What I Know About: The PITA Patient

**VivaLasViejas**, ASN, RN

I prefer to call them "high-maintenance" patients, actually. But whether you've been a nurse for thirty years or thirty minutes, you probably use the more familiar PITA designation......and you dread it when your assignment includes one or more of them.

Yes, we're talking about the patients everyone loves to hate: The narcissist who seems to think the universe was put together just for his benefit. The lady of the manor who wants everything five minutes ago and cannot fathom how the needs of the patient crashing in the next room could possibly be more important than her wishes.

The call-light abuser whose Q 2 minute requests cause staff to seriously consider a) "accidentally" leaving the device out of his reach or b) strangling him with it. The chronic complainer who whines incessantly, and for whom no amount of care is enough. Ever. My father used to call the latter "the sort who'd (gripe) if he was hung with new rope". And last, but not least, is the manipulator, who draws twisted satisfaction from playing her games: nurses against doctors, staff against family, and staff members against each other.

There are, of course, a number of subtypes of the above. But whatever form they take, high-maintenance patients get a reputation quickly, and even the most compassionate nurse can find herself bargaining with co-workers to get out of caring for them: "Hey, Carol, I'll take your insulin drip, your post-op, AND your first admit if you'll let me unload Mrs. Crank. I don't think I can deal with that time vacuum again today."

So, what I know about high-maintenance patients may fly in the face of the conventional wisdom, which is, generally, to spend as little time with them as possible in order to discourage their behaviors (read: not get sucked into the vortex of their dysfunctional lives). But I'm going to share my helpful hints with you because they're effective, much more often than not........and because we all know that these types of patients aren't going away.

When you start your rounds, don't save your most intense patient for last ...

... go see him/her first.

Investing ten to fifteen minutes in such patients at the very beginning of your shift, actually listening to what they have to say before adding your own input, may quite possibly be the best timesaving intervention of them all. I learned very early in my career that if I spent that crucial time with my 'needy' patients, heard them out, and then fixed what was within my power to fix, the vast majority of them decided I could be trusted, and that helped to decrease their overall anxiety....which went a long way toward less frequent call light use and improved satisfaction with their overall treatment.

Patients under my care also typically experience less discomfort because I make it a priority to medicate them before their pain and anxiety spin out of control. I believe that a great number of so-called 'problem' patients are that way mainly because they are in chronic, intractable pain. A thorough pain assessment early in the nurse-patient relationship is vital to preventing the pain/anxiety/fear cycle that causes so much dissatisfaction with hospital and nursing-home care; then, the nurse must take the responsibility of following up with the patient's primary-care provider, as well as the patient him/herself, to assure that pain is indeed being addressed. Never expect 'the next shift' to fulfill a promise you make to a patient---if you say you're going to do something, DO IT.

Look beyond undesirable behaviors to see the person behind them ...

... and learn to differentiate which of them can be modified and which cannot.

We nurses simply can't afford to judge our patients; they've lived entirely different lives from our own, and had entirely different experiences that we know nothing about. One patient may have been in an MVA which wrecked his back and neck so badly that he's suffered chronic pain 24/7 for forty years; who WOULDN'T be a bit crabby? Another may have had a traumatic hospital stay as a child; what human being is at her best when she's scared out of her wits?

And yes, there are people who have been mean and nasty their whole lives, and now that their health is failing, they're mad at the world and everyone in it. We can't fix that. All we can do is treat them as respectfully as we do our more likeable patients, and remember not to take their barbs and their curses personally; that way, we get through the day and go home with a clear conscience.

Kill 'em with kindness

A couple of days ago, I was assigned to the subacute wing of my new facility, where there is one room with two ladies who, according to every staff member who's cared for them, are notorious time vacuums. They feed off each other when they're not fighting, but while the lady next to the window is rather quiet and shy, the lady in the bed by the door is known to curse, scream, punch, and throw things at the staff; she is also an infamous manipulator who tells stories on the staff members she doesn't like---which is most of them---to try to get them in trouble for "abusing" her.

So, I did what I normally do---listened to report, steeled myself to NOT pre-judge this patient, and went in to see her first. The woman promptly launched into a litany of complaints about everything from the food to the CNAs to the facility administrator, punctuating her rapid-fire monologue with a number of unflattering (and profane) observations. It wasn't long, however, before I figured out what her two main issues were: she didn't like being treated with what she felt was a lack of respect on the part of her caregivers, and "those pain pills they give me, they're the same ones they give to addicts to get 'em off the heroin, and they don't do me no good whatsoever!"

I listened as she recounted for me the auto accident she'd been in way back in 1965 that left her back permanently curved and her range of motion severely limited. She also told me about all the meds and therapies she'd tried over the years, none of which in themselves or even together would be adequate for the kind of chronic nerve pain she has. "And that thing they lift me with," she continued, pointing to the sit-to-stand machine in the corner of the room, "makes me lift both arms straight up, and I can't do that without hurting so bad I can't stand it---my hands are too weak to hold on, and my shoulders are frozen. Why can't they use that other machine I've seen 'em use?"

Long story short: I had the aides use the Hoyer lift the next time they moved her, asked them to address her with respect and reposition her with great care so as not to hurt her, and got MD orders to change her pain med regimen. I listened to her. I medicated her. I answered her call light personally. And by the end of the shift, she was cooperative with care and saying "Thank you" to everyone, instead of calling them foul names. She also informed me that she'd had a phone conference with her daughter just before bedtime, and that they both had decided that they liked me.....a lot.

Well, I don't live and die by the opinions of my patients, but I can't help feeling good about what I do for a living when those small victories change their lives for the better.......if only for one shift.

So, the next time your work assignment contains a high-maintenance patient or two, just take those few precious minutes to listen to what they say---verbally and otherwise---and validate them. Tell them that you'll fix whatever is within your capacity to fix. Never make promises you aren't 100% sure you'll be able to keep, but if you do make a promise, get it done even if it costs you something. And above all, treat every patient you care for as you yourself would like to be treated.....someday, it could be your loved one, or even you lying in that bed, unable to take care of even the most basic tasks without assistance.

Good luck.....and if you find this information useful, pay it forward. ?

What I Know About: The PITA Patient

When you start your rounds, don't save your most intense patient for last ...

Look beyond undesirable behaviors to see the person behind them ...

Kill 'em with kindness

About VivaLasViejas, ASN, RN

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