Manipulative Behavior - How to Deal

AJJKRN · Jul 22, 2015

Boundaries, oh beautiful boundaries!!!

Davey Do · Jul 22, 2015

obviously faking ETOH w/d tremors for their prescribed PRN ativan.

"Obviously faking" is a subjective interpretation. If it's prescribed and time for a dose, give it and objectively chart the behavior, s/sx and VS. The BP is usually risen in alcohol withdrawal.

Have your Patient extend their arms toward you, face up. You may note some fine tremors. Have the Patient turn their palms downward. Fine pseudo-tremors can be more difficult to fake without moving the entire limb. Not a 100% accurate test, but it is worthy documentation.

And remember: we are not Nurses to judge and pass sentence on our Patients. Substance Abuse treatment is like the old leading the horse to water axiom. We can only present the option, we can't make them recover.

Mandychelle79, ASN, RN · Jul 22, 2015

If I think they are exaggerating their tremors I have then stick out their tongue.

Jules A, MSN · Jul 22, 2015

"Obviously faking" is a subjective interpretation. If it's prescribed and time for a dose, give it and objectively chart the behavior, s/sx and VS. The BP is usually risen in alcohol withdrawal.
Have your Patient extend their arms toward you, face up. You may note some fine tremors. Have the Patient turn their palms downward. Fine pseudo-tremors can be more difficult to fake without moving the entire limb. Not a 100% accurate test, but it is worthy documentation.
And remember: we are not Nurses to judge and pass sentence on our Patients. Substance Abuse treatment is like the old leading the horse to water axiom. We can only present the option, we can't make them recover.

I like what you said about if the medication is ordered and the patient meeting the criteria. It covers your butt in the off chance they actually are having withdrawal s/s and also reduces the conflicts with those who have raging cluster B traits. As a provider I have to fight it out with them at times when I won't prescribe their wish list meds but as a RN you don't need to get into a struggle over something that has been ordered, if the time is right and it isn't contraindicated just give it.

Observing a patient when they don't know you are watching if you really doubt their tremors is another method to add your your assessment but just be careful. I'm all about not playing into enabling substance abuse however be very cautious with alcohol withdrawal. These patient can die. There have been instances where a patient goes into DTs because a nurse thought they were faking and didn't give them ordered PRNs. You absolutely don't want that to happen and I'd much rather a patient get an unnecessary 1mg of Ativan than seize and possibly not recover.

celery_juice · Jul 22, 2015

Observing a patient when they don't know you are watching if you really doubt their tremors is another method to add your your assessment but just be careful. I'm all about not playing into enabling substance abuse however be very cautious with alcohol withdrawal. These patient can die. There have been instances where a patient goes into DTs because a nurse thought they were faking and didn't give them ordered PRNs. You absolutely don't want that to happen and I'd much rather a patient get an unnecessary 1mg of Ativan than seize and possibly not recover.

This is what we were doing to a T. In this specific instance he was being observed without knowing and while doing so he was found to have zero tremor or symptoms, was eating and drinking perfectly fine, but upon entering the room he was suddenly so tremulous he could not sit still long enough for a blood pressure check.

With that being said, I do always err to the side of caution because etoh withdrawal can be dangerous, so he WAS being medicated according to Md orders.

celery_juice · Jul 22, 2015

"Obviously faking" is a subjective interpretation. If it's prescribed and time for a dose, give it and objectively chart the behavior, s/sx and VS. The BP is usually risen in alcohol withdrawal.
And remember: we are not Nurses to judge and pass sentence on our Patients. Substance Abuse treatment is like the old leading the horse to water axiom. We can only present the option, we can't make them recover.

I do understand this and should have given more objective information in my original post. So to generalize, am I to go along with any behavior regardless of whether it seems genuine based on observed behavior and assessments, because to question its "genuineness" would be judgemental and subjective?

