RSSArchive for February, 2018

Dealing with Difficult Patients: High-octane energy

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Mania or an elevated mood is hard to miss. People who are manic have lots to say; have lots of places to go; have a wealth of ideas to share; and just don’t have enough time to explain all of their theories, schemes, and plans. Much like the Energizer Bunny, people with mania keep going and going, often after all of those around them have dropped with exhaustion, or walked away seeking quiet and solitude.

People with mania, especially those who have hypomania (a milder form of elevated mood and elation), love their episodes when they can say “I get so much done,” “I become super creative,” or “I am on the top of my game.” An episode can go something like this:

At first, when I’m high, it’s tremendous . . . ideas are fast . . . like shooting stars you follow until brighter ones appear. All shyness disappears, the right words and gestures are suddenly there . . . uninteresting people and things become intensely interesting. Sensuality is pervasive. The desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria. You can do anything . . .

But then things take a turn:

The fast ideas become too fast and there are far too many of them. Overwhelming confusion replaces clarity . . .  you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened. Everything is now against the grain. You are irritable, angry, frightened, uncontrollable, and trapped (Spearing).

And therein lies the problem: While in manic episodes, people deplete all of their own bodily reserves, and the reserves of others. Those caring for the manic person become exhausted themselves, generally depleting all of their emotional as well as physical energy reserves.

Making sense of manic patients

Don’t panic: When we are faced with dealing with a manic patient who is out of control, it can easily make us feel out of control too. Here are a few things to keep in mind:

  • The patient is being controlled by his or her disease. Control of behaviors and feelings is simply not possible.
  • The patient lacks any insight into his or her behavior. People in manic states do not realize they are sick, and they are unaware of the consequences of their behavior. They reject any idea that any illness is involved, and they find excuses to try to make sense of what is going on around them.
  • The patient with mania becomes frustrated, often with others who cannot keep up with him or her. The patient may lash out and show his or her frustration in inappropriate ways. It often appears that the patient knows exactly how to push your buttons, or knows the exact things about which you are most sensitive.
  • The patient with mania is hyperalert. People in manic states are hypervigilant and are often aware of things going on in the environment that others do not pick up on.

Ways to prevent cycling
When working with manic individuals, you need to help them prevent the exhaustive cycles they live through. Although that is not always possible, you can help them identify and attempt to avoid the triggers that may lead to a mood swing. One of the most important aspects of managing manic episodes is to stick to a routine.

You can also help patients:

  • Set realistic goals. Having unrealistic goals can set up the individual for disappointment and frustration, which can trigger a manic episode. Advise the patient to do the best he or she can to manage his or her symptoms, but expect and be prepared for occasional setbacks.
  • Get help from family and/or friends. Everyone needs help from family and/or friends during a manic episode, especially if he or she has trouble telling the difference between what is real and what is not real. Having a plan in place before any mood changes occur can help the individual’s support network to make good decisions.
  • Make a healthy living schedule. This is important for those with mood swings. Many people with manic episodes find that sticking to a daily schedule can help control their mood. Some examples include regular meal times, routine exercise or other physical activity, and practicing some sort of relaxation each night before bed. Also, you can help to provide a balanced diet for the patient, focusing on the basics: fruits, vegetables, and grains, and less fat and sugar. Exercise uses up some energy and helps a person sleep better. Help the patient develop an exercise plan that fits his or her lifestyle. While in the hospital, taking walks around the unit during the day may benefit the patient.
  • Get enough sleep. Getting a good night’s sleep may be a challenge for a person with mania. Being overtired or getting too much or too little sleep can trigger mania in many people. While the patient is under your care, make up a schedule for rest and relaxation before sleep. Have the patient go to sleep and get up at the same time every day, and relax by listening to soothing music, reading, or taking a bath. Do not allow the patient to watch TV in his or her room.
  • Reduce stress. Anxiety can trigger mania in many people. Ask the patient what helps him or her relax. It might be calming music or a meditation tape. Avoid those things that hype people up, such as watching violent shows on TV or listening to loud music. Helping the person reduce stress in general at home and at work might help prevent episodes. Advise the patient to ask for help: A young mother may ask her spouse, family, or friend to take care of some of the housework. If the person’s job is proving to be too much, he or she can scale back some responsibilities. Doing a good job is important, but avoiding a manic mood episode is more important.
  • Avoid stimulants, alcohol, and drugs. Many people with mania may turn to substances to try to avoid a manic episode, or stimulating substances to elevate their mood. Up to 60% of people with mood disorders also have substance abuse problems. This self-medication may give them some temporary relief, but it will make their condition worse over time. Tell the patient to eliminate the use of caffeine, alcohol, and recreational drugs (Spearing).
  • Stick with treatment. It’s essential for people with mania to continue their medication and get regular checkups. It can be tempting to stop treatment because the symptoms go away. However, it is important to continue treatment as prescribed to avoid taking risks or having unpleasant consequences associated with a manic episode. If the patient has concerns about treatment or the side effects of medicines, talk with him or her and caution the patient not to adjust the medicines on his or her own.

