Need a little feedback re: transferring a psych patient

[travkitty]

So, today in my ED I was in charge of our psych holds. One female, who I've had before, & is normally a smidge anxious but always able to be talked down, was quite over-the-top on the manic spectrum today. She was unable to stay in her room & would not stop talking, not to mention not listening. She did take 1mg Xanax PO willingly, but it seemed to have no effect.

At one point, she was almost uncontrollable, almost hyperventilating, & the MD ordered 10mg Zyprexa IM & 2mg Ativan IM. I have given this mix before with no issues. They go into deep sleep for almost the whole day.

She got the shots, then did fall asleep. Rise/fall of chest was fine, RR was 14, BP of 98/54 which can be normal for her. 97% on RA. Lo & behold, her psych room became available & report was called. They were told that she was sedated because she was agitated & could not be de-escalated or redirected. When we went to place her in the chair, she was obviously REALLY sleeping, but did rouse with verbal stimulus & squeeze my hand when asked. She was a bit mumbly & fell back asleep quickly. Again, this is what I usually see in the first hour of getting this mix. She was sent to psych with a PCT & security.

From the report I got, she roused with sternal rub & mumbled when they arrived to psych. Again, this is pretty typical. They almost wouldn't take her in, but they did. I found out that they rapid responsed her about 3 hours later when she only stirred with sternal rub for her evening meds. They did an ABG, which apparently got a much better response from her, but again, she went right back to sleep. ABG was nothing remarkable for someone in a deep sleep on those meds.

The only thing atypical is that I've never sent a patient over to psych so soon after sedation. In fact, our psych beds were coming open about 15 hours sooner than they normally do, so I've never had this issue. Do patients not get sedated for agitation on psych floors or something? It just seems like someone freaked out there, so now I'm wondering if they will attempt to write me up. They did accept the patient & the rapid response was 3 hours later.

I just have never sent a sedated psych patient to psych before (& maybe that psych nurse never received one before...don't know). Just picking some brains.

[NurseCard, ADN]

Yes, we sedate patients. To me though, if a patient can only be aroused with sternal rub,

they are over sedated. Where I work, we typically give Haldol 5mg, Benadryl 50mg, Ativan

2mg with no issues. IM of course, if pt. won't take PO.

[sauconyrunner]

Agree with NurseCard. We do give patients meds for control of anxiety etc. But if they can be only aroused with a sternal rub this is too much sedation and that patient needs to be monitored on a continuous pulse ox. They are at risk for things like- completely stopping breathing or aspiration. because they arent just "sleeping" they are much less arousable than a normal sleeping person. Obviously sedation is supposed to wear off but sometimes people do progress in the other direction. The Psych units are set up very differently than a regular medical floor, so my rule of thumb is always if I would not discharge a patient the way they are now, I probably should not send them to psych.

I always think about meds for behavior control in the sense that I can always give more, but it's hard to take it away...

[Been there,done that, ASN, RN]

Sounds like she received a "little" too much medication.

We are NOT able to see into the future. It was a prescribed dose , within normal dosing parameters.

It hit her a little hard.

I agree with you that the psych nurse may have not seen that response before. In my book, if they are arousable and the respiratory pattern and pulse ox are okay, let them sleep it off.

It would require a close watch... but aren't the patients seen on q 15' rounds anyway?

I think the psych nurse over reacted... bet the rapid response team did too.

If you would have sent her over in the manic and highly agitated state, you could've gotten grief.

You weren't able to tie her up and put a bow on her ..... if the unit has a problem, they need to get over it.

[chevyv, BSN, RN]

I'm not sure what you mean by almost uncontrollable, but we see a lot of the Zyprexa, Ativan, and Benedryl given with violence. Next time, perhaps 5mg of Zyprexa would be better. Perhaps she had been awake for a long time and that just helped her calm down enough to sleep.....way too deeply.

I too would have watched her vs and if the po2 was good, I would have been happy to let her sleep it off as long as docs were aware.

I'd rather her come to me this way then heading towards me having to call security, then medicate her, after putting her in restraints.

[Meriwhen, ASN, BSN, MSN, RN]

On psych floors, we definitely sedate patients if we have to. But I agree with the others: if it takes a sternal rub to get a response from someone, she is over-sedated.

It sounds like she got too much medication for her. Xanax, then Zyprexa 10 and Ativan on top of that...that's going to hit anyone very hard.

What happened during the rapid response? I'm curious.

[travkitty]

From what I understand, though I wasn't there, she did rouse with sternal at med time & the nurse called a raid response. The MD ordered an ABG. During the ABG, the pt must have responded good enough, & the ABG indicated, that she was okay to just sleep it off with q15 checks. I'm off today & I haven't gotten any calls from work, so I'm assuming all is well at this point. When I sent her, she would rouse to less than sternal, satting fine on RA, which is absolutely what I see on patients who get the same meds. All the same, looking back, I probably should have given her half of the amount, with the rest ready just in case.

I admit, when I was a floor nurse, I would have freaked more easily than I do now in the ED, just because there is sick & then there is SICK. Sometimes I forget that psych or floor nurses haven't dealt with possibly unstable or out of norm patients as much, therefore they are likely more apt to pull the trigger on a rapid response.