Psych pts needing medical tx

bargainhound, RN · Jun 4, 2005

That is exactly why a lot of doctors would not have performed the surgery in the first place.....she was not capable of following post op instructions.

student4ever · Jun 4, 2005

I just had a night that will go down in history as one of the worst 10 nights ever. Psych patient needed to have her foot rebuilt after a spectacular attempt at suicide a couple of years ago. Leg was operated on yesterday, ORIF and some wierd tendon thing with pins coming out her toes. Pt was to be non-weight bearing with this foot. Pt refused to remain as such and kept walking around like normal, but because of the surgery, she was bleeding through the slab and ace. Her room looked like a slaughter house, with bloody left foot prints all over the place. Found her walking towards the kitchen at one point!!! WTH was she thinking? 3 hours of work and her ability to walk at stake and she would keep walking around. No pain, She d/c'd her PCA morphine, left the S/L intact. (pt was a voluntary admit)
She could demonstrate the procedure for NWB transfers when asked, but an hour later she would be thumping to the bathroom, walking around the bedside commode!!
I called Ortho, they said "we don't know what to do for her call Psych" I call psych and explain and they say "we'll be up to see her within the next 3 days". WHAT????
So I call Ortho back and they tell me that they will be up in the morning and medically form (sign commitment certificate) her. She of course refused haldol or any other calming meds and we couldn't impose it on her. I cared that her foot was going to be forever damaged by her inability to care for it adequately. I cared and cried when she took the lid off her tea and 1st degree burned her self when it spilled all down her front and pooled under her and burned her butt. What else could I have done? No one would come up in the middle of the night, the patient didn't give a s**t what happened as long as she could have her CD's and Oh! could she have another cup of tea? I had iced towels over her, she was sitting in a puddle of ice water by the time I was done cooling off the burn, and she was just so frustrating in her total disregard for her well being. She is the one who asked for this surgery in the first place!!! And no one would let me do anything except watch her self-destruct. I did what I could, but I felt let down by the patient, the docs and the staff that I was working with that were saying just wait till the morning, they'll sort it out then. And I was an hour late leaving this morning.
I rattled all the cages and lit fires under the docs and still, nothing. She made me cry. Four times during a 12 hour shift. Unbelievable.
I'll go watch a movie and get some sleep. I switched my night 12 to a night 8 so I will have a bit more time to myself.

Jacquie,

Sounds like a really rough shift - so sorry you had to deal with that. I'm still in school for my nursing degree, so I guess I don't have a lot of experience with which to understand your situation, but I do work in a hospital so I have some knowledge at least about how our hospital works. Hearing about docs who won't come see a patient because it's the middle of the night make me want to tear someone a new ***hole!!! :angryfire

Obviously this patient was unable or unwilling to make her own decisions about her medical treatment during your shift, despite the fact that she made the decision to have the surgery (apparantly) in a competent manner. I know at our hospital we have a psychiatric emergency team who does consults at all times, day or night, and are frequently in our Emergency Department (where I work) all night. I can't believe psych told you they would see her within 3 DAYS!!!!! That is just unbelievable. Granted, you are in Canada, so things may be different there, I don't know, but I would definitely be writing a report, documenting all the doctors (by name) who refused a consult/commitment while this patient was obviously harming herself. I would then be sending that report to administration, head of the staff physicians, the psych department, etc. Something needs to be done to make sure that this situation doesn't happen to another patient.

Was ortho not able or willing to order restraints to keep the patient from ambulating on her foot and pulling out her IVs? Medical noncompliance in a patient with previous hx of suicidal behavior raises a big red flag in my mind. Sounds like you did all you could from your position to help this poor woman. Unfortunately, so many medical professionals see that a patient has psych problems and make the decision that the patient is chronically crazy and if they want to self destruct, who cares, they're not "normal" anyways, so who is it hurting? This type of attitude just makes me want to go on a rampage. :angryfire :angryfire :angryfire :angryfire :angryfire :angryfire

Unfortunately, I don't have any answers or advice, except to tell you that I feel really bad for you. You sound like a wonderful, caring nurse who did her best to try and help a patient who didn't want or wasn't able to understand the help she needed to make a successful recovery. Don't beat yourself up - you did the right thing trying to get the doctors to give this patient the proper treatment for her inappropriate behavior. The fact that they didn't listen/care is their problem, not yours. Keep your chin up - and I hope your next shift goes better.

