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...

[Happi2BRN]

I have had patients who request that I flush with saline after the med is pushed. When I tell them that it isn't necessary since they have IV fluids running, they say "Well, everyone else does it". Some days I feel like I can't take proper care of my other patients because I have to cater to the unrealistically demanding ones. I am a good nurse and gladly give the patient meds on time, but I do resent being told how to administer them just so someone can get a rush. I have been a nurse for three years and I still don't know how to handle the manipulative ones.

[VICEDRN, BSN, RN]

I think you know what to do but i think you really are asking us how to deal with the feelings you have about it.

You know to set limits and call security if they threaten. You know you will not awaken them or administer medications in their sleep or leave it at the bedside.

Thus, I am guessing that what you rally want is to know how to deal with those feelings...are you angry? I am. I think we all are. It isn't fair to the sick patients you also have to care for.

Do you feel bullied? Me too. But I try and see it in a positive light. I am getting a stronger backbone every time.

Do you worry about them reporting you to manager? Me too. And then getting fired for bad customer service? Me too. But I need to sleep at night and I need to keep this here license. And I am not alone. Every one hates theses patients. I can get another job.

Trying telling yourself some of those things next time you are confronted by this stuff. You can get another job. You are not alone. You are getting stronger and more patient every time you encounter this stuff. And you are a safe and smart nurse who administers medication in a manner appropriate for the med and the patient and in compliance with guidelines set forth by your state, the facility, the drug company, the md and your own conscious.

Girl, (or guy) , you got this. Have faith.

[jbluehorseh]

One of the biggest problems for nurses is the lack of documentation of the patient's behavior. This is because the nurse is over whelmed in the first place and may seem petty but it will save you in court if a patient decides to sue you in court. By documenting behavior, statements and reporting this to the doctor this will help save your license and job. It also has to be a team effort. So all nurse need to be on the same page. one example if your patients is complaining 10/10 back pain but can walk down four flights of stairs to go smoke then this needs to be reflected in the patients chart.

[IdrilRN, BSN, RN]

that's right everyone else does it. Pushes fast, leaves meds at the bed side, lets them go out side to smoke with a line.... wow everyone else? Maybe I'm doing something wrong! No not really, but put your foot down, don't take their temper tantrums personally, I never took it personally but it was very hard for me at first to know what to say.

I think my skilled LTC residents are worse my psych patients. I am pretty sure something could be wrong when three weeks after the procedure this man was still in severe pain and required three narcs around the clock, and a Fentnyl patch.

The most frustrating for me is when the people on methodone maintence come to our psych unit and it is scheduled for 8am and they come to us at 6am for it. And telling us they take it at 5am usually, I then say you'll have to take it up with the Doc or NP and they can change the time, but here is something else you could do to pass the time. Apparently, every person in this small state of ours gets their maintence dose at 5am. It's a small state and most have to travel quite a ways.

[baby.nurse123]

thanks for all the responses! I think I've discovered my petpeeve in nursing and I've always been irritated with these kinds of behaviors in general.

Recently, I was glad to learn a few things being done about this at my hospital:

- The ER, specialty clinics, and hospitalists will not be prescribing narcs for long term pain management. They may prescribe for a set amount of time post-op (like if it's a major ortho case or something), but otherwise this will be done almost exclusively by the PCP now

- the hospital has recently started offering conferences for long term pain management for the doctors

- the patients who were violent toward staff despite the multi-disciplinary team meetings with the patient, etc actually will not be admitted to our hospital anymore...but I do wonder how they will be at the hospital in the next town 20 minutes away? I hate to pass along the problem for someone else to deal with.

I wish there was more community support for this issue so that these patients can be better managed outside the hospital.

[baby.nurse123]

The MD does discuss the plan with the patient and help set the limits, but what I find is that the patients behave differently with different members of the healthcare team. Like when they are talking to the doctor, they act like they're on board with the plan. With the RN (the person who controls the administration of the med), the patient acts out and tries to manipulate enforcement of the plan.