3 Toxic Patient Scenarios-Study Tips

Three Examples of a Toxic Patient- Nursing Study Tips.com Study Guide
[Use this section as a discussion guide. Consider and argue how it would be best from a nursing point of view to handle the following cases. Support your case with guidelines, advice from nursing hotlines, or hospital or facility policy manuals. ] Real examples of a “toxic patient’ follow.
(a)In a major metropolitan county hospital, one ward included a patient who yelled in the early morning hours about his transportation. Although it was only 2 or 3 a.m. in the morning, the patient got into his wheelchair and sat in the doorway of his room, bellowing about how the nurses needed to call the doctor’s office for the car to come and get him. His howling distracted nurses and completely disturbed any peace of mind for any resident for 500 yards in any direction.
In all of these circumstances, consistent reporting to the physician, explicitly detailed note taking habits, and attentive observation could have prevented anxiety and stress to all parties concerned. But some shift nurses didn’t bother to take the time to document correctly the times and frequency of the incidents. Many other patients complained but were discouraged by nurses uninterested in documenting problems with their part of the hospital. Escalating the matter to senior administrators might have cut down on the amount of total time this patient caused stress and anxiety to staff and patients around him.
Study Questions for Toxic patient Example A: Nursing Study Tips.com
(1) Should the Director of Nursing have forwarded this case to the resident psychiatrist?
(2) Should one of the nurses have called the whistleblower hotline for the Ombudsman?
(3) Why wasn‘t the patient shifted to the floor of the hospital specifically for Psychiatric patients?

(b) In another scenario, a male patient over eighty years of age was admitted to the nursing home by his family members after a brief hospitalization. He was documented as having entered the rooms of other female patients in the nursing home and acting in a socially unacceptable way. Despite his frequent habit of wandering all around for years, the staff of the facility grew used to him being up dressed and out of his room, unsupervised, at all hours. They simply grew too used to his walking back and forth and stopped keeping track of him.
One day the patient simply wandered out the front door to the street, and down the sidewalk. By the time a nurse noticed he was missing, the four nurses he had walked by couldn’t even remember what he had been wearing to describe to police. The security guard set by the door had been fired to cut costs. The housekeeping staffer they had appointed for that position had been called away to clean a shower upstairs. The long term care facility (nursing home) was on the hook for the incident. The nurse who was scheduled to be supervisor on duty was made redundant (fired), for cause.
Even though the nurse was busy doing ten other things at the time, and the situation was completely normal, institutional responsibility was suffering. Technically the nurse was at fault for failing to direct other staff to prevent this calamity. The nurse should have told others under her supervision to watch the person, follow him, or secure the door. Even though the facility had allowed the situation to deteriorate to a point where the nurses were no longer vigilant, the nurse on duty that day was termed responsible.
If the nurses previous to this incident had completed their shift with documented letters to their supervisors, or copied the Director of Nurses on their notes reporting such incidents, the ongoing risk would have been noted and set into the patient resident care plan. Except that high turnover allowed even veteran nurses to forget the poignancy of such a risk and go about their other business as if it were no longer their problem to watch this man and where he went. The Certified Nursing Assistants blamed the nurses for not reminding them. The nurses were blamed for not reviewing (and updating) the situation in the licensed nurse progress notes.
