purplekath

Cogentin is not routinely given with benzos. I don't even routinely give it unless I'm dealing with someone with a known hx of ESP, or if I am giving something like Clopixol Accuphase where it is a big dose of anti-psych mx which makes ESP more probable. You say you are giving this to small children? How young? It is a little like atropine in its action, so really little children (3 and under) it is not a good idea. In any case - I wouldn't call it "a big mess"... just keep learning! You will be fine :-)

60 is routine...80 is common...more than that, quite often. Mandatory overtime....sigh.... Honestly, a 40 hour week seems quite cruisy these days. lol... sad but true

Our facility is ok for us to keep gifts - I work in a state psych hospital, and most of these folks don't have a bunch of money, so it is not really a big problem. I have an area in my study with boxes of little gifts from patients. The most precious ones are artworks, poetry, songs, crafts etc. When I've had a rotten day I'll go in there and just look at them all. One of my patients wrote me this poem...made me cry... btw, the guy was still a lil crazy I should point out...he thought he had died and was living his afterlife. He gave this to me with a drawing called "bird losing its scream". Kath the Golden Gentle friend An expert in love such kindness a gentle soul who shows no force and shares her smiles freely Today, much like yesterday, more like tomorrow So female and easy to be around My gentle friend has shown me no force And has allowed me kindness There is no time like a single moment frozen Which is a smile from silver love This much I grant you This sun is yours Stay close to those you love For always you are in my heart And forever you have a home In this, my afterlife

Hi Amy, Tricky situation for you! I'm in Australia and have no idea how the system works over there. With regard to managing this guy on the ward, you need to know that he is not doing what he's doing deliberately or to be manipulative. He is manic. This means he only has limited ability to control his behaviour. His thoughts are running very fast and loud in his mind right now, so you need to keep things clear and firm. If possible, have the same nurses looking after him from shift to shift. Gather your meds in oral and IM/IV form where possible. Zyprexa comes in IM form. Grab hospital security and several other nurses/orderlies...whatever. You shouldn't have to restrain him..just a show of presence will usually work. I'm assuming at this point, he is under some kind of treatment order and can be "forced" to take his meds. If not, this should be organised before you proceed. Approach him confidently, offer him the choice of taking his medication orally. At the first refusal, be firm, give him his medication IM, then retreat. After a few minutes, go and reassure him that while he doesn't see it now, he is unwell and needs medication to get well again. Remind him that he has been unwell before and that he is a wonderful man who doesn't behave this way when he is well. Anti-psych meds can take a few weeks to work for some, but they are quite sedating. You might also want to get him written up for something like Diazepam or Clonazepam, which can both be given IM. These will slow him down a little while the other meds work. Sleeping medication for night is a very good idea as he will have missed a lot of sleep while in this manic phase. As he begins to settle, he will then be more willing to take the Lithium, which is what he really needs to get well. Sexually inappropriate or aggressive behaviour you must be really firm about. Be clear and firm, "No (name)! This is not acceptable". Don't be afraid to call security. The other crappy manic behaviour like pulling out IV lines etc you just have to manage by the seat of your pants, using the principle of positve/negative reinforcements eg: - re-cannulate/re-tube him every time you need to if you have to...he will soon get tired of that program I can assure you! Figure out what he likes, and have it on hand as a kind of "reward" when things are going well...I know it sounds bad, but sometimes it works and when it comes to psych, there is no "right way". I have a particular very aggressive patient who LOVES gummi bears...the minute I hear he has been admitted, I buy some, and let me tell you...those little squisy bears have defused many a "situation" before it starts. Best of luck Amy - and keep us posted on what ends up happening with this poor guy.

lol...go on...I dare ya!

Actually, I'm going thru this right now. A very close friend of mine was admitted tonight and is a forensic case. Management has been really strict about it with me, and I'm actually very thankful. I'm not to nurse him, have been told I must stay in a different area for the duration of his admission and of course cannot access his file at all. I am SOOOOOOOO glad! It is a very difficult position to be in I have to say.

