my encounter with a schizophrenic

[shock-me-sane]

I am at the end of my first year of a three year program. we are currently on the med-surg floor. last week I had a schizophrenic patient who was on zyprexa 5mg and Ativan 2mg. yes, that was it. she is ESRD and uncontrolled hypertension, COPD etc, etc. everything was going fine. fine as in she wasn't out of control. she was doing a lot of muttering under her breath and talking about how her family was trying to kill her, etc. but she was responsive to me, but kept asking for her dilaudid which was due around 10. the nurse wanted me to hold all her blood pressure meds because she was scheduled for dialysis. so i did. gave her zyprexa which she wouldn't take without ativan prn so she got it around 0930. turned out dialysis was running behind and they weren't going to get to her till early afternoon. so the nurse wanted me to give the BP meds, told me to hold off on the dilaudid because she just got the ativan. (do you usually need to wait between these 2 meds?)

so anyway. i go to give her bp meds. she refuses to take them because she wasn't getting her dilaudid. i told her that she would be getting it, but had to wait a bit longer and I explained why. she went into a tirade calling me a whore, telling me to get the f*** out of her room. i sat down and tried to talk to her about why she needed her bp meds and further explain about the dilaudid. she kept repeating over and over that i tricked her, calling me other names and telling me to get out while spit was flying out of her mouth. i told her okay, but i would be back to check on her in a little while. i left the room and wanted to cry. not because she said all that stuff to me, but because i felt truly dumbfounded as to how i should have handled the situation.

later when i was able to give the dilaudid, she said something about how you just need to be mean to people sometimes and asked if we could be friends again. and she started crying when i was pushing the med. i asked if it was hurting her, she said no and pointed to her head and said it hurt inside.

i left the hospital that day feeling really confused. i don't know if i handled things right or how i should have responded to her. i love psych and do want to work in it eventually. i just want to hear anyone elses thoughts about it. what would you have said/done?

thanks.

[UM Review RN, ASN, RN]

You handled it just fine, IMO. It appears from her reaction and subsequent response that she was aware, through her tirade, that you were genuinely trying to help her.

You might ask next time if she was hearing voices or having hallucinations when she said her head hurt, because she might need some type of med that would stop them.

[shock-me-sane]

You might ask next time if she was hearing voices or having hallucinations when she said her head hurt, because she might need some type of med that would stop them.

she was hearing voices. she refuses to to take anything for them because she says they make her breathing worse. she even has psychotropic meds listed as an allergy on her chart.

thanks for telling me I did okay. makes me feel a bit better about it.

[StuPer]

Ummmm reading your post, I think you handled it very well, particularily as you didnt rise to her aggressive outburst.

Im not sure but, I think there maybe other issues here, for a start dilaudid can be a drug of addiction, so dependency may explain her behaviour. As for her schizophrenic diagnosis, I'd be interested to know if it was originally a drug induced psychosis, as paraniod ideation is very prevalent in that group.

regards StuPer

[DEE 2006]

I think you handled the situation great, but I would have asked her in the later conversation about the headache ie if she was hearing voices etc...

she is one Zyprexia but only 5 mg according to your post. Zyprexia in my experience (psy nurse 10+ years) works really well or doesn't work at all, I would however question the 5 mg dose for an adult unless she is very small, she may need an increase in the dosage. psy nursing can be as fun as you make it. the patient are trully a gift to work with, I have learned something new about nursing, life and my self with each encounter with a patient. good luck with your future.

[CharlieRN]

There is nothing to prevent a patient being sick with more than one condition. I agree that the behavior you report sounds a lot like an addict manipulating for drugs. Both the ativan and the dilaudid have a high abuse potential. They also potentify each other so there is some reason to want to avoid giving them together. This cuts both ways, in that if they are given together you might get a useful synergistic sedation, if what is wanted is sedation. Opioids and Benzos taken in combination can also supress respiration. Klonopin and methadone are a particularly dangerous combo.

