The patient who wouldn't stop screaming...

[NewWayofLife]

So I had a patient last night, chest pain r/o MI with a history of fibromyalgia, depression, and anxiety. No known history of memory loss or dementia- normally independent at home.

She would NOT stop crying. Literally. I'm taking report and she's screaming- I assess her and she's c/o "I just don't feel good" Forty questions later we determine that she has 8/10 leg pain, which is a chronic problem for her. Her vicodin is ordered 1 tab TID (scheduled) and was given at 2000. It's now 0000. So I call and get the ordered changed to 1-2 q4-6h prn, and give her two. I also give her (scheduled BID) Klonopin 0.5mg. No sooner than she swallows the pills she's screaming "oh my god, help me, my legs hurt" etc, etc, etc. I very nicely tell her I know she's in pain, that the med will take about 30 minutes to take effect, and ask what else I can do to help in the meantime. "Nothing" Half hour later I ask if the pain is improved, and she states it is, but starts crying about: SOB (LSC, 98% RA, but she's hyperventilating, and we give her O2@2L as ordered), "I want my socks off"- okay, well you were capable of putting them on, so take them off, I'm too hot, I'm too cold, I'm hungry, I'm thirsty, and my personal favorite "Oh GOD, Oh GOD I just can't stand it, HELP me OH WHY OH WHY do I have to suffer this way"- a statement made not because of pain, or shortness of breath, but get this- lady partsL ITCH!! We are not talking about an alzheimer's pt- this is an alert, oriented, normally independent 60- something year old. ARE YOU KIDDING ME? I end up calling the doctor more than once, giving extra klonopin, etc, but nothing I do can console the woman. Yes, I lost my patience. Yes, I completely lost all empathy when the woman screamed like a banshee over the blood pressure cuff, repeatedly took off her O2 and c/o shortness of breath, etc. But I tried EVERYTHING I knew to help her, and spent over 4 hours trying to calm her down (breathing exercises, visualization, pain meds, anxiety meds, hand holding, ice packs, warm packs, positioning, etc) only to hear the next shift judgementaly say "You mean to tell me she's been like this all night????)

I give up

They don't pay me enough.

[ZooMommyRN, ADN, RN]

At first, I wondered what Vit. A & G were, but I assume that G is for Geodon and Vit. A is for Ativan.????

yep, those are the ones, we've gotten away from Haldol at our facility due to a high incedence of ppl comming thru the ER on meth, give someone on meth haldol and they start climbing the walls!

[Multicollinearity, BSN, RN]

:rotfl::rotfl::rotfl:

you slay me...

but just to throw it out there, maybe she was never left to cry it out.

maybe () she was coddled to the degree where she throws a scream-halting hissy fit when no one is at her beck and call.

hmmmm...(*rubs chin*)

op, i have no patience with histrionics.

sometimes i have resorted to, "ENOUGH!!!" followed by a softer voice, encouraging pt to let meds take effect:

that stress is exacerbating mental state;

and s/he needs to deep breathe/meditate.

and that i will check on him/her in half hour.

usually, it's the shout-out that shuts 'em up.

and yes, you do have so much patience.

you're a better nurse than me.

leslie

I have a relative with a personality disorder who acts inappropriate when she's hospitalized. When she does this, I just give her a long look and say in a low voice something like, "You behavior is out of proportion to the situation. You need to take it down a notch or someone might think you are crazy."

It may sound unkind or manipulative -- until you see her behavior. So far, it has worked every time. After I say something like the above, she gives me a look like -- you mean it's not working? Did I go too far? You're not buying it?

Like pushing a button, she stops her inappropriate behavior. Too bad a nurse cannot say that.

So far, it works. But give her all the attention she demands, and her behavior just feeds on the reinforcement and amplifies. Ugh.

[psalm, RN]

I don't think that would have been possible- I barely LEFT the room (did I mention it was an ER holding area with 3 other patients IN THERE, dealing with this?) Luckily, one slept through it and the other two were too demented to understand (but were agitated by it, for sure)

I did, however, write at least 15 notes- assessments, interventions (both offered and refused), calls to the MD, AND her stated relief from pain medications. And yes, the doc was very aware of her psychological state.

When I have a very demanding pt. like yours was, I will write a shift summary in the Nursing Notes. to cover myself. Such as:

0657 Shift summary for 2300-0700: Pt. c/o leg pain that was relieved (see Pain Eval) intermittantly all shift. Dr. Smith aware and this nurse received orders X3 for pain relief, lady partsl itching and_........... Pt appeared to to be in distress she cannot specifically state. Was seen by this nurse; RT; NAs and hospitalist through out shift (see NN). Psych and Chaplain consults requested. psalmRN***************************

Looks like you did a good job of documenting :)

[leslie :-D]

So far, it works. But give her all the attention she demands, and her behavior just feeds on the reinforcement and amplifies. Ugh.

oh, i so agree with you.

i think that most of us can differentiate betw those truly anxious vs those truly demanding.

often, as you already stated, we end up perpetuating a cycle of grievous complaints that only escalate with the attn they seek.

i am a strong proponent of limit-setting with these types.

don't we all need a dopeslap from time to time?

dang, i know i do.

i have a permanent handprint on my head.

leslie

[soulofme]

Too bad there wasn't a laundry shoot near by.....

[Multicollinearity, BSN, RN]

You know leslie, that makes me think of something else. In society, if someone is acting inappropriate, he or she usually receives social cues and feedback that lets them know others think their behavior isn't acceptable. Why is a hospital bed a free-for-all zone without social feedback to say 'this isn't' ok'? Press-gainey? Hospital administration?

