fake illness...how to rule out real injury

  1. So those in corrections know we deal with fake chest pain, fake abdominal pain, fake seizures, fake everything all the time. My latest technique I just discovered is....making them wait while I monitor them. Sometimes I'm not sure if something is real or fake, and if I should call the doctor or not. I've noticed that with several inmates that they just can't stand this, and eventually they will say they are fine and "can I go back to my unit now?" Obviously I would not do this if there were the possibility of a true emergency, but in some cases it has worked without endangering safety. Any other thoughts on how to rule out malingering?
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  2. 6 Comments

  3. by   Everline
    It is sometimes hard to tell, isn't it?

    Part of my assessment is to talk to the inmate and get them to answer questions in a detailed manner. If it's an emergency, it will usually be obvious...like stab wounds, head injury, etc. But other than this, I take time to assess them. Making them answer detailed questions about what is going on often distracts them from acting. They begin to talk normally and breathe normally. I've noticed some inmates simply want someone to talk to them and attend to them for a little while and then they are okay. I also find that when they come for chest pain and I tell them I will have to do an EKG, they often say they feel better, don't need that. (I still have to do one, though!) Those in real distress will want it done because they are truly afraid they might be having a heart attack, for instance.

    I realize how important it is, working in corrections, to keep up with assessment skills and never become complacent about learning and growing as a nurse. We need to be on top of it.
  4. by   Orca
    One thing that helps to sort out the pretenders in seizure situations is ammonia inhalers. Chest pain is a little trickier. I start by asking the inmate to show me where the pain is, and to describe it. If it is along the midline, it is probably gastric. I still follow up with full vitals, auscultation of the chest and abdomen, and an EKG just to make sure.

    Many inmates have become very skilled at faking and properly describing symptoms, and you will occasionally be fooled. My motto is, better to be accused of doing too much than too little. Because of the high level of fakery, it is also easy to become jaded and dismiss something as faking without properly investigating. Don't fall into this trap, even if it is an inmate with a history of faking.

    My way of dealing with an inmate who has been a man down but claims to be ready to go back to his unit within 10-15 minutes is to keep him in a holding cell for observation. I explain that due to the nature of his complaint, I must make absolutely sure that he is OK before allowing him to return. My normal holding time is 2-4 hours, and our holding cells have concrete benches. Word gets out pretty soon that inmates can't use faking an emergency just to be seen sooner with no consequences.
    Last edit by Orca on May 5
  5. by   ilovewoundcare
    I check the objective stuff first before jumping to conclusions. VS, EKG, video camera feeds, what have you. For seizure-like activity, we have standing orders to draw prolactin and dilantin levels asap. Here's a trick for producing voluntary movements during a "seizure"- petting the patient's eyelashes. If objective data is not consistent with the subjective data I still pretend like I believe the patient. I ask them what would help with their problem. Then I give them something they didn't want, but isn't technically wrong.

    "Abdominal pain? Nausea, vomiting, diarrhea? Wow, that's a lot. What do you think would help?"
    "Gatorade would be nice. Oh, and I work in the kitchen. I probably shouldn't be working around food. Can I have a sick slip for a few days?"
    "Medical doesn't give out Gatorade. As for the sick slip, don't worry, I won't isolate you! Actually, so long as you wash your hands really well after you use the bathroom you shouldn't be a danger. Here, come to the sink. I'll show you hand hygiene. You have to get around the fingernails and wrist- that's where people usually forget. Now I'll have you demonstrate- there's an easy way to remember how long to wash your hands, too. Sing "Happy Birthday" two full times. I'll even sing it with you."

    They come for the sick slips, the restrictions, the meds, etc. Then they leave feeling silly and unsatisfied, but they rarely display anger because I acted like I took them seriously and cared about their "health condition." No one ever accused me of not educating my patients! It's such a fun game when you realize how to play it.
  6. by   Orca
    Quote from ilovewoundcare
    They come for the sick slips, the restrictions, the meds, etc. Then they leave feeling silly and unsatisfied, but they rarely display anger because I acted like I took them seriously and cared about their "health condition." No one ever accused me of not educating my patients! It's such a fun game when you realize how to play it.
    Sometimes the most aggravating thing you can do to an inmate is to give him exactly what is indicated for the condition that he reports. Most of them hope to leave with an OTC med, a lay-in from work or to be sent out to the hospital.
  7. by   NottaSpringChik
    Regarding giving the guy with the nausea, vomiting and diarrhea something other than gatoraid and time off.

    Nurse, "Actually, the doctor usually orders a full liquid diet for a few days. Do you think that might be helpful? Most people with all of the symptoms you mention are grateful for that."
    Last edit by NottaSpringChik on Jun 6 : Reason: quote not right.
  8. by   Orca
    Quote from NottaSpringChik
    Regarding giving the guy with the nausea, vomiting and diarrhea something other than gatoraid and time off.

    Nurse, "Actually, the doctor usually orders a full liquid diet for a few days. Do you think that might be helpful? Most people with all of the symptoms you mention are grateful for that."
    One of our docs at a former facility used to do this, and inmates who were hoping to finagle a really complicated diet order got really aggravated at him. He would tell them, "If you really can't keep anything down, maybe we ought not to give you anything solid for a while until we figure out what is wrong."

    Another thing that can be very revealing is to get a printout of commissary orders placed by inmates who claim to be having problems with culinary food, or who come in requesting special diets. Some of them request things so complicated that culinary would have a difficult time feeding them if we wrote an order. Another popular sport is claiming an allergy to foods that they simply don't like. We settled on allergy testing. If the allergy shows up on the tests, we record it in the inmate's medical file. If not, the inmate is charged for the test. A lot of "allergies" magically vanished when we started billing for negative allergy tests.

    We had a diabetic inmate who was baffling the doctor because of his inability to control his blood glucose level. One morning I happened to be doing unit rounds just as the unit officers were searching this inmate's cell. Literally stacks of packages of cookies and candy bars. I later told the doctor, "I can tell you exactly why you can't control inmate X's glucose levels, and it has nothing to do with your orders." Another inmate who came in demanding a low sodium diet for his blood pressure was ordering large quantities of chips, crackers, beef jerky, soup, ramen noodles, anything with a high sodium content.
    Last edit by Orca on Jun 6

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