The only suggestion I would have is about you sitting down to talk with an agitated patient who has demanded that you leave her room. You put yourself at a physical risk by limiting you own moblity by sitting down. If a patient is angry enough to raise her voice to me, I would carry on the conversation while standing well away from the patient, in the doorway where other staff can see me and I have a coice of easy escape routes. Further you demonstrated disrespect for the patient. She had just demanded you leave her room. If you told someone to leave your home and they sat down to talk to you instead, would you not feel disrespected?

In general psych nursing is process rather than task driven. I gather this client was on a medsurge floor for tx of primarily physical issues, so a task oriented approach is not inappropriate. It does make you easier for a drug seeker to manipulate. All she has to do is refuse to cooperate with the tasks you are trying to preform and she has made her problem into yours.

[shock-me-sane]

The only suggestion I would have is about you sitting down to talk with an agitated patient who has demanded that you leave her room. You put yourself at a physical risk by limiting you own moblity by sitting down. If a patient is angry enough to raise her voice to me, I would carry on the conversation while standing well away from the patient, in the doorway where other staff can see me and I have a coice of easy escape routes. Further you demonstrated disrespect for the patient. She had just demanded you leave her room. If you told someone to leave your home and they sat down to talk to you instead, would you not feel disrespected?

I understand what you are saying. I thought that possibly sitting (I wasn't within leaping distance of her) would help to de-escalate the situation, which obviously didn't happen. As far as her asking me to leave and me not doing so was disrespectful to her. I felt flustered. I was asked to give her the bp meds and I thought I could maybe accomplish the task. I was more focused on what I thought needed to be done for her physically than on what she wanted emotionally.

And I do think a lot of it had to do with drug seeking, but of course I can't say that for certain. Because if she says she has pain, than she has it. But she does have a history of poly substance abuse.

So I guess what you are saying is that I should have left when she said to leave and then came back later. I don't think that the timing would have changed anything, but just whether I came in with the dilaudid or not. It is a crappy situation I guess. Because she was there for all her physical problems and not her psychological ones.

CharlieRN, DEE 2006, StuPor and Angie O'plasty, thank you for all your replies, I really appreciate it.

[CharlieRN]

S-M-S,

As far as her asking me to leave and me not doing so was disrespectful to her. I felt flustered. I was asked to give her the bp meds and I thought I could maybe accomplish the task. I was more focused on what I thought needed to be done for her physically than on what she wanted emotionally.

thats the task oriented verses process oriented thing. Like I said, in a med surg environment you are excused for being task oriented. I'll never forget my shock when, on my first day on a psych unit, I was hustling to get a med for a patient, and the charge nurse stopped me and asked why I was not in the on going staff meeting. I explained about the med and she told me to go to the meeting, it was more important than getting the med to the patient!

[Spazzy Nurse, RN]

i left the room and wanted to cry. not because she said all that stuff to me, but because i felt truly dumbfounded as to how i should have handled the situation.

I gotta laugh because this happens all the time to psych nurses. Sometimes things just come so out of the blue we walk out wondering "what the hell just happened here?" And of course, later we always think of ways we could've handled things differently.

I think you did just fine. You're already a psych nurse. :)

[blugreeneyez]

I work in psych and I deal with patients like this on a daily basis. Most of the time when they don't get what they want when they want they tend to act like a 4 year old. Mostly because that is how they have gotten thier way for so long, what you do is just stand firm and be consistant and eventually they get over it. If the cursing continues then you have to let her know that that kind of language will not be tolerated. Good luck I love psych myself.

[hsieh]

it's been my experience that people who suffer from schizophrenia are often aware of how people react to them - so make sure you react to them in a happy, friendly way - as you would anybody -especially somebody gravely disabled. smile and be their friend. people with schizophrenia need all the friends they can get. society shuns people who don't behave "normal".

[NurseCard, ADN]

S-M-S,

thats the task oriented verses process oriented thing. Like I said, in a med surg environment you are excused for being task oriented. I'll never forget my shock when, on my first day on a psych unit, I was hustling to get a med for a patient, and the charge nurse stopped me and asked why I was not in the on going staff meeting. I explained about the med and she told me to go to the meeting, it was more important than getting the med to the patient!

See.... I'm gonna LOVE this about psych nursing! I detest the fact that what I do right now is so incredibly task oriented.