Latest Comments by TCASII

TCASII, ASN, RN 3,613 Views

Joined: Mar 20, '05; Posts: 189 (22% Liked) ; Likes: 75

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  • 0

    Quote from Dogen
    If you have a patient for a week who's still hearing voices, that's a mental illness.
    Wrong, methamphetamine and halogenated amphetamines are neurotoxic, therefore they destroy parts of the brain and can leave otherwise normal people with hallucinations for life.
    What are the long-term effects of methamphetamine abuse? | National Institute on Drug Abuse (NIDA)

    Drug-induced psychosis can last years. Never assume hallucinations will clear. I've had many who were brain damaged from it. Most of what you say is true, but in all honesty, interaction with true MI is rare compared to drugs and/or co-occuring drugs use and MI.

    I have worked petition, court-order, outpatient, state (forensic), and voluntary inpatient. I've seen it all.

  • 0

    I probably sound hateful

    I do try my best to help those who need it. I've had some great patients.

    True story, after doing psych for nearly 4 years and never feeling like I could help anyone (mainly due to the paperwork and inability to talk with them much), I was approached by a man at a coffee shop. He said thank you and shook my hand. I was like..."uh for what?" I didn't recognize this guy, who was he?? He hesitates then says the name of my old facility I worked at. I hadn't been there in over a year. I was a little teary–eyed on the way to work. I was shocked and so touched.

  • 2

    Quote from anna_91
    Wow Thanks! The post is like a psych crash course. think I'll look up what to do with addictions and communication techniques since that's a big part of it. I did my psych rotation on this unit and it is not the most acute psych ward, which is good in my opinion. But a lot of people are mandated by the court to be there, or just held ''against their will''. I think it's a good idea to review the protocols for that too...Also setting boundaries with bipolar patients is something I should be ready for. So how exactly do you do that without causing an escalation?
    I'll be honest, regardless of the patient, being nice goes a lot farther to prevent escalation than being curt or abrupt. A lot of nurses are rude, short, and demeaning to patients. They talk to them like children. Now, if you aren't getting very far with being nice, then you have to put your foot down and say "we aren't doing that....". There's a fine line and every patient is different. You can set limits all day with a manic bipolar, but it'll just be repeating yourself 100 times. They really don't listen or take what you say literally. They simply can't help be annoying.

    Patients also pick up on naivety pretty quick. They will game you at every turn. Try to capitalize on your inexperience. For example, you're overwhelmed, busy, trying to keep up and not make mistakes. A patient will come up and say "You never gave me my Seroquel" or "The doctor told me to ask you for additional Ativan if I needed it". They really think we're stupid. NEVER pass a narc without documenting it, immediately before or after. Even in a code, if the patient is being held, always write that you signed out the Ativan and when it was given. I never pass a PRN without documenting at that moment. Scheduled meds I remember.

    I wouldn't worry too much about setting boundaries for manics. They are rare and not much problem. Just annoying/needy/intrusive. The real problem children are borderlines and personality D/O NOS. Same with addicts/detox. They are the ones who escalate d/t refusal to get PRNs early, refusal to obtain the meds they want from providers, or trying to buck the staff rules.

    The problem children in psych are:

    1. Axis II (old DSM code for personaloty D/Os, mostly borderline/antisocial/cluster B)
    2. Addicts/Detox
    3. Drug-induced psychosis (meth, bath salt, spice)
    4. DD (developmentally delated, such as MR and Autism)

    That's typically what you'll see most of unfortunately. True SMI (serious mental illness) patients, such as schizophrenia, bipolar D/O, schizoaffective, are usually pretty good and passive. They are also rare.

    I worked emergency psych (petition) for a 18 months. I'd say we had 70% drug-induced, 15% Axis II, 7% SMI, 5% DD, and 3% bogus petitions. I often said, if it weren't for meth we'd have no patients.

