TCASII

I'd be surprised if they wouldn't hire a new grad RN for a psych job. Around here, they'll hire anyone, regardless of past experience. I wouldn't start on NOC as an RN working in psych. Medical is a different story. You'll learn faster on days. All you'll do on NOC is chart review/audit, med pass, admits and trivial stuff. I worked NOC for 5 years and I am glad to know how to do old school audits; however, computer charting has changed a lot of that. Day shift will expose you more to actual patient interactions, discharges, admits, providers, and possibly groups. When you get admits at night they're almost always irritated about being awake and don't really want to tell you much. Doing NOC also exposes you to providers who low-ball on meds during crisis or sometimes don't answer the phone. The providers we have on call at my current facility are a joke. Patient has BHT in a choke hold - "Okay, give them 5 mg of Haldol PO" I think it'll depend on where you live in terms of how many patients you have or what your exact duties will be. We always get 10 patients and 95% of what we do are treatment plans, charting, and administrative work. The problem is, the RN is supposed to also pass meds and do assessments. There just isn't any time for all that, and the part that gets put on the far backburner is the patient interaction. Med pass is a "Hey, here's your meds" and the assessment is a "Doing OK?". Because at the end of the day, all they care about is our charting and treatment plans. As you can tell, I'm a bit disillusioned with mental health nursing. Most of the patients are only personality disordered, and that's cluster B (e.e, antisocial and borderline). We rarely get true bipolar patients, schizophrenics, or others that are substance-induced. It's unfortunate because on paper, the field is fascinating. Hopefully SoCal is better. I've heard the hospital in California that is part of my corporation is much better.

+1 on paycheck. And I agree about the police bringing in people who are just trouble makers, as opposed to mentally ill folk. The police love to dump folks on psych hospitals, just so they can avoid work. Outside of that, not much is rewarding. The tiny percent who need and want help are few and far between.

I'm a little put off by some of the remarks in here. It's as if people don't understand sociopathy, psychopathy, drug-seeking, or personality disorders. I work exclusively in inpatient psychiatry. After 8 years, I'd say that 80% of the patients I see are simply substance-use disordered and/or personality disordered. Very few are truly psychotic or AMS. Just because you happen to work in a system that is setting limits on people for safety (e.g., involuntary hold due to SI or HI, withholding addictive drugs) does not mean you should be subjected to injury. It's one thing to understand how some medical conditions and a few mental disorders can impair reasoning, but I would venture to guess that a large number of assaults in the ER, psych, or other acute care facilities are not AMS. I have seen a handful of assaults, and 90% of them were born out of med-seeking or restrictions on leaving a hospital AMA or simply getting to do whatever they want.

I mostly agree with the OP. I've worked in TIC facilities, and despite not fully knowing the ins-and-outs of TIC, the overall theme seems to be allowing patients to determine how their treatment plays out. In theory, TIC is good on paper. You work collaboratively as a team, thus including the patient in the care plan and treatment goals. This concept makes perfect sense when dealing with select patients who have specific disorders (e.g., hoarding, OCD, PTSD, MDD, eating disorders). The problem is that most IP facilities are not treating true mental illness as a single Dx. I would say the number of cluster B (e.g., antisocial, borderline, narcissistic, histrionic) substance abusers is approaching 80%. These patients are highly resistant to treatment, and in most cases, do not want to improve. We're assuming that we can impart improvement in 7-10 days to sociopaths, and that's a fantasy. The TIC and recovery model I've encountered seems to put a high emphasis on eliminating seclusion, restraint, or even physical holds. Essentially, you are housing common criminals who spend a fair amount of time in jail or prison, but you have zero leverage for enforcing rules or preventing harm. My current facility has banned S&R and now only allows "standing" CPI-approved holds. The SW, and even AT department, have appointed CPI instructors, and they have been playing a heavy role in running codes. We had a patient in a hold, standing, and fighting aggressively, which was 100% necessary d/t this patient's attempt to assault staff. We were preparing to give IM medications and the SW coaxed the BHTs into letting the patient go. This patient went on to obtain a weapon and threaten staff with harm. This was partially avoidable had we been able to seclude and medicate this antisocial patient who voiced a desire to harm and was not mentally ill. After two events that were very traumatizing to staff, this individual was arrested; however, it took a monumental escalation to even get the police to take this person away. The bottom line, is that allowing patients to have zero accountability for their aberrant behavior is detrimental to staff and patients alike. This type of free-will attitude perpetuates an atmosphere plagued with negative outcomes. I always ask people who think the patients should be self-directed - "Would you allow your child to run free without consequences?" I'm all for reducing holds and physical intervention, but in some cases it's unavoidable. I managed to rarely do physical holds in an involuntary unit for over one year, but in reality, the notion that you can avoid physical intervention and forced medications is ludicrous.

