mebeafrn

I looked at the DSM IV while I was wrestling old charts out of med records today and it talks about behaviors"experienced in adolscence and early adulthood" when going thru the dx. criteria so it's not something established in adol. I agree too with the poster who talked about typical adol behavior/borderline being so similar,consistently inconsisent as one of our MD's used to say,but not about the kids,they hadn't had time to develop or not develop consistent behaviors. The thing that bothers me the most about over or misuse of that dx. is the instant rxn. staff often have,without ever seeing or interacting with the pt. I've often wondered what it would be like if the Axis II was unknown. To me bottom line,if not for my good fortune in the people that raised me,it could be me on the other side of the glass.

in NE we can do a 48 hour hold to determine safety,has to be initiated by a psychiatrist. In that the pt. is observed and evaled,recommendations made and if they are unwilling to go along voluntarily if considered a danger to themselves or others-this can include not eating,not sleeping,refusing meds,delusional activity,spending,promiscuity,influence on children etc..then the county has 72 hours to schedule a mental health board hearing to decide about committal. As our collegues have said,history and family/SO input can make a big difference. Does this pt. have a case manager or primary therapist you can get more info from,or your House Manager/Supervisor? I've seen what looked like really shakey 48 hour holds until I saw the dication about history an fam/SO input. Oh,sorry I missed your post on the specialty board

my little bit of info to add from experience with DID pt. The "strawbarry gal" presented with a bland facies,no makeup and very quiet demeanor. During the course of a conversation,usually after a pause in speech and looking down or away she would "switch". One very scarey switch occured in a therapy session-the therapist and myself present d/t rapid switching and concerns expressed from other alters in the system-a very angry aggressive male alter,a protector in the system came out and was very upset about not knowing where he was,who we were and who was taking care of "our"(the pt.s) children. The lengths a human being can and will go to in order to endure the unspeakable never ceases to amaze me. To me the most amazing thing is this protection of the self starts,as it must for the person to survive even if fragmented, at such an early age and on an unconcious level,amazing.

so true!!!!I see charting that says pt. "likes"(quotes are mine) to_____fill in the blank w/ such as ,staff split,manipulate,have negative attention,have males do physical holds,be gamey etc... as if this is a conscious choice and these pt. really like to have this be the way they get their needs met. Even more frustrating is trying to gently get the the nurses to look at what type of environment and life experience create the use of this type of behaviors just for survival as a child and get the attitude of "well, it's not that way now so they should just quit it" Sometimes I do ask if diabetics/asthmatics etc.. can "just quit it" sometimes I see the light come on,other times they look at me as if I've maybe taken the keys and nametag from someone:chuckle I'm so glad our techs all have at least a BS in a human service related field and most are psychology majors on their way to a MS. They provide a buffer while we get the nurses up to snuff who haven't had a solid psych backround. And yes,Borderline as a solid Axis II before age 18 is not our norm either.

thanks! Thats just how I feel when I see things like that article.banghead: I don't see my co-workers looking away-mental health facility and we produce VOLUMES of suspected abuse reports. The situations are so frustrating,we report over and over and the perps are so often just like the OP pointed out-so clever and manipulative it's hard to prosecute(?sp). Regardless, we keep reporting & trying to support and protect the vulnerable. One of our therapists often reminds us about the correlation of the quality of a society and how the most vulnerable with in it are treated.:

wonderful topic! My experience is limited with DID. I do recall one gal who was allergic to strawberries,but loved & ate them,then would "leave" when the hives began to show. This was also one of the more self injurious/high risk taking alters who tended to put the whole system at risk when she was decompensating,drugs,different types of roulette. We did see markedly changed lab values in observed situations as well. I fully agree about this not being territory for the inexperienced or easily drawn in therapist.

IMO tension relief is OK as long as only nsg. hears it. Humor puts things in a more "manageable" light.

thanks for the reply lovinghands...overwhelmed is very possible & you are right about chaos.We,the House Managers-have been taking turns working the units as the new RN's back up,letting them charge the unit with us on the meds or running program with the techs. We are letting them function as freely as they want,not stepping in unless they ask or it looks like things are getting too far out of hand,then we try helping them go thru critical thinking to get to what they need to do. I hear them making good assessments,looking at options,really sticking to least restrictive,see them doing good things,then just as I think I can turn them loose,one will do something like break every pt. safety rule we have related to passing meds when I know DARN GOOD AND WELL they know the right way because I did the teaching,modeling and watched the return demo,several times 1:1. Or I can come on the unit by a back door,so I don't disrupt an activity going on in the miliue and find the RN's huddled in the nurses station sitting on their duffs grousing. Maybe we just are picking up census too fast for them to acclimate. Maybe we are being too protective with them and we need to cut the cord. It's not like we have 300+ pt. lol thanks for you input

if you are interested in nursing,go for it. Please do keep in mind as CharlieRN said so aptly,crazy people get sick too. Our population is aging too,so we see multi-system chronicity,not just mental health. A good psych nurse needs some good solid med surg experience. Some meds can cause urinary retention,drooling,gait and other motor disturbances as well as many other s/e. Pt. may need spot cathed,injections,wounds treated and assessed, staples,sutures taken out,cental lines cared for, blood glucose monitoring,hypertension,COPD,have skin conditions and infections due to lack of self care because of their mental health problems. We see transients with awful dental and nutritional problems,Hep C,HIV, AIDS,lice,impetigo,scabies, parasites,constipation/megacolon etc.....those with alcohol problems are prone to some bad bleeding problems from varicosities,espohageal and rectal,plus don't clot well from their bad livers,you get my drift.

