Verbal abuse from a TBI patient

missmollie, ADN, BSN, RN · May 19, 2018

Was part of the injury to the frontal lobe?

TBI patients are difficult to deal with, and depending on which part of the brain was affected, they may never change. Of course, he could just be a dick about it. Look over his chart and see if there was frontal lobe damage during the asphyxiation. If there was, he will always be like this. If not, then set some limits. "I am unable to care for you when you speak to me like this. You need to change your tone, or I can call and have a different nurse take over your care". Done.

Crumityk · May 19, 2018

They never gave me any of that info and there is nothing that shows his exact history. I'll try to find out. Thanks for the advice!

cardiacfreak, ADN · May 19, 2018

Traumatic brain injury patients are difficult to deal with especially if they are now totally dependent on others. There may be some loss of control over emotional responses, try not to criticize, this is sure to make the person feel frustrated, angry, or embarrassed and this can intensify the behavior. Try to validate the emotion by identifying the feeling for example you may try to say, " I understand that you are upset, and feeling frustrated, I understand this is very difficult for you."

Some TBI patients may lack empathy, this behavior stems from lack of abstract thinking. Try to remain calm in the situation and ignore the behavior, establishing structure may be helpful, for example, keeping them on a schedule, bath time is it 10 a.m. on Monday Wednesday Friday, he'll time is at 8 a.m. noon and 5 p.m. The patient may have to relearn awareness of others feelings.

He may still be "with it", but again the abstract thinking may not be there. Try to treat each encounter as if it was your first encounter with him. Allow him to have control over certain things like what he wants to eat, what clothes he would like to wear, what TV program he would like to watch etc., allowing him to have some sort of control may be helpful

KatieMI, BSN, MSN, RN · May 19, 2018

It is TBI, to begin with. It is totally helpless human being, unable even to scratch his nose. It is pretty much hopeless, and it is to the end of his life, and he might or might not realize it. And he can speak sailor's language even before that.

I think you understand it all already.

Only one more prospective I can offer from my own days of being bedbound is that those learned, stereotypical cliche phrases, including "it is not necessary to speak like that with me" you used, "I understand that it is difficult" (which, unless you had experienced something like that, is a lie), "sorry about that", etc. can literally drive your patient crazy. Imagine, for example, people intentionally causing you pain and discomfort every time they come close enough and every single time you hear "oh, sorry about that" in the same casual not-at-all-sorry tone. I was absolutely there and understood what they did, which is questionable with your patient. But after several days I asked my nurse either to just do it silently or say something else for a change. She was shocked because she perceived "just telling something pleasant" as her "iamjustdoingmyjob" stereotype, a task of a sort, and just had no idea what else to say, but we figured it out. Later, when I was working with similar category of patients, they confirmed my impression.

So, try to be a little bit more creative with your responses while remaining professional. Take this guy as a person he is now. Do not criticise, do not confront, do not rationalize. Ask him about ways he prefer things to be as long as it is possible and within your scope of practice. Allow him as much control as possible. If he has a soft spot like favorite show, candy, etc., do go extra mile to get him that thing. If he blurts, ask in normal soft tone what exactly he wants and let him know that you won't do it till he asks without cussing.

It is a tough job to care for such patient. (((Hugs and prayers to you))))

allnurses Guide · May 19, 2018

I've worked with a patient like that, and I agree it can be very difficult, especially if they are, for a good amount of time courteous, or seeming to be with it. It's natural to assume they have a level of control over the outbursts. After many years with this one person, I came to understand that there was no way I could experience life the way someone with a brain injury does. It seemed there was a "switch" and a change of expression which preceded one of those episodes and a rapid return to what we would call a normal form of interaction. That's why my patient would also ask for water, or re-positioning immediately afterwards.

In time I was able to depersonalize the things that were said, because the many logical discussions I had with this person never fundamentally changed the behavior, and believe me I tried every form of therapeutic communication I could come up with!

These clients do run through nurses very rapidly, which is disconcerting for them, you and the agency, which is often called upon to have a "talk" about exactly why they can't keep nurses for very long.

