med/surg nurse needing feedback from Psych nurses

[kcmylorn]

I'm an adult med/surg nurse and I have a growing concern that our medical patients with psychiatric disease are not receiving proper attention to their MH issue and thus worsening their mental health diagnosis. maybe this is too harsh or unfair of me to state but ......

I work in an outpatient inner city community health center, we have a large patient population who have mental health issues. I am new to community health and as the RN part of my role is to triage patients. Given that; we, in the primary care setting are supposed to following the Medical Home model- which our clinic seems to have abandon and I am not sure why- I am guessing lack of knowledge.

I recently had 2 mental health patients I triaged and I feel they they were brushed off.

1- Patient one was a chronic alcoholic with advanced stage liver issues. I am no expert or physician but from all the years as a hospital med/surg bedside nurse and taking care of these patients w/ this issues for years, I feel the patient was discharged from the hospital on the wrong med for the fluid retention issue, I made a same day appt for f/u in our clinic and 2 other nurses were outraged and cancelled the appt and the patient was given an appt days away.

2- patient two was discharged from an inpatient MH unit, has bipolar dz and substance abuse issues. This patient had no money, but did have 2 legitimate scripts from the psychiatric but our clinic could not fill them and not charge the patient. I set the patient up with the social service dept and made this patient a same day appt to get our provider to re write the scripts so the patient could be entered into the no pay catagory and get the meds order by the specialist upon discharge- depakote and serquel. The patient had an appt for the IOP tx facility but it was 5 days away. No patient that I know of is dischaged from the hospital with any meds in hand- they are always sent to the outside commercial pharm to get them filled doesn't matter what the diagnosis is- even post MI.

I both of these cases I saw both patients making an earnest effort to do the responsible thing and were given the runaround and shotty care standards by the healthcare system for it. How are these patients to recover if the providers, nurses and healthcare system are not on board with this treatment goal? granted, our clinic does not provide mental health services but is that not part of treating the whole patient reguardless of whether a facility has formal mental health services or not.

In the first patient's case- I am new to the clinic and it is a power struggle with the LPN who for years has been doing off the record triage and now the clinic has employed a "triage RN" that LPN doesn't like it.

Please advise as I do not have "formal" Mental health experience it has always been on adult physical medicine hospital units and was part of what the patient brings with them- the medically complex patients .

Thank you

[RN58186]

I am not a psych nurse and don't have an answer to your question but one of the things that is helping where I live is that one of our hospitals has opened a inpatient medical psych unit - where the nurses are trained to deal with the medical concerns as well as the mental health concerns. These are pts who have both a serious medical condition (like your liver disease fellow) and a mental health condition that must be addressed as well. I have heard it is working well and both pts and nurses are more satisfied with the care that they receive/can give.

[Elladora]

one of our hospitals has opened a inpatient medical psych unit - where the nurses are trained to deal with the medical concerns as well as the mental health concerns.

Love this! I sometimes feel we have the opposite problem. We get so involved in treating the mental health issues that we sometimes overlook/under treat the medical ones. It seems people have a hard time understanding that those with mental health issues can become physically ill and vice versa.

[RN58186]

I have actually been admitted to mental health; I am diabetic on insulin. I have had some of the mental health nurses come into my room with the glucose meter and say to me "I understand you know how to use this, because I don't." And it was the majority of the nurses. Typically, I manage my own diabetes and my doctor will always write an order to that effect so I bring my own meter and dose and give my own insulin under supervision. I have had some scary low sugars in hospital that some of the nurses seemed at a loss as to what to do, and I was glad I was able to manage them myself. And I have found that when my pts are admitted to mental health units, I sometimes cannot get their transplant meds ordered appropriately despite phone calls and written instructions. So I get the under treated physical illnesses too. That's why I am hoping that this medical/psychiatric unit becomes standard at all our hospitals in this city, goodness knows it is needed.