Reference
Spearing, M. (2002). “Bipolar Disorder.” National Institute of Mental Health. Available at www.nimh.nih.gov/publicat/bipolar.cfm.

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.

 

Dealing with Difficult Patients: Suicidal behavior

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Many nurses don’t feel comfortable completing a suicide assessment. Some nurses can’t imagine anyone thinking that killing him or herself is the best solution to any problem. However, many of the patients we serve have thought that way and some are actively suicidal, and we are not even aware of it. Being aware of the signs of suicide, and making a suicide assessment, can save your patient’s life. As with many other assessments, practice facilitates mastery. This chapter will give you lots of guidelines and tips to help.

It is important to remember that most suicide attempts are expressions of extreme distress, not harmless bids for attention. Also, any person who has expressed suicidal ideation should not be left alone and needs immediate treatment.

What if I think someone is suicidal?

One way to determine whether a person is thinking about suicide is to ask directly: “Are you thinking about suicide? Are you planning to kill yourself?” Doing this will not plant thoughts in the person’s head. Doing this will not cause the person to consider suicide if he or she was not thinking about it. Doing this will not cause the person to try suicide. By asking directly, you show you are not afraid to tackle the hardest of situations, and it is a way to show the patient that you can be trusted. Suicidal individuals seek out those whom they trust and feel connected to in some way. One of the most important factors in preventing a suicide is the presence of a supportive person.

Don’t panic: If a person does tell you that he or she is suicidal, here’s what you can do:

  • Stay calm and listen.
  • Let the person talk about his or her feelings.
  • Be accepting, and do not judge.
  • Ask whether the person has a plan, and if so, what it is.
  • Don’t swear secrecy.
  • Do not leave the patient alone. Take him or her with you if you must, so you can get help.

Don’t ignore the warning signs

All mentions of suicide must be taken seriously. Warning signs include:

  • Thoughts or talk of death or suicide.
  • Thoughts or talk of self-harm or harm to others.
  • Aggressive behavior or impulsiveness.
  • Previous suicide attempts, which increases the risk for future suicide attempts and completed suicide.

Assessing the possibility of suicidal thoughts

Ask the patient the following questions to assess the possibility of suicidal thoughts:

  • You have been through a lot lately: How has that affected your energy (appetite, ability to sleep)?
  • Many people in your situation may feel sad and blue or depressed: Do you feel that way?
  • Have you ever felt so sad and blue that you thought that maybe life was not worth living?
  • You have been in a lot of pain lately: Have you ever wished you could go to sleep and just not wake up?
  • Have you been thinking a lot about death recently?
  • Have you recently thought about harming yourself or killing yourself?
  • Have things ever reached the point that you’ve thought of harming yourself?

If the person says that he or she has thought about self-harm or suicide, the next step is to assess whether the person has a plan and the ability to carry out the plan. Ask questions such as these:

  • Have you made a specific plan to harm (kill) yourself? If so, what is it?
  • Do you have a gun (knife) available for your use? (Find out if the person has access to accomplish the plan.)
  • What preparations have you made? (This might include purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid being found, and/or practicing the plan.)
  • Have you spoken to anyone about your plans?
  • Would you be able to tell someone if you were about to harm yourself?

Keeping the patient safe

Your next step is to make sure the patient is safe. Most facilities have policies about levels of observation or supervision for patients who are a suicidal risk. There is also a process for further assessment of the patient. Again, never leave a person who has expressed suicidal thoughts alone. Take him or her with you to get help. Always read and follow your facility’s policies.

In general, there are some universal safety measures to take with a person who is suicidal:

  • Keep the person on continuous observation, such as 1:1 or in your line of sight.
  • Restrict the person’s environment for safety. Ask the person to remain in a certain area where staff members can see him or her at all times.
  • Do not allow the person to be alone in a room.
  • Check the person at intervals of five, 15, or 30 minutes.

