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?
Man this is the PERFECT time to say, "well ma'am, im sorry (delighted) to inform you, it is never ok for anyone to treat anyone poorly, no matter how old your are. Who ever told you that is incorrect. I will not tolerate disrespectful behavior. I will attend to your needs and help you with what you are not able to do for yourself. Disruptive behavior will not be tolerated."
also mild sundowners could be playing into this. Things like UTI's can make the sweetest granny go crazy.
Boy do I love to tell people to cut the crap. And I am the most calm, non confrontational person you will meet. I hate confrontation. But when someone tries to treat me like that, they are going to get the riot act read to them. Along with the offer to discharge AMA if they dont like it here.
I worked in General Medicine 20 years ago as a new nurse and had very little knowledge of delirium. I am not sure if it was a training deficit or if it was something that just did not "click" with me. It was always very frustrating and it was very time consuming. Older people who are ill and out of there element are very susceptible to delirium. Hospitalisation is a big issue for the older adult as it means they are ill and in and in an unfamiliar environment; their routines are disrupted, they are stressed and they are usually prescribed drugs that are outside of their normal pharmacological regime.
There can also be a certain amount of delirium coupled with undiagnosed dementia. On a night shift when you have 10-12 + patients, it can really cause problems when delirious patients are not managed well. It affects the milieu of the entire unit and the quality of care of other patients. Unfortunately, these patients should be cared for with a 1:1 ratio or in a cohort, but this never happens.
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.
Regardless of the patient being "alert and oriented" apparently she is behaving in a way that is out of control. Document with quotes.
Remember, it is not about you personally. So no need to feel demeaned.
I would consider a social work consult, psych involved so that the patient can be properly medicated as to not act out in such an aggressive manner. And yes, someone can have delirium and present as alert and oriented. Or be sundowning at any point of the day, or have an effect from any sleeping medications, or an underlying cause (cocktail and cigarette every day at 5pm kind of peeps). Psych can determine if it is due to any of these causes.
Meanwhile:
"So I am understanding that the bowel medication I gave you last evening has had no effect? I can walk you to the bathroom now or we can use the bedside commode, would you like to attempt to have a bm?"
"I am not sure what you mean by 'nice' what do you need to make you comfortable?"
"For your age, you are so spry!! We want to get you functioning so you can go home!! What can I do right now to help you?"
Elders are usually very bowel obsessed. The lack of a bm, or a "good" bm sends them all in a tither! And outweighs any rational thinking.
PT consult to get her out of the bed is also a thought.....
I've never worded it quite like that, but I have gotten down to their eye level, looked them dead in the eye, and said, "I need you to stop. You are impeding your recovery by acting this way, because I cannot help you when you [insert negative activity here]." Sometimes it helps, sometimes I get yelled at. At least I know I tried.
My first thought was sundowning. My second thought was dementia. Then I read the other responses and I agree with those who are saying it could be a med side effect (meds affect the elderly in a totally different way) or a sign of infection.
I also want to just jump in here and say that my dad has an advanced form of dementia, and he can flip his moods like this and go from fine to nearly violent at the snap of your fingers. You never know what will set him off. The tiniest, most innocuous things will do it, regardless of time of day, too. Please try not to take it personally. It sounds like there's something organic going on here that's not being treated or investigated by her docs.
I had this really difficult resident at an adult foster home I worked for. She had MS, terrible bed sores, cath, needed daily digital manipulation for bowel movemts, etc... She was just bad off.
She gave people a horrible time because she was living a horrible existence.
That's not to say I never struggled. Sometimes she would get really abusive, I would excuse myself, step away and regain composure, then come back. Sometimes when she would get really bad I would remind her that I was a person too, that would help for a while.
She was really hard... But she showed me a depth of patience that I didn't know I had.
That patient is why I will be a nurse.
Point being: find a silver lining of optimism to get you through. Then, come emotionally unload here, we all know those feelings well!
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.
Specializes in ER/Critical Care/Accrediation/PI/Quality.
While I feel your frustration, several things have helped me over the years. First, that it is the patient who is having the issue. It is her issue, not necessarily mine. If I can establish a professional distance I am in a better position to help the patient and think more objectively. Try to look at the whole picture, something metabolic going on, diabetic reaction, nightmare, her own conflict with a family member? Also found that when the patient "yelled" at me, it helped to talk back to her in a very soft tone of voice. That helped me stay calm as well! Be a lifelong learner. There is so much to read about sundowner's syndrome and other hospital-related conditions. The more education you have, the more tools you have in your patient care tool kit.
OMG! Where in this post did the OP ask what her diagnoses might be? The question was essentially how do you handle a difficult patient.
Regardless of sundowners, UTI, anxiety, or what have you, we've all had a patient that drives us up the walls. How do you check your attitude? How do you prevent yourself from shooting off something inappropriate to the patient? And if you say those thoughts don't ever come to mind, you're in complete denial. Reading is fundamental, friends. Understand the question first before offering irritating answers.
Creamsoda, ASN, RN
728 Posts
Man this is the PERFECT time to say, "well ma'am, im sorry (delighted) to inform you, it is never ok for anyone to treat anyone poorly, no matter how old your are. Who ever told you that is incorrect. I will not tolerate disrespectful behavior. I will attend to your needs and help you with what you are not able to do for yourself. Disruptive behavior will not be tolerated."
also mild sundowners could be playing into this. Things like UTI's can make the sweetest granny go crazy.
Boy do I love to tell people to cut the crap. And I am the most calm, non confrontational person you will meet. I hate confrontation. But when someone tries to treat me like that, they are going to get the riot act read to them. Along with the offer to discharge AMA if they dont like it here.