Jules A, MSN · Jul 22, 2015

I do understand this and should have given more objective information in my original post. So to generalize, am I to go along with any behavior regardless of whether it seems genuine based on observed behavior and assessments, because to question its "genuineness" would be judgemental and subjective?

It sounds like you are looking for justification not to give a prn that a person is angling for and that is also subjective and totally your preference but imo should depend on your comfort level and assessment skills. What I used to use is the internal question "am I so certain this person has no history of withdrawal seizures and is not at risk that I am willing to wager my license and their life?" If so then "here is some vistaril for you" and there were times I was that confident just not that often. FWIW I usually give a standing order taper to the patients I have concerns of w/d to avoid the nasty peaks and valleys as well as the off chance a RN isn't able to administer prns as indicated.

Again in the case of even suspected ETOH or benzo w/d I'm more cautious and is it really worth getting into a pissing match over 1mg of Ativan? Do you want to be righteous or do you want a mellow milieu? In the instance you gave again I would usually tend to err on the side of caution but it sounds like you withheld the prn and thats cool if it all ends well.

celery_juice · Jul 23, 2015

Again in the case of even suspected ETOH or benzo w/d I'm more cautious and is it really worth getting into a pissing match over 1mg of Ativan? Do you want to be righteous or do you want a mellow milieu? In the instance you gave again I would usually tend to err on the side of caution but it sounds like you withheld the prn and thats cool if it all ends well.

He did receive the prn as ordered, I did not withhold it. I came here seeking advice on whether or not it would have been an appropriate circumstance to withhold and get into that "pissing match" you spoke of and see if maybe there were any other interventions I could have implemented. Instead of looking at me in a negative light maybe I came here for justification of not withholding it? Because I often do feel like im too "soft" with the patients in my care. From the responses, Ive gathered that I did the right thing by being cautious and giving the prn.

I've said in the past that Im new to this site and I also have limited experience and little to no guidance on my unit, so when I come here and ask things it really is coming from a place of genuine interest and a desire to work with this population and do right by them. Had I been with an experienced nurse that day, I would have been able to just talk to them. But I wasnt and so I came here.

Thanks for taking the time to reply to me, I do appreciate the insight

subee, MSN, CRNA · Jul 23, 2015

Maybe this topic should be moved to the addictions nursing section. I did a quick GoogleScholar search and found nothing. I'd love to see what the seasoned practitioners have to say on this topic.

JustKeepDriving · Jul 23, 2015

I've been in a similar situation - just not with ETOH withdrawal. I'm not comfortable enough with that to be able to say when a patient needs a PRN or not. However, in my situation it was with a drug seeking patient wanting the Ativan for Anxiety. Situation: 40 something revolving door patient with history of drug addiction, DSM Axis I MDD & Anxiety, and chronic homelessness admitted for SI (every couple of weeks) and on her most recent admission states she wants to go to a drug dependency center so she can have successful sobriety. I'm use to working in a forensics environment where I have a lot of autonomy in what PRN's are administered and which are held. In inpatient... not so much. So this is a similar replication of my charting to justify postponing PRN Ativan for anxiety (not ETOH... but hopefully you find it helpful):

