Dealing with delusional patients

Stephanie_R · Mar 10, 2010

I use to be like you when i was a CNA until i went to work on psych. There are the patients that require the TLC and others that require the direct to the point direction, no coddling. Now i dont know your patients dx or frame of mine but when dealin with psych you sometimes need to be stern or you will get walked over. That is probably what those other nurses were thinking would happen. Takes time to read differnet patients and even then sometimes you end up switching your ways with them after an hr or even a day or two!

nminodob · Mar 10, 2010

One thing I have noticed about certain psych pts, especially those with long-standing personality disorders like "borderlines" is their uncanny ability to "read" people's weaknesses - when they get abusive they will tell the overweight nurse she is fat & ugly, if they think you are insecure they may tell you you are incompetent, etc. I remember one I was dealing with - it was at a time when I just had my 50th birthday and was feeling a bit depressed about it, and this pt repeatedly harped on how old I was and that I had no right to hold her in isolation because she was young and I was wrinkled and old. I couldn't get over how this pt who was totally out to lunch in every other way was able to pick up my insecurity that day about my age.

The pt you are referring to may have intuited your enthusiasm as a sign of inexperience, and decided to needle you a little, then your reaction probably confirmed that she had hit a nerve. Take home lesson: Sometimes it's better to NOT have a thin skin when dealing with pts of any kind, because you never know which ones may have a personality disorder.

teeniebert, LPN · Mar 10, 2010

One thing I have noticed about certain psych pts, especially those with long-standing personality disorders like "borderlines" is their uncanny ability to "read" people's weaknesses - when they get abusive they will tell the overweight nurse she is fat & ugly, if they think you are insecure they may tell you you are incompetent, etc.

Not to minimize the OP's concerns, but occasionally a pt with PD won't be able to read someone and they'll pick something completely absurd to focus on. Some 'abusive' gems that have been thrown at me include, "shut up, brown hair," "little glasses girl," and my personal favorite, "there you sit in your blue shirt!' Seriously? My blue shirt? Oh, ouch!

Jules A, MSN · Mar 10, 2010

Its good that you recognized that something wasn't quite right and as you get more experienced that will be the time to switch gears if necessary with how you are treating the patient. Good learning lesson and as with us all delusional patients are different and will require different approaches depending on their frame of mind, the situation and the time you have to devote to them. Hang in there and learn to let stuff like this roll off your shoulders.

JoeyGirlRNNYC · Mar 10, 2010

I work on a specialty med surg floor and I've only been a nurse for six months. For some reason I've been getting a few psych patients each shift for the past month. Some of these patients are fine. Most have always been a handful. I think God is trying to test me :/

The other day I had a situation. The patient I had was talking about how she used to be successful and didn't like the way her life was going for a long time while I was giving her care. Ok, that's fine to confide. Yet, she'd sprinkle in rude commentary, was EXTREMELY nit picky, and would talk trash about the other nurses she had before me throughout all our interactions and she was extremely hot and cold. I killed her with kindness at first.

Then it got to a point where she was extremely rude, telling me how to do my job after I repeated over and over again why I needed to do what I was doing for her. I got fed up and I just blatantly, but professionally said to the patient, "You are being very rude. I am being nothing but nice to you and trying to help you. You don't need to be rude." Of course, she goes on to say, "You're being rude." Yet, her tone was different and not as brash. I said "How?" She said "I called for you three times this morning and you didn't answer me."

I chose not to explain myself because earlier in the day I already told her that I have 5 other patients to tend to and not just her. So I just asked her, "Would you like another nurse?" No response. She continues to rant and rave and then says she hasn't gotten any sleep. I tell her "I'm trying to take care of you and when I'm done doing the things I need to do for your well being, I'll do our best to let you sleep." She voices a few more petty complaints and I ask her again if she'd like another nurse. Again, no response and stays quiet.

Later on, I learn that the patient told a few of my colleagues that she thought I was 'too professional' and that I needed to loosen up. If a patient can talk behind my back and not to my face, its on them. You have an issue, be man or woman enough to tell me to my face WITH respect. I didn't like being treated that way and I literally saw myself going into that room and beating/choking the patient, so I switched the patient with a colleague.

I laugh now at it because looking back at the interactions and the patient's history, she had a SLEW of issues and it had nothing to do with me. I'm learning as the days go on:nurse:

Otherwise, I love my job and the rest of it is gravy. Experiences like this one will help me handle the next prick that much better.

Meraki · Mar 10, 2010

Delusional patients have fixed false beleifs - however these beliefs and the thought process that surrounds them could not be more real to them. So whenever you are talking to someone who has delusional thinking, anything you say will be interpreted by the patient through the filter of their delusions, leading to a many misinterpretations.

