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....

Well, my helping the new nurse didn't help anything.... All it did was get me fired. Quick back story- my supervisor had been the "I'm your buddy and I'm here to look out for my staff" person. When I started the job the facility had just failed a CMS eval and basically had one more chance to fix it before it went public and they lost reimbursement. I was told during orientation that they had hired so many nurses (40 orientees for a 90 bed hospital) because they had changed their model of care and some of the nurses had not been willing to chart correctly, so they were let go. I had been using computerized charting almost exclusively for the past few years, but had started out on paper and was learning the very specific things that were not errors but annoyed the night staff. I was called in to my supervisors office- she told me that evening shift was getting blasted between "insert profanity's" and "insert different profanity's". She had me sign a clinical supervision form, basically it stated that I had been told the correct way to do whatever it was that had annoyed the night shift. This included not writing the dose right in the middle of the place specified on the preprinted admit order sheet, and crossing off "no pain" in the box that asked for what med, dose, etc. The problem was not the no pain- it was because I had written ativan for anxiety and the time. There was no where else on the nurse flow sheet to chart it. Stuff like that. She told me that she was standing up for her staff but if we missed charting a pain med dose she couldn't fix that and it would result in a written warning. I never got a written warning- because I stayed until I was able to check the MAR's and BHT notes for a 2nd time to avoid any discrepancies. There was never another mention of an issue re: charting. It took me a little while to get comfortable and physically organized (major ADD, treated) while I set up my own system that worked with the other nurses and BHT's . Simplified a few things, which staff stated was helpful. So up until today I had not been spoken to by any coworker or supervisor about charting errors or any other issues. Our unit shares a large nurses station with another and on the nights that one or both units got slammed with tons of admits we would take turns so that no got bogged down. Often it was staff's (some registry that knew the facility better than me) decision to delegate specific tasks like one person called for orders, another wrote care plans, etc. We were good, and efficient. I was happy because not only was I more organized, everyone was working together and it was so easy that way. No one stayed late because of an admit- we all pitched in equally- and did what we each were best at. For example I tend to get a chart all out of order and I take forever to put it together, so I would take out only what my techs and I needed at that moment and hand it over the very capable slightly OCD unit secretary (god bless her) and she would put it together really quick. I was so happy to see nurses (different registry every night) all pitching in equally and not minding at all- we all won. One night we had an AWOL (she turned up in the crawl space above us). A tech and I went outside to look as she had hung herself before and almost finished the job. I realized that we had no hand held radio. Each unit was supposed to have about 4 or 5. If we had found the patient I would have called the unit on my cell phone but that was not the issue. Found out that our one radio didn't work b/c the chargers were broken. Notified maintenence, filed out the service req, and since the risk manager was right there, mentioned it to her. This had been an issue before I had started my job and was being ignored. They were getting new radios, weren't allowed to order parts of the old, blah blah. I stated that this was a huge safety issue and I would follow it up until it was somehow addressed. I followed up by calling maintenence and filling out slips every night until the supervisor said in a very annoyed voice "Just drop the radio subject, OK?" I kept quiet but still filled out the req's. The day I wrote the original rant we had that very psychotic patient show up and I felt that he was a saftey risk and not able to sign in voluntarily to boot, and I appraoched the sup, and was just saying"heads up- we have a potentially violent" she turned around said "There all mentally ill" in a very annoyed voice and walked away. Didn't stop to hear what the safety issue was. The staff all saw it and were kind of shocked. I documented that I had made the supervisor aware of safety issue. The next night the cops showed up to f/u on a report that a patient had made about an assualt on him prior to getting to our hospital. I know firearms are not allowed and at that facility the police could not come onto the unit either. I call the sup and asked if we could put them in conference rm so he could finish the report. She yelled loud enough for all the to hear "The police are never to come into this hospital unless we call them! It's a HIPAA violation, and I don't care if the pt called them, they aren't allowed to see them b/c the police are not allowed" then slammed her phone down. Again, it got real quiet and another nurse whispered "I thought they had the right to report a crime". we went on with our business, and it was decided that if I spoke to the supervisor she would not let me finish a sentence without cutting me off, and that my requests would go through other nurses in order