[Whispera, MSN, RN]

I've found that psych patients are often the "red-haired stepchild" when it comes to having their other medical needs addressed. Symptoms they are showing can be chalked up to behavior issues--even low heart rate and cyanosis! Sometimes medical needs aren't addressed when a psych patient is hospitalized for psych issues. Sometimes it's an attitude on the part of the medical staff that they're only there for psych things. Sometimes it's ignorance on the part of the psych staff. I think it's unforgivable for a psych nurse to not know how to work a glucometer or address abnormal glucometer readings! That's basic nursing knowledge. Shame on the nurses and facility mentioned by the previous poster!

I floated a hospital as the psych nurse consultant. Some things I heard people say and saw, that enraged me:

from a nurse to a doctor about a patient in alcohol withdrawal: "you don't want to do anything to medicate his symptoms, do you?"

from the in-house doctor who was called about a patient with extreme SOB and cyanosis: "he can get that taken care of after discharge."

when I went to see a suicidal patient in the ER, to evaluate him (this happened more than once): the patient was out of sight from the staff, with a bag of pills (or a weapon) beside him/her on the exam table. Staff also said, "good thing you're here--we're too busy to deal with your patient."

about a patient having seizures when medical staff was called for help: "it'll be awhile before we can get there. other people come first."

In all those cases, the psych staff, me included, did all they could for the patients. I'd feel ashamed of us if we didn't. Psych nurses need medical skills too. Medical nurses need psych skills. We are treating a holistic person and that means treating all conditions that are in the person...

(steps off soapbox)

[Christy1019, ASN, RN]

I've found that psych patients are often the "red-haired stepchild" when it comes to having their other medical needs addressed. Symptoms they are showing can be chalked up to behavior issues--even low heart rate and cyanosis! Sometimes medical needs aren't addressed when a psych patient is hospitalized for psych issues. Sometimes it's an attitude on the part of the medical staff that they're only there for psych things. Sometimes it's ignorance on the part of the psych staff. I think it's unforgivable for a psych nurse to not know how to work a glucometer or address abnormal glucometer readings! That's basic nursing knowledge. Shame on the nurses and facility mentioned by the previous poster!

I floated a hospital as the psych nurse consultant. Some things I heard people say and saw, that enraged me:

from a nurse to a doctor about a patient in alcohol withdrawal: "you don't want to do anything to medicate his symptoms, do you?"

from the in-house doctor who was called about a patient with extreme SOB and cyanosis: "he can get that taken care of after discharge."

when I went to see a suicidal patient in the ER, to evaluate him (this happened more than once): the patient was out of sight from the staff, with a bag of pills (or a weapon) beside him/her on the exam table. Staff also said, "good thing you're here--we're too busy to deal with your patient."

about a patient having seizures when medical staff was called for help: "it'll be awhile before we can get there. other people come first."

In all those cases, the psych staff, me included, did all they could for the patients. I'd feel ashamed of us if we didn't. Psych nurses need medical skills too. Medical nurses need psych skills. We are treating a holistic person and that means treating all conditions that are in the person...

(steps off soapbox)

Holy moley! I would run far far away from a facility like you described. I don't expect every nurse to know everything, but if you don't think cyanotic SOB pts or those actively seizing warrant immediate attention, then you don't deserve the title RN.

My four years of experience is in a large inner city ER that cares for a large population of those with mental health and substance abuse issues. My initial dream was to go into psych nursing but after becoming aware of the complete lack of funds, resources, and consideration of these pts, I realized that i would end up burned out within a year. I'm a nurse that will get fully involved with my pts well being, and tend to go above and beyond what is required of me. I knew that I would be constantly fighting a losing battle if I pursued that field, but have instead found ways to incorporate my additional knowledge of psychology in how I assess and respond to each pt I care for.

With that said, for some disgusting reason, our society and healthcare industry have deemed it acceptable to ignore the needs of specific groups of patient populations. The 2 most directly affected are mental health pts and elderly/long term care pts, and is evidenced by gross understaffing, unenforced regulations, limited funding, and lack of response when issues are raised. This is why many pts with psychiatric conditions or substance problems are in prisons or homeless, as well as the issues of ridiculous nurse to patient ratios that affect level of care available to each pt in LTC/geri psych facilities. The reason this continues to go on is that these pts can be so easily ignored. I mean, who will listen to some "crazy homeless guy", or "demented old lady"?