So because they are reading into your actions and words, and often with some paranoia, it is often preferable to limit your words and interactions. Keep your voice 'simple' without too much emotion or expression, say only what you need to (the more you say the more there is to misinterpret), avoid using humor until you know them and how they react and generally, and watch your non verbal body language, again keep it simple. You can absolutely still be friendly - just tone it way down, knowing that they are hearing and seeing you through a skewed lens. That's why the straightforward no nonsense approach works well - it is simple and to the point.

Delusional is quite different than having a personality disorder..their cognition is quite distorted but not usually delusional.

Boundaries and keeping the relationship professional is important across the board.

Don't take any of it personally - it isn't about you at all. Each time you deal with different types of mental illness you get a slightly better idea of what works, although different people may react differently!

DirtyBlackSocks · Mar 10, 2010

I've found that psych patients, while crazy, are highly intelligent at the same time. Able to form cognitive thought processes based around assessments they see. This is why nurses are frank and to the point with most of them - if you let your guard down they will find a way to get under your skin.

A lot of people make the mistake of thinking mentally ill patients are somehow stupid - to the contrary most of them are highly intelligent. Patients who suffer from delusions can be especially adept at getting under your skin if this is the case.

Just shrug it off - it's not really their fault when it comes down to it, if you find yourself performing suboptimal care because they put you into an altered emotional state, request to have another nurse care for them.

It is what it is.

ozoneranger · Mar 10, 2010

There's nothing like the delusional patient to spice up your night. Some of them were so insightful...they'd push your buttons as though they'd installed them personally.

I worked in pulmonary for years, so add hypoxia to delusional & you had the mix for quite a shift.

About 6 months into my 1st. year out of school I had a little old fella with severe COPD + dementia + sun-downers, throw in some Tussionex for good measure & whoopee...here we go, he was a handful for the entire staff.

A couple of nights into his stay I discovered he'd been a shoe cobbler all his life. I went to my mom's house & found an old pair of her heels & took them to him. He considered the shoes for a moment, then told me he was really back logged, but he'd see what he could do.

Shazam.

He 'worked' on those shoes all night, reaching for this tool....or that. Every night, for 2 weeks I'd bring him the shoes, he'd complain about his rising costs, offer me a deal (I was a good return customer, after all).

We no longer had to restrain him, and never again had to lift him from the floor, or chase his buck naked butt down the hall.....he had a job to do. No time to play.

Inside, he was really a sweet, kind man who'd lost grasp on reality. I don't know if it was right or wrong to feed his delusion, though it did calm him......the security of a familiar place.....though only in his head....seemed to ease his anxiety.

If only that worked on 'em all......

pinkiepie_RN · Mar 10, 2010

It is often necessary to set firm limits with patients and reality orient if possible. I've spent the past two shifts in a row with a patient who is delusional and psychotic and like someone else said, psych patients are smart and can often exploit weaknesses and it can be helpful to call a patient out on their behavior and say they're being disrespectful.

leslie :-D · Mar 10, 2010

Inside, he was really a sweet, kind man who'd lost grasp on reality. I don't know if it was right or wrong to feed his delusion, though it did calm him......the security of a familiar place.....though only in his head....seemed to ease his anxiety.

i tend to agree with you.

however, i did get kicked off the locked-unit on my psych rotation (in school) because i enabled the pts too much. :rolleyes:

an allegedly "dangerous and violent" schizophrenic (a pt i begged for) looked at me and said "you're one of the good guys" and i said, "yes, i am".

my instructor hauled me away, telling me i should've told him "my name is leslie and i am a sn".

another end-stage aids pt (w/aids dementia) was literally crying, insisting "they" were trying to take his baby.

i 'pretended' to hold it, assuring him i would keep the baby safe.

again, hauled off and after asking to shake the hand of a manic pt (he told me he was president of the us), i was permanently removed from the unit.

yet ea interaction i had, seemed to placate the pt.

i just don't know what is truly therapeutic.

leslie

Jules A, MSN · Mar 10, 2010

i tend to agree with you.
however, i did get kicked off the locked-unit on my psych rotation (in school) because i enabled the pts too much.
an allegedly "dangerous and violent" schizophrenic (a pt i begged for) looked at me and said "you're one of the good guys" and i said, "yes, i am".
my instructor hauled me away, telling me i should've told him "my name is leslie and i am a sn".
another end-stage aids pt (w/aids dementia) was literally crying, insisting "they" were trying to take his baby.
i 'pretended' to hold it, assuring him i would keep the baby safe.
again, hauled off and after asking to shake the hand of a manic pt (he told me he was president of the us), i was permanently removed from the unit.
yet ea interaction i had, seemed to placate the pt.
i just don't know what is truly therapeutic.
leslie

Has this been a while ago, Leslie? Unfortunately what is considered therapeutic seems to vary depending on what theory is in favor at that time. I believe there is room for both reality orientation as well as being supportive of some delusions in the interest of soothing an agitated patient. Depends on the situation and the patient, imo.