to get everyone's needs met. This was the first time she had acted in anything but a helpful manner so I decided that I would bring it up with her the next day. Yesterday the other staff grew increasingly alarmed about the new nurses lack of knowledge, inability to put dates on a care plan that I gave her (this happened several times). She also kept leaving the unit and disappearing, and was visibly shaking. Apparently this had happened on other units where she had also oriented. She was so clearly upsetting the pts, and other ppl had noticed. I did not go to my supervisor because of the issue she had wih me- I planned on bringing it up at the end of the shift, in her office. The BHT's that work with me knew I was totally intimidated and marched their butts down and told her what was up. She asked them why I hadn't said anything. One just said that I was trying to give her one last chance to prover herself and doing double the work, basically. The other one, who I work with nightly repeated the same thing, then said that after the interactions between us she thought I was probably a bit intimidated and didn't want to bring it up during a pt care time. The sup talked to the other nurses but said nothing to me. The tech pulled me aside and said "If you want to make her stop, drop the radio thing- I will come in and hunt down maintenance for you tmw", and then said that the supervisor actually was quite annoyed with me because she was very organized and felt that the desk still was a pile of papers. It generally wasn't b/c I make it a point to got through all of my stuff and put it away frequently. My tech told me that the sup would address the issue with me the next day- today. I walked in and was told to go with the supervisor, while I walked behind her I said " How aout we make a deal? I promise not to interrupt you with anything not urgent if you are busy, and I will leave the top part of the station clear for you to put down your clipboard" She did not answer, brought me into the conference room and stated that as it was day 89 of my employment it was time to decide whether I kept my job or if we parted ways. I had not had a negative comment about my work for over a month and the night nurse and I had gotten on better terms- she said the paperwork was fine. Other nurses, one a unit manager, told me that they had let her know I was fun to work with and would like to be assigned there if reasonable. The ADON was there and my sup told her that the other nurses had frequently complained about my lack of effort and bad performance. I had not heard about any of that. She said that I was too disorganized and maybe I couldn't handle the fast pace and that they had decided to terminate me. Then said she'd seen no improvement in my paperwork. I told her that I had heard nothing about the paperwork at all since she said that she would write us up and explained that I stayed late for a while to look at the MAR's after the med nurse was done, but about 2 weeks go had been able to leave on time b/c I had figure out a much more efficient way to get things done. She could/ would not produce any paper with an error on it. I told the ADON that I'd had positive feedback from the other nurses, and she siad that they had privately addressed the issue of my competence numerous times over that past 2 weeks. The ADON asked me if anyone had said anything at all and I stated that I had received no feedback re paperwork or disorganization. She asked me if I had asked for help with my workload since I seemed overwhelmed. I stated that it had been a bit overwhelming at first but that I'd learned who to delegate what to and that we had a very good system. Then they took my badge and keys and walked me out. I talked to my (former) tech hen she just called me on break. Apparently a coworker had gone to management about her treatment of me and unwillingness to address valid concerns. They have developed strict anti bullying rules and must've put her on the defensive when they told her that around 9 workers had witnessed each episode. She basically told the ADON all that crap about complaints and basically incompetence. Would not produce anyone who had gone to her with a concern and had no written mistakes. Because it was day 89 of my employment they sided with her and terminated me. They kept the other nurse. Help! I don't know what to do! I know they don't need a reason to fire me but I really liked this job and I am so screwed... I left a very abusive and dangerous husband and moved 2200miles away for my own safety, and crashed on a friends couch for 2 months saving up for an apartment. I am driving a very expensive rental bc my husband has my car and will not return it. I left everything I owned there anyway, including my cat. I signed a lease about a month ago. Rent is due this week as well as the car rental money, and the first round of all the bills. The job was my ticket to being on my own and starting to find out who I'd been before my husband started the abuse- which included felony assault, denial of $$ for food, and constant berating- including, get this "you are worthless, you'll never keep a job you are so stupid". I am stunned. I cannot stay with my friend again- her 5 y/o kids came to live with her and there is no room. This check will pay the major bills but I will be left with just enough to buy food for the next 2 weeks. I don't know what to do, there is no one I know here except one person. I'm sleeping on my own couch now bc I decided to get that before a bed bc I could sleep on it too. I can't believe this is happening.

