By stating that you felt that the patient "demeaned" you, it is apparent that you are allowing yourself to have a personal response to a patient situation. As the caregiver, you need to find a way to dissociate your personal feelings from your professional role.

Been there,done that, ASN, RN · Apr 24, 2016

So I had this older lady who was hospitalized for pneumonia. All evening she was very pleasant and even offered chocolate each time I went in to see her. It was mentioned to me at the beginning of the shift that the night before she had gotten out of hand and I thought this lady is so sweet I wonder what they are talking about. Well at 6am I found out. She was screaming down the hall that if someone doesn't get her water right now there is going to be a dead patient. I go in the room and her eyes are red and puffy and she starts screaming at me saying I am a horrible nurse and I neglect her and this is a horrible hospital. When I asked her why she was so upset and what she needed she started screaming how she hasn't had a bowel movement in 2 days and I don't care because I'm not calling the doctor. (The night before I did give her something)
I wanted to tell her the reason she isn't going as frequently is bc she won't get her butt out of bed! She refuses to get up to a commode or a chair. But I wasn't going to fight. She yelled for us to get her fixed up in bed so we pulled her up in bed and I laid the blanket on her and she said "this is how you're gonna leave me, you aren't even gonna make it nice." Omg! I wanted to just tell that lady to cut the crap bc she was just out of control but I know we are supposed to be cordial with the patients.
Has anyone ever told a patient to just cut the crap and stop being nasty?

Go ahead and tell a confused patient to cut the crap... how do you think THAT will improve the situation?

Educate yourself on Sundowner's Syndrome. Haldol is your friend.

Libby1987 · Apr 25, 2016

I view nearly everything as part of their illness/es. Perspective, seeing them as people struggling and reacting and having a thick slick skin makes it a lot easier.

Not just because of this thread, but I'm glad I went to school way back when or whatever it is that has formed my attitude. The littlest things that take no extra time come second nature to me, small actions actions build trust and sometimes reduce anxiety.

Anna Flaxis, BSN, RN · Apr 25, 2016

I was just curious how others handled this type of situation.

I am rarely caught by surprise when an otherwise sweet LOL suddenly turns into a raving lunatic. I actually kind of expect it.

Some potential causes are UTI, constipation, hypoglycemia, sundowners syndrome, a pulmonary embolus, worsening illness, or even just being afraid and feeling helpless. A change in mental status should trigger inquiry into what could be causing it.

UTI would be one of the more common causes, and constipation can be a contributing factor to UTI due to compression of the urethra by bowel contents, leading to incomplete bladder emptying and thus, urinary stasis. So maybe, your LOL's complaint about being constipated might not be too far off the mark. One of the more common symptoms of UTI in the elderly is altered mentation/delirium.

Also consider the reason this person was admitted-for pneumonia. Her change in mentation could be related to a worsening of her condition.

Another consideration is that often, elderly folks with milder forms of dementia compensate well at home in their normal, predictable environment, but once they are in an unfamiliar environment with different routines, the altered mentation is more noticeable. Family members may tell you that "Grandma has all her marbles" or is "as sharp as a tack", but that's in the home environment where she is able to compensate. The hospital environment interferes with this ability to compensate, and so you will see behavioral changes that would go otherwise unnoticed.

So, to answer your question, how I handle this type of situation is first, I do what I need to do in order to keep the patient safe. Make sure the room is free of clutter, the patient is wearing nonskid slippers, and offer to toilet her. I will offer warm blankets, another pillow, PO fluids or a snack. I will offer a distraction, such as TV, or ask her about her life- her children, pets, where she grew up, etc etc. Once the patient is calmed down and safe, I will take a complete set of vitals, including a temperature; if diabetic, check a CBG; and I will then notify the physician of this change in condition. The physician may want to order a UA, or a repeat chest xray, as her change in mentation may be related to worsening pneumonia.

I would then document the patient's behavior, the actions I took to ensure her safety, my assessment data, that I notified the physician, and whether any new orders were received.

RNperdiem, RN · Apr 25, 2016

I also wonder if she has some home meds that were abruptly discontinued. Over the years, I have discovered that many elderly ladies take meds "for their nerves". If they get admitted to hospital and these meds are suddenly stopped, they can go into withdrawl.