Aerolizing

Where I work, ECT is done quite often especially to those patients who have complicated medical histories who may not be good candidates for the usual antidepressants or who have had no sucess with antidepressants. The patient is NPO after midnight and for the first few treatments, stays on the inpatient ward. Our ECT procedure is done under general anesthesia and only takes a few minutes to complete. Once they get down to PACU where the procedure is done, the IV is inserted, caffeine given through IV and the patient is fitted with the rubber strap with electrodes around the head and gel to conduct the shock. A BP cuff is inflated on one upper arm to 200 and clamped to prevent meds from getting through to the hand where the seizure is observed as a clenching fist. They are given meds (we usually use brevitol and succ) to paralyze and sedate. Once the shock is applied and the seizure is measured by sight and by EEG, ( trying not to forget to deflate the BP cuff) the patient quickly regains consciousness and returns to the unit for a few hours of recoop time then normal activity can resume. Generally, patients need 12-16 treatments (three a week) and some respond very quickly, others take the whole 16 treatments to respond. Once they have had a full course of ECT, we often see them once a month for maintenace ECT. I have seen it work very well. I know people think it is barbaric but for those who don't respond to any other treatment, it is a welcome last resort. We always have quite a crowd during our ECT. There is the psych attending, psych resident, med students, anesthesia attending, anesthesia resident, psych nurse as well the whole PACU staff if we should ever need them (so far that has not happened). The worst incident that ever happened is that a patient received a small burn on her scalp from an arcing ECT machine. All in all, pretty boring. Lots of fuss for a clenching fist. First time observers always ask, "Is that it?" As for where to get training, any teaching hospital around should have plenty of opportunity to do ECT. Any teaching hospital with a psych residency program and an inpatient psych ward. Where I work, there are a couple attendings who supervise it and a few resident who take a liking to it and always volunteer to take ECT cases.

As for the breaking of sterile technique, I would simply say, ooops, you touched this or that. Then I would offer to open up or go get sterile supplies if I was there doing the assisting. As far as iv sticks, some patients are so hard, even the expert iv starters have trouble. I think that the inexperienced people should get two tries and then let someone else try. Experienced iv stickers, I would let them keep trying cuz if they can't get it, we have to call in the docs who are brutal.

Hi Shannon, Hang in there. I felt the same way during my schooling. It was pretty stressful. Others don't understand how much nursing school takes over your life. Stay committed to your schooling. Tell your boyfriend that you are doing it for the both of you. Tell him you need his support right now and if he can't, maybe he really can't. Turn to your school buddies for support. I would have never made it through school without the help of my great friend Lorrie. We both had man problems but we did make it through. It is hard enough to go to nursing school without stress from our loved ones. Nursing school was a big change from my previous way of life. I was soooo broke. I was used to going out whenever I wanted to because I had been working. When in nursing school, I had enough for books, tuition and food. I had to be creative and try to find ways to still have a social life outside of school. I sought out cheap movies at the theaters, not vcr tapes. The act of going out is important. Going to the park to build fires or play catch or walk. Just going out on real dates. Try to reconnect. I know my then boyfriend felt left out. My good school friend and I double dated so our men could complain about how neglected they are and they got to be good friends too. Good luck and know, I have been there and I survived. You can do it too. Keep thinking, it is only temporary. Just a small part of your life. Hang in there.

Hi Missy, Well, let me tell you that in my large teaching hospital, we get very complicated psych patients. We rarely have a patient with only one diagnosis. We get OB, ortho, PICC lines, COPD, HIV, AIDS dementia, angina, CVA, post op repair of self inflicted GSW, cutting, MVA, cancer, TB, oh, and everyone seems to be diabetic. We get the complicated cases other psych units won't touch. As for IV's and enemas, we give em. We also have the local burn unit so all those who have set themselves on fire are admitted to our unit after they are stable enough but still require lots of extra care. I still know how to take a pulse and do a physical assessment and neuro checks. The patients with high BP still have to take their meds while on our unit so we are familiar with newer meds. We also get a lot of delirious cases since our unit is locked which have been caused by everything from hepatic encephalopathy to flagyl to steroids. Oh, we also had a case of VRE recently. All of this is just off the top of my head. Now if you ask me about art lines and vents, I will have to tell you I don't know about those things. I think I saw them once or twice in clinicals but try not to remember things like that. I went right into psych right after graduation 10 years ago and since I am the new kid on the block, any new fangled thing that comes along, I get to take care of. So my skills have not gotten too rusty yet but ask me in 10 more years.