Also I forgot to mention that I have WICKED ADHD, go into overwhelm pretty quick in chaos. She does too, she asked me if I thought she did and I told here I thought she did. Said she'd been treated in the past but didn't stick with med b/c of side effects. She asked why I said yes so quickly- I told here that she understands me when I go into rapid fire talking. And she's like me with the pprwk tornado. I'm like Pigpen from Peanuts. Except instead of the cloud of dust behind me it's a cloud of paperwork!!

It did just occur to me that in the OR she had one patient at a time. To end up with 10 after 5 days of unit orientation must be hell. I'm gonna write down the basic schedule I go by, when we aren't getting slammed by admits. I came to this job after traveling for a while. I'm used to change and the biggest issue I had was time management. I always told the nurse orienting me that I knew the psych stuff, if they could keep me on track time wise it would be the most helpful. That and the specific expectations on the unit. Basically 1st- how are we supposed to it here, and 2nd- how do you REALLY do it here. Mark- I haven't really said much to other nurses, being the lowest person on the totem pole everytime I started a new contract is something that I have dealt with a lot. I will not be backstabbing bully, or the one that makes her feel inferior. Or any of the other types. Ppl can be soooo vicious and I know exactly what you mean. If we have time today (she's still coming in, I called to find out who I was working with) I'm gonna make her cheat sheets for every process. If we get slammed with admits I'll see if she wants to stay an hour later or come in early tmw so I can give her some info while we aren't running around in the chaos that tends to happen when we are working with a nurse who doesn't yet know the routine. At a new assignment I made sure that I got a copy of every sheet cheat they used for themselves. When a new traveler came I always made copies for them- and gave a heads up on all the stuff they hadn't covered in orientation but I wish I had known.

Hi, I just got home after a frustrating shift that ended up requiring 2 hrs overtime so that I could complete MY charting as I had been covering a lot of the stuff that the other nurse working with me would've done in a normal situation. I work at a 90 bed facility as the eve charge nurse on an adult unit. I started my job in Sept, was hired straight out of a travel contract at a psych unit at a large medical center. I decided to stay and make my home here, but found the morale and 50% turnover at the big hospital a huge bummer. So I got a job at this hospital as it similar to the settings I've been the most happy practicing in. I am in charge by default almost, b/c a lot of registry nurses are used. In that case the staff nurse is technically in charge. However while I was orienting the staff were told I would be taking over charge of the unit- they never mentioned it to me. Anyway I understand that they need to hire RN's and in AZ psych positions are not being filled by staff bc registry staff often make more $, and bc they have steady hours and either don't care about benefits or get them from a spouse. So basically the hospital announced that it had just hired about 20 RN's that had decades of experience- just none in psych. That's not really an issue, if you work with patients at all then you have some psych exp, charting is all quite similar, and I love my field, I don't mind showing someone how I do my job if they can show me things that are universal but are learned by exp. So last week I got an orientee. They give us a week of on unit orientation bf we get a full assignment- split a 20 bed unit and have a fantastic med nurse and amazing techs that I trust and do their job above and beyond. I consider them to be in charge really as they are interacting with the patients all the time and I have to fit in 1:1 time in with all the paperwork that we have to spend time on- that's universal. We work very closely and can get an amazing amount of work done bc we all know our strengths and do what we are good at. It's not computerized and I can generate massive tornadoes of paperwork, but others are organized to the point of OCD. I assess, they put stuff where it is supposed to go, etc. Anyhoo, the RN that I got was on her last day of orientation and I was in her shoes recently- I know the challenges, esp with a hosp that isn't computerized. It took me a while to get into the groove, but I had a strong background of 10 yrs of psych under my belt. I didn't know their particular system but I have the basic psych skills. The nurse I am working