apsychRN

Nurse A should have counted off with nurse C. Or whichever nurse was going to be carrying the keys while she is out to lunch. Nurse A & C should also count upon the return of Nurse A if she is given the keys back. What’s the point of A&B counting together and leaving. A&B are besties, or sister n laws or whatever so if the count is off it’s their word against Nurse C which gets you nowhere. Nurse A & C perform a count and both agree that the correct amount of medication is accounted for vs what’s been signed out. If the count is off it’s corrected then and there with Nurse A more than likely figuring out what’s happened (wrote down 43 instead of 48 due to misreading the 3 or checked the MAR & Norco was given but not signed out etc). That way Nurse C starts off with a correct count.

It’s definitely putting patients at risk for a nurse to hold any medication order without contacting the physician. If the prescriber is unaware that a medication has been held once or the entire hospital stay, the patient could be discharged with that order and take it as directed and have serious complications. Documentation should be your evidence so that when you say “Dr. A I just wanted to be sure Your aware that yesterday when the metoprolol was given to Mr C his B/P 170/62 and an hour later he was symptomatic with a Systolic drop by 30-40. Today his B/P is 160/58. I’m concerned that he will drop agin to much to fast if given the same dose. Even Dr’s don’t know how each individual person will respond with what could be a typical or even lower dose of a medication. Especially if it’s new to that particular patient or if the patient is new to the Dr. A good medical Hx May not be available etc. so without the nurse following the orders and evaluating the effects, the Dr is unable to determine the correct & appropriate dose To stabilize that individuals B/P. Communication with the patient and the physician are vital. Mr. C may have already decided himself not to take the medication again because of how he felt yesterday or may not understand whatever symptoms he had weren’t related to that particular medication at all. The Dr depends on “your nursing judgment” which includes communicating vital information of an ordered medication held for any reason and the outcome/result of withholding it, just Like if a wrong med was given.

It’s totally ok to give a hug as long as you feel comfortable with what the hug conveys. Most of the hugs I’ve given & received are hugs of appreciation from patients. A thank you for everything you did to help me. Is extremely rare for a hug of comfort until I’m positive of what those tears really are. So mad they could and are crying? A phone call or visitor that upset them? How paranoid are they at this moment? Most don’t want to be touched and certainly never walk up behind a psych patient. Most physical touch is very effective when someone is in a full blown panic attack once you have their attention. I had a patient in to see the Dr via telemed. A therapist was sitting next to her & I behind my desk. She was very calm, answering appropriately etc & all of a sudden burst out screaming & crying while hitting herself in the face (actual fist into face) I look at the therapist expecting her to “do something “ (I’m not sure exactly what) and she just raised her arm bent at elbow & gave the patient a couple of pats on the shoulder My mind was screaming That’s it! That’s all you got! My Lord help! That’s when she begin to bang the back of her head into the concrete wall.. I ran around my desk calling her name (this was very scary situation for all of us) and bent down to a little below her level trying to get her attention, I finally got a quarter of a second eye contact with her and I grabbed one of her hands and brought it to my chest while calmly as I could speak told her I needed her to breathe with me, to feel the rise & fall of my chest. It seemed a whole day had gone but it was only a few minutes when she finally began to look me straight on while I exaggerated each rise & fall of my chest & felt safe enough to gently grab her other arm & placed it with the other on my chest until she could breathe on her own. I had my other hand on her chest to feel her breaths trying to get her to sync with me. That’s when I learned the therapist strict rule of no touch! However I am a hands on nurse after all & I had no other quick idea on how to get her to stop harming herself. (There was blood, sweat, tears, bruises & lumps but nothing too serious). I came out exhausted from what the therapist called Transference. So after she was assisted back to her room & I went back to my office with the Dr & therapist is when it dawned on me that all the Dr could see from the comfort of his home (because it’s telemedicine) was a big blue blur! My butt because I was between the big screen where he sat & the patient. How embarrassing! I apologized and he laughed at me and said how helpless he felt having to watch & hearing it all. All in all the outcome was as good as it could have been I suppose but it was a real eye opening experience for me to witness how hard someone can hit themselves and do self harm. It’s not to be taken lightly. Anyway keep in mind that just because you feel a hug or some type of physical touch is appropriate or you would want a hug in a situation doesn’t mean that person thinks the same thing & wants one too!

