New grad in psych

Dogen · Jun 17, 2016

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?...

I have a conversation with them, starting with basics - I'm your nurse, how did you sleep? Did you get breakfast? Do you have a minute to talk? That usually gives me some assessment data (sleep, appetite, energy level) without sounding like an assessment. Plus it gives them a chance to tell me they need to pee. :) I often ask if I can sit in the bedside chair - use your best judgment depending on the patient. I spend 2-3 minutes getting to know them, usually asking if they're from Oregon (this is an important question to Oregonians). Then I get into symptoms. If they didn't sleep well I'll ask about that. "You said before that you didn't sleep well, can you tell me what happened? Maybe we can help you get better sleep tonight." Usually between sleep, energy, and appetite at least one is abnormal and I just ask after it like a concerned friend - tell me more about that, that sounds frustrating, I bet it's hard to sleep in a weird environment like this, etc.

By then I've been talking to them for 10 minutes or so and they're typically relaxed enough that I'll say something like, "It's common when people feel the way you described to also feel like life is a lot of work and that it's not worth living. Have you ever felt that way in your life?" Shawn Shea recommends asking about the past because it's less emotionally charged. He says to ask about the recent past, "Have you felt that way in the last few months?" then the distant past, "Had you felt that way before that at any time in your life?" and then the now, "And would you say you feel that way now?"

Regardless of their answers I thank them for telling me, because I know it's uncomfortable. If they say they're currently having those thoughts I ask if they've thought about how they might hurt themselves in the hospital, and then decide whether I trust their answers.

The most important part of a suicide assessment - and there's a lot of other stuff in a full assessment - is not making it weird. You can't be nervous or awkward. You can't look like you want to leave. They'll pick up on that and assume you don't really want to know, and say "no." Be concerned and compassionate and respectful of the fact that you're asking them to open up about something they may not have told their closest friends. I always thank patients for taking the time to talk to me, and tell them if they need anything or want to talk to let me know. That's it. Easy peasy.

TCASII, ADN · Jun 17, 2016

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.

Zelda, RN · Jun 17, 2016

I did child psych. 90% of what you need to know is learned on the job, more-so than most other specialties (in my opinion). Psych so much communication, and that can't be taught by a book. It takes a while (took me 3-4 months to feel comfortable). You learn by watching the people who are good communicators. Listen to how they talk to their patients.

Some people are excellent de-escalators. Some aren't. I had a charge nurse who wasn't. I often found myself trying to "beat" her to an escalating patient because I knew she was more likely to push the situation further downhill. She was great in a situation in which a firm hand was needed, but not when a pt needed a gentler approach.

I don't know how your unit is, but I ended up leaving my unit after 6 months. I loved the work, but more value was placed on social work than nursing, patient AND staff safety was in danger, and it was just a mess.

vitiana · Jun 17, 2016

Congrats on your job offer! Did you started already ?

Dogen · Jun 17, 2016

Wrong, methamphetamine and halogenated amphetamines are neurotoxic, therefore they destroy parts of the brain and can leave otherwise normal people with hallucinations for life.

Sure, but you seem to imply that this is more common than an actual mental illness. Evidence suggests that only about 7-25% of people presenting to emergency rooms with a first psychotic episode are due to substance use, meaning 75-93% of people presenting with a first psychotic episode have some other etiology (primary psychotic disorder, somatic illness, etc). Stimulant use is also more common among people with a psychotic disorder than the general population, especially in the US, and thus people with a diagnosis of a psychotic disorder are more likely to present with a substance on board. This is important because it would be easy to be distracted by a patient's dirty UA if you hadn't done the diagnostic interview or reviewed records to see if the psychotic disorder pre-dated the substance use.

Crebbin, K., Mitford, E., Paxton, R., Turkington, D. (2009) First-episode drug-induced psychosis: a medium term follow up study reveals a high-risk group. Social Psychiatry and Psychiatric Epidemiology 44(9), 710â€“715.

Sara, G. E., Large, M. M., Matheson, S. L., Burgess, P. M., Malhi, G. S., Whiteford, H. A., & Hall, W. D. (2015). Stimulant use disorders in people with psychosis: A meta-analysis of rate and factors affecting variation. The Australian and New Zealand Journal of Psychiatry, 49(2), 106-117.

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.

Based on the above, I don't see any reason to single out co-occurring CD and mental illness, who are people with a "true" mental illness. That being the case, I don't see any evidence to suggest "interaction with true MI is rare." Quite the opposite. Also, it sounds awfully judgmental to separate people with CD issues from people with "true" mental illnesses. There's a reason chemical dependency is listed in the DSM.

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

I've spent half my career in psych and have a master's in psychiatric nursing. I'm no slouch myself.

allnurses Guide · Jun 17, 2016

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.

Yes we do the q 15 RR checks and monitor the patients closely - we have also started using visteril instead of Ativan for anxiety especially in patients not already habituated to Ativan.

