worldnurse

Hi! How fun! I don't often think of this anymore but it was sure an exciting experience in my nursing life and one of the big challenges. I had a Munchausen patient when I was working in a Pulmonary Acute Unit in my home country. I have to say, it took a lot of intense teamwork to care for her. This patient was very ill in her disorder and as many of these patients also educated as an LPN so she knew of all the symptoms she needed to display in order to convincingly "fake" a disease. This patient had like many severe Munchausen had also had her children taken from her care since she hurt them in order to get medical attention for herself indirectly. She was as I later learned the most severe Munchausen patient in my part of the country. She was transferred to us from ICU where she had been on a respirator, I kid you not, for no precise disease. And she had the tentative diagnosis "asthma". I immediately read through her charts and called the head of the acute psychiatry department who managed some CF patients with me. She came and had a education session, not with the patient, but with ALL staff that would care for her, physicians included, to help us get her discharged without incidents. Boy, I liked that woman. This patient was extremely manipulative. Nobody was allowed to talk to her about her medical conditions or her treatment outside almost word for word statements that had been decided upon. On the rounds there were always two or more of us so we all knew what had been said and only a limited number of staff cared for her at all. Absolutely no unplanned diagnostic procedures were allowed to take place, not even a BP or a temp or an O2 sat. She would frequently request them. Of course it didn't go all that smooth, the day before discharge she went to the bathroom, fell to the floor and said she has left-sided weakness and it must be a stroke. So we sent her to the CT which showed that she was fine and then followed the one KEY POINT that the psych doctor had taught us: Always give the Munchausen patient an opening to back out of her symptoms without being called a liar. So we told her: Sometimes these thing happen and all you need to do is wait, it can subside all by itself. Of course my doctor almost bit her nails off doing nothing, but I encouraged her to hold her horses and lo and behold, the next morning the weakness was all gone and patient subsequently discharged. I had her as a patient one more time, straight from the ER, with some diffuse lung symptoms. That time I knew how to deal with her and she only stayed with us a day since there was no clinical evidence of any disease. She never came back. In my mind, I think she sought help at specialities that were easier to manipulate. I might sound rough in the way we treated her but it seemed to me the only way to be fair and patient and respectful. It seems to me that many mentally ill people are looking for boundaries and that the more you back away the more they will push to find them. It is of course worth to note that Munchausen patients often die when they actually get a real disease and nobody believes them anymore. Thanks for letting tell my story,

I have a patient who was put on Coumadin because she clotted her graft so much between treatments. I have never heard of this being done for patients who clot during treatments, but unless it's contraindicated it might be something to at the very least suggest since Coumadin works on a different part of the clotting chain and it sure sounds like you patient has some hematological issues. Are his labs normal?

UF modeling is used at my unit. I do it only for some patients who have problems with "plain" dialysis without any interventions and I don't like seeing old unique orders for it unless it is actually used. There were plenty when I started but I have since removed all but one or two. I have one patient off who you simply can't pull much fluid the last 1 1/2 hours of the run or the pt will just crash. The first 2 1/2 hours however you can pull as much as you want to, even extreme amounts. So for that patient, UF profile # 1 is a good choice, since that will allow the patient to cruise at a very low rate for the last couple of hours. Another patient has severe cardiac problems that seems to go in cycles so for that patient we will sometimes try profile 4, although it seems that that pt will simply have a poor run anyway if that is the case. If a patient comes in with a lot of extra fluid we might also try profile #3 to see if it can help remove some of the fluid overload fast, especially if there is shortness of breath. I approach UF modeling very much as a team effort, and I always confer with my techs so that they can make suggestions and the treament will be evaluated even if I'm doing something elsewhere. Especially since we do have a couple of patients who does not tolerate UF modeling. UF modeling means raising their rate at some time during their run, either intermittently like profile #4 or at the beginning like 1 or 3 and some pts simply run bettter on an even rate. And if it ain't broke, don't fix it, as they say.

I often wonder the same thing when my patients clot away in spite of painstaking flush after flush. Here's a link to a sience article that confirms it doesn't seem to work very well for stable patients at least. http://ndt.oxfordjournals.org/cgi/content/abstract/21/2/444

At my company it is not allowed to turn off UF. I have been taught that it could cause a backflow with fluid from the dialysate going TO the patient just like ch10 was saying. Our minimum rate is 300cc/hr. If the pts BP is really low and he or she is symptomatic we will give saline to substitute for this loss instead of turning the UF completely off.

NephroBSN! Since I have used sodium modeling infrequently, I'm now very curious.... what will a sodium profile 155 to 140 do to a person? How does it alter the pressure and how are the fluid gains between the runs and the patients subjective experience of what I consider to be a quite extreme manipulation of their electrolytes? I'm just really interested to learn more, since I will most likely one day be a travel nurse and will encounter all manners of strange orders.

Hi! It seems to me there are "fads" in dialysis and that sodium modeling is one of them. A while back my company did a lot of sodium modeling as a means to keep BPs up during the runs. However, the overall opinion was that the fluid removal that was gained from the better pressures was clompletely negated by the fact that the patients on sodium modeling would gain much more interdialytic weight than other patients. It seems that regardless of how you set the machine, there always is a trace of sodium left in the patient when dialysis is over. The most common profile used at my company was the sodium profile 145 linear in which the sodium is gradually removed to 140. At my unit, sodium modeling is not used anymore, except when we get transfers who are already on it and even then we wean them off it as quickly as possible. And even if pts are on sodium modeling we are never allowed to go over 145 as a start level. Personally, if it wasn't so impopular I would like to see what difference just a little sodium would do, say 143 down to 140 linear OR step. But since the opinion currently is againts I guess I will wait. I'm sure with time sodium modeling will come back, just like the bellbottom pants at the bottom of my closet.