I am a new grad and getting used to some of the realities of psych nursing.
Do your facilities have problems with discharging seriously overmedicated patients? We have one patient who is going home on scheduled 15mg oxycodone TID, 10mg valium QID, Thorazine 50mg BID, 30mg temazepam HS, probably some antidepressant, and some other stuff I can't remember. He can barely walk a straight line and slurs all his speech. He is a 29 year old male who was admitted for alcohol detox. He is polite, gets along very well with staff and other patients, well-spoken (although now slurred) and extremely manipulative. I actually can't help but like him. His detox symptoms were nebulous based almost solely on anxiety and body pains. He managed to weasel the doc into giving him the oxycodone for back pain he got in a MVA a few years back. (I was horrified to read in his chart that he was admitted for opiate detox at another facility just a year and a half ago). He asked for most of his ativan in injectable form as pills "don't work as well". The nurses eventually started to defy the doc order and refuse. I only injected him once, explaining that he can't get shots when he goes home. About day 4 of admission, he started getting 'suicidal'. Day 6 or 7, the post-traumatic flashbacks started .. day 9 or so, the 'voices' started. He has been here for nearly 20 days now, racking more and more meds. My opinion is that he truly does have depression, anxiety, PTSD issues and is absolutely desperate to remain numb (sounds like some of addiction psychology doesn't it?).
The psychiatrist has been practicing for decades. Is he easily manipulated with a bleeding heart? The nurses who have worked with him for years describes him as placating patients so they will not be issues on the unit. As pleasant as quiet days are, I am willing to deal with patient "i want more drugs" hissy fits, unless patients become imminently DTS/DTO. I am ashamed about feeding patient addictions and sending them back home more ill than when they came in. The nurses are starting to get together to complain to our unit manager about this patient; I hope something is changed. "Do no harm" is being violated.
Thank you for your input.
ps. I'm a new grad of 6months training for charge nurse; I'm terrified.
thanks for the hugs =) It is definitely overwhelming how much I do not know. I want to be a great nurse really badly, but all I can do right now is be an ok nurse who asks a lot of questions, learns a lot, tries hard, and has compassion. I've actually never seen neurotonin used for our opiate detoxes. The docs seem to only use it for chronic pain and start at 300mg TID.
our opiate detox protocol (all PRN meds)
clonidine 0.1mg q4h
flexeril 10mg q6h
bentyl 20mg q6h
Ibuprofen 400mg q8h
phenergan 25mg q6h
loperamide 2mg q?h
ativan 1mg q2h (this varies between docs)
They ask for ativan around the clock, but in my observation, it does nearly nothing for them. A cross tolerance??
Most of our patients have an ativan PRN order in which the doctor's enforce that we have to give if the patients wants it and is not heavily sedated. I remember telling one young 1st hospitalization patient that ativan was addictive and she should practice newly learned coping skills; she had no idea and was just watching all the other patients receive it for stress. She never asked again.
In my unit, there is a culture of placating patients to create a calm milieu. The milieu works like a machine that breaks if a cog slips. We have 15 patients. One charge nurse, one med nurse, and two BHTs during the day. I can tell you that it would be extremely frowned upon for me to put a patient into seclusion because I wouldn't give into an ativan hissy fit. One seclusion= all patient's meds late, admissions delayed, milieu shake up, quality assurance reviews, and tons of paperwork. I'm also still learning tension reduction skills and get scared to 'push it'. All of this crap was less evident when I worked night shift. You want people to sleep at night, so giving out sedating meds didn't seem unreasonable. I felt bullied by patients over there, but not nearly to the level I do now. in general, i feel like we give ativan everytime a patient cries or has stressful feelings. As a med nurse, I have 15 patients to give meds to in a small time frame (and these patients are on tons of meds and PRNs), also filled with worthless charting; this leaves very little time to argue with escalating patients.
so I need to navigate this system without losing my compassion, doing my best to patient advocate. Unfortunately, in this setting, patient advocating often means getting yelled and cursed at by patients :trout: I would much prefer smiles and being well-liked, but I'm here to help, not enable addiction and bad behavior.
I'm planning on eventually getting a DNP. I have the means, the drive, and the ability. I'm already frustrated about the lack of opportunity and autonomy of the RN in behavioral health.
Specializes in critical care; community health; psych.
I'm planning on eventually getting a DNP. I have the means, the drive, and the ability. I'm already frustrated about the lack of opportunity and autonomy of the RN in behavioral health.
Thank you so much for helping me learn =)
How true. I went from home health (lots of autonomy) to psych (zero autonomy). I feel like I'm always beating my head up against the wall:banghead: to try to get some credit for being anything but a PEZ dispenser.
On our dual floor, I know the patients try to bully the RNs but those nurses won't let go of a narc if their lives depended on it. Since the patients are all voluntary, they can always leave. That's their choice.
On my floor, a general psych unit, some nurses give every prn requested whereas others will at least get into a discussion about what's going on. I guess its up to us to decide which kind of nurse we're going to be. I try to be consistent but sometimes I get overriden by the charge RN who says to just "give it to them".
Specializes in Med-Surg, Geriatric, Behavioral Health.
Inthesky, your efforts and desire for something better is laudable. However, it appears that you may be caught in a system that allows little flexability for you as a nurse. The milieu sounds rigid...a milieu can, if not careful, go to this extreme (the other extreme is becoming too lax). Rigid compromises a therapeutic environment...and much may be due to inadequate staffing and/or inadequate treatment programming. And when too rigid, any disruption upsets the whole apple cart...just like in the other extreme...too lax. Placating opiate addicts with drugs is not therapeutic at all...and is hardly treatment. The unit actually grooms them to return at a later date to raid "your store." Also, placating opiate addicts with meds just to "keep the unit sane"...speaks volumes about your unit...sounds dysfunctional. There may be little you can do there...but gain some experience in psych...and maybe, move on to a better facility. Believe me, there are better facilities....just like there are poorer ones. And believe it too, not all psych/detox facilities are the same. Some are actually very therapeutic to patients and have a better milieu...better for patients...better for staff.
Thunderwolf, MSN, RN
3 Articles; 6,621 Posts
Big :icon_hug:Hugs, inthesky...lots to learn in psych...especially when new.:nuke: