Manipulative Behavior - How to Deal

Davey Do · Jul 23, 2015

hopefully you find it helpful

Wow, JustKeepDriving, that is some excellent documentation!

Being a chronic malcontent, I could critique it some, but the quality and readability of your documentation is outstanding!

celery_juice · Jul 23, 2015

JustKeepDriving -

I found your post really helpful in understanding when it is appropriate to set limits and try other methods. Thanks so much!

Jules A, MSN · Jul 23, 2015

If I was back in a forensic setting I would have just been able to call my provider and say, "Hey, patient is staff shopping for Ativan for anxiety (with SBAR). Can we change that medication to Vistaril so that we can still control acute anxiety but lessen the medication seeking?" and would have gotten the orders 9/10. Unfortunately in inpatient acute care we're heavily judged by patient ratings of our care and EVERYONE is terrified of getting rated poorly. .

What a shame and thankfully where I work my RNs have no problem making that call to me when needed. Actually in my capacity with addictions most times if they aren't happy with my service I'm probably doing an excellent job of keeping them safe and alive.

FPMHNP2019 · Nov 8, 2019

I read through the post and am trying to find some info I need. So I had this woman who was well known for DKA due to non-compliant and alcohol abuse. She said she drinks hard liquid and 20 shots a day. So she was admitted on 11/5 7:00am(her last drink was 3am)to ICU, stepped down to M/S on 11/6 and today is 11/8 at 7:00am, she scored 15. 1mg Ativan, 12.5mg phenergan given and if she could, she really wanted that 5mg Oxy for her 7/10 headache and 7/10 belly ache due to chronic pancreatitis. All pancreatic enzymes were slightly elevated probaly, I dont quite remember. but she has been given IVF 125ml/ hour for over 3 days. Funny part about her scoring was: yesterday morning, before I left, I scored her 1 at 6:30am. then day shift scored her once at 12ish, which was 8, couple if doses of Oxy and one dose phenergan given, no Ativan. tgen afternoon around 4ish, scoted 3. I took shift report in the evening, she was still sleeping...Woke up at 21:00, all the symptoms came back, huge tremors. rated headache 7/10. All vitals were within normal range except HR upper 90, which was her baseline. no sweat...again, pt wanted ativan, phenergan and oxy. Funny thing I found most if drug seekers is they all claim zofran does not work and want Phenergan...phenergan is more sedative, of course. she has no s/s of nausea/vomitting at all. During the day, she has been eating regular diet...She refude Imitex, which was for her migraine. I told her Ativan and phenergan ok, but not with Oxy. I'll give her Imitrex if she really had 7/10 headache. So she could not even wait for 20 min before I could request the Imitrex from pharm before she was out cold....from 2130 to 630am. if not because the lab had to poke her, she'll continue to sleep. The minute she woke up, she demands phenergan ativan oxy...the while thing started again.

My question: you tell me she was not manipulating scoring? Tremors caused by alcohol withdrawal is very familar to me, but that kind of huge tremor, more like she was shaking her hands and arms, is uncommon without elevated BP, temp, and HR.

Some people say it's not worth of fighting against pt for 1 mg Ativan and it was given per order. I have experienced given Benzo and hydroxazine for withdrawal and snowes the pt, the provider came back and tring to blame me for it. This woman was not trsponding to verbal stimuli. I had to shake her to wake her up. What could happen when ot was given too much Benzo? It is provider's order, but it is also our nursing judgement and our licenses to give or not to give that 1mg Ativan because it is not just 1 dose of 1mg Ativan for manipulating patients. At some points, you have to stop and think "is it Ativan or your license?"