Verbally abusive patient, worried I could have handled the situation better

[NurseMom2016]

Let me start out by saying this is a little long winded, but it has been weighing on me and I have to get it off my chest, so bear with me!!!

So, my last shift, I had gotten report on a male patient in his 60s, totally A&O, on our floor for anasarca. PMH of chf, alcohol and IV drug abuse, and hep c (from what I remember.). I work on a busy cardiac unit. This man had been sent to us from the icu on a bumex drip with a foley due to retention, along with a fluid restriction. He had to have assistance to get up, but could make it around just fine with his walker once up. The report I had gotten from the night nurse said he was a jerk, and noncompliant with the fluid restriction of 1000 cc among other things.

So first thing (before I had made it into his room), my charge nurse passes his room and he asks for coffee, she says she has to ask his primary nurse because he is on a fluid restriction. This sets him off, he begins to yell and curse so loudly, I can hear him from 2 rooms down through the closed door. So, then I go to the room. He politely asked for coffee. I politely said back, "ok, let me check the chart and see how much fluid you are at so far because you are on a restriction." This sets him off. He shoves his bedside table towards me, knocking off some of the remnants from his breakfast tray towards me. He begins to curse at me, saying things like "you stupid f***ing nurse" being the primary phrase. So, I calmly say "there is no reason to be this way to me, to be cursing at me. I will come back after you calm down." So I leave and close the door, and he is still cursing. About 5 minutes later, the tech told him that she would have to check with me before she could give him coffee, and he went off again, yelling and cursing so loudly that other patients and families were complaining. So, my charge nurse and I agreed we should call security. He arrives, and handles the situation well. The patient kept saying, over and over, "get me the hell out of here." So, in short, he ripped his tele leads off and began to pull on his IVs and foley. The physician came to the room and spoke with him, saying in short that he was welcome to leave if he did not want to comply with treatment, he could not treat staff that way, etc. so he agreed, yes he wanted to leave. The security officer and the physician said they agreed he should leave. So I removed the two IVs and the foley. While I am doing this, the PHYSICIAN brings him a cup of coffee and a cup of water (roughly 500 cc, he was already around 400 cc so far before this). While I was removing his foley, (he was sitting on the edge of the bed), he threw the cup of water over my head against the wall, but I was soaked. At this point I left the room fuming, and let the officer speak with him. He was saying he now wanted to stay since we gave him his coffee. THIS is the part I am questioning myself about-I told him "no sir, I have already removed everything and you have signed the paper to leave. The cab is on its way to pick you up." He did leave, and had to have assistance from the tech and officer to transfer from a wheelchair to the cab.

I had a hard time leaving some of the things he said to/about me at work that day. (I.e. You fata**, you shouldn't be a nurse, f***ing dumb nurse, I could go on). Remember, this man was as oriented as he could be, and was able to hold a calm conversation with others during this time. Probably some undiagnosed psych issues or something. I have never had anyone speak so poorly about me. So, yes I am glad he left within the first 2 hours of my shift, BUT my conscience keeps hanging on three things: one, that he wasn't able to walk on his own and we just sent him on his way. Two, that the foley was there for retention and it was removed almost immediately before he left. And three, that in the end I kind of told him he had to leave (I think he probably would have anyways).

Thank you if you have read this whole thing, I tried to condense as much as I could! Let me know what you think, if something could have been handled differently, etc.

[Okami_CCRN, BSN, RN]

To be honest, I would have just given him the cup of coffee when he asked for it, and educated him on his fluid restriction and why it is in place. If he wants to follow it great and if he doesn't you can inform the physician and document.

I think that everyone saying let me ask your nurse/let me check your chart/let me talk to the doctor probably made him feel like people were avoiding him and his request.

[nursemike, ASN, RN]

Sometimes our patients are having the worst day of their lives. They're frightened, they're frustrated, and acting out may be the one way they have of feeling like they have some sort of control. As much as it may not look that way, in our relationships with our patients, the power is disproportionately ours, and that can be hard to swallow for the one without the power. Indeed, we sometimes feel like we are powerless and have to kowtow to get those patient satisfaction score, which makes us want to act out a little, too.