Aside from assessing their mood, suicidal ideation, hallucinations etc which all help to determine if medication is being effective and a generalized medical including vitals etc. Take the time to learn exactly what led to them ending up there with you. Off meds? Why? You may can help with resources to fix that issue while you encourage them not to wait so long before doing something about it so as not to see you again. Most psych patients are repeats and instantly feel better when coming in because you are there and already know a lot about their mental health hx, family, living conditions, coping skills, substance abuse etc. So in a way it’s like ongoing therapy. A chance to reassess if the patient is implementing the skills taught while in your facility before. You have the opportunity to reenforce teachings and find out if they are still working on same goals or making new ones. Need assistance on HOW to accomplish a goal. And on a personal level how is the loved one diagnosed with an illness before last admission? How’s the daughter they got to see? Whatever information you got from them before? Most of all you are building a Report based on trust. And you saved their life more times than you know because you care & in the darkest moments they remember what you said, did, gave them to read to help so instead of harming themselves or others they returned to you. P.S Be careful about the way you ask when a patient is ready to discharge. Few are really ever ready. I had a patient that had eaten jagged tin in a state hospital with cameras & staff all around. I wondered why, and also wanted to make sure he didn’t try anything similar in my facility so I ask him, why? What made you do that at that moment? ANSWER: Because, all they kept asking me was “When do you think you will be ready to go home? What is it we need to work on to get you back home? What else do you need to be ready for d/c? “ Not once did they ask me how I was really feeling other than how my meds were affecting me. Not once did one staff member talk to me without mentioning “When I was going to be leaving “. ... Home if there is one isn’t always such a good place to go back to. Back to what triggered them in the 1st place. Back to emotional, physical or sexual abuse. Multiple people in the home & no room of their own, drug and alcohol use which it’s hard to say no to your mama or abusive father that’s supplying it. Or looking at the person That assaulted you no one else knows about because you can’t bring yourself to tell. No home isn’t what most patients are looking forward to. Somehow you have to give them the encouragement & compliment each tiny improvement you recognize each day so that they believe they have the strength to go back home...until another day comes..

In Texas the answers to your questions are found in the TAC, which is the Texas Administration Code. All the info on the criteria to meet involuntary status, how long a warrant or a Emergency Peace Officer Warrant aka: EPOW are good for and who is aloud to discontinue each. I worked at an emergency crisis Ctr without a MD on premises and we used Telemed. This worked exceptionally well and there was always a Dr available which as extremely important when emergency meds were needed as soon as some psych patients hit the door! No one was admitted without seeing 1st an RN to perform assessment & determine if patient was Medically stable enough to stay. 2nd. A therapist, & 3rd a doctor on Telemed. See if there’s something similar to the TAC available in your state. Possibly through the Attorney General website.

First, what items are on the unit that a client is able to do that much self harm with before being caught & stopped? Second, absolutely a nurse should address any and all wounds, especially those that happened under his/her watch or care. Third, Self harm isn't always about attention. And even if it is, SOMETHING is obviously wrong and that person deserves and should have at least the time and attention of a nurse for as long as it would take to address a wound to see what is going on in that persons mind that they felt the need to harm themselves. Some people self harm because they are so numb and disconnected they need to feel pain to feel ANYTHING. Some believe they deserve to feel pain. Some harm themselves to keep from harming others. Some People hurt so bad the only way or only thing they know to do is to feel pain physically so as not to few it so much emotionally. So my point is..if you are the kind of nurse that makes a Psych patient "clean up their own mess & dress their own wounds", you need to move on out of Psych and into another field of nursing that may suite you better. One where you actually don't need to spend time with someone or to walk in their shoes to help them learn healthy coping skills. One where you can just dictate to your patient.

I work at an inpatient crisis facility that has 2 units. One is involuntary-a lockdown unit, and the other a voluntary. This behavior isn't tolerated from either from anyone. All clients are informed of their rights upon admission and are also informed what is expected from them in order for them to be allowed to stay at our facility. This includes taking medications, going to groups, respecting staff & peers. All staff also treats each client with respect. If and when a client acts out disrespectfully and especially when it's a cluster B, or something of that nature we do our best to work things out, give the client forewarning what can and will happen if behavior happens again. And when it does, we keep our word. If client is voluntary-not risk of harm to self or others and that has already been documented, the local police are called they come in and we already have that persons belongings ready, tell the officers what happened & person has to go. We open doors, point client out & boy are they shocked when the officer approached them & begins to escort them from our building.