Patient received at 0600 laying in bed with eyes open and unlabored breathing. Q15 minute checks maintained at all times. Self harm potential assessed throughout shift. Patient did not verbalize feelings of self harm, nor were self harm behaviors observed. Current level of precautions remains appropriate. Staff encouraged patient to engage in milieu and treatment activities, maintain medication compliance and attend meals in the cafeteria. Patient has disheveled appearance- clothing has stained and hair is unkempt. Psychomotor behavior is restless. Eye contact is appropriate. Speech rate and rhythm is within normal limits and vocal cadence is monotonal. Patient has flat affect, facial expressions are restricted and mood is dysthymic. Thought process is linear and thought content is appropriate to the situations with which patient is presented. Patient perseverating about Ativan throughout shift - asking to receive it earlier than PRN administration times. Staff have provided medication education and problem solving with patient throughout shift but patient has not engaged and continues to staff shop for nursing staff to call doctor for more Ativan. RN encouraged patient to engage in on unit groups... however patient refused and stated, "I'm not here to do those." Patient attended breakfast with peers and attended AM yard. Maintained compliance with AM medications. Rested in bed and read magazines during groups and paced around nursing station asking for additional snacks. Patient received on unit education about meal and snack times but did not engage and continues to ask staff members to notify the MD for additional snacks. Staff continue to limit set and explain the snack and meal times. Patient stated, "Am I supposed to starve?". Patient educated on caloric count of on unit snack and meals.. however patient did not engage in nutrition education. Patient attended lunch in the cafeteria and yard out. Compliant with 1200 medication administration. Patient approached RN at 1300 and requested his PRN dose of ativan stating "I know I can get it now... I have anxiety." RN limit set with patient and explained that she had to run recreational group. RN encouraged patient to attend and provided coping skill education on the advantages of exercise and deep breathing for anxiety management and that practicing effective coping skills could lessen medication dependence and provide better long term anxiety control with practice. Patient stated, "But if I don't get it until after group then I won't be able to take my following dose of Ativan until midnight!". RN followed up with statement and explained that PRN didn't mean 'on the dot' and just meant "When necessary for acute anxiety." Patient stated, "Well who cares if I'm on meds for the rest of my life? We'll all be on meds here. I mean what if I get anxiety about doing recreational activities in the yard!". RN provided reality orientation and explained that patient had just been in yard 10 minutes ago by request. Patient laughed and agreed to try alternative methods of anxiety control. Patient attended recreational activities with peers. RN encouraged patient to play basketball but patient refused and instead lay out on bench in the yard. Upon returning to unit patient reapproached RN and stated, "That didn't work, I want my Ativan now, I'm really anxious." Ativan 1 mg PRN administered at 1430 for increased anxiety. Patient observed laying in bed with eyes closed, unlabored breathing and occasional snoring during follow up. PRN effective. Patient ate dinner in the cafeteria with peers. Refused to engage in PM groups. Spent time in PM yard. Continued to staff shop for additional snacks and ativan throughout shift despite staff limit setting and continuing to provide medication and unit policy education. Continue to encourage patient to attend groups and engage in milieu activities, develop frustration tolerance, and engage in coping skill enhancing behaviors so that she can successfully reenter her community.

If I was back in a forensic setting I would have just been able to call my provider and say, "Hey, patient is staff shopping for Ativan for anxiety (with SBAR). Can we change that medication to Vistaril so that we can still control acute anxiety but lessen the medication seeking?" and would have gotten the orders 9/10. Unfortunately in inpatient acute care we're heavily judged by patient ratings of our care and EVERYONE is terrified of getting rated poorly. It's taking a lot for me to reorient my thinking. I'll get there eventually. Anyway, kind of related... but as I said, I'm not comfortable enough with ETOH withdrawal to give you a good example of that. Sorry. Hopefully some of this is helpful.

Davey Do · Jul 23, 2015

Observing a patient when they don't know you are watching if you really doubt their tremors is another method to add your your assessment but just be careful. I'm all about not playing into enabling substance abuse however be very cautious with alcohol withdrawal. These patient can die. There have been instances where a patient goes into DTs because a nurse thought they were faking and didn't give them ordered PRNs. You absolutely don't want that to happen and I'd much rather a patient get an unnecessary 1mg of Ativan than seize and possibly not recover.

Excellent points, Jules!

As far as enabling, objective documentation read by the prescribing Doc will put a real spin on the situation. For example, I'll also objectively document, along with the VS and Patient statements, that the Patient is smiling, laughing, joking, animated, etc.

It's up to the Doc if they want to continue a benzodiazepine for withdrawals if there's no clinical proof of a continued concern .