Day in the life of a Psych ED nurse

celery_juice · Jun 6, 2015

I work full time in a crisis unit as a staff RN. Where I live, we also have "screeners" that are not RNs - they have a background in either psychology or sociology and are masters-level, and they are the ones who evaluate patients and make the determination along with the psychiatrist. So as the nurse, my role involves direct care of the patient and crisis stabilization/management while they are waiting for their evaluation and disposition.

If a person is already on the unit when I walk in, what I do is minimal. Meds, vitals, any type of therapeutic interactions or deescalations, then once they are dispositioned I will prepare them for transfer, give report, and fill out necessary paperwork. Throughout the day, patients will come in either voluntarily through triage, referred by the ER, or brought in from the community in various ways - either by police or as the result of a mobile evaluation. When someone arrives, they are wanded by security, then changed into a gown and socks in front of me. I document any skin abnormalities while checking or contraband. Vitals, blood work, and urines are obtained. They have an exam by the ER physician for medical clearance. Once medically cleared, they are on the list for a screening. Everyboy is on a q15m watch for safety. My unit has 9 beds and staffing will be either 1 RN with 1 MHA or 2 RNs with no MHA.

What I described above doesn't sound so bad when its written out, but the thing about psych is that your day is never predictable nor consistent. I place much more value on acuity than volume. Keep in mind that a unit packed to the brim with patients may be your easiest day, but a unit with only 2 patients who are psychotic and violent, or cognitively impaired, or demented and need constant redirection could turn challenging very quickly. Patients also do not come in one at a time, and they rarely come in voluntarily. You really hone your skills with regard to deescalation and milieu management, because things would go south fast.

Also, because it is a crisis unit, we see EVERYONE. I have had a 4 year old. I have had a 102 year old. I have seen every DSM diagnosis walk through those doors. I could have an autistic 8 year old in one bed, a combative dementia patient climbing out of another, while a med-seeker is punching walls because he has learned its a great way to get IMs, the chronic schizophrenic is disrobed in the doorway and the voluntary depressed 20-something is cowering in her room wondering what the heck was she thinking by coming here. At the same time, two patients have transfer times and the ambulances are on their way, and was that the doorbell? yup, police are here with a handcuffed and floridly psychotic man who just burned his house down.

Depending on volume and acuity, your day will either be spent in the hallway running ragged putting out fires, or you will spend it doing paperwork. Some days a mix of the two, but where I work, its either clear skies or a hurricane.

Another thing I need to mention is that we are a direct extension of the ER, so your medical knowledge needs to be there. (I hate seeing all the threads asking if we lose our skills!!! If anything, my skills are BETTER now than when I worked med/surg, because everything presents so much differently or more subtly or is masked by an altered mental status.) I frequently have patients who are not as "medically cleared" as originally thought, and are brought to the main ER for medical attention or are admitted to the medical floor. I cannot do any type of medical treatment on my unit for safety purposes - no oxygen, tubes, IVs, you get the point. Anybody who requires oxygen is held in the main ER.

So to summarize, at my job, the screeners will evaluate/disposition/make recommendations and the nursing staff does everything before, after, and in-between :) Sorry for the long reply but I loooove my job. I hope this helped!

NightOwlPsyRN · Jun 7, 2015

No worries, I totally feel where you are coming from - I work at a psych hospital and a campus with both a crisis stabilization unit and acute treatment unit. Your workflow sounds similar to mine. :) I was just wondering what the difference is compared to our workflow and that of a psych ED.

celery_juice · Jun 7, 2015

I feel as if I work in a psych ED. I mean technically, it is the psychiatric wing of a medical hospitals emergency room. Is there something different altogether you're talking about?

NightOwlPsyRN · Jun 8, 2015

I guess that's what I'm trying to find out, maybe it varies from facility to facility? The description I got from the nursing manager during my interview sounded a bit different from the work you and I seem to share where we work. I guess I will have to wait and see how it's like if I get offered the position!

celery_juice · Jun 8, 2015

Hmm. I'd be interested to hear an update if you get the position!

WCSU1987 · Jun 9, 2015

Worked in three ER Crisis unit's they shared similarities and didn't. Most were six bed unit's attached or in some proximity to the ER. My favorite unit was well staffed and had amazing rooms, kind of. They were seclusion rooms six of them padded walls and no hospital beds. Was staffed by two nurse's, one CNA, and a security guard.

Other unit's staff varies one unit worked at had a Tech and nurse, but budget changed that. That led to nurse's leaving and a mess. Psych tech's were then used to replace the Tech's then led to a security guard. Felt bad because now having only two regular staff nurses most were rotated off the psych floor. You had to vitals, blood work, admissions, discharge, clean the rooms, give medications, respond to codes, and so forth. If you needed a Tech needed to call the ER. The ER is rarely friendly where I been towards ER Crisis unit's ha.

Most of the time they don't want to share, will call yell that they have overflow going on what's taking so long, so on and so forth.

Some unit's nurse's don't see the patient basically report is given by the tech, not always.

Then you have doctor's social worker's normally attached to your unit or adjacent. They do a lot of evaluation's, check insurance, see what type of medication patient needs, and decide treatment plan's. Sometimes discharged home to another unit or hospital.

You have to deal with crises that can be from family members. Some unit's don't allow family in or deny families due to acuity.

It can be chaotic you are having individuals come in at the start of mental decompensation. They have been waiting mostly in the ER for a bed to clear, they could be off their medications, be in their own medications, or be on substances.

Then you have mix of criminals, kid's, police, so on and so forth in the same area it's chaotic ha!

You hope that they been checked by security the patient's don't have knives taped on the inside of their legs. Also don't hope no one smugglers anything in drug's or weapons. Hope your team your on is alert and prepared.

Add on top of it you have possibility of medical emergencies such as internally bleeds, heart attacks, and so forth.

Can be stressful, but decent job.

NightOwlPsyRN · Jun 13, 2015

Got the job :) start orientation mid-July. If I don't forget, I'll update on how it goes!