Delusional Patients (The "Saint")

[jdewberry]

I am a new psychiatric mental health RN at a State Psychiatric Facility. So far I feel like I have adapted well, except for one thing: I am having trouble dealing with delusional patients. (often with accompanying hallucinations)

What to say, how to have a therapeutic relationship with them, ect.

I understand that these delusions are very real to them and we are not to dispute them. However, how do we deal with them to reorient the patient back to reality based thinking?

I will give you an examples of my most challenging patient (names have been changed):

1. The Saint: Sally believes she is a saint. She hears voices from God and believes that she will be sanctified any day now. She is also a homosexual man. We call her Sal rather than Sally and sir rather than ma'am. She is very frustrated right now as she is the vegan saint of God and she is struggling sticking to the vegan diet. So she has stopped eating all together in order to stick to the strict diet. She does not want to sin because he has promised she will be sanctified any day now. She is also frustrated because he keeps telling her that he will sanctify her in 2 days and to have faith, yet 2 days come and go and she is still here. She feels as though she is stuck in a never ending labyrinth. She says she is not sleeping at all because she is hearing the voices around the clock now. She says they are sometimes comforting at night but has implied that they are getting to her. She states that god wants her to hear these voices all of the time though and wants her to stay awake, that is part of being a saint. She is also stating that it is a sin to take medication. She will absolutely not take it in any way shape or form. Lastly, she says that god will not sanctify her until she is no longer treated as a woman but is treated like a man in the hospital and is allowed to stay on the mens ward. We cannot do this as we have separated men and women's hallways and it is against policy and would cause major issues.

[Davey Do]

I am having trouble dealing with delusional patients.

I ask myself, jdewberry, Does your "trouble" have to do with the fact that Reality Orientating a Delusional Patient is probably not possible?

I understand that these delusions are very real to them and we are not to dispute them. However, how do we deal with them to reorient the patient back to reality based thinking?

Yes a Delusion is a false fixed belief in spite of evidence to the contrary, There is nothing that you can do to change this. Medication Therapy, such as Antipsychotics, can decrease Psychotic Symptoms.

What to say, how to have a therapeutic relationship with them, ect.

There's a Thread that I started sometime back. Maybe this will help:

https://allnurses.com/psychiatric-nursing/reinforcing-perception-reality-843349.html

The Best to you, jdewberry.

[Whispera, MSN, RN]

You can't orient someone who is in total belief about the unreal. What you can do is talk about the delusion and try to get to the thoughts and emotions surrounding it. When did it start? Did something happen shortly before it started? What exactly do the voices say? What feelings does the person have when hearing the voices? What would it mean to the person to be sanctified? Dig under the symptoms to find the reason they're present...

[vintagemother, BSN, CNA, LVN, RN]

You can't orient someone who is in total belief about the unreal. What you can do is talk about the delusion and try to get to the thoughts and emotions surrounding it. When did it start? Did something happen shortly before it started? What exactly do the voices say? What feelings does the person have when hearing the voices? What would it mean to the person to be sanctified? Dig under the symptoms to find the reason they're present...

For me, I find this is quite difficult. To delve into someone's personal thoughts feels intrusive. But I realize that getting the person to talk about their feelings and the content r/t their delusions will help me to provide more appropriate nursing interventions.

When I have to ask a pt how the voices make them feel makes me feel... Uncomfortable. But I know that by asking, it will help the pt develop more insight because it helps them to put their feelings and thoughts into words.

Yes, this is difficult, for me, and I assume, difficult for the pt.

[califoRNia.]

I've been a psych nurse for about two years now. Psychotic patients ended up being my favorite. :) With this type of patient Maslow's hierarchy of needs comes to mind. Your priorities become not orienting to reality but providing a safe environment, ensuring proper hygiene, ensuring proper nutrition, if she will not eat perhaps she will drink a high protein smoothie etc. Until the medication's kick in these more basic needs are a priority.