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?
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?
I saw a great meme on FB
The old lady is not GIVING you a hard time, she is HAVING a hard time...
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.
i love your thought process behind this. Makes so much sense! Thanks for sharing.
You don't need to be snotty and condicending. Sundowners does not hit at 5am. Also, some patients think you are their private nurse. I have one patient who I remind that being nice will get you further than being demanding and nasty. She then says please and thank you and I tuck her in and she sleeps all night instead of calling all night. So yes, in a way, I've yold some patients to cut the crap. Not in those words but tactfully. Nurses do not deserve to be physically or verbally abused. I for one, will walk out until the patient has settled down as long as they are safe.
I find there needs to be a clear expectation of what is acceptable behavior and unacceptable behavior with patients.As long as there's no cognitive delay or disability. I make it clear to patients this type of behavior is unacceptable, it's verbal abuse. No other profession would tolerate this so why should we. Sometimes you need to talk in plain language with these types of patients and set limits. Acknowledge their acute change in demenor or mood but make it clear it will not be tolerated.
I will say "you seem very upset right now, however the way your talking to me is unacceptable. When you are ready to talk or explain to me what is upsetting you in a calm respectful manner I am going to step away." Obviously this approach applies to the patient who is stable and their status isn't acutely changing for the worse that your documentation can support why you stepped away from the patient. There should be no tolerance for this type of behavior.
Documentation is your friend. Document thoroughly the health teaching you've done aka, the importance of being ambulatory and getting out of the bed and whether or not she indicated understanding or if persisted to refuse.
I work in ER in a downtown city hospital however I started my career on a surgical floor. This takes practice, I've been nursing for 7 years now and early in my career I would not have had the confidence to do this.
Sometimes you need to dig a a little deeper as to why this behavior is happening with these patients. They are in a vulnerable situation, can feel lonely and helpless but it is never an excuse to be talked down to or demanded to perform certain tasks for them.
We are in a hard profession. A lot of it is communication vs actual medical skills a lot of the time. Remember the way they are acting is a perception of their reality, not you. Setting expectations of behavior with patients will not only help you but your colleagues as well.
I forgot to add, try and problem solve and make sure there's no UTI symptoms or other reasons that could cause the acute change. Maybe there's some undiagnosed dementia. Think outside the box as to what may be causing this.
Some people baseline are just entitled and may need a soft reminder you have 5-6 (or sometimes even more)other patients you are caring for. Keep neutral, don't let it get to you even though it's hard not to take it personally. Time and experience makes these situations a little easier to deal with. Be confident in your care!
I appreciate both the nurses who discussed physical causes and those who said there are limits to the nasty behavior we have to take. You're all right in your own ways and those are both parts of nursing, along with therapeutic communication. However, I'd like to offer my perspective.
My mother was a malignant narcissist. Getting sick at the end of her life only made it so much worse. Because of the verbal abuse she heaped on me, I finally had to chose to be her daughter or be her caregiver.
The doctors and nurses loved her. She was sweet, articulate, adoringly vulnerable, and very kind to them. Most of the time. But her true nature would show itself when one of them didn't do what she wanted. Her face would change, she would give a death stare, and raise her voice. She alternately got very
quiet and moody or flustered and yelling. And the things she said behind their backs to me often left me wondering if I'd be able to retain them as her health care providers.
Not every crabby patient has an underlying mental disorder. But many do. Very few staff ever believed me about her true behavior. They didn't want to look past the possible physical causes or their belief that she was just reacting to her physical illness.
Please tuck this in the back of your mind. Someday you may care for a patient like this. There can be more going on than what you see or what basic assessment finds.
Been there,done that, ASN, RN
7,241 Posts
Your patient was experiencing Sundowner Syndrome. She was not just being a "witch".
She needed treatment, not judgement.