GalRN

Reminds me of a place in San Leandro where I did part of a travel contract. Big psychotic dude was stalking me and staff didn't notice or do anything about it. A fellow traveler called another unit for help, and fortunately they showed up just as he was about to corner me. I did not finish the contract and my company did not penalize me for it. If I remember correctly, you can't hold someone until they are really really dangerous, so they are almost all assaultive if they are involuntary.

Small feisty people can do a lot of damage when they are psychotic enough. Spice will do the same. The most important factor is the environment. Some places don't take safety seriously until after someone gets hurt, if at all. When the unit is running well, the same safety measures are followed. Sometimes people just explode. You need a way out and help on the way immediately. If there is a protocol that is followed that is the same for every patient big and small, it will save you from the ones that explode without warning. Also, do a google search. It is surprising how often there will be articles about people escaping or getting hurt at the bad ones.

I work as an ACT nurse and do a lot of home visits. At first I wasn't sure that I could do it safely. I have worked with the mentally ill in my area in multiple settings including in the correctional system, and I have seen many people, including some now receiving services through my team, be aggressive and threatening. The difference- we know our clients. If someone is new to the team no one goes alone for a while. There are some people that I will never be alone with even in the clinic due to past behavior. For the most part I do feel safe though. When the team sees a client daily, they know when they are starting to decompensate. It would not be safe if we didn't know them as well as we do. I do a lot of injections on the fly but there are some people who I have never seen in the clinic who don't need shots. It frees up the case managers when they are short staffed because it eliminates a round trip drive that they would have if they brought the person to me. Seeing someone where they are comfortable is a really good way to get a more accurate assessment. It is a huge benefit to me personally that I can switch my schedule and be out of the clinic when I can't sit still behind my desk anymore. I don't know how anyone gets any work done there with all of the hubbub. I also go to the medical doctor with them sometimes, visit them in the hospital, and on occasion sit with them in the ER to make sure they are cared for as if they did not have a mental illness.

I'm an ACT nurse and have a lot of clients on invega sustenna. There have been some dramatic improvements- people who went from nearly mute with flat affects to euthymic and speaking in full sentences, so delusional that hygiene was not possible to functional, able to live independently and taking showers, etc. They returned to wellness levels that I had not expected. The earliest group started it mid to late September. We are beginning to see decompensation in the ones who have been on it for 6 months. The ones with the most drastic improvements are sliding back to their previous states. It's sad and frustrating. I am wondering if they all will have this happen. These ones are on the 234mg dose. We managed to bump one up to q 3 weeks with results unknown as of yet. Has anyone else seen this? How long have your patients been on it? Anyone who has people on it and has not seen this trend?

Thought I'd throw my 2 cents in as someone who started working at a jail about 5 months ago. It was originally a 13 week assignment, but has been extended and I'm starting a position that has an opening. Last week I knew they were deciding whether they wanted to try and get me on board, and at one point someone said that I hadn't started as a corrections nurse, but I definitely have turned into one. That's good, since I plan on applying for the job. I started on the most acute men's inpt psych and now cover 3 less acute units in the mental health unit. In a few weeks I start days in acute women's. If there is a radio, and you see other nurses carrying them, you may want to find out if you are supposed to carry one. I wasn't told a lot about my job responsibilities because the person who had vacated the job wasn't there to orient me and every one said they didn't know what she did. So, I found out I wasn't doing something after I didn't do it. I didn't think of the radio.Now I carry it and use it. Very useful to be able to say you are 10-6. In my case that means messing with my phone in my car on break. The officers are with us anytime an inmate is out of his cell. Sometimes 2 officers depending on security level. It is their job to keep me safe and they do. In return, I communicate with them what I need to do and ask when it's a good time- they are sometimes a little bit short staffed. It may take a few minutes, but they don't make me wait unless they really can't help it because it's understood that we respect each others time. Occasionally there is an officer working who doesn't get it, and it makes things really hard. You need to build a rapport with the officers, more so than with the patients in this case. You are in their house, it is your job to deliver non judgemental care to the patients so that they will not suffer from their illnesses while the judicial process does it's thing. Don't get me wrong- I judge. I have a patient that killed 2 little kids with a baseball bat. He's charged with capitol murder x2. I loathe what he did, but not him, because I don't know him. And I won't- I'll know his blood sugar though, and will do his blood draws and be non judgmental in my interactions. At least I've been able to so far. I can't stress enough that you need to have a good working relationship with the officers, I've looked up and seen them writing down VS for me, one just put the cuff on them bc I hadn't mastered the art of putting it on an arm that was coming out of a slot. One called me last week to let me know that a pt was back from court and that he knew they had a stat lab, but were sorry- they had no staff until for a few hrs. Then called me when they did. He's actually in nursing school, but most ppl don't know that. The nurses that have been there for a long time will help you, but they will decide to accept you as a real peer when you show that you aren't going to do something dumb like flirt with a patient. They've seen other nurses do that, and some are pretty stand offish for a while- not saying that's a great thing, but it's how they are where I work. Overall I've been really impressed with the care that the patients receive. It is like being on a different planet. Getting used to it. Still asking questions when I don't know how they do it at their facility.