with has always worked in the OR. Probably some culture shock- just the fact that our patients are conscious must be a big deal. HOWEVER, this nurse doesn't know a damn thing about psych at all. She doesn't have a clue about the DSM criteria, what the treatments are, multiaxial dx, etc. I would be lost in the OR myself. What concerns me is her basic lack of knowledge. She has taken family members phone calls and given status updates wo checking for a release, and tells the families (even the ones with a ROI) things like "tirepitol, umm, I think it's for cholesterol, but anyway the pt is just fine." She said this to a family member who has a background in psych. She asked them to call back at time that wasn't as busy. Thank God. It was her pt, but she was making a valuable discussion into one that could have cut off communication. I needed info about a pt who had no insight, and the relative was able to give me info about what meds the pt took, what she didn't, and in this case the risky manic bx that got her there in the first place. We discussed the TRILEPTAL and she was relieved bc she felt that tegretol was worth a try and had been hoping for an antiseizure MS. I have given the nurse a number of resources- NAMI for example- they have info for every level of understanding and it seemed like a good place to start her off. I am becoming more alarmed by the day though. The staff was given a clinical inservice yesterday about steroid induced psychosis (it happened last week when a depressed lady became stark raving mad after a medrol dose pack). She said that she'd heard of it but didn't think that pt was a body builder. The techs and I explained that we were talking about corticosteroids not anabolic. She'd never heard of any of them and I had pulled out a drug ref and named as many as I could find- expecting she recognize one drug name. Nope. Not prenisone, cortisone or any of the different trade names. She doesn't know what an anti psychotic is or what it treats. Same with mood stabilizers. Keeps telling everyone that abilify is brand new and its for depression. Argh!!!! She got that from TV . I damn near fell over in report today when she asked what ativan was, and then when I told her it was a benzodiazapine wanted to know what that was. She doesn't know anything that I would expect a seasoned nurse to have rudimentary knowledge of and isn't trying to learn. I let her take report on an admit but called for my own sanity bc she got nothing- not even the pts name + age on paper. I didn't call back in front of her and no one else knew- I'm not going to make her look bad. I don't think I need to. So basically I am doing my assignment on the fly, and dealing with everything from MD orders to med ed with the pts. She is not attempting to get her feet wet. The final last straw was when I had to save her behind from a pt that should have been screened out as too dangerous and sent to county- they released him still very sick and very dangerous. He'd almost killed his case manager last week- CAH. 18 yrs as a non compliant para schiz with a record of escalating violence. In assessment gave one word answers with major latency, stared and then glared when asked about his ability to tell staff if voices got worse. All I could get out of him before he stopped talking and just glared was that he was pretty sure someone would not die tonight. I gave her the basic safety info- be closest to the door, don't turn your back and please try not to be alone with him any amt of time. Then explained that he was quiet but a huge risk, what I picked up in his presentation and meshed with his history. Told her that ANY change in bx was a sign he was gonna blow. Later he started bouncing his knee in the day room and I cleared all the pts out pronto. She stayed and let him between her and the door. I finally told her I needed her help right away in the hall. She said "in a minute". His nostrils flared and kapow. He hit her in the face. I did everything I could do to avoid this and she sooo lucky I kicked his feet out from under him so she could get away then ran myself. His CM is still in the ICU! I feel that the issue needs to be addressed bf she comes back on the unit. It is not her fault he is violent but I warned her. She lacks judgement knowledge and honestly, a brain IMHO. It will look like I'm blaming her for being an assault victim but I can't keep her safe, and the patients and do all of her thinking for her too. I could let her sink or swim but there are 20 patients and half don't deserve crappy treatment. I can't help it, can't stand it that I know the answers and she doesn't know or care to know. Advice, please?????

