Med-Surg Topic of the Week - Psych Patients

nursenatalie, ADN, RN · Sep 14, 2004

Well there are a couple different types of psych patients we get. We of course get the frequent flyers who have vague abdominal pain and have had every organ they can live without removed. Had a new type last week, it was a transfer from our psych ward because of hypotension. When I heard I was getting this patient I was hopeful that maybe they were too sick and the psychosis wouldnt be that evident. Well, the patient rolls onto the floor wearing her coonskin hat and singing Davy Crockett at the top of her lungs at about 1 am. I was furious, CNA checked vitals and pressure was 121/76!!!! I immediately called the medical doctor who had transferred her to our floor and he said that he would look at her by morning, we were stuck with her for three days with no blood pressure lower than 90's over 60's. I do not deal very well with the psychiatric types of either variety. Actually had one of the frequent flyers show up with an alarm clock which she would set for q 2 hours so she could get her Dilaudid. I asked her to stop doing that, it was not therapeutic, a disturbance etc... and she did it once more so I then told her that all electronics brought in had to be checked out by engineering before patients could use them and confiscated the alarm clock. This was at about 11pm and engineering would not be in until morning. This was the truth but I would not ordinarily be so strict enforcing it. I have advised patients who are frequent flyers to remember the story of the little boy who cried wolf.

RNinSoCal · Sep 14, 2004

I work on a med/surg unit in LA county and we get psych patients all the time. Our unit takes every type of pt that does not require telemetry including psych overflow from our overloaded psych units. On top of the psych overflow pts we also are licensed for detox. Many of our detox pts have "dual diagnosis" of addiction and a psych disorder.

I have been overwhelmed by the number of psych pts I have been getting. It is almost impossible to deal with them on top of acutely ill patients. They are manipulative and often present with drug seeking behaviors. They will time even Tylenol down to the minute and get angry if it is late. The smokers are the worst. Once they smoke that last cigarette and realize they have no one to bring them more and no money they become irritable beyond belief. It is inconceivable to them that the hospital does not provide cigarettes for them. We always offer smoking cessation with patches and nicotine gum, but they just want their smokes.

It is very difficult getting these patients transferred out of the unit once they are medically cleared. The psych units don't want them back and they usually have no home to be discharged to. Due to the nature of their psychiatric disorder they have usually "burned out" their family and friends.

We have often discharged psych pts with a taxi voucher and a one night hotel voucher after failing to find friends, family or community resources for them. It is frustrating to see the same pts over and over. We can't make them take their psych meds. We can't keep them clean and sober. There is no cure for psychiatric illnesses. We can't make them stick with community programs (if we can find one for them). We can't keep them in the hospital either. It is a frustrating dilemma in large urban areas where there is a higher percentage of this type of pt.

It is hard on the nurses in our unit because it is so discouraging to try and help people and see them return again and again with the same problems. We need more outpt facilities that have counseling, group therapy, and assistance with giving people their psych meds. There seems to be no assistance for them outside of the hospital. The facility that I work at is a private hospital. I imagine the types of psych pts they see at county hospitals in California are even worse with more behavioral problems. At least we don't take the violent ones on our unit.

It is hard not to become desensitized to psych pts. I have told my supervisors that I may need to transfer to another unit if my pt load continues to be 50 % psych. I am truly burned out by a pt population that I can not help. On the positive side I love my pts with gestational diabetes, abdominal pain, cellulitis, pneumonia, pancreatitis, hip fracture, knee replacement, MRSA wound, VRE urine,...etc more than ever because I get to go home feeling like I have helped someone. I really like being a med/surg nurse.

I respect those nurses who can do psych with compassion and perserverence. God bless you for trying to help people with psychiatric disorders again and again with more compassion than judgment. I just wish there were more of you and more resources too.

talaxandra · Sep 14, 2004

Our psych unit doesn't take physically sick patients because "we're promoting an image of wellness and this would present an image of illness" (yep, direct quote!) In fact, they only reluctantly accept stable patients on IV anti's; one of our grads moved over there in his second year and was rung at home for directions on how to flush the bung!