Study Questions for Toxic Patient Example B:
(1) was the nurse to blame or the nursing supervisor for the shift?
(2) Should the nurse (or the housekeeping employee turned security watcher) have been fired instead?
(3) Does the nurse who was fired have a case with the State Nursing Board to have the case reviewed for Unfair/Illegal Termination Without Cause?
Toxic Patient Scenario C – Nursing Study Tips.com
At a nursing home several nurses have been alternately assigned to “Jane Marx”, a patient who has a lot of complaints and irritations. “Jane Marx’ has gotten a bad rap from the newer nurses, while the nurses who have been employed a longer period of time have a much better grasp of the patient’s individual maladies. The older nurses know, for example, that the patient’s health had changed and that the patient had gone through a lot of painful operations and suffered through many unforeseen difficulties.
But ‘Jane Marx’ has a habit of putting complaints in writing to the facility administrator about problems that crop up. One of the problems she talks about is that one of the nurse consistency sleeps on the job, and watches TV and surfs the Internet watching Youtube. This nurse is older, and should know better. Other nurses have been fired for using their cellphones and none of the female nurses ever sit on the desk watching TV. ‘Jane Marx” was the patient who reported them. The current Director of Nurses has never lectured the sleeping nurse or cut his hours.
Recent staff shortages make the nurses recall other employees who quit recently. The staff discuss a very good nurse who left the facility months earlier, who got lectured by the Director of Nurses for being constantly late. Yet this male nurse gets to arrive late and wind the clock down doing nothing to ‘make up his time.” “Jane Marx “ has observed the elder male nurse staying late at night, while working nurses were busy, ‘to make up his time on the clock”. No other employee simply gets to arrive late, ‘Jane Marx” maintains, and stay after, doing nothing past their scheduled time in lieu of real work during their earlier scheduled time.
The nurses learn that ‘Jane Marx” has been raising the topic of the sleeping nurse in her care plan meetings. She has been consistently catching this nurse napping at night at the desk. No other employees of the facility ever sleep on the job. “Jane Marx” has been told that some of her treatment options are too time-consuming to pursue. Every night that “Jane Marx” comes out and find a nurse asleep, or twiddling his thumbs to “make up his time”, she argues there is time for her treatments and that the facility is not organizing its staff resources properly.
But “Jane Marx” argues that as long as nurses can “hang around watching TV” there should be enough staff to get the extra stuff done. The nurse in question often drifts around nibbling snacks and reading, waiting for the clock to wind down. Many employees dismiss the complaints of “Jane Marx’ on this topic due to her other many complaints. The day the Department of Health came around, asking questions, many nurses were startled. The agency was taking note of all this patient’s reported sightings of the sleeping nurse. The nursing home was cited and fined.
Study Questions for Example C, Toxic patients, Nursing Study Tips.com
1. Why Couldn’t Peer Pressure have kept the nurse from sleeping on the job?
2. What steps should the Director of Nursing have taken to prevent this situation from happening?

