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

Nurses General Nursing

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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.

TBH, you need to have thicker skin. I work in an ER in the ghetto and we deal with people like that on the daily. I have been called a b*** and beyond, just for doing my job, and even for things completely unrelated to me. And let me just clarify that I am extremely hard working, and many coworkers and patients have told me that they enjoy working with/being cared for by me. Its just that there's a special breed of people out there who are a little extra special. There are two issues here, and neither of them is you. The biggest one is the doctor bringing the coffee. Completely inappropriate. The doctor set you up for what is called a simple-assault by giving an aggressive patient a projectile, and walked away. The second problem is that the patients dont dictate their care. You are not there to be directed by them, you are not there to serve them, you are there to offer care as outlined in their care plan or orders, in line with medical protocols. And you arent there to be abused. I have been asked by uncountable abdominal pain patients for food, and when they are denied due to protocol for abdominal pain they go off. And I mean OFF THE WALL, cursing, throwing furniture, screaming... and im suppose to say "okay well if you want the sandwich you can have it but the consequences are yours" with a smile? Nope! We dont facilitate illness.ITS A LIABILITY. They are more than welcome to have those things, but Im not giving it to them. I would say that I would have confronted the physician about her involvement in the incident (right away, not days or weeks later), and document her actions, as well as the patients. You can also write up a physican. And as for the patient, f*** that guy. You dont owe him, and you dont need to feel guilty or rescue him just because he has medical problems. I have seen really sick people get kicked out of the ER for assaultive behavior. People have to be civil to get help. They are not owed unconditional help. The people offering the help and resources are in charge, disrespect gets the boot. And mentally handicapped patients and behavioral patients get treated with behavioral protocol, with all their belongings taken away and rigid limitations on food etc.. to designated meal times. They stay in a designated psych room, with even fewer freedoms with a security nearby. But he's A&O, and capable of making his own decision, so keeping that patient after he threw a fit to get his way only reinforces bad behavior and sets you up for future abuse. Once the IV is out and the paper is signed there is no going back. There is no "Im sorry" after the fact. Thats the arrangement of abusive relationships. I probably come accross as insensitive, but I do have compassion for these people, I understand they are suffering. But that doesnt equate to "they get to swear and torment and assault those that offer help." You can only do your best, and be professional, and thats what you did. You didnt treat him inhumanely. You allowed him to make his own choices, which is humane, respectful and professional. His situation has nothing to do with you, he is mad at the world and you wont be able to fix that, so brush it off and move on. But next time, put a halt on that dr before she really gets you hurt.

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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.

Hi guys. I am still a nursing student now, and I want to know how would you document this after you educate the patient regarding fluid restriction and given him the coffee?

Like: "Pt understood the ramification of extra fluid in his body after I educated him on fluid restriction. I gave him a cup of coffee at 0800."

I am just trying to learn how you document certain situation. Thanks!

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
Hi guys. I am still a nursing student now, and I want to know how would you document this after you educate the patient regarding fluid restriction and given him the coffee?

Like: "Pt understood the ramification of extra fluid in his body after I educated him on fluid restriction. I gave him a cup of coffee at 0800."

I am just trying to learn how you document certain situation. Thanks!

Nope. You cannot say what he understood. You can only say what you did and what he did, using patient-centred language: "Pt was provided with extensive and repeated teaching re necessity of fluid restriction. At 0800 was given coffee at his insistence."

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Specializes in Pediatric Critical Care.
Nope. You cannot say what he understood. You can only say what you did and what he did, using patient-centred language: "Pt was provided with extensive and repeated teaching re necessity of fluid restriction. At 0800 was given coffee at his insistence."

Sometimes you can say "The patient verbalized understanding" (if they did, of course).

If I wanted to be REALLY throughout, I could write something like, "Patient repeatedly asked RN and tech for a cup of coffee. RN discussed with patient that a 1000 ml/day fluid restriction had been ordered and educated patient re: effects of fluid intake on his disease process including the risk of worsening heart and lung function. Patient verbalized understanding and repeated his request for a cup of coffee. 120ml of coffee was provided at this time and MD notified of patient's refusal to comply with fluid restriction. No new orders at this time."

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Specializes in Pediatric Critical Care.
And mentally handicapped patients and behavioral patients get treated with behavioral protocol, with all their belongings taken away and rigid limitations on food etc.. to designated meal times. They stay in a designated psych room, with even fewer freedoms with a security nearby.

Could you clarify, for my own understanding - do you mean to say that mentally disabled patients are treated under the same protocols as behavioral health patients? Belongings taken away, food limits, psych room with security standing by?

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
Sometimes you can say "The patient verbalized understanding" (if they did, of course).

