Help! How do I deal with frustrating patients

[FDE123]

I am still a baby nurse and just recently began working in a Neuro ICU. I previously worked in an Intermediate care unit for 7 months at a comprehensive stroke hospital and had confused patients often.

I am am having a hard time adjusting to the neuro icu. I have been off orientation for 2 weeks and am struggling because I don't think I like it. When I accepted the position, I was expecting strokes, tumors, etc. Patients that were truly sick and needed care. This is not what I am seeing. The majority of our patients are minor strokes and most of them should be on the floor. I hardly see vents or drips.

The patient I am having the hardest time dealing with is a confused frontal lobe glioma patient. She does not meet icu criteria and is actually a med surg patient but has been placed in the icu because her son works for our cooperate headquarters and she gets "VIP" treatment.

Well, for me that was the first trigger. I believe all patients should be treated equally regardless of the "status". I feel as though this is abusing the system and occupying an icu bed that should be held for a truly sick person. She will not stay in bed and is extremely confused. Her husband gets aggressive with staff and threatens to "call the supervisor and president" because he is listening to what his confused wife is telling him. The doctors have doped her up so much that she is hard to handle. She does not sleep through the night, abuses the call light, pulls at her lines, crawls out of bed and will not comply to nursing staff.

I am really trying not get frustrated but I am seriously at the end of my rope with patience for her.

Are there any suggestions that anyone may have to help me not get so frustrated and handle the situation in a professional manor? Even for in the future?

I don't want to be that jerk nurse that refuses a patient but I also don't think i will be able to provide the best care because of all the circumstances.

[Ruby Vee, BSN]

Those types of confused patients with anal sphincter family members are in ICUs everywhere -- not just Neuro ICUs. I've had my share of "frontal" patients in CTICU when they stroke peri-operatively. A truly "special" patient like yours pops up approximately every six months in every ICU in the nation (or at least the ones where I've worked or had friends working) and harries some new grad (or new hire) into regretting their career choice, their job choice or both.

You are new in the job; you're currently working on showing your new colleagues how to view you. You don't want to make the mistake of refusing the patient at this stage of the game. It takes only one decision like that one to make a bad reputation for yourself, and it takes YEARS to overcome the reputation. The best path is to suck it up and make the best of your time with this patient and her "VIP" family. The good news is that your colleagues will have some sympathy for you and you're well on your way to having a good reputation with your peers.

I don't have any magical advice for making the best of the situation. What has helped me is to take none of it personally. It isn't personal. You got stuck with a sucky patient in your first two weeks off orientation. Sooner or later it was bound to happen. The good news is that this patient will make some very good stories for you to tell in a year or two when everyone is kicking back on a slow night and regaling the new kids with horror stories from the past. In fact, one of the things that helps me deal with the horrible patients is knowing that with time, this will be a Really Good Story. (I'm not kidding -- it helps!) If you can see the ridiculousness of the situation while you're IN the situation, it helps to deal with the ridiculousness. That family member spouting off about how special he is and how Very Important that makes is relative is acting like a fool. So go ahead and laugh to yourself about it. If you keep a journal -- and I recommend it -- you can ventilate all of your negative feelings safely in your journal and go back to work calmly the next day. Others will tell you that the family member is under stress and this is how he deals with it . . . which, while true, doesn't make him any less of an anal orifice. They'll tell you that the patient can't help her behavior and while this is also true, it doesn't make the 17th or 71st episode any easier to deal with.

Come to think of it, I DO have magical advice. Humor. There are times -- and this may be one of them -- when you have to laugh because if you don't, you'll cry. Laughing is better for your blood pressure and ever so much more fun. You don't have to laugh out loud (probably better if you don't), but try seeing the humor in every new episode and you'll be so much happier in the long run.

And again -- think of the fun you'll have in the next "My Worst Patient EVER!" thread!

[canoehead, BSN, RN]

If you were a veteran on the unit your coworkers would take turns answering her bell. You won't have to do this on your own the next time. Yes, it is a test, but now that you know that, its an easy test to ace. Just slog through. Give the same directions, be empathetic, offer food and drink, offer the number of your supervisor, repeat hospital policies over and over again, then do the opposite of the policy when your boss treats this jerk as a special snowflake. It will happen- and you need to be prepared for the frustration. Like Ruby said, it has nothing to do with you, its a dysfunctional system.

Maybe ask your preceptor if she would check on your patient when she hits the call bell, and you finally have a chance to chart. Give yourself a little break, then back at it!

[LovingLife123]

You have to find a sense of humor with neuro patients. TPA guidelines in a stroke center say they have to go to a Neuro ICU for that 24 hour period. So no, many of them don't qualify for maybe what you think an ICU patient should be, but we have to monitor for bleeding which is a huge side effect of TPA. Plus, the constant NIHSS assessments cannot be done on the floor. They have 5-6 patients compared to our 2, we can do them, while the floor cannot.