Night Owl, You made a paperwork error, not a med error. I would hate to work where you work. I always alway always miss at least one narc on the narc sheet (even though it is marked in the MAR as given). When you give the number of narcs we do, it is just a fact of life on my unit. We make a joke out of it cuz I always miss a narc on the narc sheet. But, my coworkers and I both look at the MAR to see who is on that med and who got it today. We have always found the paperwork error. I can't believe that the counting nurses did not do that and that the super did not suggest that or do it herself. Calling the police over two Restoril??? And the police came??? You must work in the prison right? I guess if that happened to me, I would never miss another narc count again. You have much more patience than I do. Where do police come for two pills?

I have a med error story of my own. I was new and had prepared my meds in cups to go into two seclusion rooms (on psych unit) with patients who needed a security escort to get meds and meals. Security was called and we were ready to go into the patient's rooms. I gave pt # 1 his meds and dinner and we left and locked the door. We went into pt #2's room and I went to give her the medications when I noticed something wrong. I had given pt #1, pt #2's medications. The only reason I noticed was that I recognized the green haldol that was in the cup and I knew that pt #2 had previously gone into resp arrest when given haldol before. I was able to go and get her the proper meds and pt #1 had no adverse effects from receiving wrong meds. Of course I reported my med error to the doc and the whole staff knew I had made a med error but I was just so happy that I did not send this really nice (but terribly psychotic) pt #2 into resp arrest. Errors are made sometimes but it gets better as you gain experience. Knowing which pills are what color and following your hospital's checking system really does help to prevent errors. Never be afraid to look up a med that you are unfamiliar with. Keep the med book close. After you look them up a few times, you won't have to do it again. Oh, and don't be afraid to admit to med errors. Hospitals have preprinted med error paperwork for a reason you know, it is not as rare as we would like. You will always sleep better knowing that you were honest.

Canoehead, Bingo. In order for people with BPD to get better, they need long term (outpt) therapy with a committment from the patient to want to change. Keeping them inpt for long periods of time teaches them all sorts of bad habits like dependence and often our patients would swap symptoms and have some sort of competition to see who could be the sickest and get the most staff attn. I have no problems setting limits with them as I have learned the hard way that borderlines can suck your will to live and create massive chaos within the staff while they just sit back and watch. I am not aware of any publication that advocates long LOS for this population.

All places have frequent fliers. We have a set of vacationers too. It is frustrating from a taxpayers point of view. It costs $800.00 a day to just be admitted to a bed on our unit. If you want meds, labs, consults, treatments--all extra charges. It really burns me up if I think of it like that. So, I try to think of it in a different way. I look at it like I know the patient so admitting them won't be hard. I know what to expect from them, they know what to expect from me. I always think that it could be much much worse and I imagine having to admit my worst patient. The frequent flyer fills a bed so if the worst patient tried to get in, she would have to be admitted elsewhere. So I use all my psych skills on myself--imagery, rational emotive therapy. Guess that stuff really does work. Some of our more familiar clients are blunt with me and tell me, they are here to rest after coke binge, being kicked out, no money left, need a break from the hubby etc. I try to think of them like family. You don't have to like them, just let them stay for a few days til they are on their feet then off with them. We are family to some of these people. We have been the only caring and almost mentally healthy people they know. When you have been kicked out, where do you go? These people have no one else. I firmly believe in tough love so a lot of this clashes with my own personal beliefs. I believe in personal responsibility. I also believe that I would make myself sick if I let it get to me all the time. I don't try to do a lot of therapy with the ones that don't come there for that reason. I do the basic review of meds, side effects and mood/hallucination checks. Lots of times, I don't even sit down for these interactions. That leaves me time for the ones that are craving to be heard. You don't get much satisfaction from fakers but when you feel you have made a small difference in someone's life just by listening to them, it really makes me feel like I have done a good job and that validates my choice of careers.

