How do I know if a patient is dangerous?

[lishka15]

Dear wise psychiatric nurses - yet another case where I would be very grateful for advice...

Today and yesterday I had to be a sitter again, and this time for a young male who OD'ed a few weeks ago. Several of the experienced nurses were scared of him the first days he was there, because he had an "evil stare" and would suddenly start laughing. There used to be three people in the room with him at all times to keep him under control, but now they consider it safe with one person only. (He is still involuntarily committed)

Yesterday was ok. I sat with him at the High Dependency Unit, where the nurses are very observant and careful, i.e. emphasized the importance of him taking his meds.

He said some really weird things during my shift, but seemed to like me and we even talked about trivial stuff. He was still weak and got up with help once.

Today he was transferred back to "my" department. He did not remember me from the day before, and seemed completely different, colder and more suspicious, and didn't connect. (And he is much stronger, sits up by himself and even gets up on his feet)

I tried to tell the only available nurse (straight out of school, the "know it all" kind of person who loves to criticise) about my observations (see below), but she just said: "I do not consider him psychotic at all", and had all kinds of explanations for the examples I mentioned. I.e. him talking about missing body parts, was "probably because of the pain in his foot". I carefully tried to say that she hadn't been with him all day, and the few times she was in there, he was mostly quiet and his few answers could seem adequate enough, but no - according to her I was totally wrong and she even rolled her eyes a little.

Some examples:

- He seemed paranoid about the meals, and once stared at the meal and said: "What is the code?" (To which I replied: "The meal has no code, you can go ahead and eat"). He didn't eat at all.

- He said: "Where are my body parts?" (I said all his body parts were attached to him, and that we were taking good care of him and had everything under control.)

- He stared at his hands as if they were unreal

- He looked at me with that "evil" stare and asked if he could have a pair of scissors. (I said we didn't have any)

- In general he looked at me with this hard to describe look, it's like a mix between suspicious and calculating.

- He lied to the nurse about taking his meds, and she believed him just like that (...they were still on his tray...)

- He asked me stuff like "are we still in the same time and space?" ..... His sentences made no sense half of the time. I asked him if he felt confused, and he said yes - that he had no control over his mind now and didn't know what to think.

- He has a scary laugh. And suddenly laughs at nothing.

He is on Zyprexa (+ morphine etc), but I suspect he's good at "pretending" to swallow them (And the young nurses at my department are so relaxed about the medication, that no-one make sure he actually swallows. They show him the different pills, explain thoroughly, and ask him if he wants that pill - and given the choice, he can't decide. In the end I told him the pill would probably improve his thinking, and that if it was me, I would take it. I don't know if that's appropriate to "influence him", but frankly - since the High Dependency Unit nurses emphasized the meds, I am a little scared what can happen if he doesn't take them. (The High Dependency Unit just gave him a small plastic cup with all his pills and asked him to take them, which worked well)

It worries me that the young nurses seem very naive, and might consider him "safer" than he truly is. They seem to see this young, handsome man their own age, and rationalize every very weird thing he says into something "normal". As a student I don't really want to disagree and "go over their heads" to talk to the leading nurse, because of course they probably know more than I do and it could seem disrespectful. But I am worried. The few times I have met psychotic people, there has been the same talk about missing body parts and that "evil, calculating" expression and scary laugh (one of them were full of antisocial traits and ended up almost killing his girlfriend).

How would you consider the examples I mention above? Is it something to report to the head nurse, or should I listen to the younger nurses? (I might have to sit with him again tomorrow :/ )

_{(For those of you who didn't read my borderline thread: I am just a clueless med student who work as a nursing assistant in a somatic department that is short on staff. And sorry again about the lengthy text and improvable grammar )}

[Jules A, MSN]

He sounds like he definitely could be psychotic from what you describe. Perhaps describe it to the unit manager and see if she has a clue? As a sitter there probably isn't much more that you can do and it doesn't necessarily mean he is dangerous but he definitely has the potential especially if he is paranoid and delusional. My general rule of thumb with psychotic patients is keeping an arms and legs length distance from them and I don't ever allow them to block from the exit.

FWIW for the nurses I personally would not be comfortable leaving his medications for him to take or not take but medical units do things way different than inpatient psych.

[lishka15]

Thanks again Jules, you are the best :)

I voiced my opinion in report at the beginning of my shift today, although the reporting nurse said he had been "okay". Luckily the others believed me :) When I got to his room, the sitter on the last shift told me the patient was much stronger today, had been aggressive and threatened physical harm. So he got transferred to the psych ward.

I will make sure to trust my observations next time, and talk to more experienced nurses if, like yesterday, I am told I'm wrong by a young self-proclaimed expert nurse :)

[Nightengail]

Could you have called a nurse on psych floor for advise. I use to work psych and the medical nurses would call. If we had time we would go down and see patient.

[lishka15]

Maybe... I will make sure to suggest that the next time :)

But if a psych nurse had seen him when he was in a good mood, she might have concluded that he was just fine... I sat there for 8 hrs straight, and his weird behavior came and went several times... in between he seemed fine.

[42pines]

The problem, as I see it, is that you cross-link the psychotic person from your past who: was full of antisocial traits and ended up almost killing his girlfriend.” Yet as, you see it, an evil, calculating expression and scary laugh,” in no way creates a connection with the psychotic killer of your past and this fellow.

Still, if you feel unsafe, even if because of a past negative experience it would be wise to ask to be removed from this assignment because he frightens you. It is legitimate to remove you from such an assignment based upon your past experiences. I would find another assignment for you with such a history.

