Advice on dealing with a patient with delusions

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Hi all,

Was just after some advice about how to care for a patient with paranoid schizophrenia. This is his first relapse (first diagnosed a year ago). He was on Risperidone which was controlling his psychoses but recently he stopped taking it and has been re-admitted. He thinks that all the nursing staff want to kill him and refuses to take his antipsychotic meds because he thinks we are trying to poison him. I've only just started working in Mental Health and am a bit unsure how to proceed with him. Most of his problems, I feel, stem back to him not taking his meds - but how do you get someone who thinks you're trying to kill him to take his meds so that you can alleviate his delusions and help with his other problems eg social relationships etc??

Thanks for your help!

Amy xx

Specializes in Psych, Med/Surg, LTC.

Its difficult w/ these kind of patients. But you have to gain their trust. Start small. It may take several days to get them to take meds. Keep all promises. I know its frustrating when pts think the staff is out to get them.

What a frustrating situation. We have a resident like that. The way I handle it is constant reassurance and redirection. I'll say "I'm so sorry that you are frightened, but that isn't what's really happening. You're in a hospital, and I am your nurse. I'm going to make sure that nothing bad happens to you. I need you to trust me." I've even shown him my nursing license, the medicine bottle, the drug book, anything I can to show him that I am legitimately trying to help him. Usually with enough evidence to prove that he is confused, I will tell him "This medicine is going to help you to be less frightened, it will help you to not be confused."

Good luck- it's going to take a lot of patience and a lot of repetition to gain his trust, and you might have to repeat the process daily.

Thanks guys for your help.

I think trying to gain his trust is the main thing I need to focus on right now. I'll let you know how things pan out! ;) Fingers crossed!

Specializes in icu, neuro icu, nursing ed.

join them!!! :smiley_aa :smackingf

Specializes in Med-Surg, Geriatric, Behavioral Health.

I explore what Schizophrenia/psychosis means and feels like for that person in order to personalize the experience. Encouraging the patient to share what symptoms are present for him/her and which are most distressing. A very matter of fact, educational, but very supportive approach. I also make an agreement with the person that it is my interest to assist them thru this, the symptoms, and to provide reality checks. I have the person contract with me to come to me any time when he/she feels distressed by the symptoms previously discussed. I approach it as a partnership. Medication education and discussion are always a part of it, but equally balanced with nurturing the trusting relationship between us. Trust is the crux of the issue...especially during paranoia. Work on the trust, the medications will eventually become less frightening. Also, I agree....keeping reasonable promises are necessary. If a promise cannot be kept due to understandable circumstances, it is fully discussed with the patient beforehand to enlist understanding. Again, part of being a partner means keeping one's partner informed. Lack of information only feeds paranoia. I make my partner feel like he/she is part of the process, not left out.

Specializes in Med-Surg, Geriatric, Behavioral Health.

Delusions: a fixed, false belief held as being true

I do not argue over the delusion if true or not. However, I do present my own take on reality and discuss that with the person. A form of reality testing. Actually, it is a back door approach in refuting the person's delusion. I will acknowledge to the person that I do hear and understand his/her delusional thought/belief....but, then...I will again present my perception on things. On a unit, I may walk the patient around to other patients and ask for their take on a situation and how they perceive things. Then, I go back with the patient and discuss what we have learned together. After this exercise or exercises like them, I have actually had delusional patients come to recognize their own distorted thoughts. I can recall several delusional patients who have come back to discuss later and say that "you know when that guy over there said this...it didn't sound right...sometimes, I think that way"...or something of that nature. It cracks the door a little more to examine their own thoughts or beliefs. Confronting delusions and presenting reality often needs to be an experiential approach with discussion. Simply telling the person he/she is delusional is too "in your face" and challenging (may jack up paranoia), is disrespectful, and is dismissing. Refusing to discuss delusional content is a disservice as well. How will you know if the delusions are lessening unless discussed? Like any symptom, it is discussed as a problem that impairs functioning and ability to interact....it causes unhappiness. Again, personalize the delusional experience. Discussing thoughts, beliefs, and emphasizing critical thinking as experienced in the milieu are often much more helpful. Part of the process is to support the person to begin challenging their own beliefs and pursuing correct information. I try to make it a fun process, not scarey. Medication education in relation to delusional thinking is also discussed and normalized as part of my approach.

Thanks so much Thunder. Really great informative posts. I'm back at work tomorrow. Will post some of those great ideas :idea: in place and we'll see how we go. Finger crossed!

Specializes in Psych, Med/Surg, LTC.

Wolfie, do you still work psych? You seem like such a great psych nurse. Aren't you working med/surg lately? How long have you worked in psych and what type of psych? I used to work primarily Adol/Child psych but floated to all of the adult units regularly. Psych needs more nurses like you!!! You seem to really take the time to help the pts instead of coercing the pts to take meds and "play the game" to get out.

Specializes in Med-Surg, Geriatric, Behavioral Health.

I used to work adult psych...was a psych CNS, in fact. Worked inpt and outpt. Was also a LPCC (licensed professional clinical counselor) as well. Areas: individual therapy, group therapy, community education, research, supervision, partial hosp, acute inpt, and detox. I worked psych for 10 years. However, burned out....tis sad, I know. Happens to the best of us. Was a lot happening in my life at the time too. Needed to make some changes. I gave up psych. Let my counselor license lapse, placed my CNS on inactive. Went back to my second love, Ortho-Neuro Med Surg.

Thanks for asking.

I just had my first exposure to a pt with long-standing hx of paranoid schiophrenia, dx 12 years ago. I guess I did not quite handle it the best way. I directly challenged the pts beliefs, telling him I understood he believed them to be true, but that I thought they were more likely an element of his illness, and not in fact true. He told me that was enough and he would not speak with me any more. It's basically been the same thing every time anyone else denies they believe him. He gets upset fairly quickly. We've had to call for meds a couple of times to prevent a crisis. I am still not clear on how to "get the wedge in the crack" with a pt who has had these beliefs for so long. I maybe expecting too much too soon.

Never argue with a delusional pt or try to "fix" the delusion...you can not win. To that person it is reality. You can only offer reality based things from your end, to build trust, approach them slowly, encourage them to voice their own feelings/needs, reminisce. You do not have to agree with them to talk to them one-on-one. Just say things like...oh that is interesting, tell me more about that. Once you have trust being built....they are more apt to take a chance and start taking their meds. Also don't try to talk them out of some sort of rituals that they feel they must do. You will spend too much of your valuable time for no avail. Find out something they are interested in doing (look at their activity assessment) maybe offer to play a game of cards, or dominos etc. They will start to trust you. Never let your guard down though...you have to be self aware at all times. Also, if they are having any type of hallucinations, do not tell them they are wrong/argue. You can say I do beleive that you are seeing/hearing (ect) that, but I am not seeing that...tell me more about that...do you recognze the voice....does the voice tell you to do something...ect. You may just find out some valuable information for your treatment plan that way. For instance someone who is not eating may have "voices" telling them that the food is poison.

Oh...by the way...if they do not take their meds...just crush them and put them in their oatmeal or afternoon snack....OK just kidding!!! :clown:

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