It is both less hectic but has much more responsibility than hospital based mental health. Not sure what Canada is like but here it involved having a "case load" of mental health clients. Up to about 20. Your job is to try and keep them well in the community. It is very holistic; you help with every area of their lives - jobs, living skills, medication, counselling, housing, financial planning, coping with their children, relationships etc. You go out in the car and visit them, or they come into the office for sessions with you. How often depends on you and what you think. You need to make sure they are travelling ok, taking medication, monitoring drug and alcohol issues, working out if they need intervention or support. You teach skills for living with mental illness or other issues, set goals, monitor progress, work out plans. I find it very challenging but incredibly rewarding. You work with ppl over years sometimes. Those with psychotic illness, drug and alcohol problems, anxiety disorders, depression, borderlines. Each have their own challenges. The borderlines who call you suicidal every friday night when they know you are going home for the weekend; the schizophrenic who goes missing and only you have any clue about where to find him as you know him so well; the depressed mother who is not getting out of bed and not handling her children well...and you need to make the decision about whether she needs more support or if her children need to be removed from her care for a time. It can be dangerous at times. You don't have duress alarms and you are generally in someone's home where there are weapons and unpredictability. You often have "his word against mine" type scenarios. You have to document so carefully. On the plus side, you get to know your patients really well...and most of the healing that is done happens in the community. But the responsibility is huge. I'm not sure I would recommend it to a new grad, but not sure if it works the same way over there.

I think most of us working in the area would agree that it is a disorder that can always use more ideas in its treatment. I think it is totally necessary to try and get a handle on the worldview of the patient, both as a person with a diagnosis and as an individual. This itself is a difficult enough thing to try to piece together ... let alone to try and find ways to help that person make changes. My theory is that most of us grow up with a pretty decent foundation - a strong floor beneath our feet. Our parents and others give us that. Sure, all parents muck things up and all of us come out with the occasional hole in our foundation, but we can still stand up most of the time and live our lives. Borderlines on the other hands have foundations that have TOO MANY holes... the floor beneath their feet resembles swiss cheese and they find it impossible to use this foundation to support them. That is why the world is a chaotic and terrifying place. ANY stressor threatens to throw them into one of the many holes in their foundation. They didn't have the luxury of a firm foundation from their parents...they must learn to build their own. Most "treatments" for bpd involve trying to fix those holes, however if we as professionals attempt to do that for the person, we are doomed to fail. There are too many, and besides, we can't even SEE them, let alone fix them. Therefore, the key has to lie in helping that person to mend the holes in their own foundations. We give them the tools to do it. But of course, they are terrified. They want to cling to anyone and anything in their world that will stop them falling in. They do not want to venture to the edge of these chasms. They will do almost anything to avoid it -- get angry, avoid, self destruct, manipulate....we've all seen the behaviours. In order to get well (and yes...some DO get well), EVERY person in their world must stand back and insist that the borderline use their tools and get to work on one hole at a time. Getting to that stage is a long and difficult process, but one of the biggest joys in my life is when I see that person stand with pride and say in effect, "look what I did! I fixed that one! And I did it by myself!" As practictioners it is our job to: * give the tools and teach how to use them. DBT, life skills, how to cope with stress, how to cope with trama, how to learn to love yourself, to love and care for others. * to REFUSE to allow that person to "manipulate" to avoid doing this scary thing.... and I use the term "manipulate" in an understanding way. It is a coping mechanism, just like most of the behaviours we see with BPD. * Understand the behaviours for what they are - hole avoidance :-) And explain that to the person in a calm and appropriate way, eg: "you smashed your room up because you we afraid to do the work we talked about. I know you're scared, and I understand why you did it. But you still need to do the work. Clean up the mess you made - I am going on a lunch break, and will come and talk to you when you are ready to use your tools. I know you can do it" (smile, squeeze hand, leave room etc) * be a cheer squad from the sideline - give messages, "I know you are terrified, but I have seen others do it, and I have seen (insert individual strengths) you be strong even though you are scared". * Reinforce as each "hole" is fixed the achievement they have made and how much easier it is to walk around without fear with each new piece of foundation. * Don't give up your patient and let them know that. It may take years and many admissions and setbacks while they learn to build their own foundation. With each new admission, remind them of the progress they made last time and remind them that they are here to work some more.... let them know you are looking forward to watching their achievements this time. Then get to work yourself. Anticipate and cut off the behaviours that avoid the work. Instruct your collegues that your patient is to be directed to you for everything that shift, and make sure she knows that will always be the case. Make regular "appointments" with her (approx 10 mins an hour or two) - snippets of your time and support. Find a system of positive and negative reinforcement that works for that particular person to encourage her to keep working. Eg: a guarantee of safety means some leave to the coffee shop with you. Breaking the fire alarm and absconding into traffic and laying on the road = her time with you is delayed for one hour. Threatening to kill self or harm you = appointment ends immediately. Talking about the feelings surrounding her suicidal ideation or rage = verbal reinforcement and appointment continues. A few ideas :-)

