Care of the Difficult Patient

A Nurse's Guide

Peter Manos, Joan Braun

• Publisher: Routledge
• Year: 2007
• Print ISBN:
  9780415358248
• eBook ISBN:
  9781134245598
• Topic: Medicine
• Subtopic: Health Care Delivery

Developed collaboratively by a doctor and nurse team, this is the first text to deal specifically with nursing difficult patients. Whether patient problems stem from mental distress and ill health, historic substance abuse, demanding family members or abusive behaviour, difficult patients place extra demands on nurses both professionally and personally. Caring for difficult patients requires both technical and interpersonal skills along with an ability to exercise power and set limits.

This text presents invaluable practical recommendations and advice, well founded in experience and supported by relevant literature, for nurses coping with challenging, real world situations. Including learning points, further reading, case studies and dialogue examples to highlight good (and bad) practice, the book covers pertinent issues such as psychiatric diagnoses, setting limits and establishing authority, death and dying, stress and work. It is ideal for pre- and post-registration nurses, providing concrete direction on the management of difficult patients.

Chapter 1

Mental status assessment

Pam Green, R.N., works on an oncology unit, having graduated from nursing school a year and a half ago. Her new patient, Mr. Allen Johnson, a high school English teacher who worked until a week prior to admission, has just been admitted for chemotherapy of his newly diagnosed, inoperable pancreatic cancer. He is terse, formal, and remote. His wife provides Pam with most of the intake history.

The next day he has not gotten up to eat breakfast. Pam enters the room.

“Good morning, Mr. Johnson.”

Initially lying on his left side facing the door, he turns away from her and pulls the covers over his head.

“Mr. Johnson, may I help you with something?”

“No, I’m fine.”

“You didn’t eat any breakfast.”

“I’m fine.”

“I’d just like to get your blood pressure and temperature.”

Earlier he had refused to let the nursing assistant get his vital signs. Now, reluctantly, he allows it.

“Try to have some breakfast, Mr. Johnson.”

Sadly recalling the association between pancreatic cancer and depression, she leaves the room, intending to return shortly.

Later, the blanket removed from his head, Mr. Johnson is picking at the sheets and grimacing.

“Mr. Johnson, what’s wrong?”

“Don’t give me that innocent bullshit. You know what’s wrong, alright.”

“Are you in pain?”

“Don’t come near me, do you understand?”

Because she doesn’t know what’s going on, Pam is unsure what to do next, but she heeds the fear she feels and does not approach any closer.

“I’m going to get some morphine. I’ll be right back.”

At the narcotics cart, she sees her respected colleague, Susan Eiman, R.N., and explains her consternation.

“I don’t know how much morphine to give. He had a lot last night but I think he wants more.”

“Did you examine him?” asks Susan.

“He won’t let me.”

“What does he tell you?”

“Not much.”

On Susan’s recommendation, they look at the night shift nursing notes. Mr. Johnson was quiet most of the night but he’s also described as “forgetful”. He had a low-grade fever. Together they return to his room. Just inside the doorway, Susan stops.

“Mr. Johnson, my name is Susan. I’m a nurse here at City Hospital. I’m coming in for a minute to talk.”

She then slowly walks around the bed to face the patient, pulls up a chair four feet away from him, and sits down. The sheets and blankets are twisted and in disarray. There is a urine stain on the sheet. She says nothing for a whole minute, which feels like ten minutes to Pam. Finally Susan speaks.

“What’s on your mind, Mr. Johnson?”

“Leave me alone.”

“You’re in the hospital and we’re your nurses here. We want to help you. Please tell us what’s bothering you.”

No response.

“Mr. Johnson, please tell us what’s bothering you.”

No response.

“Did anything unusual or frightening happen last night?”

“Just the wedding. How can you so-called nurses have a wedding when there are people dying in here?”

After they leave the room, Susan explains that Mr. Johnson is delirious and gets an order for some IV haloperidol. She withholds the opioids that might have been contributing to the delirium, and calls the intern to express concern that the patient’s fever might be due to pneumonia or a urinary tract infection and which also might be contributing to the delirium.

