Advice for dealing with manipulative patients who are frequent flyers?

[baby.nurse123]

I am a new nurse with only about 6 months of acute care nursing experience. I am learning a lot every day, but the one thing that I am struggling with is dealing with manipulative patients. I love my job and what I do, but the one thing that really gets me worked up is a manipulative patient (particularly the ones with drug seeking behaviors). I work in a tiny hospital in a small town, so we see our share of very familiar frequent flyers....

I swear some of these patients must literally sit in their rooms and watch the clock count down until EXACTLY the earliest second they can get their next dose. They like to test the waters at the beginning of each shift with their oncoming nurse to see what they can get (i.e. getting their dose earlier when they KNOW it is waaay to early). Then, when I tell them it's not time yet and offer some form of non-pharmacological intervention, they claim to "know how the system works" because they've been here so often and then eventually agree to wait for the next available dose. I've had those patients who request that I just push the med fast, which I have not and will not do (I will only push it over the recommended rate). I've even had patients tell me to medicate them even while they're asleep, to which I have replied that I can't medicate them until I've assessed their pain, and I can't assess their pain if they're sleeping...therefore I will not be medicating them while they're asleep (plus I would NEVER want to be put in a situation where a patient is medicated unbeknownst to them and then they try to claim that they never got the dose). I've seen patients who are extremely resistant to limit setting (and the nurses on my unit are very good about clearly communicating the medication plan to the next shift), and if they don't get just their way, they refuse the nurse's care and demand a new nurse. I even saw patients get violent on multiple occasions (throwing items around the room) and making threats to staff because the medication administration orders/schedule was not to their liking.

Now I know there are many many medical conditions out there that cause a lot of physical pain, and I'm not in the patient's shoes experiencing it....but I'm in need of advice on how to deal with these kinds of patients. and I know it's only a matter of time before I see them again in very similar circumstances...

[Airidis]

I think you already have some great strategies/morals in place. I always tell my drug seekers you can have your pills at this time and I put my foot down. If they ask sooner I remind them that no your medications will be delivered at xyz time and not sooner! I also had a pt request I leave her pills on her bedside table (narcs etc) I told her no she said all the others do it! I replied I'm not the others my shift my license my rules!

[nursej22, MSN, RN]

We have drawn up care contracts with a few of our challenging patients. The doctor(s), social work, nursing and the patient make agreements and carry them through.

For instance, the MD writes and amends the pain med orders as appropriate, social work sees the patient daily for counseling, nursing agrees to answer calls and administer meds as ordered, and the patient agrees to the limits. This gives the patient some control but also consequences for their behavior.

If the patient is not cooperative, security is called and the patient may be discharged.

[tokmom, BSN, RN]

We have pt care conferences with them and the MD will set the limit. If they still act like jerks and get obnoxious, then we call security on them. If the patient walks, we nicely hand them the AMA form and security shows them the door. I hate patients like that!

[tokmom, BSN, RN]

I forgot to add, I think you are doing the right thing. There is no easy way to deal with these people. Does the MD ever step in and help limit set?

[rn undisclosed name]

The contract is a really good idea. In 5 years I've only seen it done once. You just have to keep setting limits. Keep the AMA form ready at all times. If they're that unhappy they are more than welcome to leave. If they're asking for something that won't be given you can use the line that is not indicated. I love when they want dilaudid for a headache or a tummy ache. Really?

Be careful when you throw around the term drug seeking behaviors. That is a term that tends to be frowned upon by certain people.

[llg, PhD, RN]

As some of the previous posters have indicated ... it really helps to have your whole team of caregivers "on the same page" with such patients. I strongly encourage you to speak with your local colleagues and work out some plans as a team. That will give you the support that you need while it also provides the patient with a consistent set of rules to live by.

[TrafalgarRN]

Let them not get to you...its just part of the job. I work in an ED where for the last 1 year we have implemented chronic pain protocols and we have seen our frequent flyer population drop by 80 %. There are still some who will try manipulate the system by coming in and to their surprise we give Toradol, Tylenol and then ask them to follow up with their Primary Provider; of course they are not happy and our doctors are adamant about no narcotics and this seems to get the message across.

I have encountered manipulative patients who keep an eye on the clock. If they ask for pain medication and the time is due and vital signs are within parameter then i gladly dose. They say pain is what the patient describes it to be ; so if you are laughing on the phone or with your friends and states you leg pain as 10/10 who i am i to question? I will medicate and chart what i observed. As long as you are stable i will give you whatever medications are ordered.

To the OP don't let them get to you...push medications according to the recommended guidelines, set rules on when pain medications are due, and always remind them its job and no one should tell you how to do it.And trust me when i say AMA is sometimes one of my favorite words. You don't like the way we are treating you and you want to go home, please do go home instead of creating a circus. I will show up with the AMA to the bed and ask them to sign it so we can cut the circus short and when they see you have taken a stand, many will come back to reality.

[xtxrn, ASN, RN]

Let them not get to you...its just part of the job. I work in an ED where for the last 1 year we have implemented chronic pain protocols and we have seen our frequent flyer population drop by 80 %. There are still some who will try manipulate the system by coming in and to their surprise we give Toradol, Tylenol and then ask them to follow up with their Primary Provider; of course they are not happy and our doctors are adamant about no narcotics and this seems to get the message across.

I have encountered manipulative patients who keep an eye on the clock. If they ask for pain medication and the time is due and vital signs are within parameter then i gladly dose. They say pain is what the patient describes it to be ; so if you are laughing on the phone or with your friends and states you leg pain as 10/10 who i am i to question? I will medicate and chart what i observed. As long as you are stable i will give you whatever medications are ordered.

To the OP don't let them get to you...push medications according to the recommended guidelines, set rules on when pain medications are due, and always remind them its job and no one should tell you how to do it.And trust me when i say AMA is sometimes one of my favorite words. You don't like the way we are treating you and you want to go home, please do go home instead of creating a circus. I will show up with the AMA to the bed and ask them to sign it so we can cut the circus short and when they see you have taken a stand, many will come back to reality.

Ooohhhh.... that is GOOD!!! (but OP- check w/NUM before doing this at your place!). Cuts the b.s. with one signature

[TrafalgarRN]

[/b]

Ooohhhh.... that is GOOD!!! (but OP- check w/NUM before doing this at your place!). Cuts the b.s. with one signature

Oops i forgot to add that after they sign it i let the provider know whats going on and most if not all the times they are happy. If you can talk, walk and have stable VS see you the next time. And never forget to say" Thanks for Choosing Us as your emergency providers. We are here 24-7 for you"

[xtxrn, ASN, RN]

Oops i forgot to add that after they sign it i let the provider know whats going on and most if not all the times they are happy. If you can talk, walk and have stable VS see you the next time. And never forget to say" Thanks for Choosing Us as your emergency providers. We are here 24-7 for you"

Uh, yeah- that last part....:barf01: I hated scripts !!!

If they can complain about the service, they need to hire a concierge !!!

[Grumpygs, MSN, RN]

This sounds like you work at my hospital... all the way down to the circus!