ummm..noooo...this not normal at all. wow, I am floored too! These drugs are powerful and certainly not suitable for a child. I suggest you do a little detective work and find out how this kid ended up on these meds. Did you get what the dosage was? I would be curious. The side effects in adults are bad enough...I shudder to think what they would do to a child. Major psychiatric disorders are not diagnosable at this age, certainly not bipolar disorder. Wow...still floored. So, what ended up happening with this kid?

It is so important to build rapport with your patients. It humanises what can be a dehumanising experience for them. And it really helps when it comes time to ask the probing and other difficult questions, as well as in laying boundaries. Rapport building starts from the moment they are admitted. So does the assessment process. When someone is admitted, smile, introduce yourself and offer a handshake. Whether they shake your hand back is the first tip about how they are feeling. Offer a little sympathy and offer of help, "sounds like you've had a tough day huh? Let's grab a cup of coffee and I'll give you the grand tour". Be aware of how your face and body language is affecting your patient. They are in a scary place. Eye contact, smiles, nodding, relaxed posture...these are all so important to convey messages that the patient needs to "hear" when they get ready to share what they are going through. Probing questions: These are questions you need to ask, and they are easier to ask if you have taken the time to build a rapport. You don't have to fire them off like a machine gun - it can be done over a coffee, sandwiched between small-talk, little jokes...just general stuff too. The process is intimidating to the patient, so it is ok to break it up with small talk. Don't be afraid to share bits of yourself as you are comfortable. Eg: If someone expresses a delusion that they are the lead singer of a famous band, you can share the kind of music you like, the last concert you attended etc...then ask a relevant question, "sounds like you have been pretty busy, how have you been sleeping?". Limit setting: Again the rapport will help. You can share what you are comfortable to share - there is nothing wrong with that. But where you are not comfortable, just say so and move along quickly. If you don't want to share your age, just say something with a smile, "oh, old enough!". Flirtation. Depends how bad it is. If it is just flirtation, just remind them that what they said or did is not appropriate. If it is someone who is delusional about you, believes they are in love etc, it is at this time a genuine feeling to them. I say something like, "I know you feel this way now, but that is a part of being unwell. Feelings like this are quite common, and they don't last ...you'll see." If they are trying to touch or grab you, you need to be quite firm, raise your voice a little, be very clear about what will happen if they persist. With concerns, just mirror what they say, "so you feel like the doctor doesn't care? What makes you feel that way?". You don't have to agree or disagree...you just want to know how they feel.

Oh trust me...I have strong feelings too. I think most of us do. But guess that a big part of wanting to help these ppl are because ultimately it helps society, including potential victims of crime. I'd still be interested in hearing your point of view. Are you in psych nursing BTW? Do you ever nurse these patients?