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Nurse Training Tips

Nurses need to be trained how to treat patients and fulfill all their needs Nurses cannot pick and chose which chores they need to do on which patient nor do they get to arrange their timeframe that suit them best. Often a case load of staff nurse means that the patient will be juggling various jobs or needy patients they like. There is much more to nursing than giving shots or checking histories, and nurse must be ready at all times to perform all needed nursing tasks to as many patients as are required. The reality is that in medical institutions situations exist with multiple charge patient realities.
Nurses are involved in physical administration of medicines, nursing bedridden patients, charting and file administrations. his involves witnesses pharmaceutical tracking, supply ordering, LVN communication,  as well as  medicines, review of patient symptoms, and room administration. Conflicts may come up, paperwork confusions, and records administration problems that nurse must deal with and treat patents all the while. May nurses grow accustomed in training to addressing single charge situations. But in reality, medical institutions
Nursing involves all facets of the patient experience and as well as performing history and readings resolutions. The paperwork responsibilities, reporting of charting, and intaking new patients at the same time can overflow within timed shifts more often than not.
Nurses who are not well trained to perform these duties will find themselves putting in extra unpaid hours keeping up. it is not unusual to see charge nurses working unpaid overtime completing records, updating charts, and finishing up with patients. Many institutions running on thin budgets will discharge nurses after a census, and nurses must complete their shift charting and other communication and patient treatment responsibilities on their own honor.
They may be reassigned to other wards or areas as needed. There will be slow days and there will fast days, but nurses are responsible for treating all patients at the highest level of care no matter what their time limitations are. The time sensitivity of all duties a nurse performs means they must be completed whether time permits or not. Therefore a nurse must involve themselves with each patient outside the minimums of ward responsibility to make sure adequate care is administrated.
For example, in a clinical care situation in training, a nurse might have to alter the setting on a EKG machine or test out various pharmaceutical applications on a patient to achieve the best result for lowered blood pressure.  But the time and physical availability for results and communications in real time versus training environment may not match the situation in reality. Phones do not ring on the ward training, another nurse needing help, or a new admission coming onto the scene may distract a nurse.
In training, a nurse does have to deal with the  professional responsibilities and commitments. Outside training the career comes to the fore. Outside training a nurse will be assessed at all times for professional advancement and adequacy.Nurse who take too long over rote task like takin vitals get a reputations for being “spacy”, not very good at time management, and get complaints from patients about lack of communications and poor medical skills.
The nurse must support requests from the team and the charge nurse no matter how many requirements their charges have currently running. The nursing team will often offer additional training for things like vein location for putting in a line, or even best placement of equipment for taking vitals. But past a certain point poor training becomes evident and staff will officially take note a nurse is incompetent or unhelpful handling multiple charges.
Nursing students have a training experience that is of simple academic cases of ongoing treatment cases. But in reality, medical care plans are much more complex. Handling people is involved. Patients may be resistant to treatment or not observant of dietary restrictions or rest orders as given by the physician. Nurses without good people skills, nurse swith no experience dealing with patients, and nurses without a complete understanding of the pathology involved will offer career damage unless they absorb the training required.
Nurses on the job often give qualified objections because they have not had a chance to speak with the doctor before issuing pain or treatment medications to a patient they have never seen before. Patients are likewise alarmed they are not seen or given a consultation before a dosage regiment is instituted.
Nurses in this instance carry more responsibility to review both the patient set of criteria and the possible side effects of a drug versus the entire set of pharmaceuticals being introduced to the patent’s bloodstream. Often a nurse can spot a contraindication before anyone else, and the thrust is upon them to do so. Nurses must also counsel the patient and asses them psychologically at all times.
When shifts change, nurses must convey the most timely changes in patient assessment to the next charge nurse. These must be done in accurate medical terminology in a transparent style.If nurses on the next shift have poor training and fuzzy communication skills, the primary nurse’s best contribution is the maximum value to the patient ad the medical caregiver. The nurse’s clarity of thought, mission to deliver the best nursing possible, and the motivation to promote healing can transform the most basic training into a sterling bonus advantage for the patient.
Nurses must assess patients in an ongoing manner. Is the patient a physical threat to themselves or others? Is the effect of any change or restriction in medication or privileges affecting them negatively? Are they speaking to themselves or others in a manner that shows a change in self esteem or motivation to heal? These observations are important and training in them will take place over the course of a nursing career.
Some patients may create incidences of panic disorder and need to be housed a negative ion chamber. They may try to not take their medication, create obstacles to treatment, or become even more ill. Student nurse skills must adapt and grow to meet the situation. Academic training will not train a nurse to speak to a patient in crisis.
It is hard to train a nurse for the variety of challenges and issues that come up for their patients in this kind of scenario. Occasionally physicians will be flexible and changes to the individual care plan will be made. It is vital to the medical outcome that these circumstances be communicated to the next nurses and on-call physicians. Being able to perform simple tasks like recording dosages and medical administration while balancing management of multiple patients can get tricky.But adequately trained nurses will meet and surpass their challenges to succeed and shine.
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A Day in the Life of a Professional Nurse