Borderlines....What a difficult population. I totally agree, with 1:1constant supervision harming borderlines. It does make them helpless and dependent. I have been a psych nurse for 10 years and I have found some little ideas that might help you. I have never heard of DBT but I will certainly look into it. #1. On admit, tell them what their discharge date and time will be. Your doc has to agree with this of course. Make sure it is no more than 72 hours from admit time. Tell them that you are sure they will become more suicidal at time for discharge but it is a chronic condition and that you provide a service to get them past the immediate crisis and stress they have long term outpatient resources to help them once discharged. #2. Benign neglect. I love this phrase. Make sure the patient has food, water, proper hygiene, med teaching, assess for side effects and keep sharps out of reach. We place them on a q1hr (five minutes at the most and use a clock) request schedule to their nurse only. #3. Use staff interactions as a reward. If they are able to comply with no self abusive behavior and can comply with q1hr requests, then at the end of the shift, they earn 15 minutes of 1:1 interaction with their nurse. This really works if they crave staff attention. #4. Focus on immediate crisis only. Repeat over and over again that everything else is for her to discuss with her outpatient therapist. Explain the reasons why like you would need time to recover from deep therapy issues since they are so emotionally exhausting. #5. Behavioral contracts. When a patient comes in, be ready for her. I am sure you know your frequent fliers and what their behaviors are. You can explain to them that since what we have done before is not helping you, we have to come up with something else to try to help you. I love to do this. Very simple things can be made into a contract. List positives like you are expected to eat breakfast, be bathed, take meds and get vs done by 10:00. Attend each group appropriate to you to benefit from treatment. Check in with only your nurse only on the hour. List negatives like no acting out, no going to other nurses for anything, no cutting. Keep this brief so as to focus on positives. What is the reward? Interactions with you as her nurse of course. With our frequent fliers, we kept copies of the contracts so on each admit, we were ready with new copies of old contract. Offer to have her sign it but it is totally not necessary. Have the doc and the nurse sign it and tell her it is being put into place as a part of her treatment plan weather she signs it or not. #6. Consistency. This is what our staff has the most trouble with and this leads our patients to act out. Put the contract in the patients room for her to have a copy of. Let it be part of the treatment team. Make sure all staff know each and every line of the contract including the secretary. When we first started doing contracts, our frequent fliers revolted and tested our new system. We had to work out the bugs too. We often had to put patients in locked rooms with nothing but a bare mattress on the floor, blanket, one gown, one pair of footies and undies and lock the bathroom, just until they felt they were in control enough to earn back their clothes and bed linens. If they have prn's, of course, by all means offer it to them. Another thing that helps is to have a contract presented from the whole treatment team. That way it is not just the evil nurses who are doing this to them. In my hospital, it seems to work to decrease length of stay, decrease staff burnout and it seems to give everyone a sense of control (even the patient) over a very difficult population. I hope this helps you.

I have very strong opinions on this topic. I worked in public hospital who had insurance contract for our local correctional facility (the work house we call it). We had many mentally retarded too. I can't say strongly enough to PRESS CHARGES. I have been a nurse ten years in psych and know that there are people in the world who are just plain antisocial. Antisocials fill our prisons. There is a reason for that. I have seen many many truly mentally ill folks who would never dream of being violent. It was a rare event that anyone would act out violently on our floor. I think we had a great staff which helps but we gave clear expectations to our patients that violence would not be tolerated. It was a part of our nursing assessment. We did have violent felons admitted to our ward and we did not take any chances with them. We had police holds on our unit locked in their rooms. We always used two security guards to enter their rooms to do patient care. I think what some administrators don't realize is that some patients can't get into the right treatment programs because they are not court ordered. We had many mentally retarded sex offenders on our floor. What do you do with them? They can't play in my neighborhood, I don't want them. Prosecutors don't want them as they are labled incompetent. What do we do with them? They need to be court ordered into treatment programs which give them the choice of treatment or jail. Violent offenders need to be off of our streets. If you subscribe to the NAMI newsletter, they will always write about how badly they feel for victims of violent mentally ill people but they always include that they feel bad for the mentally ill who were not being treated. Court ordered treatment ensures treatment. Ask NAMI. They don't want the mentally ill in jail. They want them treated. Sometimes, the only way to get a mentally ill, noncompliant person into treatment, against their will is with a court order. I hope I have not rambled here, it is late. Diane