There have been some fatalities with IM olanzapine, and I believe it has occurred without the combo as well. I know the depot olanzapine has caused some deaths too. It's generally recommended that IM olanzapine not be given with an IM benzodiazepine (e.g., lorazepam). I have given lorazepam and olanzapine IM as a combo before and nothing happened. In fact, the patient was not affected at all. It has nothing to do with QTc prolongation, such that QTc prolongation is less than haloperidol. It is simply d/t the increased prevalence of respiratory depression/CNS depression when used together. I know of a particular patient who died after receiving a Geodon IM during a bout of agitation. He also had an underlying heart condition no one was informed about. I am sure part of the reluctance and recommendation against using olanzapine and a BZD IM is hysteria over the deaths. I'm sure if we had actual numbers of deaths from other similar drugs, it wouldn't be much different. A lot of FDA warnings have caused similar responses in the past that born out to be dispelled. Time will tell. As of now, most doctors and institutions have avoided using IM olanzapine, but a lot of that also has to with the efficacy compared to other rapid tranquilizations and worry of litigation. There isn't a perfect RT, they're all essentially the same. And if you've worked long enough in the field you will find that Thorazine, Haldol/Avitan, Geodon, or similar RT meds are hit or miss. I wanna say that I had read somewhere that the olanzapine/lorazepam IM combo thing was considered overblow, but I do not recall where atm.

The number of patients is contingent on the workload. Where I currently work, 10 patients if often too many. The amount of charting and treatment plan work is very high. If all the patients are calm and not needy, then 10 is ok. I would do a much better job if I has 6 total, however. I've had 18 on a locked emergency unit and managed to survive, but I also had 4 great techs that handled a lot of the commotion. I also wasn't expected to document half as much as I do now. Not to mention, my techs at my current job are largely uninvolved with assisting the RNs.

It might depend on where you live. Some states are a little better about staffing and making the environment tolerable. Where I live companies are not too good about staffing or providing decent work conditions. We have no state ratio limits or unions. It's right-to-work, so they can dump 20 patients on the nurse. Personally, I don't feel that psych is much better, regardless of where you work. You have to know whether the company is good about staffing and limiting the number of patients a nurse gets. I've worked in psych for 7 years and never been punched, spit on, or physically attacked. I have been accosted verbally, but nothing too awful I suppose. I've mostly worked IP, but did have an OP job. OP was terrible. Way too many patients. An impossible job. Getting yelled at on the phone or in the building because the provider wouldn't prescribe controlled meds wasn't any fun, just like IP. Every job has it's ups and downs. Psych can be as hard as you make it, and that often means deciding to set limits and be the bad guy, or placate them and make things go smooth. I typically placate them, since we aren't allowed to do holds or anything. We have no leverage.

We just went through JCAHO inspection and they knew we pre-pulled. Nothing was said about it at all. It's psych, so I can't imagine the seriousness of of it. I understand a med-surg, ED or ICU type of environment however.