The pace of a day in the nursing profession can be hard to get used to. Thinking about nursing skills and remembering important information isn’t enough. Nurses need to update their knowledge of each patient’s chart, comprehend endorsements from the earlier shift, hand off important duties to qualified staff such as supervisors, certified nursing assistants and licensed vocational nurses. Case management responsibilities may fall to a desk nurse, but the medication nurse must serve as a conduit of patient wishes and advocates for patient care.
The pace of the shift takes its cue from the total number of patients the nurse is responsible for, and the frequency of calls to the bedside from each patient. If the patient needs accelerate and the number of calls spike, it is appropriate to notify the nursing supervisor or the Director of Nurses to staff accordingly. Specific chores such as giving IV medications, assessing new intake admission patients, recording vitals for special needs patients, and delivering special treatments such as dialysis and/or oxygen administration can fill a shift before you know it. (And then there is still the charting to do).
As in every job, timing in and out is important to maintain the integrity of the facility’s nursing acuity. Oversight agencies evaluate the timekeeping rolls to derive the accurate account of the nurses assigned at any one time. A nurse who regularly arrives late or misses an entire day of work creates a practical problem that may take hours to solve. In the case that no other staff are available, other nursing staff may have to increase their workload and absorb that nurse’s patient assignments and duties. This can have a negative effect on patient care and reduce the allotted time each nurse can regularly spend with their patients. Patients will notice and feel passed over or that their case has been “rushed”.
Timekeeping is an essential but irksome chore for every professional nurse. Arriving to work on a timely basis and staying after when needed are invaluable qualities in a career nurse. Flexibility in scheduling makes any nurse a prize who is very attractive in a competitive hiring market. Nurses who arrive constantly on time will be given priority and also will get preferred responses to requested time off. Nurse who regularly call in sick or miss work, for any reason, will find themselves short hours or written off the schedule altogether.
Nursing is not always just about medication or vital statistics. The term “bedside manner” is a joke in some circles, but a very real and desired trait in professional nurses. Each patient needs to feel as if their needs are being met. Positive statements, cheerful questions, and small jokes can brighten up a patient’s day. Nurses can easily underestimate how the smallest word or gesture can seemed magnified to a patient with little outside or family contact. This directly affects the quality of care offered by the hospital or facility. During surveys and in feedback sessions, patients often remark on these issues. Positive feedback, online or via word of mouth, is crucial to any organization today.
Patients prefer to rely on key staff and feel better when the routine of their day is supported. The welfare of the patients is the priority of the nursing supervisor. New staff should maintain the behavior and tone of the other nurses. Otherwise, patients can feel estranged. A proper evaluation of the nursing staff should be their flexibility to medicate and treat each patient in the facility, not just the “chosen few”. (And charting must be consistent as well). Puzzling out idiosyncrasies is not a skill every nursing manager has. An hiring institution bringing new nurses on board expects a concordance to facility norms. To do this cheerfully and in a consistent manner is what every nursing home, private patient, or hospital wants.
Encouragement of activities and interventions according to the care plans in the patient’s charts will help the patient feel supported and well cared for. This kind of goal can help patients handle pain, lessen anxiety, and improve their ability to communicate ills and problems some patients might otherwise feel embarrassed or discouraged from sharing. The duty of care falls to the institution and its staff to observe the entire range of symptoms and conditions noted for that patient, as well as known contraindications and/or medical risks.
If a clinical condition becomes exacerbated, the nurse must be able to note increases in pain, swelling, blood pressure, blood sugar, nervousness sleeplessness, and general well-being, all from exchanging a few words with the patient a few times a day. The investment of a few jokes or special inquiries about personal interest or hobbies can pay off in certitude that a patient can rely on the nurse to note variations in their condition.

Some hospitals and nursing facilities have incentive programs for cross-checking symptoms
The manifestation of certain symptoms can be easily missed unless the nurse has established a rapport with the patient. A nursing supervisor often looks to key nurses who can be trusted to “handle” patients who have special interventions indicated in their care plan. Patients need guidance and instruction how to do things good for their conditions. Even if the nurse thinks the patients already know, reminders keep the patient focused on best habits for their own health.
Nurse should encourage patients on how to best elevate legs, attend community activities, perform approved exercises, work well with therapy professionals and stretch their muscles. Some patients may get in a “rut“ and need to motivate themselves towards physical therapy. But some patients just droop and drift into a pattern of inaction. The pattern of interaction should not be allowed to fall static. Just asking a patient what they are watching on television or what they are reading can bolster a patient’s attitude.
Regular familiarity with the patient, good understanding of their conditions and medications, a working knowledge of how to relate verbally to the patient and make them feel at ease, and an ability to confront your own fears and deal with people in a respectful manner that meets their expectations of an institution are all the traits of a successful modern vocational nurse. It is each nursing student’s responsibility to evaluate their own strengths and weaknesses, and to critique themselves and their peers for the benefit of all.