    Something I should add, patients will feign symptoms a lot. Mostly to obtain narcotics or to be sent to the ER. I'm extremely cynical and won't send them. Most nurses send them regardless. Most nurses are afraid to lose their license. I get it. I've sent patients when I wasn't sure. I'm just pretty intuitive. I told someone last week c/o chest the day before discharge that we'd keep and eye on him. IOW, he wasn't going to the ER. He was so mad. Tried to tell me he was puking. Ok, show me. He showed me some spit on the floor. Yeah, ok, MI...right. He was discharged and never brought up chest pain to the day shift. Basically, he didn't want to leave, so he wanted to sabotage his discharge.

    It's common for them to sabotage their discharge. They will cut themselves, report increasing SI/HI, ect...

    But don't be so fast as loose as me with somatic complaints. I'm pretty wise to the games and willing to take chances. Just letting you know they will play medical games, such as fake seizures a lot.

  • 4

    Good responses so far. In all honesty, not much prep is needed. It's important to know the meds as best as you can, but no one expects you to remember sides or all particulars. A lot of side effects are common among class anyhow. Very few meds interact, so don't be too concerned about that. For example, ibuprofen isn't supposed to mix with lithium, yet all it does it increase the blood concentration of lithium. IOW, giving someone a dose of IBU once and a while likely won't affect anything. I've given it to someone on lithium and the doctor was fine with it since they took it less than every other day. Same goes for the whole Ativan/Zyprexa combo. A couple deaths have occurred with Ativan and Zyprexa IM, therefore, they are contraindicated as IM together. Although, I have given 2 of Ativan and 20 of Zyprexa IM with no outcome, positive or negative. Then again, anti-psychotics have killed patients d/t underlying heart issues and other factors. I know of one who was aggressively attacking staff, was given an anti-psychotic IM and died. It happens. It's the business we're in. You can't assume everyone is gonna die or have a problem. The likely of scenarios is with falls and not having staff to watch them.

    Moreover, you are your own person/nurse. If you don't feel comfortable then don't do it, and if you need to ask, then ask. The doctor and other nurses should be helping you make clinical judgments. This field can be a bit grey at times. You won't be able to predict everything. Sometimes you will give more meds than you could fathom and the patient will still be wide awake or even acting out.

    Key points I like to make: You can't medicate a manic to sleep. Manics can be given multiple RTs (IM or PO) and never actually sleep. It takes days to weeks for them to clear. Once you've seen a true manic, you've seen them all. They are intrusive, hypervigilant, needy, annoying, somatic, and obsessive. They will c/o various medical problems that don't exist. You have to be able to ascertain what's real and what isn't. They will hear and see everything. You can look at another staff member and roll your eyes from frustration and they will pick up on it, despite not seeing it. They will steal things, from staff and patients and hoard them in their room. They will argue about everything under the sun. All you can really do is just keep redirecting and waiting for the meds to work.

    Most "manics" or patients with auditory or visual hallucinations are on meth or other drugs. True bipolars are rare. Bipolar D/O is Dx'd way too often. Most of the time to people who are borderline or anger management types. Visual hallucinations are organic or drug-induced. It's extremely rare to be from mental D/Os. Same goes for constant auditory hallucinations. It's considered malingering to be c/o constant voices. As per AH and treatment, a PRN for "voices" is a bogus intervention. It's mainly to help sedate and temper the frustration from the voices. Anti-psychotics typically take 25 to 30 days to impact voices, similar to antidepressants for mood.

    Most patients, depending on the facility are malingering or exaggerating symptoms. Yes I'm jaded, but you will see so much of this. The exploitation, sharing of addictive drugs between patients (cheeking), and manipulative behavior/stories will make you leery of everyone. Plus, the patients who are easily exploited are coerced by others to give them their drugs. In many ways, it's like prison Bx and you will see a lot of it. A fairly high number of them are repeaters and will hospital hop. A frequent story will be readmitted d/t not being able to fill Rx (money), yet was able to purchase meth and get high.

    As stated above, don't be too worried about the meds. The doses are often pretty high and they take a lot at once time. Most of the nurses I work with are paranoid giving PRNs at the same time (i.e., multiple sedating meds). My experience has mostly been with falls, not death or any other adverse sequelae. The most frequent thing I see with meds is akathisia or other movement D/Os from antipsychotics.