If you find you can't detach yourself, it is more than understandable. I won't say I completely got over the hurt some of the remarks caused me, but I got better at distancing over time.

Wishing you the best!

**canoehead, BSN, RN** · May 19, 2018

Talk to him when he's calm, and tell him that even though he's having a tough time, sometimes your feelings get hurt when he swears at you. If he gets angry maybe it would help if you both agree to a five minute break. Walk away, try again later. Tell him that if he continues to swear you won't stay in the room. Set some limits. He might not have as much control over his words, but he should respect that you still have feelings.

LovingLife123 · May 20, 2018

This is some of my patient population. I can tell you that pretty much all quads end up being very particular and cranky at a certain point. Is he still within the first year of his spinal injury? He's lashing out because he literally has no control over anything in his life anymore.

Not that it makes it right for him to talk to you that way. With asphyxiation, he probably has had an anoxic brain injury which can cause personality changes. So, he's got two things against him causing this. It's still very frustrating to be treated that way. I always try to remind myself that they can't help it.

But twelve hours can be made very long with these type of patients.

allnurses Guide · May 20, 2018

Wow. Prior to my current job, I worked for an agency for a few months. I was

offered a job sitting with a young man who was a quad for 12 hours, 3 days a

week. I believe he also did have TBI. I went out to meet him and his father

and.... wow. There was just no way. He was incredibly difficult, his DAD had

little to nothing good to say to me about anything, the situation OR any

of the nurses who had been coming out there. Just a very bad, very

high stress situation and I had to pass.

I can surely understand that it WOULD be stressful for sure... didn't mean

I had to deal with it by taking that job!

FolksBtrippin, BSN, RN · May 20, 2018

You are not being insensitive.

Given the fact that most of his insults are specific to you being a woman, he may do better with a male. I would not blame you at all for going to your sup and suggesting that a male be assigned to him.

TBI patients tend to have trouble with temper and processing and quads are notorious for control issues.

TBI patients can improve. The brain is amazing. I worked with a psychotherapist who specialized in tbi rehab. Not sure if your patient would qualify for that or not.

Since it bugs him when you say "Its not necessary to talk to me that way." I would try a different approach if you want to stay on as his nurse.

I would try this. After he insults you, stop care, take a few steps back and wait for silence. When you get a long pause, and he appears calm, say without emotion "Do you remember saying **** you suck my dick whore?" See what he says. If he does not continue to rage out, you can say "I don't like that." And see what he says. Keep your language very simple and straight to the point. Although you can't do therapy you can help him identify triggers to his behavior. Is there anything that you have noticed triggers the behavior or does it seem random? For example, does it happen before every bath?

If you do notice a pattern, know there is an art to sharing your findings with the patient. You need to wait for the patient to want to find a trigger and you need to give him a chance to identify it himself.

Even if the insults seem random it might help you to write down what was happening right before the insults while the insults are flying. That does double duty of detaching you from the situation and identifying patterns.

If the patient wants to do better in this regard, I would stay his nurse. But thats me. I love psych.

I wouldn't blame you for getting off the case. Good luck.

Davey Do · May 20, 2018

It seemed there was a "switch" and a change of expression which preceded one of those episodes and a rapid return to what we would call a normal form of interaction.

In the early '90's certain anticonvulsants, like Tegretol, were starting to be used at Anomaly State Hospital for conditions labeled as explosive disorders.

Since then, I've noticed a lot of anticonvulsants such as Depakote, Trileptal, and Neurontin are bing used as mood stabilizers.

If he's not already on one or more of these meds, perhaps this individual could benefit from their use.

meanmaryjean, DNP, RN · May 20, 2018

They are only words (crude, vulgar and hurtful words to be sure). But words are all this patient has. I used to take care of a teenager who was a C1-C2 quad from falling off his bicycle. He talked to me like that at times. Now, I do not use profanity at ALL- but I quickly realized this was the only modicum of control he had in his life. And so I just let it roll off my back. And we ended up having a good relationship despite his outbursts.