Manipulative, attention-seeking, impulsive, demanding pts

[Neurotic Student]

How do you deal with a pt like this?

I am the only female working in an all-male unit so often more than not, there are pts that want to talk to me, and I don't mind talking to them as long as they are respectful.

What I can't stand are manipulative, attention-seeking behaviors, and with threats of aggression/violence as a way to manipulate. Rarely I will get someone like this, but when I do, I don't know what is the best thing to do: give them the attention or ignore them. They keep it up when I ignore them, and I don't want my staff to get hurt. Male pts won't hit me but they will hit my staff(male). If I give them my attention, they will want it constantly and I can't get my work done. I also feel disgusted with myself when I baby them. They will start telling me they hear voices telling them to hurt themselves or hurt others if they want my attention. I can't accuse them of lying, because I don't truly know that. And plus, if I do accuse, that will make them more agitated.

I have a pt right now doing this, he is of a bigger stature. I don't know if he is all talk or if he will actually do anything. He's on my unit but he had been on another unit recently 3 times. The staff from the other unit told me when pt was on his unit he had NEVER c/o voices. He's been telling me he hears command voices. We medicate but it takes a long time for him to crash. We have to offer PO before IM and he'll take PO all the time. We give a cocktail in the beginning of the shift, and he'll barely start to crash by the middle of the shift.

What do you do?

[angeloublue22, BSN, RN]

These patients are the most difficult ones to work with. He is getting what he wants by making these reports and acting threatening in order to get a reaction. He is also guaranteed good meds. Usually, with these patients, we will take privileges away and only give them back if they behave. Have you ever heard of a behavior contract? We usually employ them in these instances. It is a contract that the signs (usually written by the counselor) explaining his adherence to good behaviors can earn him rewards and bad behaviors, those rewards are taken away. This way it puts him in control. It is also something that you can refer back to. I've found that having something written that they signed takes the "blame" off of you when you say no. I used to have patients who would say, "You won't let me (do something or other)" But I would always put it back on them saying, "You have made the choice by acting this way. You are in control. When you have decided that you want to do (whatever they wanted) then you must decide to act in a responsible manner." Think of dealing with a 2 year old. I know it sounds mean but you seriously use the same tactics. When people say they want to hurt themselves (as a manipulation tactic) we park them in our eye site by the nurses station and they can't leave until the feeling has subsided. We also give them choices. For example, "You can either speak to me in a respectful manner now or you can take a few minutes to settle yourself and try again but I will not be disrespected." It's all about the illusion of giving them choice and control because in the end they really do have a choice and you are helping them make better ones. This is how we did it at my hospital, it may not be feasible at yours but hey they're ideas, right?

[Katie002]

Sounds like he needs a Pysch consult.

[nurse lala, BSN, RN]

You give the right attention. If he is acting threatening he needs to be directed to show he is in control or go into the quiet room. He can have a PRN if indicated but the PRN is to calm, not to knock him out. He stays in the quiet room until he is in control. If he escalates, so do the restrictions. Violence needs to be stopped immediately or we implement steps to control the situation. This is how psych nurses control the unit. We reinforce good behavior by spending quality, therapeutic time when it is indicated and in cases like this, earned. You diminish bad behavior by addressing it with behavioral controls which help modulate volitional disruptive behaviors.

Manipulation is one motivation for aggressive behavior. But keep in mind that whatever the motivation, once behavior begins to escalate, you need to stick to the safety script. You are not obligated to entertain their desire to dominate your time if they are unable to be calm. That only reinforces the manipulation.

[lasair]

Never believe that a male patient will not hit you because you are female,

[Thunderwolf, MSN, RN]

Excellent advice.