Manipulative Clients

[ilovechadkrause]

Hello Fellow Nurses!

This week, I was assigned an elderly male patient, who was MRSA +, on isolation precautions, is SOB, oxygen via cannula, hx of falls & weakness.

We have discovered that he is becoming more reliant on staff to do everything for him... and I mean everything!

When we try to encourage him to do things more on his own and explain that it is good for him to maintain a high level of independence, he will either become belligerent, or agree with our suggestions only to continue his previous behavior.

I personally think he is lonely in isolation, and likely wants attention (which I can't blame him for). But some of his requests are becoming ridiculous, and simple things like administering medications or repositioning in bed turn into long, drawn out procedures because he always seems to have some sort of crisis going on.

I really want to have compassion for this guy, but his manipulation is kind of driving me nuts.

Any thoughts on how to handle situations like this?

Thanks!

[psalm, RN]

Is there any family member available to stay with him for meals, an afternoon of visiting, phone calls that you could work with to help him be more independent of staff?

It's one thing to truly need help, and with an isolation pt. lonliness is part of the package. Interest him in a TV program, crossword puzzle books, may help. I would also ask the physician to visit him and explain that this is an opertune time to rest, AFTER explaining the need for isolation and not to cry woof with the call light.

We all feel your "pain", as lonliness is a biggie with some pts. and it's important to not dismiss it...but nursing staff can't be expected to entertain the pt.

[Virgo_RN, BSN, RN]

Hello Fellow Nurses!

Any thoughts on how to handle situations like this?

Thanks!

With a sense of humor.

You don't say if you're in acute care or LTC, but sometimes we see this in the acute care unit, when a patient has been there for a long time. I think a big part of it has to do with their frustration at feeling powerless, so they try to control what they can.

[Straydandelion]

I agree he is probably lonely, but could also be depressed. Is there any activity he can be involved in with his isolation? It also might help if his room was close to the nurses station if it isn't, family visits encouraged, activity director getting involved if an LTC, chaplain/priest visits, possibly even a psych consult.

I remember one patient similar on the ortho floor. The nurses and patient finally drew up a "contract" between both parties which we all agreed to and followed. I can't remember the particulars but something along the lines of "guaranteeing" a visit for at least 5 minutes every two hours if the patient "guaranteed" would ONLY call if needed other times etc. We also made a special effort even if not our patient to wave to him from the nurses station. When he was finally well enough to leave everyone there came to tell him goodbye....for days he was missed, he had become close to all of us.

[mama_d, BSN, RN]

I work in a hospital, and sometimes when all else has failed, we inform them that if a patient cannot show us that they can safely care for themselves upon discharge, we have to initiate a multidisciplinary investigation as to whether or not skilled care is in order. Usually we get case management involved in broaching the subject, and it is usually used as a last resort. Honestly, though, given the deterioration of ability to care for themselves that some of these patients do to themselves, it is often the safest solution. It has to be handled very carefully though and presented as having the patient safety in mind otherwise they view it as a threat.

[twistedpupchaser]

On my current ward there is a LOL who presented for a minor complaint. Due to low Sats she was given O2, some how she decided she needed it every time she returned to the ward from a 4/24 cigarette break. After 2/7 of this she decided that she needed home O2, being a smoker however she was ineligible. In a protest move said LOL decided that she would not leave her bed, (and refused to be D/C) or remove her O2 for any reason, even eating is done with her Hudson mask on her forehead with frequent stops to catch her breath.

Initially she used a pan for ablutions but decided that this was not getting the desired effect so became incontinent of urine and feaces, which she then expected the NS to clean up. A tactic that some on the ward started using is to hand her everything she needs and walk from the room to give her privacy, without giving her a chance to argue, only returning when she rang the bell to let us know that she is finished.

After a few days of this she started getting out of bed to use the toilet and slipped fracturing her tibia. Then the incontinence started again and we are back to handing her the cleaning things, hopefully she will be D/c soon..........

[ilovechadkrause]

Wow - she sounds like a very stressful client. I guess in some instances, people, for whatever reason, are just unable to compromise and end up hurting themselves and those around them.

The one male client I spoke of in my original message has also started to become incontinent and also expects nursing staff to complete his entire care, even though he is capable of assisting.

The staff on our unit has begun to take a more direct and firm approach with him, which is starting to take effect. His wife is very involved, and visits him daily, which helps to keep him busy. She also seems to agree with staff that he can do more for himself than he is letting on, so she has also started talking to him about being more independent.

Thanks for all of your advice and tips! I also like the idea of having a room closer to the unit desk, and perhaps signing a contract (ex. visiting for at least 5 minutes q2h, and not using the call bell unless necessary). Very, very helpful! :)

[lovingtheunloved, ASN, RN]

I don't care how lonely I got, I'd much prefer to wipe my own orifice.

[CHATSDALE]

i wonder how much this patient understands his own condition

sometimes patients get the idea that they are much sicker than they really are esp if they require care like isolation, ivs [some believe that this is suppose to take the place of nutrition, if one shift gives him bedrest care and the next requires his participation

explain that the meds are expecting to put mrsa in remission, that the isolation is to prevent spreading it to his visitors/staff and to keep them from spreading to people he will never come in contact with

i hope that you have success with your patient...

[IamVickiRN]

I don't care how lonely I got, I'd much prefer to wipe my own orifice.

AMEN!!