Realized I hadn't ever thanked you for this info! Thank you! I've worked on a lot of units as a psych traveler, and a lot of them didn't know how to deal with patients who had severe borderline personality disorder. Travelers can't just tell them how they do it other places or that they have a better way, but once they had stretched there resources to the point where they needed some direction, I sent them to this link. The ones who followed the basic guidelines had less aggravation overall, and there were times when all of the staff were able to be cohesive enough that a patient got a little better overall and a lot better during that hospital stay. Great guide, and the info about what the pt's are trying to accomplish is extremely helpful too.

To the OP- Did the hopsital's name begin with the letter A? Because I left a facility that begins with that letter in 11/10 and will not go back through the registry I work for now. They were changing documentation after the fact, among many other things....

I was on looking for info on a local travel position I just picked up. I live here but haven't for too long, and was curious about where I'll be working. Anyhoo, I read this last yr when it was posted. At that time I was one of the experienced RN's brought in from out of state to fill a position. Now at least I'm a local. Wanted to let you know... I work registry full time, and until I signed on to the current contract I did boat loads of shifts at the the county psych facility. I heard things, in this case good for new grad things. Don't know if it's too late, but it may be possible to get an app in. Sounds like the county hired a bunch of new grads, and it wasn't b/c the hospital decided. Someone higher up has been listening, and I guess they can't make the private hospitals change their practices, but they can within the gov't. They are not full time, and I'm guessing they aren't what people should be getting after busting their butts and making it through the NCLEX, but they are 3 days a week, from what I've seen. The county nurses don't mind the new grads, although a whole bunch at once is just expected to make it busier for a while. It seems like they want new people to actually show the ropes, correctly. There is one site that is a little nervous, because most of the night staff picked that month to retire. Like right before the new hires come on. They are losing about 65 yrs experience all at once and the ones stepping up have under 5 yrs each. It seems like they are pretty enthusiastic though, in general, and I would've heard otherwise if they weren't. I hear a LOT, uncensored. If you want to do psych, it's one of the best places I'd want to learn. It's hard as hell (I have 13 yrs, and do what the new grads will be, and it doesn't get a whole lot easier), the patients are getting even sicker as they have started letting people drop off court ordered treatment. But I'd been doing this for 12 yrs when I started there, and had never had a pt with an NG tube for forced feedings, or done 7 point restraints, on a pregnant lady no less. It wasn't fun, but I learned stuff I never imagined. They do ECT there too, so the prep is another marketable skill.

DO NOT, I repeat DO NOT take a chance with your license. There is a reason they are hiring. I work for a really good registry and every nurse I met was sent there and wil NOT go back. Pt care is OK only bc of amazing techs. The campus I was at was on their last chance inspection w CMS. We stayed a night on the weekend nights to make sure stuff was neat and "in order". That included signing other ppl's name. Made a stink and keys were taken away, walked off campus next weekday. May have been isolated incident. But talked to one of the guys that did state inspections. They knew what was going on but were missing a tiny bit of info needed to bust them. Equipment was non existent too. When a very suicidal young girl is MIA it stinks to have no working radios and just a mini maglite to look up in the trees and check if she was hanging. She was in the ceiling, Grrrr. Told her she should enroll in advanced ninja training.

As my sis would say, tru dat! The risperdone made me think of a situation I was in about 10 yrs ago. Pt had a hx of non adherence. They put him on risperdone. For a few nights he paced, clearing his throat, saying it felt like a lump was preventing him from swallowing right. Had to be dystonia. Day staff thought he just didnt want the meds. Wouldn't d/c it. I finally got him to refuse the HS dose. No issues the next night. My job is to assess for barriers that could get in the way of tx. Side effects happen. We need to listen.

