Psych patients on medical floors

[rn undisclosed name]

I will start off by saying I don't like dealing with psych patients. If I like it I would work in psych. It's just not my cup of tea. In my experience psych nurses don't like dealing with medical issues.

So, my question is how to deal with these patients. Depending on how bad the patient is I don't think it is proper to tell them the psychiatrist has to come and evaluate them. The psychiatrists don't appreciate that but I don't think it is my place to say anything because that can just agitate them more if they know a psychiatrist is going to see them. If the psychiatrist determines they should be admitted for psyiatric evaluation I think they should tell the patient and not leave it to the other staff. I am wondering how others deal with this situation.

[Crazed]

This is a scary thread.

I admit I'm not a nurse yet but I've been on the other side as that "I don't like you, you dirty psych patient" and honestly - it shows. You really believe that paranoid schizophrenic can't tell you don't care for them? Come to think of it in their case it's amplified which induces panic and full on combative behavior. You get what you give.

This is a good example why in my two visits to the ER in the past ten years I have not disclosed my psych diagnosis because I didn't want it to influence my care.

It seems I made the right call.

[ChristaRN]

I love the idea of a Psychiatric Medical Surgical type unit and while they do exist in small numbers it's unfortunately unrealistic to hope for such combination units in all nursing specialties so I don't think we'll be seeing any psych-OB, psych-rehab, psych-oncology etc. It would be great if we had more nurses who are experienced both in the medical aspects of patient illness as well as psychiatric aspects. I think alot of medical minded nurses are uncomfortable with acute psychiatric issues and I understand that. For a non psych nurse I think treating mental illness is quite a challenge. We can't measure mental illness and target a certain number and aim for that as we can with BPs and glucose levels. We can give medications but that's not always really treating the problem. We can be unsure how to communicate with a patient who is acutely psychiatrically ill. I don't think those nurses who are uncomfortable with psychiatric care are talking about a patient whose psych illness is currently well controlled; they aren't trying to cast all patients with mental illness off to an island so they can be avoided. I liken it to placing a patient with an acute cardiac problem on an oncology floor - those onco nurses likely would not be comfortable because it's an acute problem which they are not familliar with caring for. I see acute psych problems in the same way. It is NOT a good idea to keep a psychiatric diagnosis from your treating physician as that disease process or any medications that one may be on to treat it are important pieces of information and can effect current medical treatment or even easily explain a problem that the patient is currently having. I sincerely hope the previous poster will keep in mind that while there may be few colleagues of ours who unfortunately may still stigmatize mental illness most will not allow that to effect the care they give and may actually be able to give BETTER care based on that knowledge. We need to advocate for ourselves in all nursing disciplines to ensure that we get adequate training in all aspects of care that would should be expected to provide and some psychiatric training is certainly something that we and our patients would benefit from us recieving. Perhaps offering a shift of shadowing in a psychiatric unit would do a world of good!

[NightOwl0624]

This is a scary thread.

I admit I'm not a nurse yet but I've been on the other side as that "I don't like you, you dirty psych patient" and honestly - it shows. You really believe that paranoid schizophrenic can't tell you don't care for them? Come to think of it in their case it's amplified which induces panic and full on combative behavior. You get what you give.

This is a good example why in my two visits to the ER in the past ten years I have not disclosed my psych diagnosis because I didn't want it to influence my care.

It seems I made the right call.

I agree that there may be some amount of prejudice, but I can really sympathize with the OP.

My former unit became what I can only describe as a dumping ground for psychotic patients needing acute medical care. A floor within the hospital system that was set up for this purpose closed, and all of a sudden our daily percentage of psych patients rose dramatically. We were not staffed for the increase in care these patients required, nor were we really trained do deal with the issues on a daily basis. Many nurses began to burn out -- I left the unit less than 1 year after the change as I felt extremely stressed and was becoming depressed myself.

As someone else said, it is very difficult to care for actively psychotic patients who need medical treatment... yes, giving a paranoid schizophrenic off their meds for months any kind of treatment takes a lot of time and skill. There are also safety issues - security was on our floor all the time. Many patients ended up in restrains; Haldol and Ativan became part of our daily routine. And when the majority of your patients have these issues, it is mentally and physically exhausting. Many of the patients never went on to psych facilities after their medical crisis was stabilized; they were simply released back to the streets. It broke my heart.

Also, most of the rooms on the floor were semi-private, and it was very unsafe, in my opinion, to have those patients in close proximity to other patients. We were supposed to also control the dynamics between the patients - we had all kinds of situations including one patient urinating on another, treatment being interferred with, to actual fights breaking out.

I actually have much respect and compassion for psych patients; it is one of my biggest pet peeve when other people, ESPECIALLY NURSES, treat these conditions like they are a joke or the behavior is patient's fault. I actually enjoy the challenge of helping these people through their medical crisis. However, I didn't sign up to do it exclusively, and I don't regret leaving for a minute.

[rn undisclosed name]

If you have the attitude that they are wasting your time and a pain in the butt, what kind of attitude do you expect from them?

