Hmmm...I don't think one day is ever like the next in psych, but I'll give you my last shift, which is a pretty "average" one.
Arrived at 7am for handover - got 8 patients and allocated one nursing student.
Rounds and environmental check - greet my patients, check their environments for any sources of danger. Remove plastic bags, glass, fire dangers etc. As I go, patients approach me, distressed about this and that.
Talk to my nursing student about what she would like to learn today and allocate her two patients that I feel best meets those needs. Do meds with my nursing student.
THEN...the chaos starts. My aim is to have about 1/2 hour with each of my patients. I spend all day trying to do this. Expecting a baby to come in with child protection for a supervised visit with a patient at 10 -- I must be present for this, visit is one hour, so must plan my day around that. Have pt#2 that needs to go to x-ray to establish where the 6 razorblades he swallowed yesterday were in his GI tract. So must plan for that also as I must escort him. Pt #3 has florid psychosis and is most unhappy about being on the ward. She spits at me and declares me "unregistered as a nurse, and places a voodoo curse on me". She secrets medications as she fears I am poisoning her, so spend maybe 30 minutes sitting with her reassuring her of her safety, explaining what occurs in a person during psychosis and why they may feel that someone is aiming to harm them. She takes the Zyprexa wafer then rushes to the bathroom and scrapes it from her tongue. As she is on an order (as all my patients are), I must then call wardsmen to give her an injection against her will ... she cries and cries, and inside, so do I.
Pt#4 is a new admission - he is awaiting a place in a prison forensic unit, but my job is to work out whether he really is "crazy". Read his history and find that he nearly killed a woman a week ago. Decide to tread very carefully with this patient. He needs obs and bloods done. I sit across the table from him to discuss how he is feeling. I watch for signs that might indicate feelings of aggression...clenched fists, tight jaw, wanting to get up and pace. I see none of these, but sit across the table in case, knowing that if he becomes aggressive I have the table between he and I. When I feel that the coast is clear, take obs and bloods, explaining what I am doing at all times. I assess him as I go, he is telling me that he is hearing voices telling him that someone is going to die. I ask, "who is going to die? You, or someone else". He replies..."I am not sure, I can't hear them properly". I ask him if can dismiss the voices by asking them to go away. He tells me he can. I observe him from afar as I go about my work. He is not responding to internal stimuli, although he has told me that he sees things that he wants to pick up but they are not there. I add to my notes that as yet, he appears "not psychotic".
Pt#5 is a BPD patient and before I get to see her she lights a fire under the sensor which causes the doors to the unit to get thrown open and all the fire doors to close. She absconds out the front door. I press my duress and proceed on foot. Security is coming towards me and I signal to them who the patient is, but signal with my hand to "hold off". I catch up with her and she threatens to hit me if I come closer. I walk with her and tell her that she must come back to the unit and discuss discharge if that is what she desires. She states, "I am just going for a walk". Talk, talk, talk. Sit with her while she smokes. Eventually she returns to the ward with me. Deal with the fire brigade who have arrived for the 4th time this week.
Complete an ARC round.
My break has passed, and now it is 10am -- baby arrives. I help the young mum with breastfeeding and discuss some of the delusions she has had about wanting to hurt her child. The visit does not go well, and must end sooner than anticipated, as she is beginning to talk about "saving her baby by ending its life" ... she becomes upset and I cannot offer medication to her as she is still breastfeeding. Consult a couple of doctors about what might be safe for breastfeeding...awaiting response as yet. But run her a warm bath and encourage her into it. Post my student at the door to watch her in case she attempts to harm herself.
X-ray is calling -- escort my patient to x-ray and back. The razors are in the lower GI. I talk with him about what he needs to watch for in terms of pain and BM if they occur. Talk about the situation that led to his suicidality - depression and how it acts inside us. Discuss the side effects he is experiencing with his medication. Hold his hand while he cries.
Pt #6 is a long-term patient who I am trying to prepare for eventual discharge by planning leave for him with his mother. Make 4 attempts at discussing it with him. He wants leave but he cannot hold a conversation without becoming angry. End the conversation each time with, "I'm sorry, if you become abusive we must try again later." Final conversation ends with a fist smashing a wall next to my head. Give up on the idea of leave for today.
Lunchtime - I need a break, and I go. 30 minutes.
On return, medicate those who are unsettled. Deal with patients at the nurse's window who have run out of cigarettes, who want to give me a letter they want posted to the prime minister stating that he is "being kept prisoner here", hear from the police who are complaining that an unknown patient has been calling the emergency number repeatedly requesting to be rescued. Attend to UDS's, more bloods, more medication, more obs. Answer questions from my poor neglected student. Organise drug and alcohol consults. Field phone calls from distressed family members and members of the public who need psych services and want admission - re-route those to the crisis team.
1.20pm -- handover is in 10 minutes. Hurridly writes notes with which to handover my patients. Lament that precious little time has been spent with my patients. Resolve to find more time tomorrow. Handover.
Spend the last hour or so trying to get around and see my patients and tidy up loose ends. More phone calls. Chasing doctors for med chart rewrites. Check in with my student about her patients, check her notes etc.
2.45pm - short inservice on restraints and seclusion. I have been before so I cover the floor on my own. Do another ARC round. Encourage some of the boys to tidy up their messy rooms. A pt returns from leave intoxicated - breath and drug test. Do a search, find cannibis in his pocket which gets locked in our drug safe. Deal with a patient who is in tears because she is unsure if 12 packets of cigarettes is quite enough to get through the weekend. Get handed a complaint form from a pt who wants to lodge a formal complaint about his maltreatment on the unit. Receive a small silver balloon from a patient to say "thankyou" for helping her through a dark time. Attempt to clean a sink drain blocked with vomit from a man withdrawing from heroin who couldn't make it to the toilet ... unsuccessful. Give him some doloxene and call maintenence. Assist a distressed pt who has lost his "chime balls" worn around his neck that he believes protect him from winding up buried alive. He accuses me of stealing them. I find them, he is happy. Spend 10 minutes listening to him decipher codes in magazines and tell me what the birds have been saying to him.
3.30pm - time to go home!!