superpsychnurse

Starting January 1, 2017 there is a standing order for new admissions to our inpatient psych unit. To paraphrase, the order basically states if a pt. is admitted and is on Depakote, Tegretol or Lithium, the nurse is to enter a lab draw to test the drug level the following morning. That is all it states. There was an instance where a pt was admitted and lithium level was done in ED. Physician reviewed the level and did not order anything further. The next day an email was sent out to nurses stating it was the nurses responsibility to enter another lithium level for the next morning. Many of us nurses do not feel it was our responsibility because it was technically a recheck level. Our nurse manager seems to be on the side of the physician and states he's being "very understanding" about the situation. It actually makes me quite angry, because I do not feel comfortable taking it upon myself to order lab work with such a vague standing order. In my eyes, if he wanted a repeat level he should have ordered it when he gave admission orders. I feel a standing order should be more precise or it is encouraging nurses to work beyond their scope. I envision a multitude of possible factors where the doctor could say "Why did you order that?" Thoughts?

Thanks so much for the input. At this time they are expecting one tech per unit to do checks and all the pt. care including groups.

I work at an inpatient acute psych unit in Nebraska. We are currently receiving the "assistance" of a consultant company. One change that has been implemented is that 30 minute checks are a thing of the past, and everyone is now on 15 minute checks unless they are under special close observation or 1:1. We have 15 minute check flow sheets that list the time for 24 hours in increments of 15 minutes where we have location and behavior code numbers on the side. In each slot we write the number for where patients are and what they are doing. The issue we ran into was with our director (who is an agent of the consultant company) telling us that if that sheet is not perfectly up to the minute with documentation, that we can not go back and fill it in because that is "false documentation." And that not having it filled in is a "terminatable offense". Our argument is that if our eyes observed that patient during that time period we can go back and document it at a later time. He is telling us that his expectation is that one tech is to carry a clipboard with those sheets on them (one for each patient) everywhere they go and make those sheets a priority. Apparently pt. care is to be interrupted to fill out the sheet. I say we can observe the patient and document on them later! Does anyone have any input on what they know to be what is considered timely for filling these in? Is there truly no leeway? Can anyone direct me to any resources or literature on this?? I believe that with all nursing you document AFTER the fact of care or assessment. It is not prudent to think that documentation can take place AS something is occurring. Who can I call???

This is great input. Basically our small unit serves about 1/3 of our state as we have some large rural areas. We serve as a crisis and stabilization unit as well as dabbling in "treatment". But when I started we were predominantly triage and stabilization. Since then our local state hospital has closed down, so we do end up getting some pretty acute patients at times. I feel like our consulting company is having difficulty understanding that all of our patients do not come in voluntarily and happy to be here. And of course we would call the police only if we don't think we can handle it on our own, and that isn't often, but it happens. I just don't appreciate being made to feel inadequate for making that judgement call, and your input has greatly helped me feel justified.

Yes, our main hospital is about 2.5 blocks away from the building where we are. Originally our building housed more services but they gradually all migrated to the other newer building. They say they plan to move us there too, but i think it's very far in the future. So meanwhile we have 20 psych beds split into 2 units of 9 beds and 11 beds. On the weekends the only ones in the building are 2 techs, 3 nurses and one guard.

Thank you. It's great to find input from other sources as I've only worked on the one psych unit for 8 years.

This is actually 2 questions: What are your policies and procedures regarding calling the police to assist with an acting out patient? It used to be part of our policy as a last resort as our psychiatric unit is actually in a separate building from our main hospital. Due to some changes in management, our hospital hired a consulting firm from out of state, and now they tell us it is prohibited to call the police unless grave bodily harm has already occurred. They tell us that nowhere they have been have they ever called the police. They don't seem to understand the acuity of patients we sometimes have (although they claim they do). We recently had an episode where a very large patient was agitated on a weekend. There were only 6 staff located in the entire building, so the police were called to assist, but luckily they weren't utilized. Being the charge nurse on duty I was called to a "meeting" about this. I feel I took proactive methods to keep everyone safe. I want to know how other psych units function in this aspect. Question 2 is related to observation of patients. Is close observation considered a doctor's order? Or a nursing intervention? We were told by our past director that nurses have the capability of placing patients on more intense supervision without a doctor order, such as changing from 15 minute checks to close obs or 1:1, but we require a Dr. order to place them on less frequent obs. such as from close obs to 15 checks. The consulting firm is now telling us that it is not in our scope of practice to order more frequent supervision. Can others please weigh in on how you handle this?