I recently had a patient in the ED who did have a lot of pain from her 1mm kidney stone. Understandable. However, the drama and borderline traits exhibited by her and her husband were highly disruptive to the staff and surrounding patients in the ED especially as we had a crashing patient who went into septic shock with a BP in the 50s before our eyes. The patient and husband were highly disruptive because of the perception that we were ignoring the patient and not taking care of her needs. I called security and the police who escorted the husband and another visitor out of the ED. I did not approach the husband as he was making a scene. We were all afraid he would come back with a gun. I did go back to the patient to give her more pain medication. This didn't stop the high drama from the patient. Besides for yelling about the pain, the patient was yelling that we didn't check her labs or urine (we did). She was also upset that we did not offer her a tampon or pad after we did her pelvic exam because she was bleeding. We never offer pads and I have never heard such an angry outburst over a pad.
Is there a one liner that you have in your back pocket that will help the patient and or visitors recognize their childish behavior and that we will not help them if they continue with this behavior.
Would something like this work? (Of course have security officer with you)
To the husband: Mr So and So, I can see that you are very upset. However, nobody deserves to be spoken to the way you are speaking. The other patients are disturbed by your outburst. If you want to be helped, you need to calm down and stop yelling. Yelling will not get you help faster. The doctor is with a critical patient at this time. I cannot give your wife a third dose of pain medication until there is an order from the doctor. I will have the doctor come check on your wife as soon as she is available. Is there anything else I can help you with?
To the patient: I can see you are very upset and would like more pain medication. As soon as the doctor puts in an order for more medicine I will bring it to you. The doctor is with a very sick patient at this time. Would you like and ice pack or some warm blankets to help manage your pain until we get an order? I will ask the doctor for some more medicine as soon as she is available. Is there anything else I can help you with?
I had a terrible time with my kidney stone. I am normally quite calm and very affable. I didn't lose it with the doctors or nurses but have the patience of a saint, as they say.
They may have been jerks, however, they may have been normal people in a very scary situation (I thought I was having a heart attack it came on so fast and was more painful than the birth of all three children).
Sorry I don't personally have a one-liner for you but many on here are excellent. Good luck!
I had a terrible time with my kidney stone. I am normally quite calm and very affable. I didn't lose it with the doctors or nurses but have the patience of a saint, as they say.
They may have been jerks, however, they may have been normal people in a very scary situation (I thought I was having a heart attack it came on so fast and was more painful than the birth of all three children).
Sorry I don't personally have a one-liner for you but many on here are excellent. Good luck!
I've had more kidney stones than I can even count over the course of 14 or so years. They're wicked, and the only thing you can do is flood your body with water & take pain meds so that you don't commit suicide. It comes on out of the blue, and the pain is different every time, depending on the size of the stone, the sharpness of the stone, the location of the stone in the ureter & if you are obstructed. I am so used to it, so I know how to treat it now----but a couple of years ago I was sitting in the waiting room at the urologist's office, and there was a woman there with her husband. The poor thing was as pale as a sheet, her hair was wet from sweating, she was holding a sick bag that she got in the ED, and you could she that she had been crying. She looked like she was dying, I swear to God. She was so pale that you'd think she needed a transfusion. I felt so bad for her. If you don't know what the pain is, it is frightening. However, one must realize that they are not the only patient in the emergency department & sometimes you have to wait a little while.
What some posters have pointed out is that you would be wise to be very cautious about using a psychiatric diagnosis to describe behaviour.
Borderline personality disorder is often misdiagnosed and should not be used as an "umbrella".
I have been diagnosed with borderline personality disorder. I get tired of people throwing out personality disorder and other mental diagnoses so loosely. It is offensive.
I simply let my pt's and their family members know that I am doing everything within my power to make them comfortable within my scope of practice with the orders received. I always advocate for my pt with the ED doc if the plan of care is not relieving the pt's discomfort.
With that being said, there are pt's and family members that are simply unreasonable and often come in angry and set a negative tone/relationship for the remainder of my time with them. In those instances I remain professional and always try to deescalate.
Every shift is different and I can be attentive to most pt needs, but if I get a high acuity pt such as a STEMI, BAT, or ICU hold then most of my less acute pt's have less of my time (which unfortunately may be a pt in incredible pain but, stable). If I have a STEMI or BAT workup, I might get a float RN to medicate my other pt's if we are slow, but if the ED is slammed then my other pt's have to wait as I can't be in two places at once. In those scenarios, I can understand pt's and family members becoming upset for having to wait, but there is nothing I can do. It all comes down to stable vs unstable or acuity vs non acuity. I will later explain to the pt why my attention was elsewhere without breaking HIPAA and most times they understand, but others simply don't want to hear it and remain unreasonable...