I work in an acute unit which deals with the forensic mental health cases for our city. Lately I seem to have had a lot of ppl with paraphilias of an illegal nature -- namely pedophiles, voyeurs, rapists etc. Often we get these patients because they become suicidal and are deeply remorseful for their thoughts/behaviour. Mostly they come from the prison system. I long since got over the emotional aspect of nursing someone whose actions repel me. I feel that it is important to HELP these ppl... for themselves and to prevent them victimising others in the future. There is precious little information out there on treating/couselling these types of ppl.... even the DSM-IV has no real advice for clinicians. So, thought I'd throw it open to my fellow psych nurses - how do you approach a paraphiliac wanting help? Apart from the basics (administering Depoprovera or Androcur and keeping them locked into the unit)...what can we do to help? What kind of therapies are useful for these kinds of patients?

Well best of luck as you study! We always need new nurses in mental health ... it is not for everyone, but if it is for you, you know it :-)

Oops, I also include a section for medication....any PRN I have given and why, and any medication changes I have requested or have been made, any adverse reactions observed.

I use this template: Risk factors: (risk self-harm/suicide, absconding, physical/verbal aggression, reputation etc) Mental State: (Mood, affect, speech, thought content, cognition etc, as well as any details you want to add about delusional content etc) Physical: Include vitals, tests taken, results, complaints of pain and what you did etc. Psychosocial: Any drug and alcohol issues, issues with children, relationships, visits that took place and how they went, upcoming court cases etc. Leave status/CRA/discharge planning etc.

Worth thinking about ...it sucks basically. The first time I found someone hanging in their closet was sooooo traumatic! When I do my checks now, I still hold my breath when opening the closet. Actually I find it worse when I find someone "not successful"...someone still alive but struggling. Chilling. And like I said, never gets any easier. There is always the question..."did I miss something they said?"..."could I have done something more?". No, it doesn't happen often, but when it does, you feel it intensely. HOWEVER, there are great rewards in HEARING a person who is in pain, and being there to hold their hand through the most terrifying times of their lives. To let them know they are not alone, that someone actually cares about how they feel tonight...right now. To hold a hand is a small thing to those who are ok...but is enormous to those who feel lost in that moment.

OK...will try to help! But I have to tell you, this confuses me sometimes too :-) CCU.............think it is critical care unit. IP ..........think inpatient is correct, but not sure OP.............could be outpatient, but where I am in means "older person". Or could just mean "operation" depends on the context. D/C.........discharge ETOH.....forget what it stands for but it means the person is an alcoholic. L..............Left maybe...I always read this as left R..............and read this as right... _pt............patient VS............absolutely no idea!! T.............temperature P..........pulse R............respiration Ht................Height????? -- yes Wt....weight??? -- yes HS..........hmmm.... nope no idea. Hx means "history of" BS.............. blood sugar TM..........no idea q.i.d.........4 times a day p.r.n..............give medication as required.

I'm sure the undergrad coursework varies from place to place, but when I was at uni, there was relatively little offered. It wasn't until I started working that I began to really understand the place of the psychosocial. However, use your clinical placements -- there is much to be learned there! Psych nurses work everywhere -- not just acute. They work in rehab, drug and alcohol units, forensic units, out in the community, in the ER, privately...in youth and adolescence, adult, older persons, eating disorders...all sorts of places. Best of luck!

No, not at all. With the DBT, I have a little training...just inservices etc, and have the workbooks etc. But mostly it is just experience, knowing particular patients well, knowing what works for them. Most of our borderline patients have pretty great management plans already in place, which are formulated over a period of time by their whole treating team, using DBT principles as a foundation. The sessions they have with me as an inpatient are just very short, simple versions of what they would do in the community, so they are getting the same kind of messages consistently whether in or out of hospital.

