A non-psyche nurse needs advice

nurse lala, BSN, RN · Mar 15, 2014

Can you be more specific? What is going on that you qualify as a psychiatric emergency? Please explain why the attempted homicide was a psychiatric rather then a criminal act. The devil is in the details, right?

When I think back to my first job as a nurses aid at a LTC, there were some clients with MH problems that were not actively addressed. This was 36 years ago, and we were less aware that the behaviors were of a psychiatric etiology and were treatable. Now a days most LTC have a psychiatrist associated with the facility, at least that is the case in Ca.

You mention the problem being a recent new onset. This brings on a slew of other questions that bear exploring. What changed two months ago? Are these new admits? Are there new staff? Maybe new providers?

Meriwhen, ASN, BSN, MSN, RN · Mar 16, 2014

If it's LTC, it's safe to presume that your population tends to run on the older side. So have you ruled out physiologic causes? For example, we all learned in nursing school that infections--particularly UTIs--are a common cause of delirium in the elderly. And it's true.

Another possible cause: polypharmacy and/or drug interactions.

MrChicagoRN, RN · Mar 16, 2014

If it's an issue of how to handle acting out patients, this can be a good resource: Crisis Prevention Institute (CPI Training) | CPI

the site has some good free information available. Also google "patient deescalation."

of course you still need to look at medical issues, medication issues, the resident environment, etc

WillyNilly · Mar 16, 2014

Polypharmacy is a problem in LTC. Seen psych med doubled on psych med with benzos on top and the pt is sent out for threat to self or others .

high doses of an ssri in an elderly person doubled with a benzo is not a good mix. Benzos will disinhibit them, make them act out and also make for a higher fall risk.

Review the meds, question the side effects, perform UA in pts -do this often.

alpha omega · Mar 16, 2014

As you can see, I'm not a psyche nurse, so I wasn't asking the right questions! This patient population was always a pretty mellow crowd, so I guess I'm wondering why so many, and why in such a short time.

Well, we had a couple suicide attempts. We had a couple of our male residents engaged in agressive sexual acting out (constant verbalizing of a sexual nature, frequent and repeated attempts at grabbing staff and female residents, "humping" inanimate objects)--one had to be sent to a psychiatric facility for a day or two because he was also violent and unable to be redirected. The homicide was a woman who decided to kill her husband with a blunt object, he called for help. The situation was very serious--she is big and strong, and if help hadn't arrived we would have had an actual homocide. She was referred to psyche eval, and the husband didn't press charges.

I guess the question is that this is all very sudden. The residents here are all rather on the mellow side, not former criminals or anything. I'm only here on a part time basis. We haven't had more than the normal rate of staff turnover, that I'm aware of. Also, these incidents have been scattered among our levels of care. In other words, Skilled care, Personal care and Independent have been pretty much equally affected (it's a retirement community).

After the first two serious incidents, we were all inserviced on de-escalation, but the incidents keep coming!

WillyNilly · Mar 16, 2014

Perhaps it needs to be addressed at the admission or review level. Have the residents been behavioral before? Do they need a different level of care? Are they being placed in a regular environment versus a dementia unit or a behavioral unit? Are the goals for the patients realistic prior to admission? What I hear from you is that they are not placed appropriately therefore it would be a level of care concern and patient safety issue on top of everything else that has been mentioned. This would be addressed with administration and admissions. Yes, education on deescalation will help tremendously for all staff but it doesn't solve the issues.

I hope this helps.

Retired APRN, MSN, RN, APRN · Mar 19, 2014

In addition to placement/level of care issues (are these patients newly admitted?), I strongly suggest pharm reviews and ruling out physical origin in the first place. It sounds like some of the patients are disinhibited, which can be related to drug interactions as well as to primary organic causes.

Have there been changes in policy, personnel or schedule that affect the patients' daily life? Has there been a change in diet or food supplier? Is there a new provider prescribing for the patients?

Like a previous poster, I wonder why the homicide attempt is considered psychiatric. Sometimes "bad" behavior is just bad, not "mad".

Clusters of events like this are very interesting. Please let us know if you find out anything more.

nurse lala, BSN, RN · Mar 20, 2014

If these incidents continue, management will need to have some meetings. With staff and residents. You all need an opportunity to talk about what is going on and what needs to change. The environment can become tense if issues go unaddressed, which sets the mood for more acting out by residents and staff.

Individuals such as the humper will need limits set on inappropriate behavior. This talk needs to come from an authority in the facility then reinforced by the nurses. If the behaviors are not curbed, then a mental health assessment is indicated.

The suicide attempts are the biggest concern. Is the staff educated in suicide prevention? Do they know what to look for? Demographics include being a veteran, a male, aged 65 or over, being divorced or widowed...the list goes on. Does this sound like your patient population? You bet it is. You are working with a relatively high risk population at it's best! Now consider risk factors: a history of suicide attempts is the #1 risk factor, loses (integrity, health, family, finances...), hopelessness, isolation, verbalizations that life is not worth living and some. Depression is not a normal part of aging. Staff need to be alert to the potential of suicides. Please visit the CDC which has up to date data on all things you need to be aware of to make a difference Suicide Risk and Protective Factors|Suicide|Violence Prevention|Injury Center|CDC.

Sometimes things just happen, and it is just chance that they occur in clusters. But if that isn't the case you need to speak up. It is difficult working in the environment you are describing and damage control is essential to stop the madness. A good nurse can make all the difference.