Staff supervision is necessary when a patient uses items such as sharps (nail cutters, razors, or scissors), cigarettes, and/or matches; is around potential poisons, such as cleaning supplies; uses the bathroom or kitchen; and/or goes off the unit for treatments, therapies, or tests.

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.

 

Dealing with Difficult Patients: Behaviors that drive you bananas

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Does a certain group of patients simply drive you bananas? Sometimes you can’t put your finger on it. Something just doesn’t fit for you. Then, someone points it out to you by saying, “Don’t you see how he or she is manipulating you?” Oh, that’s it! He or she is a manipulator and the problem is solved. Or is it? What is manipulation? How does it get in the way? Can it ever be a good thing?

Persuasion, influence, and manipulation: What’s the difference?
Persuasion and influence are often seen as positive traits. We look at people who seem to be able to encourage others to get things done and wish we could be more like them. Indeed, very popular books have been written that teach others how to persuade or influence others. For example, there is a famous book by Dr. Jerome Frank—now updated by his daughter Julia—called Persuasion and Healing. It elucidates the positive influence of therapeutic relationships and other psychological healing  techniques. In addition to this classic for healthcare providers, numerous pop books on the market give lots of hints on how to stop arguments by persuasion, get projects completed by influence and persuasion, and further your career by using your influence and persuasion.

Bothersome behaviors
Rather than using the label “manipulation,” let’s refine the definition and talk about the specific behaviors that drive us bananas. Then, let’s look at ways to handle these behaviors in our work situations.

Whether we see them in patients or our peers, the following are some behaviors that cause distress in the workplace.

First, we have the overt types of behavior that come across as verbal violence. These are often easier to handle because they are so overt. It is hard to miss them. They include:

Making demands: “I must have this weekend off to attend my cousin’s graduation,” or “I can’t go to x-ray until after I have my shower and shave.”

Violating rules and routines: A staff member consistently comes back from break or lunch late. A patient’s family member brings in food from home, even after being told that the patient is presently on a very restricted diet.

Making threats:
“I’ll throw this food tray at you if you come any closer.”

Then, we have the more passive types of behavior that are meant to persuade you to do what the person wants. These might be harder to spot. If you grew up with adults who used these, you may even think they are healthy behaviors. Once pointed out to you, however, they may become more obvious.

Eliciting pity:
The staff member who says, “You just don’t understand how hard it is for me to take care of that patient . . . ,” but says this often about all kinds of patients. Or the person who is abusing drugs: “If you had my horrible upbringing you would take drugs to numb your pain, too. Can’t you see how tough my life has been?”

Ingratiating and flattering:
The person who is always commenting on your clothes, your jewelry, and how good you look. Or the patient who says, “You are the best nurse on this floor. I don’t know what I would do if you took a day off.”

Evoking guilt feelings: When people say, “If you had called me over the weekend like you said you were going to, this would never have happened,” or “If you had made your rounds earlier like you usually do, I wouldn’t be in this mess.”

Abusing compassion: When patients say, “You acted like you were a caring person and said that you would have a hard time on a restricted diet, so why are you making such a fuss over my wife bringing me food from home?”

Attempting to exchange roles: When someone says, “I see that you have a problem with your weight. I am a fitness trainer and can help you with a personal plan to get you in shape. When you get a chance, come back and we’ll start on it.”

Pitting people against each other: When a peer says, “That night shift is something else. I don’t see them making rounds or doing any of the things I know they should be doing at night. You guys and gals on the day shift are top-notch.” Or when a patient says, “Who is that young doctor who came in here yesterday anyway? I bet you know a heck of a lot more about my condition than he does.”

Questioning competence or authority: When a patient says, “Now, honey, you just go take care of your other patients, and send in the charge nurse. I need a real nurse in here to answer my questions.”
Being overly dependent: People who allow others to do for them, do not accept self-responsibility, and then skirt responsibility if things go wrong. They say things such as “I am sure you know best. Just take care of that for me. I rely on all you nurses to make sure I get better.”

Using avoidance: People who change the subject when it comes up, avoid being around people they dislike, or are silent rather than open with their opinions. When they do speak, it is in order to avoid: “I can’t be on the same team as Susan. We don’t work well together.”

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.