Although I appreciate that psych patients deserve the same level of care as other patients, I worry about the lack of therapeutic psych support we can give - I'm not a psych nurse. This, of course, is in addition to concerns about less experienced staff, and the impact on other patients.

A while ago we had a guy with BPD who developed renal failure. He needed a strict fluid restriction, but often broke it before breakfast - any attempt to enquire about what he was drinking was met with hostility. We tried to negotiate with him, asked psych for their input ("whatever you think would be best"), with no effect. One of the residents suggested we get a patient attendant to work 1:1 with him, to 'remind' him of his restriction. it only took two hours of obsenity-laced shouting for the attendant to leave - the patient had taken in over a litre in that time!

Every few days we had to call a code, then pop him on BiPAP because he was so overloaded, usually overnight, and this was with daily dialysis. After he was discharged from the ward he still came in for outpatient's dialysis - at one stage he came in 30 kilos over his dry weight!

Clearly he was too unwell for our psych unit, but a ward which combined med-surg and psych nursing would be enormously better than the current system, IMO.

nursbee04 · Sep 21, 2004

How does your MS unit handle these types of patients?

Most of our psych patients are elderly confused/combative/wanderers in with MSC's d/t sepsis or UTI.

I assess for pain, toileting needs, I give PRN's, I call for orders if they don't have anything, I've tried walking these patients, we've taken turns sitting with these patients, I use the bed alarm. I call the family and ask them to come in and sit with the patient if at all possible. It is very hard to deal with these patients, and I think it is unsafe for this type of patient to be on a floor with our ratios and acuity.

Lots of times the combative/fall risk patients end up in restraints, usually a posey vest (which I hate!).

We get them better and medically cleared and them send them downstairs to the lockdown psych unit, where there are cameras in all the rooms and staff trained to deal with these types of patients.

I really wish we got extra staff for these patients, but we don't.

Then we get the younger, manipulative type of patients, they are a whole 'nother post. They play staff members against one another, they tell night shift all the terrible things they saw second shift do, and I'm sure they tell dayshift all the terrible things nightshift did. They are noncompliant and I just have to do the best I can with them and be firm/set limits.

RNPATL, DNP, RN · Sep 22, 2004

Thanks for all the great replies to this thread. Some great food for thought here. I agree that the psych patients that smoke are really tough patients to deal with. I had one lady smoking in the bathroom and then proceeded to lie about it. After repeatedly asking her not to do this, I finally gave up and called the police. Yes, they actually came to the hospital and told the lady that if she continued to smoke in the facility that they would issue her a citation and arrest her after she got out of the hospital. It worked for the rest of her stay, but she drove us crazy!

I am not sure what the solution is, but for those of us that are caring some some real acutely ill patients, it really is a dis-service to the psych patients and the other patients to have them coupled together.

Angela Mac · Sep 22, 2004

Unfortunately- I have seen many psych patients in long term care facilities that are abusive, combative & a threat to others- these patients belong in a lock down psych hospital.

And on the other hand- I have seen many elderly dementia patients who belong in nursing homes, institutionalized in the psych hospitals......

Anyone who demands one on one, is on a suicide watch, or is a threat to others- regardless of their age and medical condition, belongs on a lock down unit.

Let's face it- a nursing home- with 1 nurse to 30 patients- does not have time to play head games with a manipulative psych personality.

my 2 cents worth, actually 5.

I blame the cut back on chemical restraints- if psych patients are managable on their meds- leave the orders alone. :uhoh3:

nursbee04 · Sep 24, 2004

I blame the cut back on chemical restraints- if psych patients are managable on their meds- leave the orders alone.

I totally agree. "I don't want her/him being snowed" is a comment we get a lot. I don't consider sleeping through the night being snowed.