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Dealing With the “Toxic Patient”

New nurses just out of nursing school can be somewhat shocked by the challenges presented by “problem children” in the patient census. While every patient may have the expectation of the full range of services and care a nursing home or hospital provides, some patients do overtax the staff to an unusual degree. It is the facility’s choice whether or not to continue offering care to these patients. But nurses should not ignore symptoms and condition risks, no matter what hullabaloo the patient causes.
What is meant by the “Toxic Patient?”
The “toxic patient” is patient who experiences limited medical problems but exhibits uncontrolled outbursts, exaggerated symptoms, and conducts themselves in an annoying and distracting manner much too much of the time. They can make life miserable for other patients, room mates, visitors, and staff at every level. If one or more exist in any floor or ward, chaos can ensure at any moment in any shift. Important charting, endorsement reporting, or assessment activities can be interrupted. Nurses and CNA workers can start to call in sick to avoid shifts that have become too much work to handle.
The Burden of a “Toxic Patient” on a Hospital or Facility
The burden of a ‘toxic patient” can creep up. Dementia can play a role. If the patient’s aim to is to disrupt or annoy, they may simply escalate behavior on an ongoing basis. Finding out just when the patient will go too far is an ugly surprise. Tension and irritation can build. Nursing supervisors may acknowledge the problem, but depend on a full shift of nurses to cope. Then, nurses start calling in sick at the last moment, and the nurses that do report for work have their hands full. Administrators can experience headaches when the housekeeping staff, nursing staff, and dietary staff start stressing out and run in circles trying to please the “toxic patient”.
Facility Requirements for Toxic Patients
Such patients can require a hospital to engage additional staff just for that one patient. Monitoring one patient is not a cost-effective way to staff a hospital or nursing home, and these costs invariably end up as part of the overall assessment for the care plan of that patient. if no improvement is within view, and no intervention will work, a stalemate occurs between the duty of care and the real-time potential of the facility. Their duty of care commits them to deliver ongoing environmental nursing care, but the pushback from nurses and patients create s a firestorm.
Student nursing textbooks cannot illustrate the challenge of a dealing with a “toxic patient” while balancing the needs of an entire floor or ward of other patients, as well as dealing with the pharmacy, running IV lines, performing dialysis, charting nursing progress notes, and tracking medicine counts. “Toxic patients” have little to no curb on their behavior, choose consistently to break accepted facility or social barriers, and insistently pester nurses and other persons within the hospital or nursing home. Such a patient is completely beyond a home health situation. The patient community of a facility or hospital can be altered negatively just by inclusion of the “toxic patient” in group patient activities.
The “toxic patient” also disrupts the well-being of other patients. On this basis, they become a liability of any facility, because they stretch the resources at any given time constantly enough to cheat other patients of their allotted times with nurses or staff. generally speaking, a “toxic patient” can absorb 9/10 of a nurse’s spare time per shift. And when this demand overlaps the allotted time for any other patient, this “toxic” individual becomes liability to other patients as well. On this basis, patients can be liable for discharge or transfer if they become too irksome a burden to staff and other patients.
The “toxic patient” is one who refuses to heed warnings or “hints’ from the institutional staff. Such behavior is charted and discussed in the care plan meetings. Often a nursing home or long term care facility will meet with the patient, guardian, family or conservator to discuss such behavioral problems, often a psychiatric consult is advised. Yet the family or the conservator of this patient may refuse this. The social stigma maybe overwhelming for the family, and the impress upon physicians to limit psychiatric intervention may weigh heavily. The times leading up to any resolution are seriously taxing for any nurse. There is only so much a place can “suck up’.
But often, even when a patient has a long history of transgressing beyond patient norms, neither medication nor physical restraints are present or advised. Either the family members are in denial, or the physician does not have an accurate assessment of the case. It is important to complete incident reports and contact supervisors when such behavior occurs. Furthermore, sometimes a nurse may have to decide for themselves when it is a good time to call the physician (or social worker) and advise him of the seriousness of the patient’s aberrant behavior.

Circumstances will arise in which a nurse or nurses will look back and wish very much that they had used all their observational skills and cited occurrences involving the “toxic patient”.

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Welcome to Nursing Study Tips.com

Welcome to Nursing Study Tips.com!

Transforming a Nursing education into on-the-job professional nurse training
Nursing students often fail to make the connection between practical nursing performance and the run-up to a job nursing from the education emphasis on book-learning. New nursing employees often grapple with learning the pace and combination of skills needed to get through the day. Multi-tasking takes on new meaning, as nurses are expected to juggle answering phones, charting patient progress, doing rounds, performing needed bedside services, and dealing with physicians and family members. Not to mention the idiosyncratic needs of the patients themselves.


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