does the unit you are assigned to have a daily goals setting group? If so try watching how the staff enc. participation. You could also try the flip chart or marker board method vs individual paper and pencil. You doing the writing and your pt.s giving the input may get more participation. Can you do it in two parts? get pt. input as to what they want to talk about,vote on top 2-3 ideas one clinical then do the goal setting part the next clinical? That would give you specific ideas for visuals,props etc.... Best of luck. The first time is the hardest,it gets easier each time and your confidence will improve. Make sure to practice first esp. if you can to peers who can role play your perspective real group.

wow,CharlieRN,compaired to your facility we are a unit. We went thru some bad years,managed care took a hard toll, and even worse internal management was very nearly our undoing. The parent company was ready to close us. A management company has taken charge and we are beginning to pick back up,fast! our census had doubled in the last month and we are really struggling to have enough functional licensed help. To the few of us who have been there since the place first opened it is like "the old days" with 2-3 admissions per 8 hour shift, at least. The hardest part right now seems to be getting the newer RN's to embrace the increased activity and stop sitting and complaining. We "old dogs" thought this was down right fun to be busy,have the new pt.s come in,and *gasp* be assured of having a job! It seems so much has been lost. There is a core group of us trying to help our new staff adjust well and feel confident in their postions. We work hard to model the attitude we want to see replace the apathy and negativity. Thanks for the reply and suggestions. What do you do for an orientation schedule? Has anyone else seen a facility recover? or do they? thanks

Thanks for the input!! In the past we have had great success with the majority of the med-surg nurses who have come to us,I say this some what tounge in cheek since thats how we all started :-) I appreciate you perspective and suggestions,esp. the positive role modeling from our established staff and giving the new hires the milieu time. I'm seriously considering taking them with me or one of the other House Managers for a shift or two. I'm hearing a perception that the supervisors "don't help us enough." We'd tried to give the new hires more time on the unit,so had changed some of what we do. I think maybe they need to see the whole "house" running ie-what is happening on the other inpt. units,what our RTC is doing,what the access center is doing or if there is no access clinition what the House Manager is doing as far as inquiry/intake calls,back up to the other units,passing meds for the RTC if there is no lic. that shift. As I write I think we may have left out the "big picture" piece we used to give our new hires. I wonder too if seeing the whole house at once will help them see just how valuable they are as a part of the big team,not just the unit team. Thanks again,please keep the input coming. I am very interested in what size of facility/setting you are in and what your perspecitves are on the good,bad and ugly-hahah- of learning psych nursing:-)

our facility is expanding and we have nurses coming in with little to no psych back round. I am one of the few seasoned-15+ yrs. experiece plus a certification-psych nurses,a House Manager and very involved in their orientation. I'm concerned about a tendency I see toward not getting out of the nurses station and out in the milieu. So far all the new nurses have had at least a few years med-surg experience,so shouldn't they know about getting out into the population and doing MSE's,casual chit chat,getting a feel for the climate of the milieu? It's as if they expect to sit in a chair in the nurses station and have the techs hand them charts. One of them even went so far the other night as to get up in my face about transport arrangements while I was trying to get an escalating manicy pt. to take her meds and get her out of the general population before one of the psychotic pt.s assualted her for being so invasive. It was as if this new nurse had paid no attention to what was happening outside the nurses station. Frankly I'm shocked by the behavior. This is not my first time out of the chute orienting new nurses and I really enjoy helping people learn,but this is, for lack of a better term,an attitute I've not seen before. From reading the med-surg threads I don't get the impression it consists of sitting,and I don't remember doing much sitting when I worked med-surg,though it has been several years. Am I missing something? Has there been an attitude change out there in regard to what psych nurses do? how will any of these nurses work charge on a unit and keep their pt.s and staff safe? The education team is going to meet to try and address the situation. I'd be grateful for any input. Thanks!

I just started an every Sat,Sun,Mon position. I've been in nursing for 23 yrs. and my oldest is 26. She still talks about opening presents on Christmas Eve,then again Christmas Day and again later in the week depending on what my schedule was. We often chose my first day off after the holiday-saved back some presents,made special food,stayed in our p.j.s all day,played games or had a puzzle going or watched movies-the kids all still laugh about the Conan the Barbarian marathon-"nothing says Merry Christmas like barbarianism and swordplay"

ooops,clicked wrong,can't find escape key,:imbar