New grad in psych

deza, MSN, NP · Jun 15, 2016

I'll be starting as a new grad in psych also. Just waiting on testing and getting licensed. I bought the Psych notes clinical pocket guide and have been going through it while at work. It's simple and easy to read.

Kissforjersey · Jun 16, 2016

Safety safety safety and safety. Do not ever forget how important it is to keep yourself safe.. the things you learned in clinicals about you and the door is SO important I can't reiterate that enough. You keep yourself safe. Your staff safe. And ALL of your patients safe. A lot of psych patients have no control and you have to stick to your guns and make sure you follow protocols. Do not EVER doubt your gut. And remember things your teachers said to you if your heard it twice it's probably important. Restraints and IMs happen more often that you'd think.

Don't be nervous about the amount of meds you're giving either. Some of the doses you'll question and be really nervous about giving, you can always double check but some pts take enough meds to tranquilize a horse. Ativan and zyprexa cant be given within an hour between eachother.

Don't ever hesitate to ask questions. Make sure you have someone you can always go to.

Also, remember you are new at this... but that doesn't mean you aren't educated. If you think something should be changed or needs to be looked into speak up. Medical issues can happen and they can happen quickly. Be aware that just because you are in psych does not mean some serious crap can hit the fan in a few minutes hahah.

Enjoy it. And spend time with your patients. I've learned something from everyone so far. Take time out for you and your own mental health as well because that is VERY important too. It is so rewarding and so wonderful. Don't get discouraged by people saying to you "oh you should have done med surg. Atleast a year" you'll be fine. Good luck and have fun! You never know what you're going to walk into coming on shift and that's my favorite part.

TCASII, ADN · Jun 16, 2016

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.

anna_91 · Jun 16, 2016

I'll be starting as a new grad in psych also. Just waiting on testing and getting licensed. I bought the Psych notes clinical pocket guide and have been going through it while at work. It's simple and easy to read.

OOOH good idea I think I'll order one.

anna_91 · Jun 16, 2016

Wow Thanks! The post is like a psych crash course. :roflmao: 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?

TCASII, ADN · Jun 16, 2016

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.

TCASII, ADN · Jun 16, 2016

I probably sound hateful :laugh:

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 tearyâ€“eyed on the way to work. I was shocked and so touched.

allnurses Guide · Jun 16, 2016

Ativan and zyprexa cant be given within an hour between each other.

Really? It's actually the cocktail of choice for our patients who are allergic to Haldol! Everything else you said spot on.

I might also add that is very easy to be taken in by some patients. Depending on their Diagnosis they can be very good at manipulation.

Lastly don't forget that psych patients have medical emergencies too. Pay attention to signs and symptoms and don't be afraid to call a supervisor and chart what you see. I had one patient die several years ago as the result of an abdominal aneurysm. I wanted to send him to the hospital but several nurses and Doctor's thought he was faking to get pain meds. I also recently sent out a patient who had been presenting as confused for two days that I was off and it turned out the ammonia level was over 1000.

Such instance are rare but they do happen.

Hppy

Dogen · Jun 16, 2016

Sadly, I'm going to have to respectfully disagree with some of what TCASII has said. Bipolar disorder versus drug-induced manic state, or schizophrenia/schizoaffective versus a drug-induced psychosis is difficult to tell initially (since drugs activate the same areas of the brain active during mania and psychosis, so symptoms are identical), but after about 24 hours they're easy to tell apart (drug-induced symptoms will resolve or dramatically diminish). In my career I haven't found either schizophrenia or bipolar to be terribly rare, but I work in a large facility and other hospitals send us their psych patients, so we see a lot (twice as many patients as the next biggest hospital). If you have a patient for a week who's still hearing voices, that's a mental illness. Substance abuse will often make symptoms of an underlying mental illness worse (see: kindling), but co-occurring mental illness and substance abuse is extremely common. One patient told me that meth made her voices worse for days but totally silent for a few hours, and that that was worth it.

Auditory hallucinations are the most common hallucination experienced by people with a mental illness, but visual hallucinations are not uncommon, almost always in conjunction with auditory. A person with schizophrenia can have a cluster of hallucinations of different types. Now, it's uncommon for someone to have visual or tactile hallucinations alone. A rule of thumb is that tactile or visual hallucinations occurring alone are most likely drug-induced and olfactory or gustatory are more likely caused by organic brain disease (tumor, etc). But patients with schizophrenia commonly have more than one type of hallucination, many of which, like olfactory or gustatory, are never identified because we tend to focus on auditory and visual.

