Neuroinjury or manipulating the system

[abbaking]

For the past 3 weeks, there has been a man on my unit with a "Neurological" injury. This man SCREAMS every curse word on earth and disrupts the unit to the point that its an embarrasment. He is bedbound and requires total care with bathing, pericare, skin care, and feeding.

I have worked in neurotrauma before and I have cared for my share of neuro patients. In this case however, things just dont add up.

1. He is A&Ox3. - He can vividly describe his surroundings, family, friends, person, place and time.

2. There is no mention in the H&P of any major events and he has had no MRI/CT scans

3. He is able to respond to redirection

What do you think? The MD dances around the point when I questioned him about this patient. Behaviorally, this patient is a major disruption to the unit - SCREAMS, YELLS, and FOUL FOUL Mouthed man. He routinely refers to the females by the "C" word.

When I have cared for him - he will curse but does not yell or make a scene. Being 6'3" and 240 most people see me and back off.

In my opinion, this guy is on the wrong unit - He may have neuro issues but they are PSYCHIATRIC issues. He belongs in a 5150 LOCKED unit for a 72 hour hold.

Any idea's on what i can do?

Any advise is needed here cause we on the unit are BURNT out

[AnaCatRN]

Could he have Tourette's syndrome? He might just be a very unpleasant man. There are plain old jerks out there. Why is the MD dancing around the issue? I'd ask for an explanation and definitely get the chain of command going. The other patients (and staff) don't deserve to be abused this way.

[Annewr]

A couple things come to mind,

What is the census like at your facility? Does he have private insurance? Is he keeping others from taking a bed on a specialty unit? If you have empty beds and a high medicaid population... (we have all seen this, as unlikely as it seems in this era of managed care...)

If he truly seems to be a "psych" case, then you could contact your facility/unit patient advocate as he is not receiving the appropriate care.

If you feel strongly enough, you could also contact your facility/unit Ethics committee.

You mention that there is nothing in the H&P, that is most unusual. Esp as he requires total care and has had no diagnostics.. What was his admitting diagnosis? If he was admitted for infection, your psych unit likely wouldn't take a pt requiring IV antibiotics...Does he come from a SNF? Does he have any use of his extremities?

I have personally cared for a number of patients with very poor, er, communication skills. Our facility once "housed", for over a year, a dialysis pt who was banned from all area treatment centers due to his removing his access needles and threatening the staffs with his HIV infection. Finally, the hospital bought him an apartment and he came to our hospital for inpatient dialysis even though he was now, outpatient. He acquired his infection as a result of IVDA...

Finally, while he is screaming, as long as he has a call light, you can ask your manager if it is approp to close his door. Most importantly, while it is extremely stressful to care for such a patient, do your very best to turn a "blind eye" to this verbal barrage, it may be a defense mechanism that requires empathy, rather than anger...I know, its easy to say, much harder to do.

More info would be helpful:)

Best of luck in this very difficult and disruptive situation...

[Horseshoe, BSN, RN]

We don't have enough information here to determine whether this guy's problem is neurological, psychological, or "manipulation."

I would not allow the MD to "dance around" the question. Be blunt with your questions and state your concerns clearly to the MD. Get your nurse manager involved if necessary.

[HouTx, BSN, MSN, EdD]

Sounds like a typical frontal lobe injury to me. They lose all inhibition or "social" filters. If you're Freudian, they are completely id-driven. Granted, my experience with these patients has been on the acute (Critical Care) side, but I don't ever recall any of them responding to cognitive (psychiatric) therapy. Setting consistent behavioral limits (& sticking to them) was somewhat successful.

You may not be able to control the offensive language very much, but any physical abuse or sexual overtures should trigger consequences that are meaningful to the patient - such as curtailing TV or visitors. I don't have any experience or frame of reference with long-term outcomes. Sounds like you definitely need a consult from an expert psych nurse to set up a behavioral modification program.

No one should have to put up with this on a daily basis without a break. Can you adjust the work assignments to make sure that this patient's care is equitably shared and no one goes bahooties? Best of luck and major (((((hugs))))) to you and your co-workers.