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?
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.
I don't think she asked how to handle a difficult patient. Or how to check her attitude.
First she gives a terrible example of framing a strictly attitude issue that is more of a sharp change in behavior in a geriatric with acute pneumonia then asks, "Has anyone ever told a patient to just cut the crap and stop being nasty?"
I think OP was fishing for validation when her discernment between organic behavior and a nasty attitude is lacking for whatever reason.
Specializes in Cardiology, Cardiothoracic Surgical.
Gizmo to Gremlin? Sounds like your LOL is sundowning, UTI, possible hypercarbia, possible sepsis. I'd be all about an ABG, UA, bladder scan, BMP on her. That's page-worthy!
Specializes in Critical Care; Cardiac; Professional Development.
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.
This is an excellent post and exactly what I was thinking as well. I personally would check a blood glucose whether they were diabetic or not, simply because I have had more than one elderly patient become hypoglycemic suddenly with no history of such issues.
But my first bet would be on sundowning, UTI or worsening pneumonia. Honestly it doesn't matter that she was oriented at the beginning of the shift. That was HOURS ago. That assessment is completely invalid by 6 AM. Obviously.
And no, I would not tell them to "cut the crap and stop being nasty", primarily because my mind would be on what is bringing about this change in mentation and secondarily because it would be morally wrong and unjust. If I took a patient's attitude to heart every time they take an ugly turn I would go home crying every night. I'm not her friend, I am her nurse. She is counting on me to watch her with objectivity, intelligence and sharp critical thinking skills. Retaliating against her behavior by being nasty back doesn't honor any of those traits.
I have said "you are being hateful, I'm trying to help, tell me how to help you" many times, in a calm tone. And the other day when my WBAT c hip precautions insisted she was walking out, I calmly said "ok, let's do it" and stood next to her to help her stand. (She can stand, but not walk and quickly realized this, as I knew she would)
You can be kinda tough, while still understanding they are afraid and hurting. "Cut the crap" is rarely productive, but telling them they are being ugly sometimes works. Then again, sometimes doesn't because they don't effing care. Lol
I have said "you are being hateful, I'm trying to help, tell me how to help you" many times, in a calm tone.
People don't respond well to statements that begin with "you". Try to reframe the statement and lose the "you", focus on making statements that begin with "I"... Being "you"d at makes a person defensive. By using 'I' it is you that takes responsibility for the situation. Most people recover quite quickly from their melt downs if you deal with the challenging behaviour appropriately. A favourite of mine if I'm stuck is, "Well that escalated quickly?!? What can I do to help right now?" Then whatever they mutter back, I just calmly smile and say, "I know how that must feel.... I am sooo sorry about that, let's get everything sorted out". That avoids the person becoming defensive and usually prevents them arguing with you b2b taking up too much of your time. Validate.... validate.... validate. If they think you've been neglecting them, that feeling is real for them and the sooner they get over it the better for you and everybody else on your team. Before you leave ask them, "Is there anything else I can do before I go"... will save the call bell from going off in five mins time, cause you can group the tasks together and save yourself some time. Bit trickier with dementia and CALD confused patients... need to use less words to communicate the same thing or it'll go way over their head.
Specializes in LTC,Med Surg, HH,CM-BC,DON,Nurse Consultant.
Sounds like you did not think she had any dementia/ delirium. At times patients can be so convincing that they are normal without any cognitive issues and then BAM you are caught up in the middle of their struggle. Just document and try to redirect that type of behavior. However, often that is difficult to do.
Not that wanting to tell a pt to "cut the crap" hasn't crossed nurses minds a time or two, but I've noticed most of the replies refer to Sundowners Syndrome. But if you read the post before judging this nurse at her wits end, she says the pt was very pleasant all EVENING and started being nasty come morning (not typical of sundowners). Yes. Physiological variants in elderly pts can cause changes in mentation. But there is nothing saying that nurses have to take verbal abuse from pts.
You can explain to the pt that her behavior is not necessary but regardless you will do everything you can to take care of her. Elderly pts can be just as manipulative as younger pts.
They never 'act up' for nothing. There is always an underlying cause and a good nurse must take the necessary steps to alert the md so that the 'problem' is properly diagnosed.
This may have been a poor example of the point of OP's post. In this instance something was probably wrong, whether it was sundowning or an anxiety didorder or whatever. However, there ARE "irrational patients" who are truly just plain jerks. And even though they are going through a particularly rough time, and I can empathize with that, does NOT mean that I should have to take verbal abuse because it's simply the nature of things.
Again, poor example, but I think overall a good thought provoking question. What are ways we all cope with behaviors while remaining professional, when sometimes on the inside we want to scream (because after all, we are human too and being pushed to and beyond our limits.)
Libby1987
3,726 Posts
I don't think she asked how to handle a difficult patient. Or how to check her attitude.
First she gives a terrible example of framing a strictly attitude issue that is more of a sharp change in behavior in a geriatric with acute pneumonia then asks, "Has anyone ever told a patient to just cut the crap and stop being nasty?"
I think OP was fishing for validation when her discernment between organic behavior and a nasty attitude is lacking for whatever reason.