In addition, visual and auditory hallucinations can also be caused by alcohol withdrawal or delirium (lack of sleep). This is important to consider in newly admitted patients who begin acting out. If you suspect delirium due to alternating level of consciousness avoid giving a benzo, as they can make delirium worse. It's worth being familiar with the diagnostic criteria of delirium, and you can read up on the Confusion Assessment Method (CAM) for identifying it. Obviously, alcohol withdrawal that includes hallucinations needs immediate attention if the patient isn't already being treated with Ativan, Librium, etc.

I have not found that most patients want to stay, or that they exaggerate their symptoms, but this may be a difference in settings. As an RN I work mainly inpatient at an urban hospital where people would prefer to discharge home rather than go through the court system and potentially be sent to the state hospital. It's not uncommon for patients to tell me they don't hear voices and then to observe them speaking to unseen others in their room when they're alone. You'll come to recognize institutional behaviors of people who have spent a lot of time in hospitals and jails, including hoarding food, clothes, radios, etc.; stealing food; and requesting everything they can (food, PRNs, toilet paper, etc).

Speaking of PRNs, they're your best friend and your worst nightmare. Some patients will know every med on their MAR and request it. You'll get the person who can barely stand, slurred speech, telling you they're having an anxiety attack and need Ativan. You'll also have other staff tell you they think your patient needs a PRN Ativan or antipsychotic. You're going to have to figure out what you consider worth fighting over and how to tell both patients and staff that you disagree. Is it worth getting into an argument over two Tylenol, or just letting the patient have them as long as it's not unsafe? On the other hand, when I was brand new I had a patient I suspected had delirium secondary to substance use and an MHT asked me multiple times to give them Ativan and eventually went over my head when I kept refusing (didn't work, but still).

More experienced nurses are a good resource, but don't assume their practice is safe or best. Some are phenomenal, some would prefer to medicate everyone until they're asleep, and some want to play the strict parent and set hard lines on everyone. The latter tend to be the ones that walk with a limp after getting beat down by multiple patients over their careers. Don't be that nurse. Your patients are people, doing the best they can with the resources they have (cognitive, emotional, and physical). Treating them with respect will go a long way, especially when you eventually have to set firm boundaries (such as with a borderline patient).

Know, at least very generally, the diagnostic criteria for the most common diagnoses on your unit. Chances are good there's a DSM on your unit you can reference. This is helpful when writing notes or talking to providers. No one cares if your schizoaffective patient slept 12 hours and didn't attend any group activities, but they will (maybe) care if your major depression patient does those.

Psychosis is like fire. It burns in the brain, damaging brain cells and eating up antipsychotic medications. That's why you can give a psychotic patient high doses of medication without seeing significant effect.

Know the difference between serotonin syndrome and neuroleptic malignant syndrome. Both are uncommon in hospital settings, but you don't want to miss it.

Geodon has to be taken with food, at least 500 calories. If it's ordered with meals, give it with meals. Bioavailability is reduced about 50% if taken without food. Know how to draw up IM Zyprexa, Haldol, Geodon, Benadryl, and Ativan. You don't want to be in an emergency and have to look up whether Zyprexa is reconstituted with 2.1ml or 1.2ml of sterile water.

Some antidepressants can cause withdrawal symptoms, particularly venlafaxine (Effexor) and paroxetine (Paxil). If a patient is on one of these meds and describes feeling electric shocks in their brain or going down their arm, or popping sounds or a buzzing inside their head, try to ensure they get their dose close to the same time everyday.

If a patient is refusing their meds, ask if anyone has worked with them and knows how to get them to take it. I've had patients who refuse asenapine (it tastes awful) or other ODTs, but will take them readily in OJ.

If your patient is paranoid offer to open the medications where they can see them, and don't be surprised if they ask to look at the packaging. Patients who believe they're being poisoned are more likely to eat packaged food, like pudding or crackers, than food brought up on a tray. I really like paranoid patients, for reasons I can't explain.

