To believe or not to believe (the patient)?

Nemhain · Nov 7, 2005

I am a first-year nursing student and a somewhat skeptical person. Since a large amount of information that we obtain about a patient is self-reported from the actual patient, I'm wondering how do you know whether or not the truth is being told? What is the appropriate action to take if a patient is suspected of lying about there condition.....either for wanting more drugs, more attention, sympathy, etc.? What are some other reasons of why a patient would manipulate the system? Responses/discussions are greatly appreciated! :typing Thanks.

I always try and give them the benefit of the doubt. Sometimes you may never know if they are lying or telling the truth. I make an attempt to take what they're saying as truth. I don't ever call them on it in a confrontational manner if I suspect otherwise.

As far as pain...let's see...if I ask "mr. Jones" if he has pain and he says no, but I notice him wincing, grasping the bed rails and grinding his teeth while passing a kidney stone, I'll say, "Mr. Jones, you did say you weren't having any pain, but I notice that you're wincing and grinding your teeth, these are good visual indicators of patients experiencing pain. Can we talk about this?" If someone has had quite a bit of pain medication and they want some more I give as much as the doctor allows (providing that their vitals signs are okay ...heart rate isn't 10 or BP isn't 80/40). I'd rather give a little more to someone who is maybe wanting more than they need than to deny someone pain med who is in pain, but is able to laugh or smile. Besides everyone has different pain tolerances and not everyone grindes their teeth and swears when they are in pain.

When someone want attention...give it to them! Being ill is no fun and the hospital can be lonely. I take extra care with the ones that have very few or no visitors. I will do my charting in that pt's room. I've only had one so far where she wanted me to basically be her personal nurse and entertainer...no I can't do another crossword 'cause I've got meds to pass!!!

Not that you would, but I just need to say that a nurse should NEVER punish a patient for being annoying or wanting to get more attention out of you. Explain your duties and your boundaries. You don't have to like your patients, but they're still deserving of your best care! If you suspect you are being manipulated or lying for more pain meds speak to the nurse manager and discuss it with the patients doctor.

KatieBell · Nov 7, 2005

Most self reported information is either supported, or not supported by objective signs. What we get to do is to combine the subjective statements with the objective observations to make a complete picture.

For example: A patient complaining of SOB, may exhibit adventitious breath sounds, a low SpO2 reading, tachypnea, diaphoresis.

Or they may complain of SOB, and exhibit, hand tingling, clear Breath sounds, normal SpO2 reading, tachypnea....

Both patients are having a respiratory difficulty: One is acutely SOB for some reason (Asthma, Emphysema, CHF overload etc). The other is probably hyperventilating. Requires different treatment, even though both patients may present saying, "I can't breathe" Both require treatment.

Hyperventilation may not rank high on your idea of a medical problem, but for the patient it is. We get into trouble when we judge people for their complaints. But we do have to be able to match the subjective with the objective....

It is difficult to assess someone elses pain, and decide if they warrent pain medication or not, so I always go wiht the patients assessment of pain. This can be pretty hard to swallow when a patient states 10/10 pain and is merrily talking on a cell phone, clicking away at the TV... But better to err on the side of giving relief, than withholding because you made a decision to withhold based on your personal criteria for "What people in pain look like"...

Patients (who incidently are also health care providers), often manipulate the system for things like work excuses, pain medications, familial attention, disability benefits. It is important in these situations to stay neutral. If you suspect a patient is having a problem with addiction to prescription drugs, this may need to be assessed, but it is difficult to get this done- as drug seeking patients visit many different Emergency dept and are quite cunning in knowing how to obtain meds and create symptoms. It's also important to realize that the drug seeking is not personal- these patients have a problem and need assistance- like most patients, unfortunately their problem is that they are hooked on Rx meds. Most Nurses get into problems when they start to take the drug seeking behavior (which is often trying to patience) personally. The patient would have presented no matter who was working. (I try to tell myself ALL patients are seeking drugs, just some of them want antibiotics, antihypertensives, antiemetics...) Some things can be done via process to discourage this: for example, many hospitals have stopped using Demerol as it is not a great drug and gives drug abusers quite a high. We have stopped using Promethazine for many patients due to the side effects, preferring Ondansterone- which has less of the desired side effects that drug seekers desire, and very good anti-emetic effects. Someone initially prescribed these people these drugs, so many physicians are also under fire for unusual prescribing habits. Some of my worst drug seeking patients are "retired" nurses.