I know exactly what you mean.... And it does happen all the time with older patients. I had been a nurse for at least 5 yrs when I got a job on a dementia unit. We had a new lady, from an acute care unit, still with a UTI resolving. I was floored when she complimented my shirt, I told her it was my favorite, and then she referred to it as my favorite shirt the next day. Doh! Thing is, the cases of delirium I've seen lately weren't in anyone over 35. My lady with cogentin toxicity- she was 32, and the staff (who are very good) noticed that she was kinda incoherent, so the MD backed off on a bunch of her meds. When her uncle came in and totally tweaked I paid better attn. He wanted to know why she was worse. At that point, so did I. The notes clearly document a descent into total lala land over about a week. Even her uncle said she was med seeking. She was known to fake all kinds of symptoms- she liked thorazine. So they decided that she was playing a game for meds. Problem- when I gave her the AM meds, she didn't know what they were, then forgot about them, then dropped then, once we got em into her mouth she forgot to swallow them and gagged when they dissolved. She was sooooo obviously seeing very clearly, stuff that was on the floor and appeared to be trying to get away from her. It was just, THE LOOK. See it once and have it correctly identified, never miss it again. The other most recent and most obvious is also the most enraging and tragic thing I've seen. And I've been a nurse for 13 yrs. As above, 24 y/o male, no prior psych hx, no illegal drugs. Just bought a house with his girlfriend and was on unemployment but had a steady working history. Healthy, other than shoulder surgery 6 months ago. He had his circadian rhythm upside down, agitation and AH?VH at night with delusions. For 5 nights. His parents didn't think psych. They took him to the ER bc they thought maybe he had a neuro issue. But psychosis = crazy= not important get em outta here. He was at the facility for under 5 hrs. Went from polite, to stressed about the "ppl outside from back in high school", to running up and down the halls (accompanied by some very tired techs trying to avoid seclusion or restraint). He ended up in restraints. 7 points. And even after I'd given him 8mg IM ativan, at least 25mg IM haldol, 2 of cogentin, plus 50mg of benadryl, he was still bucking, and yelling and barely restrained. Then I noticed that his upper lip was twitching kinda regularly, which was NOT normal (relatively). The doc had been on the phone with me for an hour. She was really worried. Then he started having an overall twitch, about every 30 seconds. It just looked way too tonic clonic to ignore. Called 911, and per order of the doc, and my own nursing judgement, I gave him 10mg IM valium. And stood there with an ambu bag waiting. This kids brain was frying! We couldn't get vitals, due to his movement. The FD showed up, laughed, and said they couldn't take him to the ER b/c they "weren't trained in restraints". Also seemed to think it was an act. The left us. 911 left. *** do you do when 911 leaves you??? I pointed out that his airway was not secure with all of the benzos, had kinda figured they could help with that.... Never would've given that amt of benzos in another situation, and without the FD on the way. The captain told me that as long as he was twitching he was breathing. That made me mad, but now it just makes me sad. After they left we called the county hospital to find who they used for transport. Called them. They understood, and sent a paramedic and RN. They scooped him, in our restraints and all. The 02 sat on the way to the ER was 39%. He flatlined twice in the ED. Last I heard he was still unconscious, and it's been a few months. He isn't coming back. The Phoenix FD cost him at least 30min of 02. The ER that didn't check anything cost him his life. We did everything we should've and more. I was very proud of the whole team. It went beautifully, except for the part about the pt. They don't know what caused his delirium. Just that it was there. Of note, during the whole episode, the ER who had sent him called with someone else to transfer. Suicide attempt- GSW to the abdomen - 5 HOURS PRIOR!! 2 holes, but they didn't know if it was entrance/exit or 2 bullets. H + H dropping. We were able to ignore that guy, usually we have to justify all refusals to the medicaid ppl. They give us half the record, not realizing that I will ask for a MAR if I see a med ordered and that telling me there isn't one just makes them reveal what idiots they think we are. GRRRR. Is this an AZ thing? I am from MA, and worked in CA too. Never saw this stuff. I make an effort to broadcast it a non annoying manner that IF IT IS VISUAL, THINK ORGANIC! I do mention quick onset, but am broad. Rule of thumb- if the patient hasn't been like this for a long long time, and there is no medical explanation, it is a medical emergency. And it is your job to either rule something in or make sure everything possible is ruled out. Even if you send them to the ER and they test for stupid stuff, it's a start, and a legal defense, really.

A unit that I worked on as a traveler had a rep for giving out MS Contin And oxy's like they were candy. Had a couple of pts that came in when their drug dealer went on vacation or their SSDI check ran out. They would stand and ask for whatever prn they had, nodding off, slurred speech and eyes at half mast. I would tell them that their sedation concerned me and they had to wait. A couple of them hade IR meds for breakthrough pain, and were well aware when they were due. They asked repeatedly anyway. I just told them that if they couldn't remember the time and asked a second time that concerned me, because of their altered level of consciousness. That usually made them stop messing around. I have been on the other side though. It stinks. I used to take lithium (had to switch to something less potent, toxicity) and have a hx of migraines. I used to get toxic from NSAIDS, common side effect. Went to the ER for anti emetics and fluids. Didn't ask for pain meds, they aren't worth the nausea for me. When the RN went to give me compazine I told her that I had experienced really bad akathisia in the past and requested that if she couldn't get the MD to order zofran, she at least give me benadryl at the same time- it helps some. She called me a med seeker and shut the curtain around the gurney I was on. I ended up with severe akathisia, and they knew it, but kept the curtain closed. Guess what, I WAS med seeking. The med I was seeking was benadryl! Still ****** at that hospital for treating me like a criminal as soon as I said no to the toradol. They hadn't heard of the interaction and made up their minds then. Us crazy ppl aren't crebile right? That was extreme, but I stop and think before deciding that someone seeking meds is doing it to get hiigh