You will learn. Neuro patients can be the most frustrating at times. You do have to walk away and breathe. Hopefully you work on a team where they can take a couple of call lights for you. And sometimes I just say, I cannot properly do your nursing care if you are constantly calling in me in here. I never mind helping you and making you comfortable, but now I am late on your required medications to help get you out of here. Or, if it's something I totally cannot control and they are pulling at lines and constantly becoming a danger to themselves, restraints are in order. You don't always have to do wrist restraints, there are tons of othe types as well.

Most of all, have a sense of humor.

[Rin287, BSN, RN]

"I don't want to be that jerk nurse that refuses a patient but I also don't think i will be able to provide the best care because of all the circumstances".

First of all, you are NOT a jerk for refusing a patient, and if you're working in a culture that fosters that kind of criticism, you're working in the wrong place. And not because of the patient population, but because of the people you are working with.

I work on a neurology unit and our patients predominately come from the Neuro ICU. Our staffing matrix is operating as a med surg floor when in reality the acuity of our patient population is that of a progressive care unit. With that said, it is not uncommon for there to be a list of nurses and nursing assistants requesting to not have a patient again.

Granted, these patients I speak of have occupied our unit for months and are just as/if not worse than the patient you speak of, but no one is chastised for being self-aware and introspective enough to recognize that their need for a break of sanity is ultimately the best thing for the patient and the nurse.

I'm sorry you feel like you can't speak up. In an industry where we pour our time, energy and emotions into advocating and taking care of strangers, we are often quick to fail at advocating for ourselves.

Oh, and I absolutely agree with you that all patients and family members should be treated equally. The patient's husband is abusing his powers of "people he knows" which is ultimately impacting how you care for this patient, subsequently impacting how you care for your other patients. I would bring this issue up the proper chain of command to ensure the husband is clear about what is and is not acceptable in this very difficult and emotionally draining environment.

Don't be discouraged. Things will get easier. Humor is important, yes, but can often be hard to see when clouded by frustration, especially as a new nurse. Just remember to advocate for YOU as much as you advocate for others.

[KeepinitrealCCRN]

We try to rotate really difficult patients so you do not have them twice in a row. You could also suggest a sitter or restraints if she is truly a high fall risk. You could also wrap IVs with gauze to "hide" them from the patients or at least give you some time before they pull it out. There are many tricks you can learn for confused patients but as others have said they can be very frustrating.

A true neuro ICU has a high acuity of pts. Often they are vented have electrolyte imbalances, multiple drips, drains/ICP monitoring and they change rapidly and can be a real challenge to manage. The brain can affect the entire body so you can see problems all over. Post interventional pts can be interesting too even if they are not intubated etc. The unit you are on seems to be a less acuity unit, maybe if you went to a different neuro ICU in the future you might like it but be sure to ask what types of pts they have and the acuity levels before you accept the position.

[offlabel]

For starters, I'd recognize that the patient and their families don't think it's a picnic either. But they don't go home after your shift.

[Rosie_one]

I would also make sure the husband isn't making your confused/agitated patient worse. Often family members will talk to and expect conversation and just stress a patient out more than if the family wasn't there.

I'd explain to the husband that his wife isn't herself due to nature of frontal lobe, what that actually means for their wife, what to expect.

I'd also educate the family on the importance of low stimulus and regular rest periods to aid in their wife's recovery, reduce delirium etc.

Some family get distressed how their family member is acting. I find every shift I'm explaining this, even if the patient has been there awhile.

These type of patients are common in ICU as wards can't handle with their patient loads. We have lo-lo beds that can go to the floor which are much safer. If a line is deemed unnecessary, ask the drs whether you can remove it. One less thing to pull out.

Restrains are often required were I work due to traches, which would be pulled out. Sedating a patient isn't always an option due reduced ability to assess neuros, but if you think it's causing distress to family, get the drs to chat to them about what to expect. A nurse can say it all they like, but families like a dr to say it to them too.

Put a positive spin on things. A patient's rolling in the bed. Self pressure area care tick.

[Rosie_one]

Oh I forgot to mention. When you start out in ICU, you will be given the stable patients. They are assessing your skills with "simple patients", mind you often mentally draining. If you can handle these patients, your acuity of patients will slowly go up, as they get to learn your skill level and teach you skills to look after more unstable patients. ICU will take the longest to progress so work hard and you can go far. Even experienced ICU nurses to a new unit are given stable patients first.

I've been working in ICU long enough now to not care about allocations anymore. I found it helped changing my mindset. Give me whatever patient and I'll look after them the best I can. If their confused/agitated, I try to see if my nursing style/care makes them less so or more agitated than previous shifts as if I'll discover the secret to a calm patient lol.