Psych patient on the acute care unit

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Specializes in Cardiac Telemetry, ED.

Hello, psych nurses! So one of my patients had an MI, and she is mentally ill. Her working diagnosis says "Bipolar", but I'm thinking there is more to her behavior than that.

Her psychiatrist, the hospital psych doc who rounds on inpatients, is making changes to her medication regimen, and she is not happy about it, and neither is her mother, who sits in the corner and watches the patient's interactions with nurses, occasionally interjecting a comment or two. The mother is incredibly enabling, and the patient's behavior seems worse when the mother is present.

The moment I step onto the floor, I am dealing with her, with no time to check on my other patients or even look up labs, imaging, meds, etc. She is on her call light demanding to see her nurse immediately. She states she is having a "seizure" caused by "withdrawal" and demands that I call the doctor. She is lying in bed, her legs are shaking, and she states that her teeth are chattering, though I am not observing that. Her vitals are WNL, and it's been over a week since she last had the medication that she states she is withdrawing from, plus she is on an anticonvulsant. She states that she is miserable, and that she "will have relief". Now, I did call the hospitalist, who refused to come see her or prescribe anything. He believes that this is a psych issue, and that this is the psychiatrist's call. I attempt to call the psychiatrist with no success. The patient is accusing me of "not relaying the extreme urgency of the matter", and that is why the psychiatrist will not call back. The mother of the patient is asking me how I can find out whether the psychiatrist is in the hospital and when he plans to round (he rounded earlier that morning). I tell her that there is no way for me to know where the doctor is and that I have no control over the doctor's actions, and that I am doing everything I can for the patient.

All in all, this is very frustrating for me, because I am not used to dealing with this sort of thing. We do get psych patients occasionally, but I've only had one other that was more demanding than this, and it was a nightmare. I thought to myself that I needed to just be calm and set firm limits and go about my business as usual, so that is what I did. When the patient would call me in to complain of a "seizure" (all the while, her vital signs are WNL and she's lying there looking at me and talking to me) and make accusations about the supposed lack of care she is receiving, I would simply listen, nod my head occasionally, say "Uh huh" and "I can see you're upset", then reiterate that I am doing everything I am able to do, then calmly walk out of the room.

By the end of the night, she was apologizing for her behavior and complimenting me for being such a "good nurse". Still, up to that point, it was incredibly frustrating for me.

Any helpful tips, in case I have her again tonight?

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Specializes in Cardiac Telemetry, ED.

Just wanted to add that her cardiac issues are resolved, and the only reason she's still in the hospital is because of problems with where she will go at discharge. There are no beds available on the inpatient psych unit. The mentally ill are really underserved.

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Specializes in Family Nurse Practitioner.

Hang in there. It sounds like you did a great job especially by documenting her vitals etc. each time she called you with the 911 emergency. :) Personally when someone sounds as if they are hinting at reporting less than adequate care I would call an administrator just to cover my bases. I also hope you documented her statements of how lacking your care was at first and what a great nurse you were in the end to demonstrate how labile she was. As for Mom, sadly I have found that the patient often isn't the sickest one in the family, sigh. Good job and I hope they find her a better spot soon.

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Specializes in Psychiatric, Detox/Rehab, Geriatrics.

Sounds like you were dealing with a classic borderline patient. You did a good job with setting firm limits, which is what borderline patient's need or else they will walk all over you.

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Specializes in Med-Surg, Geriatric, Behavioral Health.

I feel for you...being caught up in this web of manipulation.

Document, document, document.

Big hugs.

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Specializes in Med-Surg, Geriatric, Behavioral Health.
As for Mom, sadly I have found that the patient often isn't the sickest one in the family, sigh.

Amen.

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Specializes in Psychiatric, Forensic, MRDD, Home Health.

You did great. You recognized that the patient wasn't in an any acute distress, despite her demands. A lot of psych patients want drama and attention, pulling you away from the patients that really need your attention. Point out the objective data, with reassurance. "hey, your BP and heart rate are great now, you're really coming along, you're doing much better!" That kind of thing.

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Specializes in Cardiac Telemetry, ED.

Thanks everybody! She was actually pretty good tonight, thank goodness. I was NOT up for another repeat of yesterday.

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Specializes in pedi, pedi psych,dd, school ,home health.

sometimes people with issues such as hers need to know how you will respond to them in case of an emergency so they will test you and test you to see if you are consistent. once they see that you are; and feel that you are listening to them they will back down...good luck!mary

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Definately sounds like this patient has some classic Axis II Borderline Personality Disorder stuff going. Sounds like you did a great job, despite having to face it with little help from the hospitalist or psychiatrist. Absolutely document everything, especially her statements made.

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Specializes in Psychiatric.

I think you did a super job! It could be a good ol' Borderline Personality, or a Dependent Personality, and she is under a lot of extra stress because of her hospitalization and illness and is reaching out for reassurance, or to test you. I use the 'firm but fair' approach...I do set limits, fair ones, and I stick firmly to them.

Good job!:yeah:

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Specializes in mental health; hangover remedies.

Or it could be that she's just plain scared out of her wits after an MI.

The Dependent notion struck me more than the BPD. With her mental illness it's likely that she's experienced the normal paternalistic approaches of psychiatry so her 'reaching out' for reassurances is perhaps a conditioned behaviour of how either her mother has maternalised her - or psychiatry has paternalised her.

Just curious - why is/was she being discharged via a psych bed?

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