TsavarenaRN

Hi All! Graduated Meridian Community College's ADN program May 2008. I've been working adolescent mental health ever since (private facility then changed to state facility).

The only thing I could guess based on what you have written would be a med error due to lack of order for med given. This is usually (and this is based just on MY personal experience) handled by a meeting where you get written up, counseled/educated, and an opportunity to disclose your personal statement of what occured and why. Always check your MAR, I know it's hard and time consuming especially usually being responsible for 30+ patients and sometimes over the entire freaking hospital. Also considering drawing up Ativan is like sucking cold molasses through a coffee straw, even with a 16g needle. And believe me, I want every drop of it in that syringe that I am supposed to have during those situations. But you can never assume anything. It really shouldn't take them that long to investigate the situation, but state hospitals can be weird sometimes. Be honest, make sure you documented everything, but if they fire you over something like that it would be pretty severe (but not unheard of) punishment. Even if they do not treat it as an opportunity for education and as a mistake that I am sure you have learned from, you will. Sorry for what happened, and goodluck getting the situation straightened out. :redpinkhe

Just in short, had a doc treat one of the psych inpatient children with blatant disreguard to apropriate restraint and seclusion technique. We use CPI, not sure if many other facilities do. Pt was turning over furniture and loudly swearing. Def disruptive to milieu and poss danger to other pts, so def a reason for restraint/seclusion according to our facility guidelines. Doc placed the pt in seclusion using a very less than apropriate technique to 'escort' pt while I chased behind them asking the doc to stop, support staff was on the way, we could easily carry pt. Doc refused, told me to get out of the way, chunked pt in the room, closed the door and gave me a VO for some PRN med for agitation. Where I work, VO orders for seclusion are not allowed, no exceptions. I attempted to ease into the docs office a few mins later with the chart to quietly remind her/him to please write the order for the restraint/seclusion (had the doc order page flagged so she/he could flip it open and write what was needed easily, I knew docs temper was still pretty up there) and was given the irritated 'wave' of the hand meaning, "get out I'm busy." So I slipped the chart on the desk and got my butt out of there. Few mins later I see the pts pushing the chart cart back to the nurse's desk and catch the doc slipping down the stairs. No orders written. I called to have doc paged with no response. Sooooo what I did write was an inter-facility incident report and chart a narrative progress note on the pt. on what I saw, and who did what. No personal opinions, accusations, or assumptions inserted; just the very blunt, objective type of charting I was taught in school and have always used. Incident report was for the way the pt was handled, progress note just to detail the circumstances of restraint/seclusion, when the pt was released, were they hurt, behavior on release, etc. We typically have a form for when we have to call the doc to restrain or seclude, but it is set up for TO ONLY. So I just wrote a narrative, feeling that filling out the TO order packet would be just plain lying. I didn't point out the doc and say "She/He abused a pt!!" or even write the word at all. Just the bare bones facts. I also told my nursing supervisor and left a voice mail to our facility pt. advocate that I needed to speak with her about pt. #00000. Monday morn I get a call to come in and meet with the higher ups to talk about the incident, but after a 30 min wait past our agreed appointment time, I told them we would just have to reschedule, I had to be at my other (full-time) job. They were not very happy. Phew. Not so short. Anyway, my real question is, since our facility has a problem with 'losing' important paperwork I copied the work I had done that night blocking out all identifiable info except for the pt account and medical record number, which is unique to the facility and is only accessed by staff. Just in case I may have to go to court or whatever. Is this info usable? Was there a better way to handle this situation?

Love and prayers for you, you're team, and the boy. :redpinkhe:redpinkhe:redpinkhe No real suicide attempt on my peds ward since I've been there, (Thank God) but a few fights and some superficial self mutilating here and there. I know how I feel when this kind of thing happens when they are under my care, I can attempt to imagine how I will feel if one seriously makes an attempt. I hope I will be as observant and able to trust those gut feelings like you did.

