andreadrea

The legal process varies by state, I think. In California there is a thing called a Reise Affadavit that a judge can sign that means the patient cannot refuse psych meds for the rest of that hospitalization. There's also an Affadavit B, but that refers to people on conservatorship. But I'm pretty sure this is just for California, other states have other terms.

Personally I never did any med/surg nursing before doing psych, nor did I ever feel that I needed to. However I always tell nursing students it is their choice, as some feel more comfortable doing this. My first nursing job was at a long term care psych facility with 89 patients. I was responsible for 30 of them. Of the 30 on my hall, I had 5 diabetics, I think 8 with COPD, one with chronic liver disease, one with a weird overactive pancreas thing where he'd get hypoglycemic occasionally, as low as 31 one time. Lets see, there was also wound care, I had 2 patients who would periodically get MRSA infected wounds. The other patients on other halls were a similar mix. So what did I do? Well to start with, this was a long term, chronic care facility, so anyone with medical issues was supposed to be "stable". Still, I wrote down everything I wasn't familiar with, and when I'd get home I would research this stuff so I would know what signs to look out for, if a patient was "going south". I would do internet searches, and I bought a few books off Ebay, as well as referring to my med-surg text from nursing school. Once I felt confident with my knowledge of the patients on my hall, I researched the illnesses of the patients on other halls. A lot of shifts, I was the only nurse working. This facility employed mostly LVNs and LPTs (licensed psychiatric technicians). In fact the Team Leader for each shift, the person in charge of everything, was usually an LPT! So I wanted to make sure I knew what was going on with all of our folks, so that I could be a resource to other staff. My research paid off. I detected quite a few problems that required a trip to the emergency room in my two years working there. There were a few EMS calls as well. I learned an enormous amount from the nurse-practitioner that came there a few times a week. It was a steep learning curve, but it was doable. I had also told the director of nursing that we HAD to have some nursing and medical reference books on the floor, which she supplied. I learned so much about diabetes and COPD that I taught inservice trainings on them. We always had a MD on call for questions or concerns, which helped. And of course I learned a ton about the care of mental illness as well. About 2 years ago I changed jobs and went to work at a large, public hospital in an urban setting. It has 4 psychiatric units plus a jail/psych unit. I had another learning curve, but it wasn't too bad. After all, I'd already seen a lot! Since that time I've dealt with a stroke, a few codes, delirium a LOT, a few serious chokings, and a lot of calling our MERT (Medical Emergency Response Team). No one has ever criticized my reports to the MERT when they arrive, and in fact I've gotten kudos a few times. I'm now charge nurse of a unit, so when we call the MERT I am the one to give them report when they arrive and coordinate everything. I'm 4 1/2 years into my nursing career, and so far I've never missed having med/surg experience. Although somedays with all of our complicated patients, it feels almost like I am working med/surg. It might have been easier to learn this stuff working med/surg, but I never wanted to do it, and I'm happy with the path I've taken. Now my biggest challenge is getting nurses on med/surg to give me a complete report when they transfer a patient to me! When I ask about mental status, etc, they say things like "He's acting like a psych patient." Oh do tell, what precisely does THAT mean?!?

Ugh, I need to vent a little. I usually work well with borderlines. Last night my 3 patients were all borderlines. One of them is a very troubled 18 year old male who also has factitious disorder and had the most traumatic childhood I've ever heard of. He has been in the hospital for the past 9 months, every time we try to place him he hurts himself so he gets sent back to acute care. He's very used to being in the hospital, is comfortable there. He cut himself, then wouldn't let us bandage his dripping arm, started to thrash around and punch himself in the face, bang his head on the wall. This was on a unit that is trying to eliminate restraints/seclusion. Sooo we wrestled him to the floor and held him, while paging the doctor on call to get IM meds. we got the IM meds ready, as he was refusing to accept PO meds, refusing to talk, just screaming and moaning on the floor. As soon as I approached with the IMs, he yelled "no shots I'll take the pills!". So back for the pills, then it took him 5 min to take them....long story short I spent 95% of my night just with him, every time I tried to take care of another patient he would start moaning and screaming, and if that did not get him the attention he wanted he would start to hurt himself. Oh, and while I was on the floor trying to keep him from punching himself or me, another of my borderline patients came over and held out a cup and said "can you get me some ice?" LOL! Sure, I'm going to let go of the bleeding screaming patient to get you some ice. I have a lot of empathy for these patients, some have truly horrific histories. But some days they drive me nuts. Especially this 18 year old who seems to think he can manage to live at the acute care hospital for the rest of his life. This one unit gets most borderline pts, our hospital has "focus units", there is a women's focus unit, latino focus (with spanish speakers on staff), gay/lesbian focus, yadda yadda yadda. Women's focus tends to get borderlines, anyone who is pregnant, or PTSD. I think out of 22 patients, there are currently 10 borderlines. We have no CNAs or Mental Health Workers, so while 3 patients may not seem like much to some, the nurse does all the care for those patients. Actually its usually 4 or 5 patients, last night we had good staffing. As much as I care about these patients, by the end of last night I wanted to send them to a 3rd world country, maybe just for a day or 2 so I could get a break! Or I could go to the 3rd world country, it would be a nice vacation. I've been studying Marsha Linehan's books on BPD and its treatment, and some of the stuff works with some patients. But this one male with BPD seems darn near untreatable, nothing works. I don't know what to do with him. Last night the "solution" was to dope him up on Ativan and Thorazine. After 5 hours of hourly doses, he finally nodded off. Oh and put him on low dose oxygen with a mask for the hyperventilation, as he refused a paper bag- not dramatic enough. I'm a float, not a regular on that unit, so maybe they'll float me elsewhere tonight. (crosses fingers) I think I'm a little burnt out on this particular patient, so if I am on that unit tonight I'm going to ask for a break.

Well to answer the original question, Dialectical Behavior Therapy can be effective with borderlines. Marsha Linehan wrote 2 books: Cognitive Behavior Therapy for Borderline Personality Disorder and Skills Training Manual for Borderline Personality Disorder. They are EXCELLENT. I'm looking into training so that I could do skills training groups at my hospital. Although the books emphasize that the best way to treat it is not in the hospital, but in intensive therapy/skills training outpatient. The books also give a great view into the mind of a borderline, and have a great deal of empathy for the very real pain these people are in. I highly recommend them for someone who is interested in learning more about treating borderline patients.