difficult patients

I'm a fairly new nurse who has encountered a difficult patient. She has a bipolar diagnosis but is in my facility for rehab. She is in pain from RA with contractures. She questions all actions of the nurses and stna's. I'm opening this up to get suggestions on how to deal with this type of patient!
I work in psych so I deal with this type of patient a lot. Bear in mind that she has a mental illness as well as a painful debilitating physical one. That combination is not usually going to make for an easy, pleasant patient. My advice would be to not take anything personally and try not to engage in power struggles. Do what you can within your ability and that's all you can do. Try to remain calm and not feed into the negativity. Remain matter of fact and let her know what her choices are and that that is all you can do.

i let her know that if she wanted a different nurse that was her right...she questions my fingerstick method for accuchecks, my eyedrop method, etc....it's a control issue and i want to help her and let her be in control as much as possible but it's becoming rediculous..

Good move, dlrrn. Gathering data is an important part of the problem-solving process. Quote from dlrrn2010 She questions all actions of the nurses and stna's.

Just be kind to her. I know it is difficult but it will be easier for you just to smile. Maybe no one has been kind to her for a long time. Also give her choices and that will help with her control issues. For example, ask which finger she wants you to stick if you are checking BG. Ask which arm she wants her insulin shot in. Ask her what helps to reduce her RA pain. You get the picture. We get lots of these patients and kindness goes a long way.

He behavior does not come accross as having anything to do with her bipolar dx. Are you seeing signs of mania or of depression. Someone being "moody" is really not part of the dx. This behavior, to me, comes accross as more what we might see with an Axis II dx such as borderline personality disorder. However this could also just be her own personality. Being patient with her and explaining that she may do things differently and each nurse may do things a little bit differently but that you can assure her that she is being taken care of. Acknowledge how difficult it is to have others in control of her care when she is used to doing things for herself at home but that she can be assured that all of the staff is there to be sure she is well taken care of. It is not easy for some patients to feel a loss of control of their own health/care and they often times over compensate out of the anxiety this feeling creates for them. If there are things that maybe you could allow her to do herself this can help. Some units will allow a pt who is used to doing their own BG check to do it themself on the unit--yes with the nurse there supervising the entire process. Or even after drawing up the insulin letting the pt administer it to themself witht the nurse there and watching closely. I have worked in a couple of places where this was allowed. Think of times when a nurse may work with a patient newly dx with DM to assure that they are able to do the BG check and draw up and administer of the insulin as part of the pt teaching for d/c. We want them to be able to do this for themselves when they go home. So as long as the pt can do it safely with supervision what is the problem? Usually if you talk to the doc and the doc feels this is appropriate for the pt they will write this as an order for the nurse to monitor closely and the pt to test or give the insulin injection. This kind of thing can help a lot in giving a pt back some control of their care when they are really struggling and this is causing a problem. As long as you are professional and can deal with her in a kind and respectful way while letting her know that you need to do your job in a firm way it can be effective. Its all in how you package it. Being empathetic goes a long way.

Go to your happy spot, and answer her questions, before you enter the room take a deep breath knowing you're going to get asked a bijillion questions and just bite the bullet.that's how I deal with patients like that Michelle

I find that chanting "she has a mental illness, she can't help it" helps me sometimes. I'm sure my crying jags when I was in the throes of depression were no fun for my family to deal with, but I truly couldn't stop myself at that time...I figure it's gotta be the same with some of these folks. Even if they are able to recognize that their behavior is out of control, their psych diagnosis could easily be preventing them from being able to alter their behavior to a more acceptable level.We also tag team when we start getting frustrated. Of course, we present it in a way so that the pt doesn't know that's what's going on..."Jane is tied up in another room right now, and I have time to help you to the bathrrom instead. Is that OK with you?"

The patient has already lost control of her body and having the pain as well can be very depressing. Maybe the way she acts is her only control of anything

thanks for all the info....I've tried most of your comments, even offered to let her do her own accucheck but she declined...My STNA and I tag teamed and she was a good distractor so I could administer all the meds..I think that's what we will keep on doing for right now. Glad to hear your comments and know I'm on the right track! Thanks

Quote from dlrrn2010i let her know that if she wanted a different nurse that was her right...she questions my fingerstick method for accuchecks, my eyedrop method, etc....it's a control issue and i want to help her and let her be in control as much as possible but it's becoming rediculous..

Give her choices as much as possible to take away the resistance. If you tell her "We need to do your FSBG between 11-12:00, what time do you want it?, it saves her arguing about WHY it needs to be done at all. Distraction, just like you did with your STNAPerfect choice of interventions, keep up the good work.

You know, dlrrn, your post has really got me to thinking. There are so many times when Patients with Mental Illness or Personality Disorders or just PIA Patients try our souls. I neglected to mention one action that has a tendency to decrease the tension: Common Ground.If we can find a common ground, or some other way to identify, relate, or even have some sort of positive bond with a Patient it can greatly enhance the therapeutic relationship.Personally, I've found that if I can laugh with a Patient over some trviality, that comaraderie greatly decreases stress, making life easier for everyone involved.Just more I wanted to throw in. Thanks.Dave