It's not uncommon for patients with mania or paranoia to suddenly decide you're bad and refuse to work with you. It's also not uncommon for patients with psychosis or mania to suddenly like you. Don't let it get to you. I had one bipolar patient who spent the first half of the shift refusing to talk to the MHT working with her, saying he looked shady, then when I got back from lunch she accused me of stealing from her and would only talk to the MHT for the rest of the day. You just learn to roll with it.

If you're fat, ugly, short, tall, gangly, thin, have weird hair, bad teeth, or any other quality, patients will point it out to you in the most colorful terms possible. You can't be thin-skinned, and my typical response is, "Yeah, I could stand to lose a few," and then redirect. I have a beard - just a regular beard - and patients comment on it several times a week. My favorite was, because my beard is (naturally) more red than my hair, a patient experiencing psychosis yelled, "Just because you put highlights in your beard doesn't make you the boss of me!"

Redirection is an exceptional skill to cultivate. Observe people who seem to have good rapport with patients and steal lines from them whenever you can. After all these years I still hear a line and think, "Oh, that's good, I'm keeping that." But only say things that sound authentic coming out of your mouth. Patients know a faker.

Dogen · Jun 16, 2016

Really? It's actually the cocktail of choice for our patients who are allergic to Haldol! Everything else you said spot on.

There's an FDA warning against IM olanzapine and any benzo given within one hour. There have been ~50 adverse events and 8 deaths with the combo. The warning on Zyprexa says, "if use of intramuscular olanzapine in combination with parenteral benzodiazepines is considered, careful evaluation of clinical status for excessive sedation and cardiorespiratory depression is recommended." In my facility this means Q15min RR checks.