OK, maybe this is a pet peeve, but curious... Have you noticed the huge group of patients with delirium - do they get ignored in your facilities? By ignored I mean no one notices that there is something organic and reversible going on. Most nurses I meet think that it is something that you see in elderly pts with UTI's and think no furthur. I work registry and so I get to see multiple facilities and their lack of response. Part of it is the ER's fault. I'm not knocking the ones that do the tests they should and rule out everything obvious. A lot of them do only the tests required to get them out of the ER. I had a pt last month- a 24 y/o with no previous psych hx, brought to the ER for a medical workup by family. He had been sluggish during the day and for 5 nights prior to coming into the hospital he had been hallucinating and stating that he could see ppl in his house, thought they were going to steal his guns. Very agitated. This was a sudden change. At the ER they did a CBC, BMP, UA, UDS. That was it. He became very psychotic and agitated, finally tried to head butt a sink and was put in restraints. This crisis unit was not equipped, we couldn't get accurate vitals. By the time the whole incident ( which included FD refusing to transfer him and leaving) was over, he made it to the ER and coded. He is still not conscious. Another more recent case was in a woman around 30 y/o. She had been psychotic when she arrived but it was almost resolved. Apparently it evolved of a week's time. I had not cared for her but her uncle made a stink (thank god) and looking at prior notes this was not her baseline. She was trying to pick up things from the floor that were not there. She couldn't eat, too distracted, didn't even know what yr it was. It turned out to be cogentin toxicity. Am I the only one who sees this as a growing problem that is not picked up by staff due to lack of knowledge? Or are the patients with delirium coming to the psych units more often?

Hi, I went from resp step down ICU to psych, where I come that is considered a step down from regular nursing and not paid as much per hr. LTC is around there in "status" and a little lower in pay. God forbid we pay our nurses equally, skills are different in each setting and nursing is hard no matter where you work! I love psych, and left acute medical nursing in 2001! I am still in the same specialty, and have not regretted my "self demotion" in that whole time. I have an entirely different skill set and it is something I am proud of. My mom, who works neuro at a well known hospital, say she's a "real" nurse,. I guess she is entitled to her opinion, but I see other wise. Guess who she's calling when she has a pt with borderline personality disorder, and putting me on speaker phone while her co workers ask me questions too? I have worked plenty of LTC, as registry and for stints as a staff member. It is HARD. No constant drug calculations, or pts crashing, but it is challenging. Less medically acute pts means MORE. Day shift had anywhere from 1 RN per 15 pts, and on night shift, I had 50 alzheimers pts with 2 CNA's. I have a dad with dementia now, and can't imagine being the nurse who deals with me every day. And I'm just 1 family member. I recognize now, the importance of the job, even more so than when I did it! One thing I wondered if you had considered. I don't know the specific things that made you dislike acute care. I hated so many parts of it. But it seems like you must've been ok at it, even if you hated it. Have you considered signing up for a staffing registry? There's a lot to be said for predictable hours, and benefits, so it might not be an option, but ave you considered working for a registry? I do now, full time, and have insurance, although if I wasn't a little flexible with my hours I wouldn't get 40. Just a thought, it seems like you have a lot of variety in your skill set.... LTC will use those skills too, and you'll learn a whole set more. If you can't duck, wait til you give an old lady a shower! And trust me, it isn't your job, but some day when theCNA's are trying to feed everyone and a pt ends up covered head to toe in whatever, you'll end up doing it. Good luck! I hope the drop in pay is manageable. It is worth it, or was for me anyway. I hated my job, now I like it most of the time, and even a bad day for me is better than a good day in acute!

I've had acouple of pts with the disorder and remember them being pleasant but in lala land and could not care for themselves. It's also near and dear to my heart b/c we are still wondering about my dad.... He had several psychotic episodes and had to be medically detoxed each time, starting at age 66. He is now 71, in LTC and can't remember what he ate for breakfast or anything else. They made a clinical diagnosis of Lewy body dementia, which can account for his mask face, recent shuffling and lack of spontaneous speech. However I think it's combined, a bit of each, he drank about a 6 pack a night (he's a little guy so that's a lot) every night for the last 50 yrs. It breaks my heart, we were so close... I also had no idea his alcoholism was as bad s it turned out to be. He never drank until us kids went to sleep....