If I wanted to be REALLY throughout, I could write something like, "Patient repeatedly asked RN and tech for a cup of coffee. RN discussed with patient that a 1000 ml/day fluid restriction had been ordered and educated patient re: effects of fluid intake on his disease process including the risk of worsening heart and lung function. Patient verbalized understanding and repeated his request for a cup of coffee. 120ml of coffee was provided at this time and MD notified of patient's refusal to comply with fluid restriction. No new orders at this time."

Great note. But you'd have to lock yourself in a closet and turn your phone off to chart all that without several interruptions.

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Haha! What?? You mean I can't start my note with, "Responded to room upon hearing commotion and profanities coming from room. Pt agitated and states, "______

I choose words carefully, but I confess I'm regularly quite thorough, especially when I think someone might come looking.

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I have worked in psych longer than I care to think about. It has been my experience that A&O x 3 doesn't mean diddly if the patient you are dealing with is a jerk. The fact that the patient in question could switch from having a rational conversation one moment and start throwing a 2 year old tantrum the next suggests to me that he has learned through years of practice that if he starts ranting and raving and throwing things he will get his way. Giving him coffee is just playing into his game.

Some people brought up his "rights". Well, the OP has a right to not be verbally and physically abused. The other patients and their families have the right not to be subjected to this sort of thing or be afraid. Where is the concern for their rights.

This is a classic example of a behavior issue. In the facility I work in there is no way we would reward his bad behavior by giving in to him. Rewarding bad behavior guarantees more bad behavior.

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Hi guys. I am still a nursing student now, and I want to know how would you document this after you educate the patient regarding fluid restriction and given him the coffee?

Like: "Pt understood the ramification of extra fluid in his body after I educated him on fluid restriction. I gave him a cup of coffee at 0800."

I am just trying to learn how you document certain situation. Thanks!

In this situation, I charted everything specific that I remembered him doing, including quoting some curse words in there that were said. I chatted one big long note after he left, with a rough timeline. Like:

0815 called to pt room by charge RN, states he asked her for a drink and then started cursing loudly when told she would check with primary RN. Upon entering room to speak with pt, he politely asked this nurse for cup of coffee. This nurse stated "let me check your chart to see how much fluid you are at as you are on a fluid restriction." Pt then began to curse and yell loudly again, also shoving bedside table forcefully at this nurse. This nurse then left room to return in no more than 5 minutes to allow him to calm down.

0825 returned to pt room. This nurse educated pt that he has already had 400 ml out of his 1000 ml for the day. Pt became agitated, yelling at this nurse, said "you are a f***ing liar, I haven't drank sh*t." He then threw his fork, empty cup, gown, tele box, and wristband across the room and continued to yell and curse directed at this nurse. Charge RN was notified of problem and security was called."

That's something like what I charted in the beginning of my note. I always document some of the things that I can clearly remember them saying (and usually I "censor" the words too, although I know some nurses don't). I think thoroughly, objectively documenting pt behavior like this could help you later if it ever came up again. I also later documented that "pt stated several times 'get me the f*ck out of here", also that he stated he wanted to stay after he got his drinks and what I told him. That way if you have to look back on it in 3 years, you have a pretty clear picture of what happened, and so does anyone else reading it.

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Some people brought up his "rights". Well, the OP has a right to not be verbally and physically abused. The other patients and their families have the right not to be subjected to this sort of thing or be afraid. Where is the concern for their rights.

This is a classic example of a behavior issue. In the facility I work in there is no way we would reward his bad behavior by giving in to him. Rewarding bad behavior guarantees more bad behavior.

Thank you. In all the comments, you are the first I think that has looked at it this way. I understand he has rights as a patient, but what I'm getting from a lot of the other comments is that I don't have a right to leave the situation when I'm being verbally abused. It's like we are expected to bow down to this kind of behavior and accept it as part of our job-well we shouldn't! If he would have calmed down after a few minutes of being alone after I left the room the first time, this would be a whole different story, but he didn't. He was completely calm when speaking on the phone and to the officer. But me and the physician, pct, and charge nurse? No way. The officer saw that behavior too.

Looking back now, I am glad this patient could not ambulate completely independently, or he might have been coming up to the nurses station doing who knows what.

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Specializes in ER.
Nope. You cannot say what he understood. You can only say what you did and what he did, using patient-centred language: "Pt was provided with extensive and repeated teaching re necessity of fluid restriction. At 0800 was given coffee at his insistence."

Be sure to include: 'Pt said "You f-ing b---h, get me coffee right now!". Then pt threw water across the room getting me wet, continuing to use profanity. Charge nurse and Dr Jerk notified. Dr Jerk arrived and brought pt coffee after writing discharge.'

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Specializes in Pediatric Critical Care.
Great note. But you'd have to lock yourself in a closet and turn your phone off to chart all that without several interruptions.

Haha! I was thinking that too! I nearly fell asleep writing it (that explains the typos). I vaguely remember that I meant to say something about how it might be TOO thoroughly charted :lol2:

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