All I can really say is...dive right in! Nursing school did not prepare me for psych, but it was what I really wanted to do. I was able to be hired right out of school I believe because of the lack of nurses willing to apply for psych positions in my area, but I know of several hospitals that will take new grads right in to psychiatrics. I'm 8 months in to my new career. I will admit to several days of clocking out feeling discouraged, enraged, or just not giving a crap, I have stuck it out and learned how to handle most situations effectively. I've settled in and finally earned a little respect from and gotten to know most of the people I work with, gotten sorta comfortable with the facilitiy policy and procedure, and given up on the idea of being 'perfect'; which I think fueled a lot of my anxiety about psych nursing. It just took time, experience, and the ability to take a lot of BS(Just like all nurses!). After passing boards you're not going to walk onto a med surg floor and fall right into place, and neither will you on a psych ward. You will have the basic nursing judgement and medical knowledge to keep your patient's safe. "Don't panic when you feel overwhelmed, keep your patient's safe and alive. Paperwork can always be finished later." says a nurse to me during orientation. I chant this in my head when my patient's have one of their out of control days. And yes, I have been fussed at for not dotting an i or crossing a t on my paperwork due to lack of time, energy, or just forgetfullness, lol. But I've kept them safe, no one has died or suffered from a preventable injury And I feel satisfied that I am helping and having a positive influence on my patient's mental health. Good luck on boards and in your nursing career :redpinkhe

Last I checked, central MS is still in need of nurses. Especially in long term care and psychiatric facilities. The medical hospitals in my area are still posting nurse openings also.

Sorry this is a little long, but I had an awesome psych instructor in nursing school that taught me this train of thought for mental health assessment. Also inservice at work was slightly helpful. This is based on an entire written narrative, mine at the facility I work at has a quick-look checklist on the front of the assessment that covers the majority of assessment with writing area on the back to cover problems/interventions and anything not covered in the checklist. I always think of Maslow's when I chart, and just expand on the area concerning the reason the patient is in the hospital and not in outpatient treatment. http://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs (quick refresher) Focus on any problems that you verify, how you intervened, and what was the outcome? Like the above poster said, chart the abnormal, out of range, problems voiced by patient. But keep the questions listed below in your head as you assess. This covers your behind, and keeps their insurance covering them (particularly Medicare/Medicaid, I notice their chart people checking up on the nursing assessments pretty regularly). I address the Pysiological briefly first because if they aren't breathing or have horrible chest pain, their shizo or depression becomes a very secondary concern. Assess: Are they in any pain? Any fresh looking wounds or bruises? Vital signs normal? Are they losing/gaining weight? Notice any signs of Tardive Dyskinesia or Extra Pyramidal neuro symptoms from the pysch meds? Have they been eating? Sleeping? Usually if nothing is present this can be covered with a simple 'NAD' (no acute distress) if your facility allows this abbreviation. If there's a complaint, chart what they stated, signs and symptoms and how you intervened. Next I address the Safety, thinking of: Are they having any financial problems? Have they been allowed to speak with their family/close friends? How was that experience? Homesick? Worried about their children on the outside? Their job? How do they feel about where they are going when they leave the facility? (Mine are acute 90 day, so this may not always apply.) How have the staff been treating them? Are they having audio/visual hallucinations? Nightmares? Did they tell you they are contemplating suicide or homicidal intentions? If so, chart how you intervened (Counseled pt 1:1, called to alert Doc for orders/PRNs, asked what more we can be doing for their tx and what their response was, place on suicide/assault watch, placed on visual contact, etc.) How do they feel their medications are working for them and did they have any concerns? Love and Belonging and Esteem sorta go together, for these: Are they dressed apropriately? Are ADLs completed? How are they getting along with their peers? Are they participating in group? Are they interacting apropriately with staff and peers (being respectful/disrespectful, withdrawn, isolating)? Are they saying things to indicate they I have self esteem issues? "I hate myself and everyone else." "I'm hopeless." "These groups are useless." Are they depressed or anxious? Will they admit to being depressed or anxious? Have them rate these on a 1-10 scale. Do they have fears of returning to their family or job after being placed in a mental facility? (Again this may not apply to long-term or life-long commitment) They can pretty much ignore or avoid these questions at which point I would chart "guarded, will attempt to approach pt. again" and follow up with that later. Self Actualization ties in with the above if they can even admit to why they have been involuntarily placed in the facility. "Patient denies any depression/audio visual hallucinations/suicidal homicidal ideations." "Denies paronoid thoughts." Do they feel motivated for tx? Do they feel an improvement with their problem? This also addresses their insight, which can be poor or good depending on how well they understand their situation. Which should also be charted. From this point I wrap it up with how good was their eye contact? Was their speech normal, clear, rapid, coherent? How was their mood? Calm, somatic, manipulative, anxious, depressed, labile, hyperactive, manic? Affect? Flat, blunted, WNL (within normal limits), irritable, guarded, euthymic, elevated? Chart that you asked them if they have any other requests or conerns, what they stated, and how you intervened or addressed it. I always also chart that I encouraged them to come to staff if they begin to feel out of control or have suicidal/homicidal intentions, or pain; and if they verbalized or "nodded" understanding, or if they appeared to ignore me. Even if they deny a/v hallucinations, did it seem they may have been responding to internal stimuli? Did you notice their answers delayed or did they keep looking away from you off to the side? I tend to chart a lot of "patient stated ........" or "pt verbalized......." as mental health isn't something you can monitor with labwork and machines, but by their behavior and the things they say. I see this constantly but I would advise to NEVER EVER chart this: "Will continue to monitor and provide safe theraputic environment." I was told by legal counsel that writing this puts you under even more scrutiny if something uncontrollable happens such as: fight breaks out between pts while they are off unit in cafe or outside and injuries were sustained before they could be stopped, one of them slips and falls, breaking a leg, while they are with the mental health techs. A pt. codes and dies. Didn't YOU just chart that YOU were monitoring them and providing the safe theraputic environment? Where were YOU? Of course if things like this happen it still falls under your liscense and liability but by charting the above you are saying that you are right there with the pts. all the time, and I know I am incapable of doing this at my facility. So where were YOU when the incident happened? Legally this statement will press even more liability onto you and can be used as another tool against you in court. This also applies to med/surg. (Getting off my soapbox now ) This seems super long, but my actual narrative is anywhere from about 5-10 lines just depending on if the patient has had any changes or is acting bizarre. Checklists save tons of time, as does learning and using your facility's approved abbreviations. The more of them you do, the faster you will become at them. Hope this helps! :heartbeat