I think I love psych nursing because no day is ever "typical". I'm in acute inpatient, and some days I look back on the day and think "wow". My last shift went something like this: Handover, medications, meet and greet patients, check their environments for safety etc. I was the ECT nurse for that morning, so up to theatres and into scrubs to assist with the ECT. Only one patient that morning, a woman with postpartum psychosis who believes with all her heart that she has killed her baby...she hasn't. Return to ward. When she is awake and stable post anasthetic, encourage her to shower, do her hair and sit in the sun for awhile. The seizure was excellent and I managed to get some IV fluids pushed through before she woke, so she is feeling good. Broach the subject of seeing her baby. She is starting to understand that she hasn't killed the baby. She talks about the devestating loss to stillbirth the previous year and we talk about that as a contributing factor to the onset of depression. She is not ready to see the baby yet and I let it rest. A new admission - a terrified young woman with her first psychotic episode. She believes she is being photographed in the nude and clutches her coat tightly around her. A tearful call from her father and I arrange an family meeting with her, him and me later in the morning. Followed around unit by man who assaulted me last week but who now thinks he's "in love" with me. Have to playbad cop and be very firm with him. Have been stalked one too many times and know this is what the best approach is. He becomes angry wanting me to say I am his girlfriend - I disengage. Called to the assessment wing to see an 11 yo boy who I obviously cannot admit, but who I must figure out what to do with. He is in the back of the police wagon and the wagon is rocking..he is throwing himself against the inside walls. 3 cops don't know how to get him out without hurting him. Children's services come and they try to cajole him out. Decide to do the "mother" voice ... commanding... after 10 minutes he is at least listening. Then engage him in conversation throught he glass about his fake tattoo and the ninja on his shirt. He walks to the assessment room and we begin a couple of hours of tantrums etc. He discovers the code black button and learns that if he presses it people come running. Eventually find a unit suitable for him and he is taken there. Family meeting with father and daughter...some education about psychosis and informing them both that she will need to stay with us for awhile. She begs her father to take her home, she is frightened. He is frightened. Wipe both their tears. Encourage him to sit outside her door while she showers, so she feels safe. She likes this idea. Do a little DBT with a borderline lady in for a short stay. Go through some distraction techniques...disengaging when she is acting out, doing some planned engagement. Another woman absconds out the front door and heads for the traffic (followed a visitor out). Set off on foot at full speed. Call a code and have some assistance to bring her back to the unit. Do some bed juggling to make way for new admissions. Attempt to do some reporting. Hear shrieking from afar and go to find out what is happening. There is a fight between two young males that needs breaking up and it is causing nearby females to scream. Quickly settled. Administer a couple of depots, take some bloods, make a few calls to pharmacy, case managers etc. De-louse another headlice victim. Do some obs. Run to code alarm - a woman who is attempting to rip her arm open with a ballpoint pen. Extract pen, medicate, move to HDU for time out, some more DBT to do. Have a patient accuse me of stealing her underwear..."I can see right through you, I can see you are a liar" she says. Attempt to explain to a pt WHY he can't smoke, chew nicotine gum and wear a nicotine patch at the same time. Get call from chemistry saying a young Clozapine pt has a CK level of 640. Tell them to get a Troponin, check young man for NMS symptoms, then find doctor and ask, "would you like a Troponin"..thankfully she says yes as I've already organised it! lol Do an ECG, find some bundle branch blocking and report it to doc. Hurridly try to finish some reports, interrupted constantly by requests for cigarettes, leave, someone wanting to look at the contents of their lockers, phone calls, patients coming to the window "just to chat" about various delusions. Reiterate to a young man why he can't ring his mother (she has a restraining order against him) ... he won't let up, perserverating ++. Think, "boy it must be lunchtime"...look at my watch and realise that the shift is almost over in a few minutes.... another day gone! lol I love psych nursing.

