What Our Patients Don't Tell Us

From The Floor

What Our Patients Don't Tell Us

Every successful nurse needs to be part detective!

By Genevieve M. Clavreul, RN, PhD
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I have always thought that being a nurse means being 50 percent caregiver and 50 percent detective, since patients rarely tell us the whole story. Am I saying that patients don’t tell the truth? Of course not! Though a very small percentage of patients do consciously lie, most don’t realize they are leaving out important information. There is a whole list of very human reasons why patients don’t always come clean.

As nurses, we have to rely on the patient’s case history, and in the case of NICU/PICU and Peds, we need the mother’s case history also. We must also do direct observation in order to get the full picture. Whether we know it or not, we wear our detective’s hat each time we observe a patient or listen in on their conversations (this is not to be confused with eavesdropping). By integrating all this information, we sometimes learn critical things that can have dramatic impact on the treatment and outcome for the patient.

A few years ago, I was working in a NICU in the San Diego, CA area. This particular NICU seemed to admit a higher than normal number of babies born drug addicted. Any nurse who has worked with drug-addicted babies knows the symptoms by rote, and after caring for a few you quickly learn to identify the telltale signs.

What the Young Mother Forgot to Mention

One night, as I came on shift, the team of nurses that cared for the patient I was assigned had convened an informal meeting. The central issue was whether to request that the infant under our care get a drug screening. It displayed all the classic signs of a drug addicted baby: the incessant crying that can never be quelled, the shakes, not gaining weight, always being hungry, and so on. However, what mystified the nurses was that the mother’s test at delivery was negative. Except for being very young (under 17 years of age), she worked diligently with the nursing team to learn how to breastfeed, bathe, and provide care for her newborn. At the conclusion of the meeting, the nurses decided that they would request that drug testing be done, if only to rule it out so that we could move ahead with appropriate treatment. I left the meeting to take a break, and as I entered the cafeteria, whom should I run into but the young mother.

As usual, she stopped to say hello and thank me for the care I was providing her newborn. Never one to be shy, I asked how she was handling being a new mother and coping with breastfeeding. She was jubilant as ever, explaining that between breastfeeding and her diet she was getting back to her pre-pregnancy weight. That’s when I noticed the can of diet cola in her hand, and I couldn’t help but ask her how many diet colas she was drinking every day. The answer left me stunned:10 -12 diet colas a day! At this point, I began to suspect that the drug the baby might be addicted to was caffeine.

I used this opportunity to praise her for being so ardent about breastfeeding, but I also stressed that going on a strict diet, especially one comprised primarily of diet cola, was not necessarily a wise thing to do when breastfeeding. I explained that she wanted her breast milk to provide as many nutrients as possible to her baby, and to do so, her body needed to have good “fuel” to keep her and her baby healthy.

When I returned to the unit, I suggested that the treating physician test for caffeine. Sure enough, the poor baby had such a high level of caffeine in his system that it could almost be described as poisoning. None of the nurses, myself included, had thought of caffeine as a possible cause of the baby’s symptoms. Yet, if it hadn’t been for the chance meeting in the cafeteria and the young mother’s comment about dieting, we might not have come up with the answer as quickly as we did.

Our patients don’t intend to withhold information. But, they may fail to integrate all the information and thereby omit a crucial piece of the puzzle. Sometimes this failure can have farreaching effects.

Sometimes Our Patients Outsmart Us

Back in the beginning of the HIV/AIDS epidemic, I joined with several other nurses to provide care to a friend of a friend, so he could spend his last few months in his own home. As fate would have it, he got accepted into the AZT trials.

While many of us may remember the horrible side effects from the early days of AZT therapy (before we knew to adjust the dosages), he was actually thriving. Then one day I came on shift earlier than usual and as he greeted me from his bed, I noticed that he was working on a project on his bed table. I got closer so I could see what had him so engrossed. I watched as he took his AZT capsules, emptied them, and then repackaged them so that he could take them one-third at a time throughout the day. No wonder he did so well. He had adjusted his dosage to be time-released throughout the day. (Like so many AIDS patients at that time, he was emaciated and the dosage he had been prescribed was for an average weight patient). The question that remained was, did he ever tell the clinical trial investigator that he was doing this? Something tells me he never did.

Sometimes our patients learn to outsmart us. My daughter’s physician threatened repeatedly to place her on blood pressure medication if she couldn’t bring it under control. So my daughter, ever dutiful, worked on lowering her blood pressure. She dieted, reduced her intake of salt, everything that the nurse and physician had said would help. Yet, there were still times when the readings were high regardless of the interventions.

Then one day she took an early morning doctor’s appointment instead of going in the late afternoon as was her custom. The physician commented on the great strides she had made in lowering her blood pressure. My daughter, no slouch when it comes to putting two and two together, wondered if the time of day had any effect. As a test, she scheduled her next appointment in the late afternoon, and sure enough, her blood pressure reading was through the roof. She followed up that visit with an early morning appointment and the result was a lowered number. From that point on, she only scheduled doctor’s appointments in the morning, before the stress of her job and lateness of the day caused her to have an unfavorable reading. My daughter didn’t ever share this strategy with her nurse or physician. She justified her silence with the reasoning that she made her care providers happy and didn’t have to take extra pills.

The Mystery Coma

Embarrassment or cultural taboos are common reasons why our patients may not be completely open with us. Once, at the end of my LVN training, I was assigned a patient who had been admitted in a coma with no known cause. Tests revealed an elevated zinc level. Nothing in his history or in the information provided to us by the family shed any light on either the high zinc readings or the cause of the coma.

The physician ordered treatment for the elevated zinc and in a short time our patient was out of his coma and doing well. We discussed the results of his test with the patient and prepared him to return home. Since I worked the 7 pm to 7 am shift, I often got upset that the janitorial staff expected the night nurses to do janitorial chores on top of their nursing assignment, but not this night. Because, as I reached down to take the trash out, I saw two used tubes of Preparation H (which has a high zinc concentration), and I asked myself, could it be that simple?

I shared my discovery with the other members of the nursing team, checked the chart, and confirmed that the Preparation H had not come from the hospital. I shared my findings with the physician, and though neither of us thought the patient would have used the entire tube at one time, we also had nothing to lose in asking him. Though embarrassed, the patient confirmed that he had being using it, and that he had not realized that he shouldn’t apply the entire tube all at once.

Patients don’t start off with an agenda to misinform or lie to us, but they almost always want to please and appease us. This is why, as nurses, we sometimes need to put aside our stethoscopes and put on our deerstalker caps and “detect.” We must make sure that we are not only listening to, but also hearing, what our patients are telling us. We must ask questions in such a way that they solicit the answers that we need, and that we do not discount what we observe.

I always encourage nurses to follow their instincts. Often it’s that “little voice” that has picked up something the conscious mind has overlooked or ignored. By trusting our instincts, integrating available patient information, listening to the context of what our patients (or their families) are telling us, and by applying the nursing skills learned both in school and on the job, we are able to provide the best possible care.

Geneviève M. Clavreul, RN, PhD, is a healthcare management consultant and a former Director of Nursing.

This article is from workingnurse.com.

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