paranoid schizophrenic w/auditory hallucinations

[RockyCreek]

Every week or so I have to admit a frequent flyer that comes in by ambulance hearing the voices that warn her that someone is going to kick het butt. Of course, she also has some vague medical condition that has to be addressed before she can go to the psych unit. She has flat affect 90% of the time but the other 10% of the time is she screaming at us to leave her alone [and using the most colorful language]. She has told us that most of the time she can tell that the voices are lying but she feels that they real and she is compelled to listen. The doctors say that she is escallating and she will start acting out more until we can get her into a stable, secure and supervised environment. I am worried for my staff since we are not trained to treat psych patients and the med/surg halls are not equipted to handle things.

Could someone point me to a reliable website or books where I can get the information I deparately need to deal safely and effectively with this woman. All help is greatly appreciated.

MedSurg Staff RN

[Mish56, BSN, RN]

Rocky;

You must hate getting psych patients as much as I hate getting med patients! In my hospital we are currently creating a job for a pysch nurse, to work with the med surg nurses who haven't a clue how to deal with our "frequent flyers", and they are scared to death. Just like we say "you want me to change a dressing on a WHAT?? port a cath????" Whose crazy now eh? We are clueless on our end also.

So, I'm praying your hospital has an inpatient psych department. Have your manager call their manager and have a psych nurse on your unit with this patient for 3 shifts at least. Maybe a trade? There are techniquies/approaches we psych nurses do without blinking, that your nurses could easily learn. Things like "stop acting like a lunatic, you've been worked up for this 10 times in the last 2 months! This is anxiety! (or paranoia, whatever). "stop listening to the voices, focus on my voice right now! Tell them to shut up for 10 mins!". I don't think "regular" nurses realize how often we psych nurses directly acknowlege the patients symptoms, validate them, and get on with the reason for hospital level of care. It's not like the patient doesn't know they have odd thought process', they do know it. They often are relieved when their caregivers acknowledge them, but remind them "these are the thoughts that interfere with your life eh?".

I've had patients sent to the ER for chest pain (etc), when my instructions to "relax, deep breath" work just as well as a million dollar work up that comes up negative.

That being said, I also get on my soapbox about psych patients having very real medical problems, that get ignored because they have a primary psych dx. So, as you identify this patient as a frequent visitor, a strong collaboration between psych and med-surg RN's would be mutually beneficial to all involved. Go for it!! Your med surg RN's can call the psych RN's, and the psych RN's can call them and say "what do ya think? This is what the patient is saying, this is what I observe, what would you do?".

Good luck!!

I'll get off my soapbox now.

So now I re-read your request for a website/book. Although I believe a collaborative effort would be far more beneficial, one would need to know dx 1st. I'm guessing "axis 1: paranoid schizophrenic?? Axis 2: borderline personality disorder? gotta know dx before could make a worthwhile website!

[RockyCreek]

Thanks for the info - you are absolutely right about our concerns about dealing with this lady. I am more afraid that I will do something wrong psychologically than medically. We do the million dollar work-up every time she is admitted but, once she is cleared medically, she goes to our sister hospital which is the locked psych facility.

I was not aware that you could be so 'strong' with the voices or that she might still be able to control their influlence -- thank you for that invaluable insight. I will continue to speak to her in calm, controlled ways but I will directly address the disruptive behavior more.

You have been a great help - thank you!

[SuesquatchRN, BSN, RN]

RockyCreek, understand that kindness goes a long way. "That must be frightening" acknowledges that she is in a real state of fear without validating that that which is causing the fear is real. Does that make sense? If you can spend some time just sitting with her when she's frightened that goes a long way. And a PRN order for Haldol or another strong antipsychotic should she begin to escalate is you friend.

Good luck.

[Thunderwolf, MSN, RN]

Another thing to assess...are the voices "heard" inside her head OR outside of her head?

My best to you.