Thanks guys -- I'm all re-grouped now. I think that is how I do psych nursing ... tears after work a couple of times a week, then onward and upward. Still never gets easier though. Thanks for the support.

Today I lost a patient to suicide. Not in the unit. He never made it to us. I have known him for a few years, and just a day or so ago was wondering why I had not seen him for awhile...he was a "frequent flyer". Read about it in the newspaper. I never get used to this. Not ever. I am so very sad. Going over and over in my mind... was there anything we could have done better? Lit some candles for him and sending him the love and care I wish I could have expressed better when he was here. Guess I just wanted to share, and to ask you -- to share your experiences, how you felt, how you grieved, how you moved on, how you learned for next time? I know I'm not alone - it is something all psych nurses have happen. But it just never gets any easier.

Well maybe my advice is a touch different than the norm...but I say, if you have a heart for psych, then DO IT. Don't suffer another moment in a job you dislike. Life is far too short. Yes, it is specialised, but mentally ill people get medically ill too, so even though I'm a psych nurse, I have regular experience in medical things. In fact, it is often more challenging, because on med/surg, you EXPECT people to be physically ill...in psych you rely on your own assessment and diagnostic skills. In addition, there are very specific medical conditions that occur exclusively in a psych setting. Neuroleptic malignant syndrome, EPSE, anything drug and alcohol related (seizures, all kind of heart problems etc) ... the autonomy is wonderful in mental health too... since it is often not a precise science, you get to use your own creativity with each and every patient. Anway... if I were in your shoes, I would jump into psych with both feet :-)

Haha...supernurse? Nooooo...put me into a clinical setting and I'd probably kill someone in the first hour!! lol

