help with schizophrenic or bipolar diabetic patients

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    Hi, I have a question for those who are experienced with schizophrenia, bipolar disorder, and other serious psych issues.

    I work in a primary care clinic and spend the majority of my day helping our patients with Type 2 diabetes. So, this mostly boils down to the people who have the highest blood sugars, the highest a1c levels, the most hospitalizations, the most difficulty coping with stress, the most social issues. My most time-consuming patients (and the most emotionally draining for me) are the patients with the psych conditions I've mentioned as comorbidities.

    Depression is a big one too, but not such a baffling component- it just seems more straightforward.

    What I have trouble with is reigning in the rambling talk, getting to the heart of what the issues are, identifying needs when a person is kind of talking in circles and not getting to the point, or changing the subject to a favorite tangential fixation.

    Any pointers, ideas, tips?
    Davey Do likes this.
  2. 9 Comments so far...

  3. 0
    Is there a better forum to post this in? Mods, should I try reposting?
  4. 1
    It's a primary care clinic that cares for all medical conditions? If that's the case, what's being done to help with the psychiatric disorders? A person whose bipolar disorder or schizophrenia is stable, wouldn't be rambling, circular, or tangential. If they aren't stable, then the doctor needs to address the psychiatric disorder. Are the patients on psychiatric medications? Are they the appropriate medications? Are the dosages correct? Are they getting any therapy?

    Treating the psych disorder is a big priority. It's difficult to communicate effectively with someone whose intense psych disorder is intensely operational. There's a range of disorders though, from "kind of" to "off the chart." Most people with bipolar disorder, who aren't hospitalized, aren't at the "off the chart" level and are able to be re-focused.

    That being said, sometimes it helps to just ask the patient to stop talking, gently, interrupting the flow of tangentiality. Sometimes you have to do it repeatedly, telling him or her you need to get specific information and talking about other things isn't helpful. Ask what you need to ask, and ask again, without answering or responding to the circular statements. Is there a family member present who can help? Ask for help from him or her.

    If I have a relationship with a patient, I've found it helpful, in tangentiality, after trying to re-focus, to gently say "stop!" as often as it takes, to get the wordiness to stop.
    Davey Do likes this.
  5. 1
    Thanks for your reply. This gives me a lot to think about.

    We don't prescribe the more serious psych meds- we refer to a psychiatrist who treats the underlying psych disorder. But, most of our patients are Medicaid so access is a problem. Our docs may communicate with the psych or get a fax report, but I don't have anything to do with that directly. The docs then want me to "get the patient to take his insulin" or "find out what his blood sugars are." If I can get a case manager to send the blood sugars via fax, that's great, but I try to encourage self-efficacy with all the patients I deal with, and going through a case manager or family member seems to go against that. Or do I assume that because a person gets a daily case manager visit, I should just go through that person and forget about self-efficacy?

    Most of the patients fall into the middle area of the tangential rambling continuum you are talking about. I haven't really developed the skills you have. I worry about making people angry or escalating them. I can just say "stop?" Really? I will try not responding to the unhelpful talk.

    Sometimes it's not even verbal. We started an email system via our electronic chart and have a couple patients with bipolar disorder that have latched onto it...sending giant blocks of text that don't really go anywhere, or ask a direct question, or use accusatory language.
    Davey Do likes this.
  6. 2
    If they have a case manager, that person should have a relationship with them, and they are appropriate to ask to act as go-between. That's what they're for.

    People with bipolar disorder and schizophrenia aren't always able, period, to do things someone without their disorders could do. Their thinking isn't what ours is. It's clouded with racing thoughts, and maybe delusions, paranoia, and hallucinations. They just don't "see" things the way we do. It's not possible for many of them to not ramble out loud, some, because their thinking isn't straight-line. Expect the unusual and not what you define as "normal." It's not possible. Self-efficacy isn't always possible with manic or schizophrenic patients.

    Yes, you can just say, "stop," if you've tried to re-focus with the "I need to get information and getting off-topic isn't helping" talk. You say it gently and persistently. They're not likely to flip out...they're people who can't think clearly, not rabid, ready-to-attack or go-into-an-angry-rage people. They're far more likely to hurt themselves than you, either by self-talk or actions. Tell them what you need to do, and don't get sidetracked by their sidetrack-ed-ness. If they fall in the middle of the continuum, they're even more likely to respond to your goal of getting needed information or doing teaching. They are at the clinic for care. They know they need what you bring to them. They want what you are giving them. It's up to you to do for them what they can't do for themselves.
    Davey Do and SHGR like this.
  7. 1
    Yes, I didn't mean at all that I associate psych with violence- I know that that is a very unfair stereotype. However, we do have a couple of patients that escalate and both also have substance abuse issues.

    We have diabetes registries that we work off of, that alert us to the patients that are overdue for care, and part of my job is to get people care that are not actually seeking it! It seems absurd when I lay it out there like that.

    "They are at the clinic for care. They know they need what you bring to them. They want what you are giving them." This applies to some, but not the majority. It may be that the patient is there looking for a letter for disability, or a sore throat, or something else, but doesn't want to address their estimated average blood sugar of 300...or noshows many appointments that we schedule when I am able to reach him or her. Or, the patient might have a period of coming in for appointments and then disappear again for a year or more with no contact information- homeless, transient, whatever. Sometimes I hear about an ED or psych crisis visit but there might be no clinic followup, and no phone number.

    I guess I am rambling too. In a way this seems like an unfair assignment, unfair in the sense that I could help many more people with pre-diabetes in the time it takes me to work with 20 psychiatrically complex patients.
    Last edit by SHGR on Feb 5, '12
    Davey Do likes this.
  8. 1
    If the patient doesn't want to address his diabetes and its managment, then all you can do is what you can do. This applies to all your patients. Make your best shot at it, and document what you did and the response you got.

    If the patient is there for another issue, how about saying, "I need to go over _____ first, and then we'll do your ____." ?
    Davey Do likes this.
  9. 1
    Quote from Whispera
    If the patient doesn't want to address his diabetes and its managment, then all you can do is what you can do. This applies to all your patients. Make your best shot at it, and document what you did and the response you got.

    If the patient is there for another issue, how about saying, "I need to go over _____ first, and then we'll do your ____." ?
    Well, I know it is possible to do more than what my current best shot is. I will practice the above. I'll look into communicating with the therapist/psych if the patient is un-redirectable or changes from baseline (should be the MD's job though). I wonder if there is a way I can practice some communication skills in a safe way. How do people learn this stuff? Beyond the patho, meds, and basic science of it?
    Davey Do likes this.
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    practice and experience...also look for information on therapeutic communication or interpersonal skills....read and practice what they preach...

    the practice is much more important than the reading...
    Davey Do likes this.
  11. 1
    It's really great to read an interesting correspondence between two competent, compassionate caregivers.

    I applaud your actions, suz, in searching and researching the area of Psychiatric Nursing and methods of communicating specifically with this population to better enhance your workplace skills.

    And here's to you, Whispera, for relaying pertinent information in your honest, straight-forward way.

    Keep on keeping on!
    RNgrrl09 likes this.


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