Susan Eiman, R.N., an expert clinician, suspects from the onset that this is not a case of depression or anger. Checking the night notes she finds that the patient is described as “forgetful”. She persists in asking questions, even when put off by the patient. The patient responds strangely. His judgment appears impaired. He finally expresses his delusions and hallucinations about the nurses having a wedding outside his room. Aided by her experience, Ms. Eiman has assessed his mental status, though she did not follow a fixed set of questions to do so. Because she is a nurse, just sitting at the bedside and looking at the patient, she is doing an assessment. She might not even be able to voice all the elements of her observations. In this chapter, we offer you an outline of a mental status examination, and some specific questions that you may find useful.

Parts of a mental status examination

Evaluation of any problematic behavior demands at least some attempt to assess the patient’s mental status. A mnemonic will help you recall the outline of a mental status examination that can help you organize your thinking: A Beast Prom (or A Beast Romp, if you like) (Table 1).

Table 1 A mnemonic for the parts of a mental status examination

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Appearance

Behavior

Emotion (mood)

Affect

Speech

Thoughts (delusional, suicidal, homicidal, violent)

Perception (hallucinations)

Reasoning (including judgment and insight)

Orientation

Memory

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Appearance

Facial expression may be tense, worried, sad, happy, sneering, ecstatic, pained, angry, laughing, suspicious.

You may wish to describe appearance only at your initial evaluation or if a change occurs. Note unique facial features, tattoos, jewelry, body piercing, grooming, hygiene, posture, and the presence of IV lines, drains, catheters, monitors, bandages, and restraints.

Appearance may give diagnostic clues:¹ poor fingernail hygiene is often associated with dementia because demented patients overlook grooming. An excessive display of masculine symbols may give clues to the diagnosis of antisocial personality disorder: heavy chains, a knife worn on the belt, the tattoo “born to lose” on the deltoid or “H A T E” on the knuckles of one hand, “L O V E” on the knuckles of the other, a heavy belt buckle, and so forth.

Although generally part of the physical examination, you should consider pupil size as part of your evaluation. Opioid intoxication is often associated with small pupils but pupils tend to become smaller as people age (Buckley et al. 1987; Pickworth et al. 1989; Hennelly et al. 1998).

Anxiety is often associated with large pupils (Lader 1983). In the general hospital though, interpretation of pupillary size is complicated because other medications may affect them. Recall, too, that people’s pupillary size diminishes with age.

Behavior

Is the patient drowsy, alert, restless, agitated?

Agitation is purposeless motor activity: pacing, picking at the air or at bedclothes and sheets, constantly shifting position in bed, or repeatedly sitting and then standing. It is usually associated with anxiety, that is, fear without an object of fear. Agitation is worrisome. It should be documented and evaluated. Agitation may be caused by anger, fear, delirium, pain, and physiological deterioration – new fever, new pneumonia, new hemorrhage, etc. Is the patient experiencing drug withdrawal? Is the patient experiencing an acute dystonia or other extrapyramidal side effects such as akathisia?² (Ferrando and Eisendrath 1991).

On the other hand, the patient may simply lie in bed, unmoving, minimally responsive. It is commonly assumed that such a patient is depressed; consider, however, over-sedation, pain, nausea, dyspnea, delirium, hypotension, electrolyte imbalance, etc.

The following adjectives also describe behavior: irritable, sullen, resentful, indifferent, friendly, dramatic, impulsive, evasive, cooperative, flirtatious, etc. Strong descriptions, however, cannot depend on adjectives. Verbs and nouns are more precise and better understood. A brief, concrete, written description of your patient’s behavior may be helpful to the entire staff. “Ate all her breakfast. Slept well. Up and about without difficulty. Talked on the phone and laughed.” If the patient is concurrently complaining of intolerable pain, something is amiss.

A drug-seeking patient may complain of pain at level 10 on a 10 level rating scale. By all means document the complaint but add, if you observe it, that the patient was also cheerfully talking on the phone, going out for a smoke, etc.

Although it might not be considered behavior per se, muscle tone and movements should be noted – for example, myoclonic jerks may be caused by meperidine toxicity (Lauterbach 1999).

Emotion – mood and affect

Mood refers to enduring emotional state. Affect refers to the observable expression of feeling or emotion (Serby 2003). Affect may be fleeting, registered at the time by the patient’s tone of voice, facial expression, motor activity, and speech. In a sense mood is to affect as climate is to weather. The summer climate (mood) in Cherokee, Iowa is hot and humid but the weather (affect) on this particular summer day is cool and cloudy. Mrs. Johnson is generally in good spirits (emotional climate) but today is nervous (emotional weather) about the results of her husband’s test. A person may be suicidally depressed (mood) yet appear cheerful (affect).