I hadn't seen this warning but am glad you brought it to my attention. I usually am not the person giving the IM but that's no excuse for not knowing.

hppy

allnurses Guide · Jun 17, 2016

Sure, but you seem to imply that this is more common than an actual mental illness. Evidence suggests that only about 7-25% of people presenting to emergency rooms with a first psychotic episode are due to substance use, meaning 75-93% of people presenting with a first psychotic episode have some other etiology (primary psychotic disorder, somatic illness, etc). Stimulant use is also more common among people with a psychotic disorder than the general population, especially in the US, and thus people with a diagnosis of a psychotic disorder are more likely to present with a substance on board. This is important because it would be easy to be distracted by a patient's dirty UA if you hadn't done the diagnostic interview or reviewed records to see if the psychotic disorder pre-dated the substance use.
Crebbin, K., Mitford, E., Paxton, R., Turkington, D. (2009) First-episode drug-induced psychosis: a medium term follow up study reveals a high-risk group. Social Psychiatry and Psychiatric Epidemiology 44(9), 710â€“715.
Sara, G. E., Large, M. M., Matheson, S. L., Burgess, P. M., Malhi, G. S., Whiteford, H. A., & Hall, W. D. (2015). Stimulant use disorders in people with psychosis: A meta-analysis of rate and factors affecting variation. The Australian and New Zealand Journal of Psychiatry, 49(2), 106-117.
Based on the above, I don't see any reason to single out co-occurring CD and mental illness, who are people with a "true" mental illness. That being the case, I don't see any evidence to suggest "interaction with true MI is rare." Quite the opposite. Also, it sounds awfully judgmental to separate people with CD issues from people with "true" mental illnesses. There's a reason chemical dependency is listed in the DSM.
I've spent half my career in psych and have a master's in psychiatric nursing. I'm no slouch myself.

I might also add to your very cogent statements that once the brain is damaged in such a way that the hallucinations become a permanent fixture it's still a mental illness even if it was caused by substances in the first place. Still as you noted I have observed that many of my "Frequent Flyer" psychotics use street drugs to self medicate.

Keep being the great patient advocate you are - I am learning quite a bit from you.

Hppy

Dogen · Jun 17, 2016

Keep being the great patient advocate you are - I am learning quite a bit from you.

Thanks, I really appreciate it. I'm glad my super long posts are useful to someone, rather than being ignored.

anna_91 · Jun 18, 2016

yeah i had a clinical in child psych as part of my community rotation and the nurse has a lot of roles, like you said, resembling social work. School visits, running parent-child CBT groups etc. But that rotation was waaay harder than inpatient adult psych.I was slightly losing my mind towards the end. I think you need basic psych and peds experience to work there. Also, I found that the diagnoses,behaviours and communication were VERY different from adult psych and I felt unprepared...I think this job in general adult psych would suit me better.

EKUGRAD, BSN, MSN, RN, CNS · Jun 23, 2016

I really hope you meant this as a facetious statement! I have been a Psych Nurse over 24 years and watched new meds and techniques come and go. One thing that never changes is the behavior of persons with untreated or poorly managed schizophrenia. Look back to your history; hebephrenic (disorganized type) schizophrenia exhibiting disorganization syndrome (part of the three-factor model of symptoms in schizophrenia, also reality distortion and psychomotor poverty). I have seen "new" schizophrenics exhibit what you call "manics" with nary a drug in sight, including MJ.

Please add some statement to your posting that makes it clear that you are expressing an opinion and factual basis for it, as we are all free to do. Some fresh from the mint nurses may take your word as gospel here on the Specialties Forum.

Scarlettz, BSN, RN · Jun 24, 2016

I've only been a psych nurse for 5 months, but here are some pointers:

-The vital sign machine and nursing assessment are my new best friends. I have had some patients who are med seeking, ER seeking, or "anything" else seeking. I had a patient who was in no apparent distress say she was having trouble breathing. She stated that she wanted a new roommate b/c her other one was messy and she could not breath. I took a full set of vitals and of course she was 100% on RA. I said to her, "100% that is perfect." She then told me she wanted something hot or spicy to help her breath better. I have another patient who is a frequent flier who thought she was having a stroke. She would slur her words, but then speak perfectly clear to her roommate. She often tries to go to the ER or get more meds. I told her I would come in and do a neuro exam. Everything checked out alright, and I told her, "I don't see anything abnormal about your neuro exam." Sometimes you have to be concrete with them and assure them.

-Be consistent with your patients. Every now and again someone will ask for a Gatorade or crackers. If they are in the dayroom alone or they are new to the unit, I will oblige and give them a snack. But, now I have become quiet strict with saying "No, because I don't have enough for everyone." Treat your patients fair and stick by your rules. Sometimes you want to give in, but you cannot say no to one person and then a few minutes later yes to another. Patients talk!

-Be nice and stick by your word. This sounds so simple yet it goes along way. Many of my patients like and respect me because I am patient, don't get annoyed by their requests, I stay calm, and stick by my word mostly (I'll admit, I am human, and forget to follow through with something.) If someone asks for something during a big med pass, I'll tell them that I will write it down and bring it to them. Follow through with your words.

-Be consistent with PRN timing. Otherwise, patients will want something earlier and earlier than what it ordered.

-I come from a med-surg hospital environment where customer service is highly valued and drilled into you. While I still try to make patients happy, and I think I do, it's different in my psych facility. These folks sometimes need a little push to live a productive life: to get up, take their meds, bathe, do for themselves. I feel less like a server as a psych nurse than my med-surg gig because it is our job to help these patients get on their feet. So, I guess what I am saying is, don't be afraid to try and motivate patients to do for themselves, because it is actually beneficial to them. I sometimes want to baby them, but that is not always best.

-A coworker once said that some of the patients have a childlike mentality. He said to me once, "They are like your children. You have to be stern with them and stand your ground. But, then show them that you still love them." I have found this to be wise words because sometimes you will get so annoyed and upset by someone, but it might not be their fault because of their mental condition. So, you still have to be kind and caring to them.

-Find ways to distract or help patients besides medications. Sometimes you will come across fellow coworkers who will just say "Give them a shot" or "They need a shot!" But, a patient may not necessarily be causing trouble. They just want them to go to bed for their own convenience. We had a patient who was IDD. She wasn't doing anything wrong, really, just lingering around the desk. I offered her some crayons and a coloring page. That kept her busy for awhile.

I'm sure there is more.. I'll add more advice as I think of it.