I have my own issues with charting. After a few years traveling, mostly to places that used eMARs, I am back to paper charting. I've realized that electronic charting is good as far as time goes but doesn't really cover all the bases and often can be done by clicking enter, which leaves a bunch of notes stolen from the previous shift. But, it is quicker to type and the systems are less redundant. On paper, I write and often look back at it and realize that I left out a detail or don't like the way I presented the info, but can't change it w/o rewriting the whole thing. I just started a job at a place that uses BIRP notes and I hate them. We actually use PBIRP, with Problem being the first part. Thing is problem is really just the pt's Axis 1 diagnosis. So if the problem is Bipolar d/o, then I have to fit all of the behaviors relevent to that dx in the behavior part, and then address them all under interventions. There is no place for elaboration, so god forbid I have a conversation with a patient. There is really nowhere to chart the details.

Medscape is the way to go, definitely. They have a psych mental health nursing resource center, good info, articles, and free CEU's. Also, they keep the creditss for you to print out any time you need them.

Thats a really good question. I've wondered myself for a while now. I don't think there is much risk of the med going into a blood vessel in the areas where I inject, but a few times the injection sites have bled more than I was comfortable with.

I am being renewed at a hospital that I love, which I'm psyched about. However, I'm a little bummed out because the other traveler had no problem getting a week in between contracts and my company says there is no way. I am to give the NM the date I would like to start the new contract and if she ok then I get the time off. If there is an issue, I'd have to either not go home for a week or not sign on for the next contract. I really really need to go home- my dad is in a nursing home and I haven't seen him since late April. If I could avoid it I would- my marriage stinks and I don't want to get all stressed out but I need to have a few days off. What is the norm?

Hi, I am at a facility in AZ, and have 4 weeks left out of 13wk contract. How long do they wait before asking you to renew? That of course, is assuming they want to renew you. The facility where I work is losing nurses b/c of a new unit opening at a nearby hospital. I told the NM 2 weeks ago that I'd love to stay and she said that with any traveler she needs to evaluate the staffing needs and then go through management. Duh. The thing is that I need this job, love the facility, and can lease directly from the owners of the place I'm living (which is luxurious, and would be vacant otherwise). I also need to keep working- can't afford to go home for more than 2 weeks. Last time I went home w/o something lined up it took me 2 months to find something else. I think they are considering renewal, I've had supervisors, peers, and techs coming up and telling me that they think I'm doing a really good job and are glad to have me there, and saying that pt feedback is very good. That's not something that happens often, and almost never with all the staff at once. I can only assume that the thoughts were there b/c they have been asked by management how they feel I'm doing, whether the dynamics are good, and generally if they want to keep working with me. Pretty sure the answer is yes, but I really need to know as soon as is reasonable. So what is a reasonable time frame? At what point should I assume they aren't renewing and start sending my portfolio around?