Physicians can walk in a room and do this. Psychologists can do this. Why can't nurses?

Thinking out loud, here.

[takeittotheicu]

All aboard the crazy train....now headed for looney ville and hysteria junction.

And who says you can't tell a patient they are being inappropriate? lol. I've told people that before. You're in pain? I will do my best to treat it. You're scared? I will do my best to support you. You don't understand why? I will do my best to teach you. Something is making you uncomfy? I will try my best to fix it too.

Sometimes.....you can't fix bananas. I stop just shy of letting people scream bloody murder and throwing temper tantrums. I can be one of the most tolerant nurses in the place....you have dementia? I understand that no rational speech will curb your behavior and I will keep you safe. Just about the point where she started screaming about her va-jay-jay itching...I would have cracked up and started snorting. I understand that it's not theraputic to laugh at your patient, but sometimes that's all you can do. I get that comfort is individualized...but come freakin on!!!

It sounds like you did an awesome job at caring for her. But that's prob all you got to do....was take care of her. That always infuriates me. (Like the other poster....red faced and temples throbbing) And it never fails that the one who is super needy, isn't all that critical. I won't go into details now, but the last two nights were difficult for me.....on patient was a witnessed home arrest (Vfib) and prob has profound anoxic injury. (18 min without a pulse will do that to most) he was the one I NEEDED to manage. He can't hardly autoregulate anything right now. But my other guy was a big lumbar surgery that was POD 2.....and was mean/crotchety, demanding, and consistantly in pain. I don't doubt that he was in a good amount of pain....but he also had a morphine PCA 1mg demand q 5 min and oxy ir q 4. (Average hourly demand on the PCA do you ask??? 67 times per hour)He was using that thing like an atari joystick. He also had totaled up enough drugs to have knocked out a small mule. (Despite HOURS of teaching and re-enforcement about it) I seriously couldn't get 12 feet away without this man screaming out for me. I even got him a soft touch call light so he would be able to hit it. Sheesh. After more than a few hours of that behavior I simply told him that I was doing the best I could to manage his pain (everything we're taught to do intervention wise) I finally looked him in the face and told him "I am not going to be able to make you pain free. You had back pain before and you just had a big back surgery. And the only was to get you pain free would be to tube you or a large act of God."

He settle down for about a minute....but that was all.

You can't do it for everyone. Just thank your lucky stars it's only work, and you don't have to go home with her!

[FireStarterRN, BSN, RN]

:rotfl::rotfl::rotfl:

you slay me...

but just to throw it out there, maybe she was never left to cry it out.

maybe () she was coddled to the degree where she throws a scream-halting hissy fit when no one is at her beck and call.

hmmmm...(*rubs chin*)

op, i have no patience with histrionics.

sometimes i have resorted to, "ENOUGH!!!" followed by a softer voice, encouraging pt to let meds take effect:

that stress is exacerbating mental state;

and s/he needs to deep breathe/meditate.

and that i will check on him/her in half hour.

usually, it's the shout-out that shuts 'em up.

and yes, you do have so much patience.

you're a better nurse than me.

leslie

Hey, you knockin' my brilliant theory??? I was gonna base my doctrinal thesis on this premise. I'll invite you to my book signing...

[imenid37]

Years ago, we had a woman in her 40's w/ some drug w/d issues and probably a psych disorder too who kept screaming the "F" word on the 11-7 shift. The other call bells were on like Christmas lights. The resident told us we could give IV Valium to Ms F. When we told him we were not allowed to push it and he would have to do it, he said "enjoy the screaming!" I think she just burned out after a couple of hours and shut up. This is why you could not pay me enough to do med-surg or the ED. These manipulaters also know that all they have to do is complain to administration when the nurses are nervy enough to expect these competent, supposedly sane adults to act

appropriately. My favourite was the man w/ the "fetish", meaning it could be turned on and off who felt stressed and wanted to wear a diaper and talk baby talk because he was stressed re. being in the hospital. He wanted the nurses to treat him as a baby...like his mom did at home. He was in his 40's and held down a full time job.

[Neveranurseagain, RN]

Why can't you put a movie on for her to watch? Something soothing...it might calm her down so she screams less....how about One Flew Over the Cuckoo's Nest!?!?!

[Black Jade, BSN, RN]

This sounds like the patient who came to my clinic during lunch time crying to be taken to the hospital because she was in so much pain (she also had fibromyalgia and anxiety). Then when I told her the paramedics will be coming (waste of tax money), she stopped crying and asked something for nausea.

Believe me, I understand how you feel. In my clinic, we see a lot of patients with conditions that are unbelievable. I had a patient who was having chest pain at 1am, 4am, but decides to come to the clinic around lunch time when the doctors are out to lunch; patients who complain of excruciating pain coming before closing time and they get upset because there are no appointments available. It they were in so much pain, then why do they bother waiting until the last minute? Also, patients who get upset because they have been waiting an hour (between noon and 1pm-lunch time) to receive medication refill. Excuse me, but don't they know that we eat lunch too and that there is nobody available around that time? My God, these people! There are times that I feel like screaming.

Believe me, I feel for you...

[VivaRN]

As a quick aside, I just read an article in JAANP about undx'd genital herpes in the elderly causing A LOT OF PAIN, lady partsl complaints and diagnostic run-around.

Could this be your patient?

One of the case studies is a woman who got so bad she was labeled a drug-seeker... until she was correctly diagnosed and treated with acyclovir. The lesions can also be inside the lady parts (ouch!), and if in doubt one could do the blood test for HSV-2.

From here you can get the full text:

http://www3.interscience.wiley.com/journal/119878460/abstract?CRETRY=1&SRETRY=0