Best practice to manage the low functioning, aggressive, psychotic patient

viperblue72 · Apr 17, 2015

Our psychiatrists usually let us have thorazine 50 (for average size patients) q4 or 6 scheduled while awake with carbamazepine if they were bipolar, and a low dose beta blocker bid or tid which studies show helps with agitation in lower functioning patients. From a nursing standpoint, prayer, simple directives, and any kind of simple entertainment that can be provided.

elkpark · Apr 17, 2015

"Pick your fights" carefully. Don't put any more demands on them than really necessary. Have enough staff around. Be always alert and proactive; try to keep them from heading down the path toward getting angry and aggressive in the first place. Go out of your way at all times to try to build a positive relationship and therapeutic alliance with these folks. Err on the side of caution with the prn meds (don't wait until they're throwing stuff ... :))

Jules A, MSN · Apr 17, 2015

These are very challenging patients but a great population if you embrace their abilities and limitations. In my experience the more supportive, positive and encouraging your staff is to these patients the better chance you will have managing them safely. Get to know them because you will probably see them again and their triggers will be the same. Monitor their interactions with other peers who will sometimes very justifiably become annoyed and make comments that instigate them.

Lastly I'd remember to have empathy because what horrific lot in life. Not only are they cognitively limited but also with psychosis? Few of them have family who remain involved and live in group homes. Think of how many times they have been hurt and traumatized by being called derogatory names. It must be terrible and again I find the more kind and supportive the staff is the more comfortable these patients are and the better their behavior will be, within reason.

Barnstormin' PMHNP · Apr 18, 2015

I agree with all above posters, especially about being proactive, but JulesA comment about rapport and monitoring their interactions reminds me of my unit. We have a couple of nurses and tech's on our unit that are complete idiots when it comes to managing these types of patients. It never fails, they always end up getting the patient spun up and out of control due to their (the nurse or tech's) need to 'be in charge' of the patient. It never ends well for anyone and makes for a hell of a shift.

fawnsternurse · Apr 21, 2015

Thank you everyone for your input. I appreciate it.

No doubt you must have very special staff working with these patients because if not, they will explode.

I too find that many times staff are provocative and ultimately that is what causes them to escalate.

I appreciatr you all taking the time out to respond.

Yave · Apr 24, 2015

I went to work in a new facility recently. The medication nurse talked down to the patients. A patient became irritable and said to her "don't talk to me like that, you work here too long." She went back at him verbally, berating him and shouting at him. He became agitated and began shouting at her. Crisis was called and the patient was medicated with Ativan and Thorazine IM. I felt really bad to be a witness in that scenario. The patient was right and was asserting himself the best way he knew. As a new employee; you are not supposed to voice your opinion. You are not supposed to complain. You are not supposed to advocate for patients. I no longer work there.

Jules A, MSN · Apr 24, 2015

As a new employee; you are not supposed to voice your opinion. You are not supposed to complain. You are not supposed to advocate for patients. I no longer work there.

The nurse sounds like she was totally inappropriate but the above sounds a bit melodramatic. I hope you at least reported it to someone or on an anonymous tip line.

Yave · Apr 24, 2015

Do you really believe anonymous tip line exist in nursing? :no:

fawnsternurse · Apr 24, 2015

Unfortunately those scenario's are far too common. I have certainly witnessed my share in psychiatric nursing except for the most professional places I have had the pleasure and opportunity of working.

I wish there was an anonymous tip line for psychiatric nursing!

At any rate I think many times this type of behavior is tolerated unfortunately and it becomes the culture of the milieu to speak this way to these patients.

elkpark · Apr 24, 2015

Do you really believe anonymous tip line exist in nursing?

I worked for several years as a psych unit/facility surveyor for my state (the state healthcare licensing agency) and CMS. We took anonymous complaints all the time about dangerous or inappropriate situations on psych units, esp. potential client abuse, including staff behavior, and it was the policy of my agency to investigate every complaint. We frequently got complaints from staff reporting their own facilities. We did our best to get people to tell us who they were (although we kept that information confidential when we investigated the facility) because it was our policy to report back to the complainant on the results of our investigation, but if they wanted to remain anonymous and were willing to do without getting informed of the results, that was fine with us.

Jules A, MSN · Apr 24, 2015

d unfortunately and it becomes the culture of the milieu to speak this way to these patients.

I agree and would encourage everyone to take ownership of not only their actions but the culture of their milieu and attempt to set a positive example of therapeutic ways to deal with patients who are struggling. Modeling positive behaviors can be a very effective way to subtly teach new ways of managing patients even if you are initially met with skepticism.

When situations happen like psych.eduec describes I believe it is our duty to attempt to do something to bring about change rather than just complain or leave. Not that leaving an unsafe or unprofessional atmosphere isn't appropriate just that I do think we should try to make things better for our patients and teams.