In times like these, it's very important to understand that people may be dealing inappropriately with their anxieties and stress because they just don't know any other way. Nor is it wrong to step away a moment, take a cleansing breath, and keep in mind that some of these people were probably jerks long before we ever met them, and will be long after they're discharged.

[Sour Lemon]

To be honest, I would have just given him the cup of coffee when he asked for it, and educated him on his fluid restriction and why it is in place. If he wants to follow it great and if he doesn't you can inform the physician and document.

I think that everyone saying let me ask your nurse/let me check your chart/let me talk to the doctor probably made him feel like people were avoiding him and his request.

I agree. That type of patient is not worth aggravating myself over. I am a little irked with "Dr. Coffee", though ...I would have asked him to take pudding to room 206 and ice to room 300 since he was so eager to help out.

I've had at least one VERY questionable discharge that haunts me to this day, so I understand how you're feeling about that. You've just got to live with it (and so do I).

[Apples&Oranges]

I agree with the first poster, just give the man his damn coffee if he understands the ramifications of going over his fluid restriction. Probably what I would have done in this situation.

I also think you were totally justified in wiping your hands of the whole situation. I love it when verbally/physically abusive patients decide to leave AMA. Cool. Let me do everything I can to make that easier for you, bro. If you throw stuff on/at me (even water) that is battery (NOT assault!!! - assault is THREATENING to do it, doing it it BATTERY) and you are lucky as **** if I choose not to press charges.

Please leave my hospital immediately.

If he was A&O, understood the consequences of his actions (to himself and to you) and chose to leave...good riddance. On my unit, that bed will be filled with another jacka** within 10 minutes of it being cleaned. And it begins again...

[NurseMom2016]

Yes, giving him the cup of coffee crossed my mind as a possibility. But, in the moment, the way he was treating me and everyone else (including our brand new, nervous little 19 year old tech), made me want to do everything but give him the coffee. I was mad and angry at how he was treating me. Again, looking back on it maybe I should have just given it to him-but could that have made him stay longer in the day, and then I would have had to deal with him even longer?

[beekee]

Yup. I'm the fluid restriction educator, not the fluid restriction enforcer. if the patient is A&Ox4, aware of the restriction and the reason for it. Educate. Document. Move on.

A power struggle with a patient is very unlikely to end well for you. Customer satisfaction, complaints, long, miserable shifts...I don't have the energy or the time. And I'm going to lose any way.

[Apples&Oranges]

Let me add one more thing - your original question was something like, "Could I have handled it better?"

Of course. We all could handle 80% of of our patient interactions better.

A more relevant question is, "SHOULD I have handled it better?"

Maybe I'm just at the end of my patience allowance for the month, but...my vote is no. Some people just need to be shown the door.

[NurseMom2016]

I am a little irked with "Dr. Coffee", though ...I would have asked him to take pudding to room 206 and ice to room 300 since he was so eager to help out.

YES lol-it is a female hospitalist and she is sometimes very good at throwing nurses under the bus, others she acts like your best friend.

[Sour Lemon]

But, in the moment, the way he was treating me and everyone else (including our brand new, nervous little 19 year old tech), made me want to do everything but give him the coffee.

I guarantee you he was 100% aware of that fact, too. You were both playing games, he was just playing a much less restrained version. Next time just give him the coffee, then go home and count your money.

[NurseCard, ADN]

I honestly probably would have handled the whole situation exactly

the way you did, though like others have said, that probably wasn't

the best way to handle it.

I'm in agreement with those who say, "just give him the coffee", but I

have no patience with someone who acts like that.

[Penelope_Pitstop, BSN, RN]

When I worked MedSurg, we weren't "allowed" to go over a patient's restriction. I think the best bet is to educate as much as possible and then give the dang coffee, as others have said, but this would have landed me in hot water when I worked on the floor. Same with giving extra carbs to diabetics. Now I work in home health and although it's not my preferred locale, it's refreshing that we aren't expected to be the enforcers, but rather the educators.