Manipulative patient

[freckles23]

So the other day I had this patient who came in for abdominal pain and found out she has gallstones that need to be removed. She is refusing surgery and refuses most of her meds. She really sent me for a loop hole the other day and I let her get the best of me. She kept ringing the call bell all night and having me run back and forth and I was pretty much on the brink of tears because I had 8 patients and this lady was trying to take advantage of me. She kept saying why am I not in ICU? So the doctor came to see her and he decided to keep her on our floor. She was basically trying to make herself decompensate and her ABG was all out of wack, and told the aide "im using my intelligence". I went thru one hell of a night and dreading going back. My main question is how much charting is too detailed? I mentioned what she stated about how she said no one went to check on her and no one cares and that she is dying and that she is using her intelligence. I that documenting too much if I quote what the patient is saying? I know they say too much documenting kind of is just as bad as no documenting at all. Also what are the best ways to work with manipulative patients without letting them get under your skin. Thank you!

[Nurse SMS, MSN, RN]

Exact quotes are the best way to document outlandish patient behavior. The important thing is that you document each time you were in the room and any time the patient makes statements that directly contradict any desire to be compliant. Keeping your emotions out of it or any kind of emotional interpretation on your part is the key. So instead of "Patient is being unreasonable", you chart Patient stated "I am using my intelligence" or some such.

[Been there,done that, ASN, RN]

Did you consider the cause for this behavior? If " her ABG was all out of wack" , it could be causing confusion and anxiety. What was done about the ABG's abnormalities?

[freckles23]

We feel it was more psych related and she is on 6L of o2 at home. She is a regular and they say she is always like this when she gets admitted. Her pH was fine so she was compensating. She was refusing bipap, she was not in any respiratory distress. Final result was a high flow NC sating around 92%. Intensivist was very angry when called because her vitals were fine and patient was in no distress.

[smf0903]

If she's refusing surgery and refusing meds/care, it's time for discharge papers.

[Crush]

Exact quotes, facts only with no interpretation. Also, include any patient teaching. If ABG is "out of whack" be sure to document any interventions, doctor aware and no new orders at this time, or patient refused doctors orders after education/rational explained, etc.

[Been there,done that, ASN, RN]

We feel it was more psych related and she is on 6L of o2 at home. She is a regular and they say she is always like this when she gets admitted. Her pH was fine so she was compensating. She was refusing bipap, she was not in any respiratory distress. Final result was a high flow NC sating around 92%. Intensivist was very angry when called because her vitals were fine and patient was in no distress.

If it is a psych issue, what does the psych consultation suggest? This is a doctor problem, as much as a nurse problem. If she is refusing treatment, the attending needs to handle it STAT.

In the meantime, set firm limits.. and I would assign this type of patient to a different nurse, each day.

Administration also needs to be made aware, as it disrupts the functioning of the unit.

Best wishes with borderlines.