This is becoming the norm, unfortunately. In a psychiatric setting, if the patient has a psychiatric Dx, then the police will not take them to jail. This means that nearly 98% of the patients will not be arrested for an assault. Even the detox patients are admitted with co-existing psych Dx's, such as MDD (major depressive d/o). Those admitting Dx's are just for billing, they aren't a valid or accurate Dx. Just a preliminary ICD code. We had a supervisor get punched in the face 4 times by a patient a while back. The patient had a psych Dx and flat out told the police that they weren't sorry and would hit her again. Yet, no arrest. Even more ridiculous is that so many psych patients are malingering or partial malingering (exaggerating for secondary gain). Healthcare has really devolved into an unsafe atmosphere and patients are not held responsible for anything. ETA: What gets me, is that the police would taze, nightstick, or shoot a psychotic patient if they were being assaulted, but the rules only apply to some it appears.

EMTALA, malingering, partial malingering, noncompliance. To be honest, most of the patients I see are homeless and substance abusers. The majority have no desire to get better. They make a mockery of the system and don't even try when they discharge. They use the hospital as a hotel with meds, a social network setting (drug connections) and hook-up joint. They know that reporting suicidal or homicidal ideation is a bed. And frankly, the providers enable them. I have dozens each week who report "detox", yet only left the same hospital a few days prior. 95% of the time they are prescribed buprenorphine and/or a benzo. There is zero accountability or moral practice in mental health treatment nowadays.

I pull my meds around 0730, med pass is a 0900. I can give between 0800 and 1000. Same goes for midday meds - One hour before, one hour after. The only reason I can see not to pre-pull is impending order changes. Our meds go in a book with pockets containing the patient's photo and MRN sticker. Unless I'm afraid the meds will be lost or taken, but I can leave them in the med room and we have a camera. Seems odd not to pre-pull.

I wish I would tell you how. Aside from removing contraband. I mean, aside from holds and S&R, your options are limited. The patients knowing you can’t do anything just exacerbates the problem. My hospital has decided that any hold that isn’t CPI is against their rules, so I’m getting out ASAP. I refuse to work in a place that harms staff.

Around my area, nearly all the hospitals are just meds, assessments, and busy work. I wouldn’t have time to run a group; I barely have time to talk to my patients. I have 10 or more patients asking for PRNs and acting out all day. Plus, several discharges and admits. Lots of documentation and treatment plans. Some places do IVs, but it’s not common. Those are just the facilities with medical units.

You couldn’t pay me enough to work in that environment. It’s unfortunate that all anyone cares about in psych is money. Staff have no protection nowadays. I’ve been in the field for 7 years and I’m disgusted by most hospitals. Doing away with seclusion, restraint, and even holds is recipe for serious injury. I sure hope the staff that are injured sue these places. I know I would.

Wrong, methamphetamine and halogenated amphetamines are neurotoxic, therefore they destroy parts of the brain and can leave otherwise normal people with hallucinations for life. What are the long-term effects of methamphetamine abuse? | National Institute on Drug Abuse (NIDA) Drug-induced psychosis can last years. Never assume hallucinations will clear. I've had many who were brain damaged from it. Most of what you say is true, but in all honesty, interaction with true MI is rare compared to drugs and/or co-occuring drugs use and MI. I have worked petition, court-order, outpatient, state (forensic), and voluntary inpatient. I've seen it all.

I probably sound hateful I do try my best to help those who need it. I've had some great patients. True story, after doing psych for nearly 4 years and never feeling like I could help anyone (mainly due to the paperwork and inability to talk with them much), I was approached by a man at a coffee shop. He said thank you and shook my hand. I was like..."uh for what?" I didn't recognize this guy, who was he?? He hesitates then says the name of my old facility I worked at. I hadn't been there in over a year. I was a little teary–eyed on the way to work. I was shocked and so touched.