anna_91 · Jun 16, 2016

Sadly, I'm going to have to respectfully disagree with some of what TCASII has said. Bipolar disorder versus drug-induced manic state, or schizophrenia/schizoaffective versus a drug-induced psychosis is difficult to tell initially (since drugs activate the same areas of the brain active during mania and psychosis, so symptoms are identical), but after about 24 hours they're easy to tell apart (drug-induced symptoms will resolve or dramatically diminish). In my career I haven't found either schizophrenia or bipolar to be terribly rare, but I work in a large facility and other hospitals send us their psych patients, so we see a lot (twice as many patients as the next biggest hospital). If you have a patient for a week who's still hearing voices, that's a mental illness. Substance abuse will often make symptoms of an underlying mental illness worse (see: kindling), but co-occurring mental illness and substance abuse is extremely common. One patient told me that meth made her voices worse for days but totally silent for a few hours, and that that was worth it.
Auditory hallucinations are the most common hallucination experienced by people with a mental illness, but visual hallucinations are not uncommon, almost always in conjunction with auditory. A person with schizophrenia can have a cluster of hallucinations of different types. Now, it's uncommon for someone to have visual or tactile hallucinations alone. A rule of thumb is that tactile or visual hallucinations occurring alone are most likely drug-induced and olfactory or gustatory are more likely caused by organic brain disease (tumor, etc). But patients with schizophrenia commonly have more than one type of hallucination, many of which, like olfactory or gustatory, are never identified because we tend to focus on auditory and visual.
In addition, visual and auditory hallucinations can also be caused by alcohol withdrawal or delirium (lack of sleep). This is important to consider in newly admitted patients who begin acting out. If you suspect delirium due to alternating level of consciousness avoid giving a benzo, as they can make delirium worse. It's worth being familiar with the diagnostic criteria of delirium, and you can read up on the Confusion Assessment Method (CAM) for identifying it. Obviously, alcohol withdrawal that includes hallucinations needs immediate attention if the patient isn't already being treated with Ativan, Librium, etc.
I have not found that most patients want to stay, or that they exaggerate their symptoms, but this may be a difference in settings. As an RN I work mainly inpatient at an urban hospital where people would prefer to discharge home rather than go through the court system and potentially be sent to the state hospital. It's not uncommon for patients to tell me they don't hear voices and then to observe them speaking to unseen others in their room when they're alone. You'll come to recognize institutional behaviors of people who have spent a lot of time in hospitals and jails, including hoarding food, clothes, radios, etc.; stealing food; and requesting everything they can (food, PRNs, toilet paper, etc).
Speaking of PRNs, they're your best friend and your worst nightmare. Some patients will know every med on their MAR and request it. You'll get the person who can barely stand, slurred speech, telling you they're having an anxiety attack and need Ativan. You'll also have other staff tell you they think your patient needs a PRN Ativan or antipsychotic. You're going to have to figure out what you consider worth fighting over and how to tell both patients and staff that you disagree. Is it worth getting into an argument over two Tylenol, or just letting the patient have them as long as it's not unsafe? On the other hand, when I was brand new I had a patient I suspected had delirium secondary to substance use and an MHT asked me multiple times to give them Ativan and eventually went over my head when I kept refusing (didn't work, but still).
More experienced nurses are a good resource, but don't assume their practice is safe or best. Some are phenomenal, some would prefer to medicate everyone until they're asleep, and some want to play the strict parent and set hard lines on everyone. The latter tend to be the ones that walk with a limp after getting beat down by multiple patients over their careers. Don't be that nurse. Your patients are people, doing the best they can with the resources they have (cognitive, emotional, and physical). Treating them with respect will go a long way, especially when you eventually have to set firm boundaries (such as with a borderline patient).
Know, at least very generally, the diagnostic criteria for the most common diagnoses on your unit. Chances are good there's a DSM on your unit you can reference. This is helpful when writing notes or talking to providers. No one cares if your schizoaffective patient slept 12 hours and didn't attend any group activities, but they will (maybe) care if your major depression patient does those.
Psychosis is like fire. It burns in the brain, damaging brain cells and eating up antipsychotic medications. That's why you can give a psychotic patient high doses of medication without seeing significant effect.
Know the difference between serotonin syndrome and neuroleptic malignant syndrome. Both are uncommon in hospital settings, but you don't want to miss it.
Geodon has to be taken with food, at least 500 calories. If it's ordered with meals, give it with meals. Bioavailability is reduced about 50% if taken without food. Know how to draw up IM Zyprexa, Haldol, Geodon, Benadryl, and Ativan. You don't want to be in an emergency and have to look up whether Zyprexa is reconstituted with 2.1ml or 1.2ml of sterile water.
Some antidepressants can cause withdrawal symptoms, particularly venlafaxine (Effexor) and paroxetine (Paxil). If a patient is on one of these meds and describes feeling electric shocks in their brain or going down their arm, or popping sounds or a buzzing inside their head, try to ensure they get their dose close to the same time everyday.
If a patient is refusing their meds, ask if anyone has worked with them and knows how to get them to take it. I've had patients who refuse asenapine (it tastes awful) or other ODTs, but will take them readily in OJ.
If your patient is paranoid offer to open the medications where they can see them, and don't be surprised if they ask to look at the packaging. Patients who believe they're being poisoned are more likely to eat packaged food, like pudding or crackers, than food brought up on a tray. I really like paranoid patients, for reasons I can't explain.
It's not uncommon for patients with mania or paranoia to suddenly decide you're bad and refuse to work with you. It's also not uncommon for patients with psychosis or mania to suddenly like you. Don't let it get to you. I had one bipolar patient who spent the first half of the shift refusing to talk to the MHT working with her, saying he looked shady, then when I got back from lunch she accused me of stealing from her and would only talk to the MHT for the rest of the day. You just learn to roll with it.
If you're fat, ugly, short, tall, gangly, thin, have weird hair, bad teeth, or any other quality, patients will point it out to you in the most colorful terms possible. You can't be thin-skinned, and my typical response is, "Yeah, I could stand to lose a few," and then redirect. I have a beard - just a regular beard - and patients comment on it several times a week. My favorite was, because my beard is (naturally) more red than my hair, a patient experiencing psychosis yelled, "Just because you put highlights in your beard doesn't make you the boss of me!"
Redirection is an exceptional skill to cultivate. Observe people who seem to have good rapport with patients and steal lines from them whenever you can. After all these years I still hear a line and think, "Oh, that's good, I'm keeping that." But only say things that sound authentic coming out of your mouth. Patients know a faker.

Thanks for all the info!!! Everything you said sounds a lot like this unit, from what I remember from clinical. Also, there was a patient admitted after a suicide attempt. When I spoke to my patient in a brief conversation she denied suicidal ideation but after having a 20 minute conversation with the doctor she admitted to him ''having regrets it did not work''. It was shocking because she did not tell me this when I asked. I am afraid of missing such an important clue in my practice. How do you get depressed patients to open up to you?...