Or, in the alternative, realize that an evil stare/grin, evil laugh and perceptions of missing body parts mean zip about a patient's inclination to cause you bodily harm and try to enjoy the fellow. Your answers sound perfect. And psychotic (he is) (oops I'm a nurse—I got to remember I cannot diagnose) really can be fun. Never play with them; never, ever tease them. Honest answers are good and responses can still be humorous.

I remember a psychotic fellow that I was PCA for who seemed upset and I said What's the matter xxxxx? He replied: I was talking to the devil.” I said: Really, how interesting, what was the devil wearing?” The response was: Stripes.” That's sort of neat,” I responded, what does the devil look like?” The fellow (who by the way was about 6'2” and towered over me and who had an evil grin and laugh) seemed to think about that a bit and then he pointed a finger directly at me, and said: You!”

Whoa, that was a rush. He scared many people and he did have an evil look about him, but he was as sweet an a person can be and to this day, though years have gone by, when I see him out in the public (with an caretaker) he runs over to shake my hand. Psychotic and schizophrenic, as well as scary looking he was but I still remember our times together fondly.

[RatchedAfterMidnight, MSN, APRN]

Glad you trusted your instincts, he definitely sounds like he is experiencing psychosis. Like Jules was saying, never put yourself in a position where the patient is between you and the door. Before someone becomes aggressive, there are signs that the patient is escalating. I have never had someone go from just talking about bizarre things and laughing to immediately jumping at me. They either become verbally aggressive, physically restless, or begin taking a guarded stance with you. Nurses are taught to use the SBAR (Situation, Background, Assessment, Recommendation) format for speaking with other nurses at report and for getting orders from doctors. Take out the subjective verbiage and describe factual observations. If you use this method while a patient is escalating and a "know it all" nurse doesn't listen, you have the go ahead in my opinion to go higher to the charge nurse. It does not sound like this was the case on the shift but for the future:

Situation: "Pt A has been increasingly loud while speaking and appears to be responding to internal stimuli. When I ask him questions, he screams profanities at me and wrings his hands"

Background: "Pt A came in for an OD. Earlier in the day he was laughing to himself and engaging in conversations with me. This is a departure from his previous behavior."

Assessment: "I believe Pt A is escalating and could potentially become aggressive"

Recommendation: "For this reason, would you consider speaking to the doctor to increase the sitter to patient ratio (or to get him a PRN?)"

AND as a medical student and future Doctor, us nurses would love for you to know that Zyprexa is one of the few antipsychotics that comes in an orally disintegrating tablet. It is wonderful for patients that you believe are cheeking pills. It is called ZYPREXA ZYDIS. Thank you, dallasmiss

[Sun0408, ASN, RN]

To answer just your title; they are all dangerous or have the potential to be. My statement is in every care setting, not just your current field/ situation. As for the young nurse, you can try to talk to her again. If that doesn't work you can talk to her manager. Not to get her in trouble but as a precaution.

[Davey Do]

lishka, it's always good to be on vigil and believe that any Patient has the potential to be dangerous.

However, none of the examples listed posed an imminent threat of harm to himself or anyone else:

- He seemed paranoid about the meals, and once stared at the meal and said: "What is the code?" (To which I replied: "The meal has no code, you can go ahead and eat"). He didn't eat at all.

- He said: "Where are my body parts?" (I said all his body parts were attached to him, and that we were taking good care of him and had everything under control.)

- He stared at his hands as if they were unreal

- He looked at me with that "evil" stare and asked if he could have a pair of scissors. (I said we didn't have any)

- In general he looked at me with this hard to describe look, it's like a mix between suspicious and calculating.

- He lied to the nurse about taking his meds, and she believed him just like that (...they were still on his tray...)

- He asked me stuff like "are we still in the same time and space?" ..... His sentences made no sense half of the time. I asked him if he felt confused, and he said yes - that he had no control over his mind now and didn't know what to think.

- He has a scary laugh. And suddenly laughs at nothing.

Like Jules said- he could be psychotic.

I sense, that possibly he senses, and is using, the fear of you and others to his advantage in a game of power play.

But keep up the good work in being on vigil and the good communication between team members!

Good luck to you lishka, and please let us know how this guy pans out!

[FolksBtrippin, BSN, RN]

I think you did better this time, with how you responded to the patient.

Remember that psychotic doesn't equal dangerous. Most people who hurt other people are not psychotic when they do it.

Be aware of your fear and separate that fear from your observation of the patients behavior.

Psychosis is scary to witness. This doesn't mean the patient is an actual threat.

[Meriwhen, ASN, BSN, MSN, RN]

To answer just your title; they are all dangerous or have the potential to be. My statement is in every care setting, not just your current field/ situation. As for the young nurse, you can try to talk to her again. If that doesn't work you can talk to her manager. Not to get her in trouble but as a precaution.

This. ANY patient has the potential to be dangerous. The most dangerous one we had this weekend was a 70 year old woman who came out swinging, throwing chairs and barricading herself in her room. Treat any and all patients as being a potential threat.

And trust your instincts. If something doesn't quite seem right in your gut about a patient, act on it. Better you do that and be proven wrong about a patient, than not do anything and find out the hard way that you should have.

[Meriwhen, ASN, BSN, MSN, RN]

Psychosis is scary to witness. This doesn't mean the patient is an actual threat.

This too. Assess the patient and look at the whole picture. If you're not sure, get the opinion of someone who is more experienced in psych to give you their take.