We don't have protocol pain orders for anything. I think protocol orders have made a lot of pt's addicts, and seeking pts. Yes kidney stones are horrible & on the level with chest pain, but automatic pain med orders are never a good ideal.
It took me a very long time to figure out that when people are being insulting and uncooperative it's usually because they're scared. Or they're just jerks. But most of the time by the time I see a patient they've been admitted from the ER, been to radiology, been to angiography, been to nuclear medicine, and God know where else. They have experienced lots of scary uncomfortable things, have their clothes off so they're cold and vulnerable. They might not have eaten for hours or days, no one has told them anything and they are truly terrified.
So so when they arrive in dialysis mad as a wet hen, spitting insults and telling us we aren't doing our job, I introduce myself, help them settle into bed and I stop for a minute, let them get their bearings. I smile and talk in a calm voice. If they keep ranting I'll touch them lightly - hold their hand or put a hand in their arm, whatever feels appropriate - and I'll say "have you had a bad day?" And I let them get if off their chest. When they calm down I'll say "I'm going to start your dialysis. Once we get started I'll sit down with you and we can talk. The main thing I want you to know right now is this isn't going to hurt. You won't feel anything. You can just relax and let me take care of everything."
It it tskes an extra 5 to 10 minutes but it ratchets down the tension quite a bit. I usually find that they don't know what's going on and nobody has answered their questions. Chances are someone did, but when you're in panic mode you can't take in anything new. So I'll explain at least the dialysis part of things and help them deal with their fear.
I have the unique opportunity of having time to talk to people, so I use it to help them calm down. I realize that not everyone does, so I kind of appointed myself the ambassador of new information. It makes it better for everyone. They calm down, they feel better, they stop abusing other staff, and they start to develop trust. It doesnt always work, but I would say it works about 90% of the time. There is no pleasing some people. For those I keep it light and professional, smile, and say just what they need to know so they can't twist my words around - as sometime happens. But people are who they are. You can't change the way people talk. They probably talk like that at home and have gotten away with it for 50 years. I can't turn that around in a day.
I also wanted to say to say that if people are acting out and I get angry it's because I'm scared. I had to learn that for the most part people are harmless. They might be acting tough as a way of coping. it I am wary if I feel threatened. If I truly feel unsafe I will call security but fortunately I've only had to do that once. Most of the time I can get the situation under control and they stop acting out. Not always. But usually. I had to learn to deal with my fear too. It got easier with time. I hope that it gets easier for you too.
Specializes in Med/Surg, OR, Peds, Patient Education.
We don't have protocol pain orders for anything. I think protocol orders have made a lot of pt's addicts, and seeking pts. Yes kidney stones are horrible & on the level with chest pain, but automatic pain med orders are never a good ideal.
I hope that you never have issues with kidney stones. However, if you should have this issue I, honestly, think that you would change your mind.
Granted the patient who was coding took priority, that is a given, but kidney stone pain is something that you have to experience to comprehend. That type of pain does need strong pain medication and copious amounts of fluids. Fluids can be given PO, if the patient is not nauseated or vomiting, and IV if they cannot tolerate PO fluids.
I stand in front of the patient, at a distance that is comfortable for us both - (as long as my physical safety is not compromised), raise one of my hands to the level of my head, palm facing patient, hand flat, and say " I am not going to engage in this disussion (or continue with this assessment, or perform this procedure - whatever fits) unless it can be done in a manner that is respectful to both of us. Please come and find me, or another RN, when you feel this can happen. In the meantime, if you feel more unwell, or become distressed, please notify us or get someone to do it for you." All said quite politely. Then I walk away. I have found this approach blows many patients away - the last thing they expect is a response of this sort. If the patient is escalating his/her behaviour - they are obviously looking to engage and push things further. For the most part - this has worked very well for me. Side note - I work in ER. Many years ago we had an ambulatory teenage patient arrive c/o shortness of breath, dizziness, tingling in hands, anxiety, trembling - the nurse who assessed him felt he was having a panic attack and hyperventilating - which proved to be correct. She got him to recline on a stretcher in a treatment room and tried to talk him through regulating his breathing. He just would not acknowledge what she was saying and refused to co-operate. The patient was quite stable - so she tried another approach. She got a paper bag - rolled back the top edges a bit, and placed it over his mouth and nose - all the while telling him what she was going to do and the rationale for it. We do have non-rebreathers and such - but the paper bag was handier. Anyhow - the patient ripped the bag off - ripped it into pieces and refused anything she offered. I was in the room with her. Her next approach - she looked at the patient and in a non-threatening tome said " I'm trying to help you. You are obviously not willing to play the game. When you are, please ring your call bell and let me know."