I'll be honest, regardless of the patient, being nice goes a lot farther to prevent escalation than being curt or abrupt. A lot of nurses are rude, short, and demeaning to patients. They talk to them like children. Now, if you aren't getting very far with being nice, then you have to put your foot down and say "we aren't doing that....". There's a fine line and every patient is different. You can set limits all day with a manic bipolar, but it'll just be repeating yourself 100 times. They really don't listen or take what you say literally. They simply can't help be annoying. Patients also pick up on naivety pretty quick. They will game you at every turn. Try to capitalize on your inexperience. For example, you're overwhelmed, busy, trying to keep up and not make mistakes. A patient will come up and say "You never gave me my Seroquel" or "The doctor told me to ask you for additional Ativan if I needed it". They really think we're stupid. NEVER pass a narc without documenting it, immediately before or after. Even in a code, if the patient is being held, always write that you signed out the Ativan and when it was given. I never pass a PRN without documenting at that moment. Scheduled meds I remember. I wouldn't worry too much about setting boundaries for manics. They are rare and not much problem. Just annoying/needy/intrusive. The real problem children are borderlines and personality D/O NOS. Same with addicts/detox. They are the ones who escalate d/t refusal to get PRNs early, refusal to obtain the meds they want from providers, or trying to buck the staff rules. The problem children in psych are: 1. Axis II (old DSM code for personaloty D/Os, mostly borderline/antisocial/cluster B) 2. Addicts/Detox 3. Drug-induced psychosis (meth, bath salt, spice) 4. DD (developmentally delated, such as MR and Autism) That's typically what you'll see most of unfortunately. True SMI (serious mental illness) patients, such as schizophrenia, bipolar D/O, schizoaffective, are usually pretty good and passive. They are also rare. I worked emergency psych (petition) for a 18 months. I'd say we had 70% drug-induced, 15% Axis II, 7% SMI, 5% DD, and 3% bogus petitions. I often said, if it weren't for meth we'd have no patients. Something I should add, patients will feign symptoms a lot. Mostly to obtain narcotics or to be sent to the ER. I'm extremely cynical and won't send them. Most nurses send them regardless. Most nurses are afraid to lose their license. I get it. I've sent patients when I wasn't sure. I'm just pretty intuitive. I told someone last week c/o chest the day before discharge that we'd keep and eye on him. IOW, he wasn't going to the ER. He was so mad. Tried to tell me he was puking. Ok, show me. He showed me some spit on the floor. Yeah, ok, MI...right. He was discharged and never brought up chest pain to the day shift. Basically, he didn't want to leave, so he wanted to sabotage his discharge. It's common for them to sabotage their discharge. They will cut themselves, report increasing SI/HI, ect... But don't be so fast as loose as me with somatic complaints. I'm pretty wise to the games and willing to take chances. Just letting you know they will play medical games, such as fake seizures a lot.

