Awful Awful

[Meerkat]

I have a minor patient (minor in the sense of age, not minor in significance) who is the most complex case I have dealt with, and I just don't know how to help.

He is delayed, supposedly with an IQ of 36, and sexually aggressive as well as violent. He is restricted to his room because he is inappropriate with the female patients. The other day I was trying to coax him back to his room, as he had come out to the dayroom. I was the only nurse, and the tech was running a group.

He grabbed me between the legs, and I hopped back but he refused to go to his room. Eventually I had to call a code and have some big guys take him to the Quiet Room.

He got 50 of Benadryl, 10 of Zydis, 5 of Haldol and 2 of Ativan and was still going strong. I never saw anyone so resistant to meds. Talking to him was useless. He kept calling for a nurse, only to call me a f-ing ***** when I went to see what he needed.

In the QR, he masterbated and urinated on the walls.

He apparently had a grand mal seizure as a baby, which led to the developmental delays. It is suspected that he was sexually abused in a group home.

What can be done for this kind of patient? Is he doomed to be instituionalized?

[romie]

One approach would be to make sure that you don't reward his negative behavior by making a big production when he exhibits his targeted behaviors. Minimize the number of staff intervening and limit the number of spectators. The children I used to work with often sought the attention that they would get when going to the quiet room. Then the other children would be set off because they became jealous of the attention the other kid got. I think this child is only to be institutionalized only if the staff give up and see him that way. If you think someone's an idiot, the person will act like an idiot. So changing your thinking and actually visualizing the client acheiving success works wonders because it changes your behavior around them and then they respond differently to you.

[Meerkat]

One approach would be to make sure that you don't reward his negative behavior by making a big production when he exhibits his targeted behaviors. Minimize the number of staff intervening and limit the number of spectators. The children I used to work with often sought the attention that they would get when going to the quiet room. Then the other children would be set off because they became jealous of the attention the other kid got. I think this child is only to be institutionalized only if the staff give up and see him that way. If you think someone's an idiot, the person will act like an idiot. So changing your thinking and actually visualizing the client acheiving success works wonders because it changes your behavior around them and then they respond differently to you.

Wow! That's a great post. I guess sometimes getting another perspective is important. I've been off for a few days so I wonder if he will still be there when I go back. (We are a short term facility).

Also, what about spitting? How do you protect yourself from this? We do not have those fluid-guard masks.

[barbyann]

Key to this situation is to reward good behaviors. Remember all behaviors are meeting a want or need. What does he need? Maybe interactions with others? Maybe fun? Maybe physical touch? My suggestion, If he is quiet and not exhibiting target behaviors that is the time to intervene. Give him what he wants at that time. Ignore bad behaviors when at all possible. I had a patient once who used spitting as an attention seeking behavior. I solved this problem by giving the patient TicTacs everytime I saw her. She loved the candy and would never spit it out. Also realize that brain damaged patients, such as the one you describe, have a very high threshold for sedating medications. They also have more paradoxical reactions than the norm. Document carefully any abnormal reactions to medications, this is valuable information for the future.

[Meerkat]

Key to this situation is to reward good behaviors. Remember all behaviors are meeting a want or need. What does he need? Maybe interactions with others? Maybe fun? Maybe physical touch? My suggestion, If he is quiet and not exhibiting target behaviors that is the time to intervene. Give him what he wants at that time. Ignore bad behaviors when at all possible. I had a patient once who used spitting as an attention seeking behavior. I solved this problem by giving the patient TicTacs everytime I saw her. She loved the candy and would never spit it out. Also realize that brain damaged patients, such as the one you describe, have a very high threshold for sedating medications. They also have more paradoxical reactions than the norm. Document carefully any abnormal reactions to medications, this is valuable information for the future.

Well, it's hard to know what he needs. His speech is very hard to understand.

Whe we do allow interaction with others, he gropes them. It's just not fair to have him out on the milieu with patients who have already been traumatized. Touching him is GUARANTEED to result in getting humped. He is dangerous in this regard. There is no 'in between'. It's either stay out of arm's reach or get sexually assaulted.

Why are brain damaged patients resistant to meds? I did not know that! It makes sense now, his resistance! Do you have any links that I could look that up? Thank you!

[NPAlby]

Wow, I thought I had a bad day. I was floated, had a pt flash me, got cursed at (a non-psychotic pt) and dirty looks and no help from the techs but you've got me beat.

Is it possible for the pt to have been on a 1:1 for pt and staff safety? That's what I think we would have done but I work with adults so maybe it's different in child/adolescent psych.

I didn't know that about brain injury pts either. Makes a lot more sense considering some of the pts I've worked with. What does work with pts like that? I had an adult pt very similiar to your guy there while working at a state psych forensic hospital and he was continous 1:1. He was way too dangerous to ever not be on a 1:1. TBI pt also with the garbled speech and extremely sexually preoccupied and agressive. Hope your guy doesn't end up like him. Very depressing working with him.

Glad you came out of it okay. Do you guys ever have debriefings for events like that, for staff I mean? I've heard of some hospitals doing that but never seen it and I'm a traveler.

[Meerkat]

Wow, I thought I had a bad day. I was floated, had a pt flash me, got cursed at (a non-psychotic pt) and dirty looks and no help from the techs but you've got me beat.

Is it possible for the pt to have been on a 1:1 for pt and staff safety? That's what I think we would have done but I work with adults so maybe it's different in child/adolescent psych.

I didn't know that about brain injury pts either. Makes a lot more sense considering some of the pts I've worked with. What does work with pts like that? I had an adult pt very similiar to your guy there while working at a state psych forensic hospital and he was continous 1:1. He was way too dangerous to ever not be on a 1:1. TBI pt also with the garbled speech and extremely sexually preoccupied and agressive. Hope your guy doesn't end up like him. Very depressing working with him.

Glad you came out of it okay. Do you guys ever have debriefings for events like that, for staff I mean? I've heard of some hospitals doing that but never seen it and I'm a traveler.

Debriefing is a great idea...what exactly does it mean? I was punched in the jaw tonight, but I doubt we will debrief. The patient who attacked me also injured two other patients and another nurse tonight. And she's only 14!

[beochicken]

My workplace (forensic psych ward) does debriefs whenever someone on the shift feels the shift has been a bad one. The debrief takes place after the new shift has started (we get payed for an extra half hour), and is in a non-formal setting where people can talk about their day, the patients, and so on. Especially for the newer people on the shift it is usefull, as it is easy to start blaiming yourself, and not the patients illness, when a patient does something bad, or communicates how little they like you and what an evil person you are. It is a good way to let of a little steam. Im thinking it helps the personell a lot, and helps keep people working at a ward populated by somewhat difficult patients a lot longer. There are a couple of good books about debriefing out there, id do a search at amazon.com if i wanted to learn more about it