Thought I would ask my fellow experienced ED nurses about good tricks both medical and nursing when dealing with patients who have complex psychiatric/intellectual/social issues that occasionally overlap with obvious behavioural problems. I exhausted all my usual techniques tonight and was wondering if the smart AN people could give me some ideas. We have all dealt with this kind of patient at one time or another.
Nightmare pt.-no fixed abode, intellectually impaired with an IQ tested around 50. Profound prejudicial childhood, foster care, emotional and protracted physical abuse both from parents and foster carers. Very sad. Diagnosed with ADHD, BPD. Mother with significant substance abuse problems. Pt. will get drunk, overdose on paracetamol (LOTS) and present, generally requiring NAC infusion. Presentations escalating and largely behavioural. Given our duty of care and pts' limited capacity to understand the more complex consequences of his actions was recently reluctantly admitted under mental health briefly given potential for significant risk of self harm, unfortunately re-enforcing his behaviour. Presentations continue on essentially a second-daily basis.
The patient plays the usual games. Attention seeking, absconding, lying, manipulating. Shift started when he was on his 16 hour bag and he kept fidgeting with his IV to make the machine alarm, after doing several other things to try and get my attention (has terrible access). I usually do one of two things with patients who play games, I either do everything they ask and give them nowhere to go, or shut them down completely. Unfortunately what he wanted were things that I couldn't do which I highly suspected he knew. I turned his drip off. He cracked the you know whats because he couldn't play with me and absconded, twice. We know he is pushing for admission and that his suicidal ideation is chronic and largely unlikely but he batters his poor body. I made the suggestion about addressing his behaviour with mechanical restraints which was met with the usual obstruction but we don't do it often enough in my opinion. There just aren't any negative consequences to anything he is doing (that he can rationalise). Years ago we had a similar pt. who would do almost precisely the same thing, she would save money from her pension while in hospital and had exhausted her welcome in many facilities. On about her thousandth presentation, our consultant gave her no drugs and put her in restraints until she was reviewed by psych, and the next time, we did the same thing. She never presented again.
I am curious about other facilities and how they deal with pts such as this. I just feel as if we are not helping by all this positive re-enforcement and someone needs to have the guts to give some negative consequences to this behaviour. I'm out of ideas. Don't get me wrong, I am not a fan of restraining people but I can't think of any other way with this poor soul. I do the best I can but I just couldn't win tonight.