To clarify- This patient was known to the facility, and although I had not been his nurse, I had been lucky enough to read his admit and d/c notes, as well as the previous restraint records. He was one of the few pts I have met who was attention seeking and psychotic (not in a micropsychotic process way). He had been upset that another pt, who he thought was engaged to him, did not want to stop playing Uno to discuss the God machine that they were creating together. He had been off of his meds for a while (Magellen decided to stop covering the ones that worked for him). His psychotic belief was that he was already God or Satan, he would cease to be God and become Satan forever if he couldn't finish the machine, which he could only create with a female God counterpart. He also had mentioned necrophilia and witches in his mouth- but that didn't appear to be the cause of this episode. The abrasion that he caused with the toothbrush was manipulative behavior, to get the other patient to notice him.... the tech assigned to his 1:1 knew him and was the one de escalating him as I tried to get the order. They could have taken him down and put him in restraints, but in the past he had gotten worse after a restraint and stopped working with the staff to stay safe. However- there was a bed ready and restraints were being set up while the de escalation was attempted. If his hand had even twitched there were enough ppl to forcibly prevent him from hurting himself. It had been written repeatedly over many hospitalizations that the best way to deal with him in a standoff was with meds. He had stated during his debriefing after a prior restraint that he felt it would not have been necessary to restraint him physically if he had been given meds in time. He had always been helped with the cocktail given. Zydis, other injected meds, and everything except for Haldol had given him severe akathisia. The other effective antipsychotics (the ones that help him) are not available in a fast acting injectable form. Yes, I drew up the meds knowing that I had no order and possibly the MD would have chosen others if he had decided to choose at all, but I had only a few seconds and drew them up and decided to have them on hand- it would've taken more time if I'd gotten the MD to order them and then gone back. Had he rx'd something else I would have gotten it. I had no problem wasting the meds in the syringes I had if the MD thought something else was better. The med was given, and written up as a chemical restraint simply b/c he would not take po form. He had asked for it earlier but had no rx. I wholeheartedly agree that if I was in charge I would've done things differently- but the supervisor was there and clearly didn't want to just grab him and get the pen right away. It wouldn't have helped to talk it out in the middle of this. We discussed it later. He would prefer to de escalate with enough staff ready in case of a struggle. I'd be more comfortable justing grabbing the pen and and the patient but if he's there when the crisis starts and he takes charge I'm not going to question it in front of the patient. This is a facility that swears all the pts are voluntary- they really think that, yet this guy was there. It's one of the issues the medical director is meeting with people to get written guidelines on. She is realistic and hopefully she'll force a policy to be documented soon. She hasn't had a chance- she just took over. In the meantime- the tech was doing a really good job de escalating while I was trying to get the order. The rest of the staff was letting her have a go at it (usually I see 5 ppl talking to the pt at once). She actually was able to bring his attn to the choice of whether to return the pen, and how he could not create any machine if he was dead. She asked him if he'd be willing to take a med po and he'd said no. I did not ask, so I assumed that he would have said no to the injection. In other specialties you could say it was not a restraint and assumed implied consent, but it's kind of sketchy, I think. I basically told him I had meds for him and that I'd need to inject them. He was put in a hold for that and not given a chance to say yes, really- he may have consented but frankly it was quicker to get the meds into him given his record of clearing up once meds were on board. It is the policy of the hospital to medicate and only use the restraints as a way to keep someone from moving while being injected, and to allow time for the meds to work. The laws in various states are different, and I try to work within the tightest I've seen in an emergency b/c I would rather impinge less on someone's freedom from being tied to a bed than to have less meds. It's my experience that once that OOC, the pt cannot pull it together without meds and try to physically restrain someone until they kick in only. In the state I come from the pt can only be physically restrained for that time and once calm all restraints have to come off at once. I have worked in settings where it was common to have much more violent pts and have restrained ppl very quickly when necessary, then gotten meds. In this case we couldn't have gotten an order elsewhere. This MD does not allow others to cover for him. Has to be called at home for any orders. It sucks. It has gotten to the point where ppl have waited 2 hrs for a call back from him. There is one other MD like this. The 3 other attendings share a practice and are always available with rotating coverage. This is a situation I walked into and it's not going to be hashed out now just b/c I am here. I have brought it up and the medical director is doing her best. She is one of the reachable ones, and said that in the future I can call her in a crisis regardless of who the MD is- she's got a pager and has always called back right away for her own pts. She can over rule the others now if she sees fit and I don't anticipate this happening again b/c I'll page her in front of him. He is in trouble- only b/c I sought her out and spoke to her. It is documented that the med was held up b/c of MD taking forever- and it's in the paperwork that he was there. I put it so I'm covered but unless asked there won't be a huge issue made on paper. The director has the info, and she'll deal with him- she's ****** and did call management. It sucks to be the newbie- especially when you want to stay employed- tough balance when advocating for the pt AND trying to keep your job....