manipulative patient - page 2

Hello psych nurses! I hope that you can help me. I work in LTC and don't have a lot on psychiatric nursing experience. We have a resident that is very manipulative (has mild, fluctuating... Read More

  1. by   graemesouness
    one thing worth considering is focusing your attention on rewarding socially acceptable behaviour and ignoring other behaviour patterns (easier said than done!!), also having regular team meetings for support and direction and in times of difficult situations have two nurses deal with him/her at the same time, use time out if appropriate and yes be firm its the only way!!
  2. by   KathleenRNNP
    Hello everyone. The comments on this topic have been really helpful. I work in a small emergency department in Northern California and we have been getting repeated visits by a very manipulative bipolar/BPD patient. He is condescending, asks for help but then refuses our care and says we are incompetent. Claims he is a lawyer (and that his wife and brother are both doctors and lawyers). Holds his iphone out when the nurse or doctor is in the room and claims he is recording the conversation to use in court. If he comes in again, i will for sure use patience and reflection as well as comment on positive things he does. I am just wondering if there is any other advice out there?

    the facts: man in 60's with Diabetes, kidney failure, Bipolar and borderline, heavy marijuana use, addicted to soma too, came to ER because he fell and had a big bruise to his back, c/o of pain, states he is allergic to all opiates. The ER doc offered to do a significant work up on him but he was arguing with her from the start, not letting her complete sentences. She said in order to give him a pain shot with a non-opiate, she would have to check his urine. He got angry stating he will not be able to pee for several hours (ranted on how was he expected to wait for this). I offered to him that the only way we can get the urine quicker is with a catheter (that went over like a lead balloon). He said he was leaving but he refused to sign AMA, did not let the doctor explain the risks and benefits and then accused her of not warning him of risks and benefits. He left.
    Returned several hours later---pretty much the same song and dance (did give urine specimen).
    following day he went to a bigger hospital (they called for his records).

    he returned again to our small ER about 24 hours later.

    My written description pales in comparison to what actually happened and being there.
  3. by   Mish56
    Quote from KathleenRNNP
    Hello everyone. The comments on this topic have been really helpful. I work in a small emergency department in Northern California and we have been getting repeated visits by a very manipulative bipolar/BPD patient. He is condescending, asks for help but then refuses our care and says we are incompetent. Claims he is a lawyer (and that his wife and brother are both doctors and lawyers). Holds his iphone out when the nurse or doctor is in the room and claims he is recording the conversation to use in court. If he comes in again, i will for sure use patience and reflection as well as comment on positive things he does. I am just wondering if there is any other advice out there?

    the facts: man in 60's with Diabetes, kidney failure, Bipolar and borderline, heavy marijuana use, addicted to soma too, came to ER because he fell and had a big bruise to his back, c/o of pain, states he is allergic to all opiates. The ER doc offered to do a significant work up on him but he was arguing with her from the start, not letting her complete sentences. She said in order to give him a pain shot with a non-opiate, she would have to check his urine. He got angry stating he will not be able to pee for several hours (ranted on how was he expected to wait for this). I offered to him that the only way we can get the urine quicker is with a catheter (that went over like a lead balloon). He said he was leaving but he refused to sign AMA, did not let the doctor explain the risks and benefits and then accused her of not warning him of risks and benefits. He left.
    Returned several hours later---pretty much the same song and dance (did give urine specimen).
    following day he went to a bigger hospital (they called for his records).

    he returned again to our small ER about 24 hours later.

    My written description pales in comparison to what actually happened and being there.

    "He is condescending, asks for help but then refuses our care and says we are incompetent."
    1st I would remind this man that he is being spoken to with respect and you will except nothing less in return. 2): If he wants to dictate care, I would remind him he is practicing medicine without a license. 3). remind him he sought care, you did not go grab him off the street. 4) You or your docs need to be in communication with his PCP or psychiatrist. My concern would be, why is he using multiple ER's for his health care?? He is only in pain when his doctor's office is closed? If he's gonna keep coming in you need to have a partnership with his other care providers!
    My patients always say they are allergic to all neuroleptics! His allergy to all opiates leads me to think of 2 things. Either he has had previous addiction to them and is actually trying to avoid relapse, or he is simply trying to lay down a really good challenge ie: "I'm in pain and let's see if you can treat me" without a traditional approach.
    He says he has a sibling and wife, does he allow you to contact them? I'm sure they would be an excellent source of history.
    He sounds like a complex patient so the more info you have the better equipped you will be to deal with him. From the glimpse of him you have given us, it sounds like he may be more manic than anything (demanding and hostile, ? maybe grandiose). Sounds like a nightmare either way. GOOD LUCK!! You'll need it! I wish I could let some of my patient walk out the door!

close