As a new nurse in psych I was already anxious/stressed. Also suffering from marriage problems. Started seeing a therapist 3 months ago, using my company's insurance plan. I am even taking some controlled substances prescribed to me; Adderall, Tranxene, and Ambien, as well as Prozac. I researched this with the outpatient facility that I go to and was told that my insurance company has no legal right to disclose anything concerning my medical information to my employeer unless I give them explicit written permission, or tell them myself, which I have no intention of doing. I even work with my therapist as he works part time at my facility, we maintain a professional nurse/doctor relationship all the same. He assured me up front in my first visit that legally everything is entirely confidential unless I decide to share my own information. I avoid taking the Tranxene and Ambien during working hours, but take my Adderall and Prozac regularly. But I do keep a copy of filled scripts from my pharmacy in the glove box of my car as proof of prescription just in case of those random drug screens. And even so, my employer has no right no know why I am taking the medication. I've been able to become more focused at work and attain confidence and a better attitude with my therapy and meds. I just use my own judgement as to when to take the sedative meds so that my judgement is not impaired. So unless these laws vary by state, which I believe are covered under HIPPA and should be the same, there is no reason for you to deny yourself the emotional/mental help you need. Needing emotional help is just the same as if you acquired some medical problem or sickness. Your employeer has no legal right to know your personal medical business unless it begins to affect your nursing judgement.

My facility keeps them on the same floor, adolescent girls on north wing, children age 5-12 on south wing. It does seem to pose more difficulties as there is only one elevator for all to share, one med window, 4 baths for showering, one nurse's station. With a capacity of 20, we are allowed one RN, one LPN, and 4 Mental Health Techs. The kids and teen girls are not allowed to interact with each other at all, but the pinpoint planning that is required to keep them away from each other is extremely difficult as they all have to share the same facilities. One of the children called a depressed, suicidal, self mutilator, overweight teen girl 'big fatass cow'. Didnt' exactly brighten her day or mine. One of the teen girls ran down to the children's dayroom and flashed her boobs. I'm sure their parents would love to know that. These types of incidences occur on a daily basis, although not always as extreme. Of course this is all documented and privaleges are taken away, doc is informed, nursing sup, and administration also; but the temptation to meddle with each other is always right there in their face. I feel like another staff memeber or two could help with this, but I just don't see it happening. Getting to my point, it's a crappy set up and not as theraputic of an environment as these patients deserve. I really don't believe that it should be allowed at all.