I will NEVER forget it because it was very out of character for that particular nurse to say anything along those lines. The patient had a friend who was going to stay with him so we knew we would be notified if the patient's condition changed. In any case - it was only a few minutes later when the patient rang his call bell, the paper bag went on and symptoms eased off within minutes. Another life saved!!!
In my experience, people do not respond well to being told "you need to [do this or that]." And I'm not quite sure what made you diagnose a patient whose pain may interfere with rational thinking to be 'borderline' but anyone can exhibit needy, selfish, desperate or manipulative behaviour when they are suffering. They are not privvy to the critical patient's information...perhaps all she knew is that she was bleeding and could not understand why something as simple as a pad could not be provided. Frankly, I can't understand that either. Unless you are actively working the crash or you are a punitive nurse, there is no reason to at least give a chux. As nurses we provide pts with dignity when we treat them. Allowing a pt to bleed lady partslly without intervention and in the throes of a kidney stone deprives the pt of her dignity.
That said, I understand that there are many dynamics to a situation and they can't all be fully captured in a few paragraphs.
Best trick I ever learned? Keep quiet. If they're yelling, do not open your mouth, do not quirk your eyebrows, do not make a single expression beyond 'this is my paying-attention face.' Let them yell until they are finished - this usually takes 45 seconds to a minute. Key point here: if you interrupt or respond in any way prior to the end of that minute, the timer restarts to zero. The temptation is to step in too soon, especially once the personal attacks start. Resist. There will be a couple of pauses for breath; resist. You're waiting for them to respond to you, not you to respond to them.
So let them yell and expend all their ire and only once they have stopped yelling and started to speak in a normal voice do you respond. Emotions are like a balloon leak - letting them fizzle out makes less noise than taking a pin to them.
Many of our patients are not schooled in health care, and that kind of unrelenting pain, often accompanied by fever, is terrifying. They want a professional person, trained in dealing with them to put their mind at ease. Yes, the spouse was probably just as frustrated, seeing a loved one in pain that you can do nothing about brings out the worst in a lot of men. I also think the situation was showing how fear also effects nurses a patient crashing with a BP in the 50s right before our eyesâ€. Are you really that angry at this patient, or upset over what you feel helpless to control? I have noticed that ER staff are often more compassionate to those who's situations are life threatening, must be the adrenaline rush associated with a code. Does not make others needs less important to them…
She was also upset that we did not offer her a tampon or pad after we did her pelvic exam because she was bleeding. We never offer pads and I have never heard such an angry outburst over a pad.†Do you really think that outburst was over a pad?????? This woman went to a hospital to receive competent and compassionate care, and her pain, fear and humiliation of bleeding lady partslly onto her clothing that others could see is not even addressed! What kind of a facility will not give a patient a pad if she is experiencing her period and has none with her??? Where is the patient advocacy here? I would be extremely upset, being in pain, waiting for care, and the response to asking for a sanitary napkin received that haughty answer!!!! If I had been her nurse, I would have gone to my purse and given her one of mine. That's what nurses do, put their patient's needs ahead of everything else. Please do me a favor, let us all know what hospital you work in, so we can avoid it. Patients don't need this kind of demeaning care! No, this is not bullying, just recognizing that the younger generation of nurses are much more concerned with their own needs, Lord help the baby boomers!!! Apparently compassion is not taught (nor should it have to be) in nursing school anymore!
.thumb.gif.fc0b5b00a77a1cf676541776e02de0f9.gif){kind=avatar}
TracieAnn
2 Posts
I had a terrible time with my kidney stone. I am normally quite calm and very affable. I didn't lose it with the doctors or nurses but have the patience of a saint, as they say.
They may have been jerks, however, they may have been normal people in a very scary situation (I thought I was having a heart attack it came on so fast and was more painful than the birth of all three children).
Sorry I don't personally have a one-liner for you but many on here are excellent. Good luck!