manipulative patient

  1. 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 dementia) and is disrupting the unit as only a "borderline" person can. I realize that it is beyond my scope to be diagnosing her. I am finding it extremely difficult to obtain the resources to build a behaviour careplan for her. We really need to get a consistent approach in order to deal with her demands that we just cannot accomidate. I'm trying to set limits on her bahaviour and just end up feeling like a big meanie at the end of the day. There was a terrible outburst yesterday, and she's starting to get really verbally abusive towards staff and co-residents (we're talking about life-long coping skills here). I do have access to a psychiatrist, but want to work from the ground up before tweaking her meds anymore.

    Do you have suggestions on how to properly deal with her? Are there sources on the net for free psyciatric care plans. I don't have access to any textbooks on psychiatric nursing right now.

    Any advice would be welcome.
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  2. 15 Comments

  3. by   Loray
    Hi Adrienurse,
    I have some ideas but don't now what a LTC is therefore I don't now if they would be helpful.
    Cheers Loray.
  4. by   aus nurse
    Hey there Loray,

    LTC stands for long term care...equivalent to our nursing homes I think but said in a much nicer way

    Good luck adrienurse..I can relate to your problem. We have a regular patient who comes in to our acute care unit who is a borderline personality disorder and who disrupts life to the max! Consistency is the key as you say, but often hard to acheive I know.
  5. by   adrienurse
    Yes that's right. I work in a nursing home. Specifically on a 30 bed, locked, dementia unit.
  6. by   sbic56
    adrienurse
    Dealing with Borderline personality is one tough chore! I worked psych for 8 years and that was the type I had the hardest time with. Sooo draining! In true BPD, the person needs to "learn" what they missed at the age where they were becoming independent and trusting of their environment. Basically, you are dealing with a 2 year old that never grew up well. They did learn to manipulate their environment to get their own way though! They did not learn boundaries and self esteem is low.

    The best way to survive these people is to have a primary caregiver on each shift, for consistancy and so staff splitting can be avoided. A specified care plan has to be adhered to. The patient also needs to contract with the primary in agreement to the plan. Positve behavior is complimented and rewarded, response to negaitve behavior is minimal. You do not punish, of course, but neither do you show much emotional reaction to negative behavior, because this is just what she wants. Any attention is good to her....even if it is negative.

    I know what you are going through! Using a good and consistant team approach is the only way to make headway with this patient. Best of luck!
  7. by   jevans
    Hi
    Iwas going to ask a simular question when I found this thread.

    I have a lady in her 60's she has a long term psych history but has recently had a stroke. We are trying to mange her on a stroke unit.

    She is extremely aggressive but so far only verbally.

    Her latest strategy for attention is to throw herself on the floor. When questioned her reply is that it is the only sure way for her to attract attention fast. When I asked her why she does not use her call bell she said she is not prepared to wait!

    Myself and colleagues are concerned that we do not have the knowledge or experience to deal with her. And we are concerned that we may be causing more harm

    Any advice is sorely needed

    thanks
    j
  8. by   researchrabbit
    Instead of thinking of yourself as the "big meanie" you might consider thinking of yourself as Mom (or, if you are Catholic, Sister).

    In other words, you are the big kahuna who accepts the patient but does NOT accept the behavior. It is important to divorce your feelings about the patient from her behavior because her behavior can make it very difficult for you to care for her.

    It is important not to rant and rave with your coworkers about her because that will keep everyone stirred up (rant and rave all you like on allnurses or at home -- just no names or identifying factors 'cause you never know when you'll run into someone who knows her). Besides, the more attention she gets (negative or positive) the more she'll act out.

    A primary caregiver per shift is a great idea (consistency of care).
  9. by   Janey
    Why does anyone seek attention ?. Seeking attention is often because their feeling lonely and helpless, insecure, frightened, unloved, unworthy, insecure or just plum bored. In an unfamiliar environment without any control thats how I'd feel. In my limited experience consistency in the form of positive feedback a smile, a wink, a complimentary word in passing, a cuddle and a peck on the cheek, with a reminder I care often brings a begrudged smile, that's pleasure enough.
    Try it......... you might be surprised.
  10. by   Orca
    Borderlines push everyone's buttons. Many of the worst patients I had were Axis I - Bipolar disorder Axis II - Borderline personality disorder. Give them a nasty disposition and lots of energy to fuel it.

    Borderlines are continually testing (and contesting) others. If you shy away from them or reject them because of their aberrant behavior, they see it as confirmation that people don't like them. It is the ultimate self-fulfilling prophecy. They perceive that others do not like them, and they behave in a way that pretty much ensures that this is the case.

    Many borderlines are insufferable to deal with. Nothing ever seems to please them. When we got an acute case on the unit, we often took turns dealing with the patient so that one person did not get stuck with the whole task for eight hours.

    Patience and reflection are your best tools.
  11. by   sjoe
    Janey--all I can say is that apparently you don't have borderline personality disordered people in the UK, or you'd not say that. I guess there are all over HERE.

    If you'd like to learn more about the subject in an easy way, may I suggest reading "Prozac Nation." It is a personal account of a young woman who has chronic depresssion and MANY borderline characteristics.

    (Sometimes good intentions are simply not enough.)
    Last edit by sjoe on Oct 5, '02
  12. by   Orca
    I'm with you, sjoe. Cuddle and coddle a borderline, and you have opened up the floodgates of bizarre, aberrant and confrontational behaior. You are reinforcing the very behaviors you are trying to extinguish. Smile at them at just the wrong time, and they may try to take your head off.

    Nurturing and smiling may work with other types of patients, but borderlines require a firm hand. Even then, progress is very gradual.
  13. by   Janey
    Did Sjoe and Orca read the question under discussion ?????

    It wasn't about a young BPD patient. That was a question posted elsewhere, had I wished to answer that question, I would have responded quite differently.

    The question was about the maipulative behaviour of a patient with 'a mild fluctuating dementia' who is in LTC.
    The features of a Dementia is global impairment in cognitive functioning (this includes memory). Now I deduced from the question this was and elderly person since its mostly elderly in such a setting!!!!

    I dont know about the USA, but in the UK with a diagnoses of such then would allow for memory impairment, and traditional management of BPD is hardly suitable in this instance.

    No Sjoe BPD doesn't discriminate, and occurs in other parts of the world. I wonder at such a comment !!.
  14. by   sanakruz
    These are some technigues I've found useful to use with a BPD.1)be patient ,kind ,but firm.2) point out this persons strenghts to them with each and every interaction-"Youve been able to deal with this before,remember how you had that difficult roommate...." Give the person + feedback for even minutiae that warrants any. 3) one contact person per shift.4) tell this person of their diagnosis. If one doesnt know thery're suffering from BPD, they can't recover. Use a partnership approach "I know it's hard but you can do it, youve gotten through tough times before etc. etc. Were here to support you in your recovery." I swear it works wonders! I end up dealing with a lot of BPD as my co-workers identify me as being "good with borderlines" We call them marrow suckers because of their neediness-And they often have substance abuse issues so keep your eyes open for benzo abuse- Some docs have created true monsters that way! Most (not all!) BPDs are women- I keep my sanity by looking at their troubles in a feminist light (Legitamate gripes) and keeping my sense of humor-a must in the psych world.:chuckle

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