Forcing Meds on psych pts.

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I work in the ED at a federal hospital. We had a pt come in that was having a psychotic episode. She was also yelling, screaming, jumping on the bed, refusing medication. The ERMD did not make her an Involuntary hold for metal evaluation, usually 72 hours. Known some places as a 5051 or a 1013.

The ER MD then gives me orders to sedate the pt with Haldol and Ativan and of course the pt refuses. The ER MD, who has yet to get out of his chair, yells at me to give the medication now. I tell him that I need to speak to my charge nurse about this and he yells "This is never an issue at [my other job.] I want to speak to the charge nurse!" Now the reason I want to speak to the Charge Nurse is to formulate a game plan. This is a Female Psych pt that has already taken off her clothing and still yelling and screaming. I'm a male. I am not going into her room alone. I know may male nurses that are not concerned about this but I am. We live in a very litigious society and the hospital I work at is very punitive to the nurses regarding any complaints. I'm also concern for both my safety and the safety of the pt.

After the ER MD speaks to the Charge Nurse, who apparently sides with him, 5 people go into the room, one of which is a female, hold the pt down and give the meds. Situation resolved.

The problem for me is that I am the only male on my shift. The other nurses I work with - and I mean no offense here - are in no condition to assist with holding a pt, even if they wanted to, and they don't. We have police at the hospital - real police that carry guns. They will not touch the pt to assist us even if we have committal forms filled out and signed. And this leaves me thinking if someone trained for violence is not willing to hold a pt while I medicate, should I? You can say it is my job but while I appreciate a certain danger involved in working as a nurse I expect the safest environment possible. Otherwise, why use gloves. One of the nursing staff got bit by a pt and made a fuss about it and was removed from the department.

I would be interested in hearing the thoughts of others on this. No doubt I'll be disagreed with but still, if I'm able to get something out of this that is helpful, then I'm fine with it. And if does feel nice to vent, so there is that.

Thanks,

Irving

Did they actually expect you to give an IM injection to a screaming, naked psychotic patient by yourself? A chaperone and help restraining the patient would have been perfectly legitimate requests (or even demands). It's less clear why you would ask to speak to the charge nurse (as a starting point) instead of simply communicating with the MD, though.

Restraints and emergency medications are unfortunately fairly common place and necessary at times in psychiatric settings to protect the patient and others on the unit. This sounds like one of those times, just not in a psych setting. I'm certain the physician didn't expect you to restrain and administer the EMed alone, but you did the right thing communicating with your charge nurse when you weren't comfortable/confident with a situation and now you know how to better handle this in the future - speak with your charge nurse about recruiting volunteers to assist in the hold if you can't talk the pt into taking the med voluntarily.

What surprises me is that you and your coworkers are expected to restrain a patient without any training on proper restraint procedures. That poses a large risk of injury to the patient and the staff and places the hospital, the physician, and YOU in a very liable situation should an injury occur.

I work in the ED at a federal hospital. We had a pt come in that was having a psychotic episode. She was also yelling, screaming, jumping on the bed, refusing medication. The ERMD did not make her an Involuntary hold for metal evaluation, usually 72 hours. Known some places as a 5051 or a 1013.

The ER MD then gives me orders to sedate the pt with Haldol and Ativan and of course the pt refuses. The ER MD, who has yet to get out of his chair, yells at me to give the medication now. I tell him that I need to speak to my charge nurse about this and he yells "This is never an issue at [my other job.] I want to speak to the charge nurse!" Now the reason I want to speak to the Charge Nurse is to formulate a game plan. This is a Female Psych pt that has already taken off her clothing and still yelling and screaming. I'm a male. I am not going into her room alone. I know may male nurses that are not concerned about this but I am. We live in a very litigious society and the hospital I work at is very punitive to the nurses regarding any complaints. I'm also concern for both my safety and the safety of the pt.

After the ER MD speaks to the Charge Nurse, who apparently sides with him, 5 people go into the room, one of which is a female, hold the pt down and give the meds. Situation resolved.

The problem for me is that I am the only male on my shift. The other nurses I work with - and I mean no offense here - are in no condition to assist with holding a pt, even if they wanted to, and they don't. We have police at the hospital - real police that carry guns. They will not touch the pt to assist us even if we have committal forms filled out and signed. And this leaves me thinking if someone trained for violence is not willing to hold a pt while I medicate, should I? You can say it is my job but while I appreciate a certain danger involved in working as a nurse I expect the safest environment possible. Otherwise, why use gloves. One of the nursing staff got bit by a pt and made a fuss about it and was removed from the department.

I would be interested in hearing the thoughts of others on this. No doubt I'll be disagreed with but still, if I'm able to get something out of this that is helpful, then I'm fine with it. And if does feel nice to vent, so there is that.

Thanks,

Irving

A few thoughts, but really questions.

First- yes, it is normal to force meds on an out of control patient. It is far safer than lengthy physical restraint, or letting the patient continue the behavior. In a perfect world, we would have soundproof padded video surveillance rooms like in the movies.

"Female Psych pt that has already taken off her clothing and still yelling and screaming. I'm a male. I am not going into her room alone. I know may male nurses that are not concerned about this" There is a name for any male nurse unconcerned about this: Idiot.

But, your story is a little hard to understand. While you say you were talking to the charge nurse to formulate a plan to enact the orders, it seems that the doc understood you to be questioning the validity of the order rather than the need to make a safe plan. You then go on to say that the charge nurse sided with the doc- this implies that there was in fact a conflict.

Also, you didn't give the med yourself as part of the plan, implying that your charge also saw the same.

Maybe I am reading it wrong, but to me it reads like:

  • Doc give a legitimate order, which you did not want to carry out. From the sound of it, you are unfamiliar with how common this type of order is.
  • Maybe the doc was a schmuck about how he communicated with you. On the other hand, apparently you did not say "I'll medicate the patient, but first I should talk to the charge to make a plan to do it safely".
  • The charge nurse got the impression you were not on board with the plan, and took care of business.

Specializes in PMHNP/Adjunct Faculty.

I am a psych nurse and psych nurse practitioner student. Forced psych meds and the legalities of it are commonly misunderstood by nurses who do not administer them frequently. The ONLY time that a restraint and forced meds is legal is if the person is a danger to himself/herself or others. Out of control, throwing things, threatening staff all falls under this. If a psychotic patient refuses his/her PO meds and is Involuntary, this is also not a reason to force IM meds in place of PO meds, it has to be court ordered and this is usually done in a third or fourth court appearance, not in the initial 72 hours. If you see an order by a physician like this you should question it! Even psychotic patients have the right to refuse PO meds while involuntary! Only force IM psych meds when acutely a danger to self or others.

It sounds like your charge nurses and your nurse manager need to sit down and do restraint training for the entire ER. You should always wear gloves, the police can never be involved. Perhaps designate a restraint code team for each shift, page a code overhead when a situation calls for it, quickly administer the IM injections, put a psych 1:1 on the patient, and continue on with the shift. It just doesn't seem like there was enough communication on your floor in this situation.

I hope this helps.

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