:balloons: It's nurses who care - like you - who have inspired me to go into this tough, thankless profession. Sometimes the efforts we make seem to go unnoticed and unappreciated, but you never know whose life may be changed by your actions and your caring. Glad to know that our neighbors up north have some really great caring nurses! :balloons:

Morning-glory · Jun 4, 2005

I do believe that because this patient has been chronically challenged by her illness that the docs just wanted the whole situation to go away. It wasn't intentional, they just didn't know her and the Ortho guy was just not familliar with psych issues enough to deal with it. Obviously, psych should have done something, in coordination with Ortho prior to her operation. The staffing coordinator did try to get a sitter for her, but it was 1 am. Hopefully they got something done today. I'll see when I go in later.

J

kat911 · Jun 4, 2005

It sounds lilke this patient pushed all the right buttons and got to you. You can't force someone like this to be compliant, in fact they love all the attention that this type of behavior generates. Sometimes you have to remember these are her choices, she can make better ones but chooses not to. We have had a lot of medical/psych patients lately. I don't expect that we will be seeing any fewer in the future. Our nurses are having to learn to set limits and stick to them with these types of disruptive patients. Everyone who interacts with them must know the limits and how to deal with the patient. Your doctors are probably as frustrated as you are, except psych, they should have responded within a few hours. I know of one patient that they finally did a flap from one foot to the other leg to keep the patient from walking around and from playing with the wound. Sometimes you have to be creative. You have a big heart, protect it and yourself.

z's playa · Jun 4, 2005

Wow..I'm sorry to hear about your night Jacquie. :icon_hug:

Were you crying because a big part of you wanted to strangle her? Understandable.

I would have strapped her to the bed....taped the earphones to her head...got an order for Haldol from the doc who refused to see her after the pt repeatedly compromised herself :eek: ...and administered it before I lost my mind and slapped her. :)

Of course thats easier said than done. And yes I know she had some psy issues........and no I'm not entirely serious but the thought would have run through my head...and I would have mulled it over abit. :chuckle

I wish you luck in the nights to come. You're a great nurse with a heart of gold. Keep us posted.

Z

CharlieRN · Jun 5, 2005

As a long time psych nurse I have a lot of sympathy for you. Psych pts in a med/surg setting should be 1 to 1'd or have a "Psych sitter". She was endangering herself and others by her behavior, that is grounds for restraint, chemical or physical. The failure to give the patient the protective measures she requires due to her impaired mental health is most likely actionable malpractice. Her doctor of record is the one responsible. I hope you wrote it up as an "incident report". It is not a nursing problem but one of inadequate medical treatment.

Morning-glory · Jun 6, 2005

Kat911, I hear you on the creating boundaries thing. I essentially had to let her do what she wanted to do after about 6 hours. I just couldn't cope, and the docs wanted to wait till morning so in my head, I just said if the doc can wait then so can I. I wasn't happy about it, and I continued to monitor her from a distance, but I was done fighting with her. I provided a wheelchair for her to get around and a commode for her to use and left it at that. Z- the thoughts did cross my mind!!!

I was floated to another floor the next night so I didn't have to quit nursing. I did go down and see what they had done during the day. Same thing as on nights, nothing! But psych did come and see her. They didn't even write a note in the chart, but they did look at her!!! When I was there, I heard her walking around again. I wished the nurse who was with her good luck and left. I won't follow up anymore. She will do what she wants. I will continue to try to be the best nurse that I can be.

Thanks for the support. I really needed it.

barefootlady, ADN, RN · Jun 7, 2005

Jacquie,

You were placed in a no win situation by the doctors and the patient. I starting writing you a longer post but in the end it boils down to CYB, CYB, and more CYB. Good luck, this situation may get worse before its over.

Mystery5 · Jun 8, 2005

Were you crying because a big part of you wanted to strangle her? Understandable.
Z

Yes, psyche pts can ellicit this feeling in nurses! :uhoh3:

You know, I am known for my bedside manner. I can establish trust and rapport usually very quickly. But psyche pts do not interest me whatsoever. I'm always left ashamed by my lack of sympathy for them. They irritate me with their shenaghans. :angryfire

I guess everyone has their calling. Some nurses are incredibly inspired to work with these pts... Not me!