Have always wanted to do psyche, but now not so sure...

[NurseCard, ADN]

Hello all..

I'm a Med/Surge RN, have been for three years, and am looking to switch specialties in the hopefully VERY near future. Totally getting burned out. Have been on the same unit for seven years; the first four as an aide.

I have always thought that I would really like to do Psyche, but after an incident that happened a few nights ago, I'm not so sure. I had a patient get very belligerent, very demanding that he go smoke, very agitated about the fact that he "wasn't getting good enough pain medicine".

First of all, this guy was young, and had JUST gotten back to the floor from having surgery. Having said that... it was rather MILD surgery but still, the fact remains that smoking is very detrimental to healing and I explained this to the guy and he still absolutely insisted that he be able to go smoke. Since I had explained the ramifications to him I told him that he could go smoke ONE time.

He did that and came back. A little while later he asked for pain medicine. I took him a Vicodin; the doctor had ordered him one Vicodin q4 hrs for pain, and also Morphine. Since the guy was probably only going to be here a few hours, I really didn't want to give him Morphine IV; he's not going to be able to go home on that! So I took him the Vicodin and he got really sarcastic and nasty saying "Oh that's not going to be enough!" BEFORE he even took the stuff. But, he took it anyway and I basically said "You know, give it some time and see how it works for you".

I went back in a little while later and the guy is practically bouncing up and down on the bed saying "You have GOT to let me go smoke, I' m a nervous wreck!" I firmly said "I can't let you go smoke anymore". I mean, this guy had JUST had surgery and had JUST been down to smoke a couple of hours prior. He also complained he was still hurting; I offered the Morphine. He got really smart and nasty with me saying basically "That s**t isn't going to work!" and yadda yadda yadda. Well, his behavior was getting a tad out of line and inappropriate at this point and I said "I'll give you the Morphine but you are NOT going to smoke" and walked out of the room as I was saying it.

I went and got the Morphine, hoping that it would ease his leg pain and maybe calm him down a bit. He also had Phenergan ordered, so I was going to go ahead and give him that also. When I got back to his room... he was UP OUT OF HIS BED HOPPING AROUND practically on that leg that had JUST been operated on, and he was just... TEARING into me saying "Don't you disrespect me again. Yadda yadda!" and just really yelling at me and flailing his arms around. Well, I looked at him and calmly just kept saying "I apologize, I shouldn't have said that"... I said this about three times, but he just kept going on. Well, probably by this point I should have already left the room, called security, had another nurse come in the room, something, but instead, I just was trying to get him to calm down a bit but he kept on and finally when *THIS* came out of his mouth... "You think I'm just some kind of DRUG SEEKER!" Oh, I got a little bit... MAD. I said to him "Sir, I did NOT say ANYTHING to you about not giving you pain medicine. I said that you could not go SMOKE!" And I said all of this, in a rather um, loud voice. Not YELLING at him per se, but I did raise my voice. Anyway, he said "Get out of my room, I want another nurse, and I was like, "Fine" and walked out and had another nurse and a guy from security go in there.

So... I um, didn't handle this guy very well, I don't think. I don't work with a lot of young people acting out. I mostly currently work with dementia patients. This guy did claim that anesthesia in his system made him a bit "wirey" and really I felt bad later on because I thought he probably wasn't even in his right mind but turns out that not only WAS he in his right mind, he went to the ADMINISTRATION about me!!!!

As soon as I could see that he was going to be a bit out of control, I should have just turned around and walked out of the room right then, instead of trying to talk to him or reason with him, I guess. The situation just escalated and I ended up just upsetting him worse.

After this happened, I thought... maybe I don't want to do psyche after all. =(

[rn/writer, RN]

Don't let one incident upset your apple cart. You wouldn't expect to switch to OR nursing without taking time to orient to the unit and learn the new skills and equipment, would you? Psych is no different. Because so many psych interventions deal with intangibles (mainly talking), it's a temptation to underestimate their importance and their power. And to think that you should already know what you're doing because, after all, you to talk to patients every day, don't you?

The reality is that you need to learn how to talk to PSYCH patients--how to de-escalate, disengage, redirect, set boundaries, and more. You probably do some of these things on a lesser scale now, but psych intensifies the challenge.

And think about it. This guy had several things going on at once. He was an immediate post-op, going through nicotine withdrawal, with some AODA issues and some psych issues and who knows what else. He probably should have had a nicotine patch, along with whatever pain meds were ordered for him.

On a real psych unit, you would have all kinds of protocols for unacceptable behavior, as well as the example of more seasoned staff who know how to put the kibosh on this kind of manipulative/threatening behavior before it gets too far along.

You're right, that you should have cut his craziness short and summoned security and other staff. The fact that you can see that in hindsight says your instincts are fine. You just lack training and experience.

Don't let a single bad incident turn you away. File it under "Lessons Learned" and pull it out if you ever find yourself in this kind of situation again.

Most of all, don't expect yourself to act as if you already know this stuff. Go forward with the attitude that you're ready and willing to expand your repertoire and that some opportunities will be more strenuous than others when it comes to stress.

I wish you well.

[CharlieRN]

RN/W has the right idea.

The guy was an addict and was drug seeking. He was a nicotine addict seeking his drug. He may well have been an opioid addict as well.

Personally, I think a straight "no" to the cig would be the best answer but a good alternative would be to kick the problem into the MD's lap and seek and order for that "drug". If the MD says "may smoke ad lib" then you are off the hook. Any post op damage from either the smoking or the running around are the Doc's problem.

One trick with difficult folks is to ask them to define what they want. Then you can evaluate that request and bargin toward a mutually acceptable plan.

[Orca, ADN, ASN, RN]

One thing I noticed from your narrative is that you seemed to tend to relent in negotiation. Many people on mental health units require firm limits, and once you show that you can be manipulated, that tends to bleed over into other areas. This patient probably believed that once you caved in on the cigarette the first time, he could get you to do the same thing on other issues if he held his ground long enough and was belligerent enough.

It is not a crime to realize that you may not be the best person to deal with a particular patient at a particular time. It happens to all of us. Sometimes the best thing is to walk away and let someone else take over.