How to prepare for first hospital job in inpatient psych unit?

Puertoriiquena · Jul 9, 2015

Not much you can read in a textbook to prepare for psych. Aside from learning about the medications, psych patients will present in maybe three ways - 1. nice/pleasant, 2. entitled/demanding 3. psychotic. Manics will be extremely intrusive, argumentative, nasty, manipulative, and require constant redirection. Some manics are surprisingly pleasant, but they are busybodies and basically all over the place. Don't expect manics to really sleep much, if at all. Snowing them doesn't work, so don't try.
Psychotics are varying degrees of bizarre. From talking to themselves and isolating from the group (e.g., pacing) to acting out and causing problems. In my experience, from working crisis and voluntary, the problem children with psychosis are meth-induced or on spice (drugs in general). Non-exogenous induced psychotics aren't usually that bad. They hear voices and are troubled, but unless pushed will not cause problems. They might be easily agitated, but left alone, they are okay.
Then the majority of the patients are personality d/o IMO. They might say they are bipolar, however, I find that a large number of these "bipolar" patients are simply anger-management types. No history of staying up all day and night, no true manic Sx. Look at Mayo Clinics differential video on bipolar versus borderline and it explains things pretty well. Personality disorders aren't billable codes, therefore, the Dx of a primary psych problem is required. You aren't really treating disorders anyhow, rather symptoms.
Last but not least, and unfortunately, psych patients are not very honest. They will tell different stories to suit their needs. They think we don't communicate with each other as staff. They will often lie about when they received a narcotic thinking we don't keep record. They will staff split, meaning try to tell one staff that another said it was okay when it wasn't. A lot of them openly admit to their peers that they are just at the facility for pills (e.g., Ativan, pain pills).
As far as being on guard, I never felt very unsafe. Be mindful of your patients problems and history. A history of assault/arrests/DTO will often mean that they might hurt someone. The more limits you set with your patients, the more resistance you will get. They don't like rules or structure. If someone is aggressive and possibly a problem, I let them have their way unless it's a true problem/violation.
I always try and treat my patients with respect. Regardless of their problems, intentional or not, they are human beings and just want to be treated with fairness and honesty. A lot of RNs and techs will test them and even lie. They will know and act upon that. Even the most manic and psychotic patients know what's going on. If you are nasty or disrespectful to a manic or psychotic patient, they will remember it and know you for a long time. They will often apologize for bad behavior after they clear from an episode.

Thank you!! This was super helpful!!

Puertoriiquena · Jul 9, 2015

Make sure you are familiar with the medications used in an emergency situation on an inpatient psych unit. We use a lot of haldol, Benadryl, Ativan, and Thorazine (either IM or PO) in emergencies. Also review some of your routine psych meds given such as depakote, lithium, zyprexa or latuda. Be aware of your environment at all times, keeping a clear exit to the nearest door. Best of luck!

Thank you! I'll re-visit the meds!!

TCASII, ADN · Jul 10, 2015

Thank you!! This was super helpful!!

Also, a lot of people don't seem to realize that manics won't clear for days, even a couple weeks or more. An acute episode of mania requires an antipsychotic to break, not just a mood stabilizer. I have seen practitioners not order anything except a mood stabilizer for acute mania. Not typical, but sometimes.

With psychosis, voices are not usually impacted for an average of 20-30 days. The premise that you can give an anti-psychotic for voices as a PRN, much like you would a pain pill for pain, is nonsense. You might temper their anxiety and slow them some with an antipsychotic, but the voices aren't going away. Unless it's substance-induced or some other short-term metabolic etiology, then it's gonna take a while. So give the PRNs, just remember, it's not doing what people think. Try and give benztropine (Cogentin) with antipsychotics. Sometimes they're only PRN but the patient is on a scheduled Zyprexa or Haldol, so it's not hurting to stave off EPS/akathisia. Benadryl is fine for this too, just not as commonly used from my experience. Propranolol is better for akathisia.

I will also remark, despite this being a personal opinion only, that Abilify and Latuda seems to be pure crap. I have seen no true symptom reduction in patients prescribed these meds as a primary antipsychotic. Maybe some effect when used as an augmentative, but never on their own. I don't care what the textbooks say, they are junk.

With benzodiazepines, Ativan is really your go-to drug. It's preferred for any possible liver impairment d/t glucuronidation metabolism and no active metabolites. **Important - very few people, even some NPs and MDs, seem to know that benzodiazepine half-life is not a true measure of clinical effectiveness because lipophilicity determines the effect. For example, diazepam (Valium) is extremely lipophilic and is redistributed out of the brain after 1 to 2 hours. Only repeated administration results in concentration gradients that translate to longer half-lives. Slower onset BZDs, such as lorazpam will take longer to enter the brain but last longer, again, because lorazepam is less lipophilic. As with most agents, the faster the onset, the shorter the half-life or clinical effectiveness. This explains it well: Benzodiazepines: A Guide to Safe Prescribing | The Carlat Psychiatry Report