Hmmm...I don't think one day is ever like the next in psych, but I'll give you my last shift, which is a pretty "average" one. Arrived at 7am for handover - got 8 patients and allocated one nursing student. Rounds and environmental check - greet my patients, check their environments for any sources of danger. Remove plastic bags, glass, fire dangers etc. As I go, patients approach me, distressed about this and that. Talk to my nursing student about what she would like to learn today and allocate her two patients that I feel best meets those needs. Do meds with my nursing student. THEN...the chaos starts. My aim is to have about 1/2 hour with each of my patients. I spend all day trying to do this. Expecting a baby to come in with child protection for a supervised visit with a patient at 10 -- I must be present for this, visit is one hour, so must plan my day around that. Have pt#2 that needs to go to x-ray to establish where the 6 razorblades he swallowed yesterday were in his GI tract. So must plan for that also as I must escort him. Pt #3 has florid psychosis and is most unhappy about being on the ward. She spits at me and declares me "unregistered as a nurse, and places a voodoo curse on me". She secrets medications as she fears I am poisoning her, so spend maybe 30 minutes sitting with her reassuring her of her safety, explaining what occurs in a person during psychosis and why they may feel that someone is aiming to harm them. She takes the Zyprexa wafer then rushes to the bathroom and scrapes it from her tongue. As she is on an order (as all my patients are), I must then call wardsmen to give her an injection against her will ... she cries and cries, and inside, so do I. Pt#4 is a new admission - he is awaiting a place in a prison forensic unit, but my job is to work out whether he really is "crazy". Read his history and find that he nearly killed a woman a week ago. Decide to tread very carefully with this patient. He needs obs and bloods done. I sit across the table from him to discuss how he is feeling. I watch for signs that might indicate feelings of aggression...clenched fists, tight jaw, wanting to get up and pace. I see none of these, but sit across the table in case, knowing that if he becomes aggressive I have the table between he and I. When I feel that the coast is clear, take obs and bloods, explaining what I am doing at all times. I assess him as I go, he is telling me that he is hearing voices telling him that someone is going to die. I ask, "who is going to die? You, or someone else". He replies..."I am not sure, I can't hear them properly". I ask him if can dismiss the voices by asking them to go away. He tells me he can. I observe him from afar as I go about my work. He is not responding to internal stimuli, although he has told me that he sees things that he wants to pick up but they are not there. I add to my notes that as yet, he appears "not psychotic". Pt#5 is a BPD patient and before I get to see her she lights a fire under the sensor which causes the doors to the unit to get thrown open and all the fire doors to close. She absconds out the front door. I press my duress and proceed on foot. Security is coming towards me and I signal to them who the patient is, but signal with my hand to "hold off". I catch up with her and she threatens to hit me if I come closer. I walk with her and tell her that she must come back to the unit and discuss discharge if that is what she desires. She states, "I am just going for a walk". Talk, talk, talk. Sit with her while she smokes. Eventually she returns to the ward with me. Deal with the fire brigade who have arrived for the 4th time this week. Complete an ARC round. My break has passed, and now it is 10am -- baby arrives. I help the young mum with breastfeeding and discuss some of the delusions she has had about wanting to hurt her child. The visit does not go well, and must end sooner than anticipated, as she is beginning to talk about "saving her baby by ending its life" ... she becomes upset and I cannot offer medication to her as she is still breastfeeding. Consult a couple of doctors about what might be safe for breastfeeding...awaiting response as yet. But run her a warm bath and encourage her into it. Post my student at the door to watch her in case she attempts to harm herself. X-ray is calling -- escort my patient to x-ray and back. The razors are in the lower GI. I talk with him about what he needs to watch for in terms of pain and BM if they occur. Talk about the situation that led to his suicidality - depression and how it acts inside us. Discuss the side effects he is experiencing with his medication. Hold his hand while he cries. Pt #6 is a long-term patient who I am trying to prepare for eventual discharge by planning leave for him with his mother. Make 4 attempts at discussing it with him. He wants leave but he cannot hold a conversation without becoming angry. End the conversation each time with, "I'm sorry, if you become abusive we must try again later." Final conversation ends with a fist smashing a wall next to my head. Give up on the idea of leave for today. Lunchtime - I need a break, and I go. 30 minutes. On return, medicate those who are unsettled. Deal with patients at the nurse's window who have run out of cigarettes, who want to give me a letter they want posted to the prime minister stating that he is "being kept prisoner here", hear from the police who are complaining that an unknown patient has been calling the emergency number repeatedly requesting to be rescued. Attend to UDS's, more bloods, more medication, more obs. Answer questions from my poor neglected student. Organise drug and alcohol consults. Field phone calls from distressed family members and members of the public who need psych services and want admission - re-route those to the crisis team. 1.20pm -- handover is in 10 minutes. Hurridly writes notes with which to handover my patients. Lament that precious little time has been spent with my patients. Resolve to find more time tomorrow. Handover. Spend the last hour or so trying to get around and see my patients and tidy up loose ends. More phone calls. Chasing doctors for med chart rewrites. Check in with my student about her patients, check her notes etc. 2.45pm - short inservice on restraints and seclusion. I have been before so I cover the floor on my own. Do another ARC round. Encourage some of the boys to tidy up their messy rooms. A pt returns from leave intoxicated - breath and drug test. Do a search, find cannibis in his pocket which gets locked in our drug safe. Deal with a patient who is in tears because she is unsure if 12 packets of cigarettes is quite enough to get through the weekend. Get handed a complaint form from a pt who wants to lodge a formal complaint about his maltreatment on the unit. Receive a small silver balloon from a patient to say "thankyou" for helping her through a dark time. Attempt to clean a sink drain blocked with vomit from a man withdrawing from heroin who couldn't make it to the toilet ... unsuccessful. Give him some doloxene and call maintenence. Assist a distressed pt who has lost his "chime balls" worn around his neck that he believes protect him from winding up buried alive. He accuses me of stealing them. I find them, he is happy. Spend 10 minutes listening to him decipher codes in magazines and tell me what the birds have been saying to him. 3.30pm - time to go home!!