You may ask a patient, “How are your spirits?” “How’s your mood?” “How are you feeling?” These all assess mood. Of course, the patient may not wish to “complain”. A patient may be “down”, or “blue” or “not so good”, phrases which may indicate depression, anxiety, anger, or guilt.

Since you don’t really know what these phrases mean to the patient you might wish to ask an open-ended question, i.e., a question which doesn’t lead to a specific kind of answer. “Could you tell me more about it?” is an open-ended question, as is, “Is there anything else?” Close-ended questions begin to narrow the range of inquiry and possible responses. For example, “Are you worried?” “What are you worried about?”

Illness is often depressing and many ill patients are depressed (Goodwin et al. 2003). The word depression in this context may simply mean an unpleasant mood, a feeling of dejection or listlessness, which will resolve in a few days or weeks when the situation improves and which needs no treatment per se, except for the skillful, empathic attention of nurse and doctor. If a depressed mood lasts for weeks, is relatively persistent during the day, and if the hospitalized patient has lost interest in people, feels guilty, cries frequently or has thoughts of suicide, depression may be more serious (Cavanaugh et al. 1983).

How do you assess the seriousness of a patient’s depression? Part of this is intuition on your part, of course, but there may be signs that further questioning is necessary. The seriously depressed patient may keep the shades drawn, interacting minimally with you or with visitors. You will want to know how the patient is feeling and you can start with the questions above.

A depressed elderly man with a history of alcoholism was hospitalized for the treatment of lung cancer. Throughout his hospitalization, he asked for help for pain and insomnia. One morning he was found in bed, the plastic garbage can liner over his head. He had taken his accumulated stash of opioids and sleeping pills and committed suicide. No one, including his family, had understood the depth of his anguish. Probably no one had asked.

Are you concerned that asking these questions will “put ideas” into your patient’s head, increasing the risk of suicide? Everyone knows what suicide is, and it is unlikely that your questions will increase the risk in a particular patient. The greater worry is that by not assessing suicide risk, the danger in a particular patient will be overlooked.

A stoic 60-year-old man with multiple myeloma, and multiple spinal compression fractures appears depressed. His nurse asks him about suicidal thoughts. He admits that when he’s in a lot of pain, he wants to die, but that when the pain is controlled, he wants to live. He says he’d never commit suicide. He has no history of depression and no family history. His nurse arranges for better pain control. He does not need suicidal precautions.

Suffering due to pain, nausea, dyspnea, fatigue, or fear may become intolerable even for the most stable and resolute of us. Strange as it may sound, the thought that suicide may be available as an escape can provide some psychological relief, even hope. In this book we are not addressing the ethical arguments for or against suicide, assisted or otherwise. We are simply reminding you that suicidal thoughts do not in and of themselves demand an immediate response from you. Suicidal plans, however, do.

Suppose the patient says he’s depressed and you’re worried. You ask the patient to tell you about it. You ask the patient what else is on his mind, etc. Now let’s say you are more worried.

Consider asking in order the following set of questions to assess the possibility of suicide:

• “Do you ever feel so bad that life doesn’t seem worth living?”
• “Have you considered taking your own life?”
• “Have you thought about how you might do this?”
• “Do you have the means to do this?”
• “Have you thought about where you might do this?”
• “Have you thought about when you might do this?”

If a patient has more than vague, fleeting wishes of death – which many people have when they have severe pain, malaise, nausea, and the li...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of tables and figure
• Acknowledgments
• Introduction
• Chapter 1: Mental status assessment
• Chapter 2: Substance abuse
• Chapter 3: Delirium
• Chapter 4: Psychiatric diagnoses
• Chapter 5: Setting limits
• Chapter 6: The nurse’s authority
• Chapter 7: Manipulation, clinging, sexual provocation, anger, and violence – the feelings they evoke and the interventions they may require
• Chapter 8: The ethics of limit setting
• Chapter 9: Families
• Chapter 10: Communicating with doctors – the difficult and the easy
• Chapter 11: The nurse and the dying patient
• Chapter 12: Nurses and stress
• Chapter 13: Getting psychiatric consultation
• Notes