Good responses so far. In all honesty, not much prep is needed. It's important to know the meds as best as you can, but no one expects you to remember sides or all particulars. A lot of side effects are common among class anyhow. Very few meds interact, so don't be too concerned about that. For example, ibuprofen isn't supposed to mix with lithium, yet all it does it increase the blood concentration of lithium. IOW, giving someone a dose of IBU once and a while likely won't affect anything. I've given it to someone on lithium and the doctor was fine with it since they took it less than every other day. Same goes for the whole Ativan/Zyprexa combo. A couple deaths have occurred with Ativan and Zyprexa IM, therefore, they are contraindicated as IM together. Although, I have given 2 of Ativan and 20 of Zyprexa IM with no outcome, positive or negative. Then again, anti-psychotics have killed patients d/t underlying heart issues and other factors. I know of one who was aggressively attacking staff, was given an anti-psychotic IM and died. It happens. It's the business we're in. You can't assume everyone is gonna die or have a problem. The likely of scenarios is with falls and not having staff to watch them. Moreover, you are your own person/nurse. If you don't feel comfortable then don't do it, and if you need to ask, then ask. The doctor and other nurses should be helping you make clinical judgments. This field can be a bit grey at times. You won't be able to predict everything. Sometimes you will give more meds than you could fathom and the patient will still be wide awake or even acting out. Key points I like to make: You can't medicate a manic to sleep. Manics can be given multiple RTs (IM or PO) and never actually sleep. It takes days to weeks for them to clear. Once you've seen a true manic, you've seen them all. They are intrusive, hypervigilant, needy, annoying, somatic, and obsessive. They will c/o various medical problems that don't exist. You have to be able to ascertain what's real and what isn't. They will hear and see everything. You can look at another staff member and roll your eyes from frustration and they will pick up on it, despite not seeing it. They will steal things, from staff and patients and hoard them in their room. They will argue about everything under the sun. All you can really do is just keep redirecting and waiting for the meds to work. Most "manics" or patients with auditory or visual hallucinations are on meth or other drugs. True bipolars are rare. Bipolar D/O is Dx'd way too often. Most of the time to people who are borderline or anger management types. Visual hallucinations are organic or drug-induced. It's extremely rare to be from mental D/Os. Same goes for constant auditory hallucinations. It's considered malingering to be c/o constant voices. As per AH and treatment, a PRN for "voices" is a bogus intervention. It's mainly to help sedate and temper the frustration from the voices. Anti-psychotics typically take 25 to 30 days to impact voices, similar to antidepressants for mood. Most patients, depending on the facility are malingering or exaggerating symptoms. Yes I'm jaded, but you will see so much of this. The exploitation, sharing of addictive drugs between patients (cheeking), and manipulative behavior/stories will make you leery of everyone. Plus, the patients who are easily exploited are coerced by others to give them their drugs. In many ways, it's like prison Bx and you will see a lot of it. A fairly high number of them are repeaters and will hospital hop. A frequent story will be readmitted d/t not being able to fill Rx (money), yet was able to purchase meth and get high. As stated above, don't be too worried about the meds. The doses are often pretty high and they take a lot at once time. Most of the nurses I work with are paranoid giving PRNs at the same time (i.e., multiple sedating meds). My experience has mostly been with falls, not death or any other adverse sequelae. The most frequent thing I see with meds is akathisia or other movement D/Os from antipsychotics. It's important to provide anticholinergics to patients on antipsychotics (Benadryl, Cogentin). They can help but won't always prevent TD. I'm at work, I have to go. I'll check back for follow up.

This is pretty typical. They lie a lot. The way of dealing with this....send them back. Do not admit at all, just turn them around and teach the hospital a lesson.

I probably wouldn't want my wife working on a psych unit, but that's the male protectiveness in me. It's hard to say. I've worked psych for a few years now and only had one major problem. I personally have never been attacked, nor have I seen an outright assault on a staff member that wasn't already out of control. I do know of several who have been assaulted though regardless of size or gender. It does happen. I've only been uncomfortable a couple of times. The one instance a female staff member on my team was badly injured during a takedown. The patient was extremely agitated and looking to cause harm to anyone. We had already placed him in seclusion and given an injection. It did not phase him. He was very antisocial and pretended to pay nice to be let out. Unfortunately he would begin an assault as soon as the door was opened. On a second attempt to give him an injection he managed to kick a girl on my team in the chest so hard it fractured her sternum. She couldn't breathe right for months. I felt terrible as the nurse, and it bothered me for a long time. Overall my work has been uneventful. Obviously you'll do takedowns, but I personally won't get near someone if I think I could be seriously hurt. It's not worth it. The key is to have good techs and supportive staff. Also helps to recognize building agitation in a patient and try to medicate. The problem is, most providers are paranoid about medicating and think Vistaril is your best option. It often gets to the point where you're calling the provider more than once because the original order didn't work. You'll find with experience that you can anticipate when a weak med isn't gonna cut it. It's a shame really, and a lot of attendings lose respect for the field after see how emergency psych patients are dealt with, or aren't dealt with rather. You have to decide for yourself what you're comfortable with. Some facilities are staffed with excellent techs and helpful staff. Others will expect you to manage with too many patients and no real help. Finding the right facility is important. I wouldn't say it's any more dangerous than similar jobs. ER patients assault and hurt staff, ICU/Med-surg patients same.

I managed to survive 18 months at a crisis facility, as the sole nurse on a locked unit with 15 to 18 involuntary patients. Most of them were high on meth, but extremely agitated, psychotic, manic and unruly. Very few were actually true MI, and the ones who were caused less trouble. Only the manic bipolar Pt's were difficult d/t constant redirection and the fact that you cannot medicate a manic to sleep. I honestly attribute my ability to survive on my the techs, namely two who were part of my team every shift. Without those two people I would have quit. The other saving grace was the provider on call was an NP who really allowed me to medicate when I needed it. Having said that, most places here in AZ are difficult at best.

