Why do we as nurses on med surg units have such a responsibility to manage patients like these? i had a horrid case of PCP (we think) detox for the last 2 days. Pt was absolutely psychotic, running in the halls naked. I had a doc who would not aggressively treat, and so we were left calling secuirty, doing all we could, literally tackling the guy down in the halls. Of course, one of my floor managers was after me, chiding me for not assessing him properly, not being "aggressive" enough in getting more orders for more sedation, etc. I was BEGGING his doc to give us more to work with, but he just would not give us what we wanted. The entire experience was just absolutely demoralizing. Our hospital has a protocol that we use w/ ativan ordered for parameters, and we were using it, but it wasn't doing a thing for him.
I work on a neuro floor, but I do not feel adaquately trained to manage these patients. I'm tired of the risks we incur (the guy came up from the Ed w/ a pocket knife still in his jacket which one of our night nurses found.), tired of the abuse, tired of the drama and the stress of it. Why does our huge hospital not have a special unit dedicated to detox w/ staffed experts who can recognize the specific symptoms of each type of detox, staffed w/ case workers, with psychiatrists -- whatever to take care of these people? They are frightening to others patients, they take up all our time -- I mean -- try managing other patients, discharges, admits all going on while your nutso detoxer is sprinting towards the elevator and/or threatening you w/ physical harm half the day?? I just cannot do it and each one of them presents in different ways.
I learned that PCP is especially dangerous, that PCP users can be extremly psychotic and dangerous to themselves and to others -- yet my hospital sends this patient up w/ no sitter, w/ no advice on how to handle him and assigns a doc that seems to know nothing about PCP detox!
I will admit -- nursing school taught you that DT's are dangerous -- I know that, but that's about all I know and I feel I really could use some expert advice on these types of patients.
I could not agree with you more! Heres the best part, I work in a facility WITH a dedicated detox unit. Unfortunately we CANNOT send our actively withdrawing to them until they are at least detox day 3! Not day 3 when they start, but at least three days after the start of active withdrawl. The reason.....they are not medically stable and thus need to be on a med surg floor.
So we get to break out the morphine and the ativan and occasionally if we have a really progressive doc on call the Haldol, set the bed alarms and proceed to spend the whole night restarting the ngs, foleys, and IV's they keep pulling. Running down the hall every 5 seconds when the bed alarms go off. Listen to them scream, threaten, run naked, and everything else and calling the docs every 10 minutes to beg for restraints or sitters.
And if we are lucky enough to get a sitter it comes out of our matrix. So when we have 2 techs for our 24 heavy post op pts with JP's, ostomy, penroses, chest tubes, foleys and NG's galore; blood sugars, turn q2, EVERYONE needs assistance to the bathroom, q4 vitals, and lab draws, actively sundowning and dementia: ONE tech gets to do all that while the other has to sit. Then you get to spend the night fielding phone calls from bed desk and the nursing manager "We need to get that sitter d/ced. Do everything you can to get that sitter dc/ed."
It is ridiculous! It is totally unsafe. You spend your whole night dealing with these fools while your other 6-7 patients who need you get ignored. You don't get to eat, pee, or sit down. You get to spend the night dodging their stool, spit, and whatever else they can find to throw at you. Your almost guaranteed a trip to another fall prevention inservice because they always fall.
And the best part is getting called into the managers office two days later to be told:
"your patient in this room had a 8/10 pain rating for 45 minutes before you got them anything. That is not in alignment with our core values."
Or patient X called patient relations on you because you forgot to bring them an extra blanket.
Or you did not complete the vaccine assessment on your new admit and the nurse who followed you complained!
I HATE detox patients!
My God, do you work on my unit?? This describes my situation to a "T." Describes my whole weekend.
Our protocols have not only ativan, but geodon, haldol and 5 point restraints based on pt's level of agitation.
Your original post seemed to be about your doc not ordering meds and treatments appropriately, but your subsequent post seems to express more frustration with the fact that you did not predict your pt's acuity correctly. Please, clean off your crystal ball and get with it. I'm not sure how your manager can even give you a hard time about not being able to correctly predict your pt's course of detox. Why not simply say: "He gave no indication of untoward behaviors on my shift; he was stable and the CIWA protocol was completely adequate for his care at that time. How exactly do you want me to predict the unknown? Do I pull a crystal ball from the med pyxis, or does is it supposed to just pop out of my a$$?"
Well, you could leave that last sentence off, but imply it with your tone. Honestly, I'm just usually blunt with my managers, and I find when confronted, they either agree with my handling of the situation after all, give me very specific instructions on how to handle it, or stutter a bit and then leave me alone.
As an RN that works in a dedicated detox facility staffed with other nurses/MDs/psychologists/counselors I truly feel sorry for you guys out there in med/surg-land. The problem for us is when they have been "detoxed" in a med-surg ward, only to find that they were sedated to the point of being completely snowed on ativan. Now, they have a whole new substance they need to be detoxed off of....whee! Not to mention that the whole addiction cycle never gets addressed in that type of scenario. I'm a big believer that they need to feel the effects of their withdrawal (to a point--I"m not talking of life-threatening detox symptoms), as in "see what you've done to your body?" This is especially true for the opiate addicts. I always tell them that detoxing shouldn't be a cake-walk, and they are going to feel like crap for a while. This will pass, and although they may feel like they are going to die from their withdrawal, they aren't. After the worse of their withdrawal is stabilized, we have them start attending groups and lectures where they (for those willing to learn) talk about their addictions and are started in a 12-step program. Thankfully, our facility also has outpatient programs that help some that are willing to change their lifestyles. The amount of patients that relapse, though, is astoundingly high (we call them our frequent-flyers).
FYI--we don't use physical restraints, ever. If they are that violent, we call the cops. We do use haldol, and risperal as needed for hallucinations/psychotic episodes. I've gotten used to the streakers, foul language, nasty attitudes, and pukers--my condolences to those of you that need to deal with this on a "normal" unit.
Our protocols have not only ativan, but geodon, haldol and 5 point restraints based on pt's level of agitation.
Nice. If we'd just had the haldol on board, we would not have even had the problems we did.
Your original post seemed to be about your doc not ordering meds and treatments appropriately, but your subsequent post seems to express more frustration with the fact that you did not predict your pt's acuity correctly. Please, clean off your crystal ball and get with it. I'm not sure how your manager can even give you a hard time about not being able to correctly predict your pt's course of detox. Why not simply say: "He gave no indication of untoward behaviors on my shift; he was stable and the CIWA protocol was completely adequate for his care at that time. How exactly do you want me to predict the unknown? Do I pull a crystal ball from the med pyxis, or does is it supposed to just pop out of my a$$?"
LOL. Wish I could speak up to my managers that way. I'm not there yet as I've only been a nurse less than 2 years. They need to hear it, though. And you're right -- I honestly really was working in real time, not w/ an ability to predict the patient's behavior. The worst part was my manager didn't want to hear any of it. It was just all my fault. So, there are many problems with this situation on many levels.
SoundofMusic
1,016 Posts
My God, do you work on my unit?? This describes my situation to a "T." Describes my whole weekend.