    It's important to provide anticholinergics to patients on antipsychotics (Benadryl, Cogentin). They can help but won't always prevent TD.

    I'm at work, I have to go. I'll check back for follow up.

  • 0

    This is pretty typical. They lie a lot. The way of dealing with this....send them back. Do not admit at all, just turn them around and teach the hospital a lesson.

  • 0

    I probably wouldn't want my wife working on a psych unit, but that's the male protectiveness in me. It's hard to say. I've worked psych for a few years now and only had one major problem. I personally have never been attacked, nor have I seen an outright assault on a staff member that wasn't already out of control. I do know of several who have been assaulted though regardless of size or gender. It does happen. I've only been uncomfortable a couple of times.

    The one instance a female staff member on my team was badly injured during a takedown. The patient was extremely agitated and looking to cause harm to anyone. We had already placed him in seclusion and given an injection. It did not phase him. He was very antisocial and pretended to pay nice to be let out. Unfortunately he would begin an assault as soon as the door was opened. On a second attempt to give him an injection he managed to kick a girl on my team in the chest so hard it fractured her sternum. She couldn't breathe right for months. I felt terrible as the nurse, and it bothered me for a long time.

    Overall my work has been uneventful. Obviously you'll do takedowns, but I personally won't get near someone if I think I could be seriously hurt. It's not worth it. The key is to have good techs and supportive staff. Also helps to recognize building agitation in a patient and try to medicate. The problem is, most providers are paranoid about medicating and think Vistaril is your best option. It often gets to the point where you're calling the provider more than once because the original order didn't work. You'll find with experience that you can anticipate when a weak med isn't gonna cut it. It's a shame really, and a lot of attendings lose respect for the field after see how emergency psych patients are dealt with, or aren't dealt with rather.

    You have to decide for yourself what you're comfortable with. Some facilities are staffed with excellent techs and helpful staff. Others will expect you to manage with too many patients and no real help. Finding the right facility is important. I wouldn't say it's any more dangerous than similar jobs. ER patients assault and hurt staff, ICU/Med-surg patients same.

  • 1
    vintagemother likes this.

    I managed to survive 18 months at a crisis facility, as the sole nurse on a locked unit with 15 to 18 involuntary patients. Most of them were high on meth, but extremely agitated, psychotic, manic and unruly. Very few were actually true MI, and the ones who were caused less trouble. Only the manic bipolar Pt's were difficult d/t constant redirection and the fact that you cannot medicate a manic to sleep.

    I honestly attribute my ability to survive on my the techs, namely two who were part of my team every shift. Without those two people I would have quit. The other saving grace was the provider on call was an NP who really allowed me to medicate when I needed it.

    Having said that, most places here in AZ are difficult at best.

  • 4
    LPC2RN, chevyv, Hygiene Queen, and 1 other like this.

    Yeah, I had a patient once who was totally antisocial, not MI at all. He fought with us for 5 hours! Five hours of back and forth with a patient only because the doctor refused to allow us to keep him in seclusion for more than 20 minutes. Each and every time we opened the door it was a full on brawl. Not just acting up, but a fight. He was biting, spitting, and doing all he could to hurt us. He had two RTs with no effect, even though his eyes were red and the meds were clearly in his system. It wasn't until he started hitting his head on the floor in seclusion that we were allowed to put him in restraints. Luckily by this time the wonderful house psychiatrist gave the order to keep him in restraint for 2 hours.

    He remarked later to administration that he enjoyed what he did and wanted to hurt people. He fractured one of our sweet female techs sternum in the process as well. I was heartbroken and felt responsible for this happening. She was just trying to help. Nearly everyone had strains and injuries.

    So there are times where holding someone down just isn't enough. We'd been spit on and hurt enough.

  • 2
    marigoldey and LPC2RN like this.