Yeah, I had a patient once who was totally antisocial, not MI at all. He fought with us for 5 hours! Five hours of back and forth with a patient only because the doctor refused to allow us to keep him in seclusion for more than 20 minutes. Each and every time we opened the door it was a full on brawl. Not just acting up, but a fight. He was biting, spitting, and doing all he could to hurt us. He had two RTs with no effect, even though his eyes were red and the meds were clearly in his system. It wasn't until he started hitting his head on the floor in seclusion that we were allowed to put him in restraints. Luckily by this time the wonderful house psychiatrist gave the order to keep him in restraint for 2 hours. He remarked later to administration that he enjoyed what he did and wanted to hurt people. He fractured one of our sweet female techs sternum in the process as well. I was heartbroken and felt responsible for this happening. She was just trying to help. Nearly everyone had strains and injuries. So there are times where holding someone down just isn't enough. We'd been spit on and hurt enough.

Unfortunately this is common in psych. Techs and RNs will watch as staff are assaulted. I personally believe it's a two-tiered problem. One, the staff are afraid of being injured. Two, the climate has shifted to not putting hands on someone d/t liability and associated paperwork, patient injuries, and "trauma" to the patient. I have seen my fair share of people get fired because the take-down didn't go buy the book, but they never do. Only when the patient stops as soon as you grab them can you initiate a proper hold. If they resist, then that's it, it's a fight. No one wants to get hurt. When I worked in crisis and involuntary patients came in high on meth, if they went into a hold, it was a fight. Luckily my administration were pretty understanding that we tried to do the right thing and realized that nothing goes perfect. On the paperwork side of it, I will often do whatever to avoid a hold. If I think a patient will go off because they aren't allowed to do something, I will give in because it's just not worth it. The doctors at my place are the same way. No one wants to put their name on a S&R packet. It has really become taboo. The sad part is that patients know this and exploit it. Psych is really a disappointing field IMO. I've even seen a good number of interns say they lost a lot of respect for psych after seeing how patients are dealt with, or not dealt with actually. A good discussion of that was brought up on SDN and I agree. The avoidance of using IMs or RT when a patient is actively aggressive, resulting in other patients being traumatized just isn't right. Oh well :-/

At my facility I typically have 11 to 14 patients. It's way too much. I never have time to talk to patients or have any clue what's going on with them. I barely get enough to chart an assessment. The shift change is always a disorganized mess. Nothing is finished from shift to shift. The paperwork takes hours and there is so much that you can spend a whole night fixing charts, auditing, and putting labels on papers. We're always out of meds and supplies. Horrible. :-( I was told 1/8 upon hire. The original team was told 1/6. It's been 1/14 more than I can count. We often only have 2 techs on the floor with 35 or more patients. Very sketchy.

I can tell you that 99% of the time there is no problem with adding other antipsychotics on top of another drug. I've given Zyprexa, Risperdal and Haldol at the same time. I've given injections to individuals already on a load of meds; More than I can count. You run more risk of inducing akathisia than anything. Nurses need to understand that most patients are on such low doses of these meds anyhow. Back in the day they use to given up to 20 MG of Risperdal a day. Haldol can be dosed up to 100 MG. I've seen Geodon given as twice the daily max dose and all they did was sleep good. I'm not saying to play fast and loose, but aside from prolonging QT and inducing EPS side effects, it's pretty safe. I've even given the ole nasty Thorazine to patients on 20 of Zyprexa and 100 mg of Benadryl. Working crisis kinda gave me a clue as to how many meds people can tolerate. Sometimes you feel that the whole pharmacy wouldn't touch them. If they're new to the meds then obviously their tolerance and potential reactions are higher. As posted above, a lot of them are addicted to the pills and want everything to feel drugged.