I work with female adolescents on a pych ward, everyday the nurse is required to give a one hour nursing group related to the patient's probs, meds, etc. I've been doing this for about 4 months and I'm burned out on the flat boring material that the facility provides for nursing group ideas. I've run med education, stds, and self respect groups in the ground. Does anyone know of websites with some good printable material related to female teens and the problems they face? That might actually be interesting? ( I know, shot in the dark! lol) I also run into a problem keeping their attention for longer than 20 mins, but don't know if that could be helped

I work at a psych hospital with assaultive adolescent females, needless to say I get beat up on occasion. After one such incident of being pushed down by a pt. twice my size, my lower back started to become painful, not screaming or crying, just sore and stiff. Couple weeks later, hasn't felt any better, filled out an incident report when this happened, but went to my own family Doc and put it on my ins. Got some meds and was put on a weight limit restriction of no more than 20 pounds and to avoid twisting and turning (ie. breaking up fights, forced seclusions etc.) as he knew the history of where I work. I come in to work this am and turned in my modified duty slip and was told to go home, with no pay. I work baylor weekends, so there goes half my paycheck. I'm not understanding this as they allow pregnant techs and nurses to work the floor but I am not due to modified duty. Their suggestion to me was to call the doc and be released from modified work so I could clock in this am. Um, no. Anyway, is their anything I can do? Did I mess up by putting it on my own health ins? Can I sue for lost wages? Thanks in advance for any advice.

First job as an RN, at a very nice nursing home, been there about 3 weeks now; I'm learning fast and I feel like things are going well, except for this one silly thing, which I may be getting a little over emotional about... No one believes I'm a nurse! Doctors, nurses from other areas, administration, social workers, etc. will come to the nurses station to handle their business and ask me "Hey dear, do you know where the nurse is?" or a doctor looking down at a chart begins to ask me a question then looks up and says "Oh, nevermind, you wouldn't know, can you get the nurse for me?" Or when an administrative office type person visiting the ward tells me, "Oh you know, only nurses are allowed in the medicine room, don't want you to get in trouble now." :angryfire I'm 25 years old, but I'll admit I look a little young. I'm very gentle and soft spoken with my coworkers and my residents. I'm one of the few nurses that will actually help with turns, baths, and feeding meals. I worked hard to get where I am, and I'm not trying to power trip or anything, but is there anything I can or should do to help with this first impression of me? Or am I just being silly? Thanks for reading :)

I know how you feel. I got out of school and got my NCLEX results almost the same as you. I went applying like crazy and got pretty discouraged when I didn't hear anything back immediately. I was always up front about being a new grad but that I was also ambitious, ready to learn and excited about breaking into the nursing field. It took a bit, but all of a sudden I was getting calls and emails from several places that I applied, even those that claimed to require 1-2 years experience. I felt like I could just take my pick! Just be sure you have a perfect, honest resume and that you have good personal references. I used some of my most excellent nursing instructors. Good luck finding your dream job and grats on passing boards! :heartbeat

I am going into 3rd semester this fall. I am working as a student nurse at a local hospital. Although I do not get to do anything beyond the scope of an aid, the nurses I work with are always offering me learning opportunities by watching procedures or assisting. (And the pay is not too bad either!) I've actually seen a lot more while working there than I have in clinicals. Also just being there has made me a lot more comfortable (and confident) with the hospital setting. Other than that I am taking it easy! I am planning on looking back through all my notes and reviewing some things I struggled with in previous semesters when it gets closer to school time, but we'll see how that goes! Some of my fellow classmates are taking summer courses of gerontology and/or nutrition, although not required my instructors have said they are helpful with the ATI and other mandatory exams that we will be taking; and of course just building on your general nursing knowledge base. Hospitals around here also offer externships where you are allowed to execute skills you have passed off on while following another RN around. Another opportunity to learn, interact with patients, and get paid! Best of luck to you in your nursing career! :wink2:

The pharmacist prepares and distributes physician prescribed medications. Pharmacists work closely with nurses, physicians, and other health care providers to evaluate the efficacy of clients' medications. The pharmacist can also provide information about medication side effects, toxicity, interactions, and incompatibilites. The pharmacist is a key component in maintaining the patients five drug rights. Sounds good for a resume, yea?