    Unfortunately this is common in psych. Techs and RNs will watch as staff are assaulted. I personally believe it's a two-tiered problem. One, the staff are afraid of being injured. Two, the climate has shifted to not putting hands on someone d/t liability and associated paperwork, patient injuries, and "trauma" to the patient. I have seen my fair share of people get fired because the take-down didn't go buy the book, but they never do. Only when the patient stops as soon as you grab them can you initiate a proper hold. If they resist, then that's it, it's a fight. No one wants to get hurt. When I worked in crisis and involuntary patients came in high on meth, if they went into a hold, it was a fight. Luckily my administration were pretty understanding that we tried to do the right thing and realized that nothing goes perfect.

    On the paperwork side of it, I will often do whatever to avoid a hold. If I think a patient will go off because they aren't allowed to do something, I will give in because it's just not worth it. The doctors at my place are the same way. No one wants to put their name on a S&R packet. It has really become taboo. The sad part is that patients know this and exploit it.

    Psych is really a disappointing field IMO. I've even seen a good number of interns say they lost a lot of respect for psych after seeing how patients are dealt with, or not dealt with actually. A good discussion of that was brought up on SDN and I agree. The avoidance of using IMs or RT when a patient is actively aggressive, resulting in other patients being traumatized just isn't right. Oh well :-/

  • 1
    nickfitz1969 likes this.

    At my facility I typically have 11 to 14 patients. It's way too much. I never have time to talk to patients or have any clue what's going on with them. I barely get enough to chart an assessment. The shift change is always a disorganized mess. Nothing is finished from shift to shift. The paperwork takes hours and there is so much that you can spend a whole night fixing charts, auditing, and putting labels on papers. We're always out of meds and supplies. Horrible. :-(

    I was told 1/8 upon hire. The original team was told 1/6. It's been 1/14 more than I can count. We often only have 2 techs on the floor with 35 or more patients. Very sketchy.

  • 1
    vintagemother likes this.

    I can tell you that 99% of the time there is no problem with adding other antipsychotics on top of another drug. I've given Zyprexa, Risperdal and Haldol at the same time. I've given injections to individuals already on a load of meds; More than I can count.

    You run more risk of inducing akathisia than anything. Nurses need to understand that most patients are on such low doses of these meds anyhow. Back in the day they use to given up to 20 MG of Risperdal a day. Haldol can be dosed up to 100 MG. I've seen Geodon given as twice the daily max dose and all they did was sleep good.

    I'm not saying to play fast and loose, but aside from prolonging QT and inducing EPS side effects, it's pretty safe.

    I've even given the ole nasty Thorazine to patients on 20 of Zyprexa and 100 mg of Benadryl.

    Working crisis kinda gave me a clue as to how many meds people can tolerate. Sometimes you feel that the whole pharmacy wouldn't touch them. If they're new to the meds then obviously their tolerance and potential reactions are higher.

    As posted above, a lot of them are addicted to the pills and want everything to feel drugged.

  • 0

    double post...delete

  • 5

    It all depends on the situation and patient. Having worked crisis, I have dealt with so many patients who are either manipulative or labile to the point that once they've acted out, giving a PO is "too little too late". Example, a patient who acts out, hits staff, throws something...whatever. One instance of this occurred recently whereby they patient had been acting out all night. The doc refused to order anything until it was out of control IMO. They had to be escorted to seclusion with the door open for a "time out". The order was finally given for PO Zyprexa. I knew this patient would refuse, and they did. After a period of calm, the patient began to act out again. This time staff was "hit", albeit minor hitting. I called and informed the doctor that the patient was refusing POs and hitting staff. Finally got the order for IM. Naturally, upon entering the room with the syringes, the patient attempted to bargain and ask for PO. I personally was against it and so was everyone else. We gave the IMs. Patients always try to talk their way out of things once they see the needle. Manics are good at that. I've also had antisocials try and manipulate into taking POs just to cheek them and continue with their behavior.

    Sometimes you have to force meds.

  • 0

    I agree. I set limits as much as I can. If someone uses the phone as a disruptive tool, then phone time is eliminated. As I said, unfortunately, my experience working in 5 major facilities is that the administration and/or MDs don't back up nurses at all.

  • 2
    JuanabePHNurse and Hoozdo like this.

    Quote from Puertoriiquena
    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