I stay neutral in family arguements, when someone in the hospital is playing martyr, and trying to manipulate other family members. This means, I make no statements about family members (unless it is an abusive situation), nor do I endorse any sort of comments such as "If you had agreed to bring Jimmy sooner, he wouldn't have gotten sick" This statement may be true, but, I try to say, "well, Jimmy is here now, so we will do what we can..." It is up to the family, not me, to sort out their issues.

I do the same for work notes. If a physician gives a work note, I give it, if not, I explain that I can not. Unless it is an obvious oversight by the physician I don't get involved. SOmetimes it is obvious that the person could go back to work, but I do not want to get into a mental pissing match over someone elses 1 day off work.

If a patient is on disability- and should not be, I suppose that should be reported to the appropriate people, but seems many times our documentation is what supports the disability, and some agencies encourage a certain type of documentation that allows their patients to stay on the accounts.

As far as lying about symptoms for attention. Well, most of us don't have enough time to be giving extra attention, but it is pretty easy to verify using clinical studies their complaint. If they continue to be attention seeking in dramatic ways (c/o can't move my arm, walk, etc) they usually end up getting a psych consult- which embarasses them and either sorts out an underlying problem (had a woman who used to consistently intoxicate herself with water...psych consult revealed all sorts of stuff, but she had been hospitalized over 20 times before this was suggested!) or the patient stops the behavior.

All that said, it is important to trust the patient. Some patients do not have a lot of experience with pain, and so a stubbed toe is agonizing...most really just want to get better, unless they give me some sort of overt signal I err on the side of trusting.

Oh my, well, I've written a book. Hope this helps.

hipab4hands · Nov 7, 2005

I give the patient the benefit of the doubt. However, if a patient tells me one thing, but thier actions are the opposite, then I will try to clarify what is going on.

As an example, if a patient calls and tells me that they are very sick and need a urgent appointment, I'll do what I can do accomate that request. However, if I arrange for an appointment and they start telling me they can't come in because they have to take the kids to soccer, go get a manicure or go to baseketball practice --then I have to start to doubt the severity of thier symptoms.

Nurse Cozmo · Nov 7, 2005

Until you have clear evidence to the contrary, I would consider it negligent to not believe what the patient says.

As far as pain medication goes, if there is a prn order for pain medication and the patient tells you that he /she is in pain, give them the medication. It is not for you to judge, pain is very subjective, believe what they tell you. If the patient has a suspected or admitted history of recreational drug use, that doesn't mean that they don't deserve good pain control. In fact, a person with a history of drug abuse needs more pain killers than the average person, because they have built up a tolerance.

Thunderwolf, MSN, RN · Nov 7, 2005

Until you have clear evidence to the contrary, I would consider it negligent to not believe what the patient says.
As far as pain medication goes, if there is a prn order for pain medication and the patient tells you that he /she is in pain, give them the medication. It is not for you to judge, pain is very subjective, believe what they tell you. If the patient has a suspected or admitted history of recreational drug use, that doesn't mean that they don't deserve good pain control. In fact, a person with a history of drug abuse needs more pain killers than the average person, because they have built up a tolerance.

Good post.

NurseLatteDNP, MSN, DNP, RN · Nov 7, 2005

During my clinicals I had a elderly patient who lost 7 lbs in one day after she recieved diuretics. She has recieved the same dose she was supposed to take at home every day. Fluid retention got her into the hospital (again), but she claims she has been taking the pills. After the doctor visited her, he told me that she could not have taken those pills at home, because she lost so much weight after she has taken them in the hospital. But there is nothing he could do, but believe her. So he had to order her an increased dose for home, even if there is an overdose danger.He said the best thing we can do is write down that you obtained the information according to patient. That would beck up his order for a inreased dose. But we do have to assume they are telling the truth.

lisa1130 · Nov 7, 2005

I appreciate all of the responses, advice and personal stories. I will definitely keep all of it in mind when I am confronted with such a situation. Thanks for all of the help....and feel free to share more similar experiences!