As for the Etoh liver failure pt, what med were you concerned with and why so? As for the other 2 nurses I hope you told them to concern themselves with their own pts and to never again cancel something you've ordered because you felt it was necessary. Plus with these types of pts you gotta keep in mind that they are least likely to be compliant with home meds, especially their lactulose b/c of the bowel effects, and can often be assumed to be intoxicated when really their ammonia levels are through the roof, and if living alone, can be unsafe.

As for the bipolar pts, as well as with the schizophrenic population, there is a high % of noncompliance and substance abuse for a few main reasons. 1. The antipsychotic meds put them in a fog, cause lethargy and extra-pyramidal effects, keep manics from getting that high with mania, cause significant weight gain, and are obnoxiously expensive. (I take seroquel for sleep and without insurance it was $700.00/mo before generic, and $550.00/mo as generic!)

2. These pts conditions are often poorly managed resulting in unemployment and requiring SSI, have little if any family support and end up homeless in the inner city where they won't be arrested. This surrounds them with high crime rates and drug use, so they resort to that lifestyle to survive.

3. The substance abuse is so high for two main reasons; self medicating and a result of depression caused by all of the factors listed above. Manics in depression are likely to use an upper (crack, coke, meth, pcp etc), to mimic that euphoria assoc with manic episodes. Manic pts and paranoid or hallucinating schizophrenics may use downers to either calm down, or use sedation to get rid of hallucinations (heroin, weed, opiates)

It's sad to think that our culture can so easily ignore the plight of others who in reality, need us the most, to advocate for, and protect as they are unable to do so for themselves.

[jh07418]

mh issues make it more difficult to recover medically. I work on an inpatient Medical/behavioral floor and I've noticed that mh is just not taken as seriously. we have a psychiatrist on board and everything. I think that health care is so driven towards length of stay, tangible recovery that there is no place for mh to be sufficiently dealt with. Everything is too focused on how to get the patient in and out successfully and for the least amount of money. There needs to be more serious outpatient settings that can help this population. But then there is not funding for things like that.

[Whispera, MSN, RN]

The issues I wrote about weren't saying the psych nurses didn't pay attention to their patients' medical needs. Staff who didn't work on the psych floor were the ones who ignored/avoided/under-cared-for the patients...

[rnrevajohnson]

I work on a mental health unit and we have hospitalists in the hospital. We are 100% inpatient telemedicine. The hospitalists are to come up and assess all of our patients for the medical part of the H&P, however, a lot of times the hospitalist never makes it up to see the patient until after they are discharged. For example, I had three patients the other day that were admitted through the night. The hospitalist was called at 0600. The hospitalist came up to see the patient at 1530. All three patients were being discharged and one had already walked out of the door. Another example- I had a patient who was battling cancer and prostate problems and I called the hospitalist about the patient having pain when urinating. I asked if I could restart the medication he takes at home. The doctor said 'no' and that he was going to start the patient on something new. The doctor then said he would be up in half an hour to talk with the patient about this. The doctor did not show up for 6 hours and the patient was discharged half an hour later.

[Christy1019, ASN, RN]

I work on a mental health unit and we have hospitalists in the hospital. We are 100% inpatient telemedicine. The hospitalists are to come up and assess all of our patients for the medical part of the H&P, however, a lot of times the hospitalist never makes it up to see the patient until after they are discharged. For example, I had three patients the other day that were admitted through the night. The hospitalist was called at 0600. The hospitalist came up to see the patient at 1530. All three patients were being discharged and one had already walked out of the door. Another example- I had a patient who was battling cancer and prostate problems and I called the hospitalist about the patient having pain when urinating. I asked if I could restart the medication he takes at home. The doctor said 'no' and that he was going to start the patient on something new. The doctor then said he would be up in half an hour to talk with the patient about this. The doctor did not show up for 6 hours and the patient was discharged half an hour later.

How did the patients get discharged if the doctor never came up to write discharge paperwork?

[Whispera, MSN, RN]

The psychiatrist writes the discharge orders on a psych floor. Psychiatrists don't usually do medical stuff with their patients. They ask a hospitalist or a general or family practice doctor to come do those things, as a consultant.