You're going to encounter psych patients in any area where you work, just as psych patients come to in-patient units with a host of medical co-morbidities. It doesn't sound like you are being asked to lead group therapy or perform psychiatric intakes. What exactly is your problem here?

And if you think that it's not a part of your job to find out the details of a possibly abusive encounter...just wow. What happened to being an advocate?

I encounter psych patients all the time. It's impossible to not come across someone with a psych background. Just because I don't like dealing with acute psych disorders does not mean I have the above attitude you stated I have.

I do treat these patients the same as I treat my other patients. Explaining plan of care, educating them on treatments/meds/disease process, etc.

When I ask the patient what his plan is after discharge and he tells me he is going to stay with someone who is not anywhere near where his wife is staying because he does not want to go back to that situation I can not do anything else but believe what he is saying to me. I should not have to jump through hoops to get in touch with their spouse to find out if they feel safe if that person leaves the hospital. Yes, making more than a few phone calls and leaving messages should not be required. I am a nurse and not an investigator or police officer. If there was a question regarding her safety the police were at their home and it is a police matter. The police interviewed all individuals involved or should have. This person should be in the hospital on a police hold and he was not. I advocate plenty for my patients so thank you very much. If this person ever said he was going to go after her then it would be a different set of circumstances. He said the same story to me, my charge nurse, the psych liason, psychiatrist, and atending physician. This person was not a danger to himself. Talking to the other person involved in the domestic situation is out of my scope of practice as a nurse. The patient had manipulative behavior and had his sister call the hospital and pretend to be his wife (I know this because the phone number was the same on my phone d/t caller id and the person's voice sounded identical). My training as a nurse does not include making a determination based on evidence if the patient is going to seek revenge on another person.

[seizetheday]

If you you don't want to deal with people with psychiatric illnesses then I don't think you should go into nursing. Almost 20% of the population experiences mental illness and no matter where you work you are going to encounter with current or past psychiatric problems. And really most psychiatric illness have a neurobiological basis so they aren't all that different than other illnesses. You can have a woman in labor who has depression, who can have a patient in surgery who has an anxiety disorder - truly you aren't going to be able to get away from dealing with mental health nor do I think you should, anymore than a psych nurse should say s/he won't deal with physical health. I have often had to call families about medical issues as well as psych issues to get history or confirmation. That to me is part of nursing, it is holistic and deals with more than a diagnosis and treatment. Everything I do for any patient obviously takes me away form my other patients - that too is part of nursing - each patient has different needs and you have to figure out how to juggle and meet all your patient's needs. You can't resent time you spent on mental health needs or see that nursing care as not being valid.

That doesn't mean there aren't times that a patient's symptoms or progression of illness is beyond your level of expertise. An acutely psychotic patient is going to be more than most med-surg floors can manage and in the same way an acutely unstable diabetic is going to be more than most psych floors can manage. That is different than a blanket statement that you don't want to work with an entire sector of health - be it physical or mental. I truly think if that is the case you shouldn't be in nursing - patients deserve respect and proper nursing care from someone who does it without disdain regardless of why they are admitted.

ETA: I just saw your post above that was posted while I was writing. I think if you had focused your post on being presented with an ethical issue it would have come across very differently. If what you really wanted to know was how to deal with a situation where you are asked to do something that you feel is outside your scope of practice - that is very different than saying you don't want to deal with patients who have mental health issues. Ethical issues can arise with any patient.

[FancypantsRN]

I encounter psych patients all the time. It's impossible to not come across someone with a psych background. Just because I don't like dealing with acute psych disorders does not mean I have the above attitude you stated I have.

I do treat these patients the same as I treat my other patients. Explaining plan of care, educating them on treatments/meds/disease process, etc.

When I ask the patient what his plan is after discharge and he tells me he is going to stay with someone who is not anywhere near where his wife is staying because he does not want to go back to that situation I can not do anything else but believe what he is saying to me. I should not have to jump through hoops to get in touch with their spouse to find out if they feel safe if that person leaves the hospital. Yes, making more than a few phone calls and leaving messages should not be required. I am a nurse and not an investigator or police officer. If there was a question regarding her safety the police were at their home and it is a police matter. The police interviewed all individuals involved or should have. This person should be in the hospital on a police hold and he was not. I advocate plenty for my patients so thank you very much. If this person ever said he was going to go after her then it would be a different set of circumstances. He said the same story to me, my charge nurse, the psych liason, psychiatrist, and atending physician. This person was not a danger to himself. Talking to the other person involved in the domestic situation is out of my scope of practice as a nurse. The patient had manipulative behavior and had his sister call the hospital and pretend to be his wife (I know this because the phone number was the same on my phone d/t caller id and the person's voice sounded identical). My training as a nurse does not include making a determination based on evidence if the patient is going to seek revenge on another person.

Don't you guys have a case manager or social worker to do this stuff? I agree, it sounds like too sticky a situation to be involved in. I would not feel comfortable making that call on whether he gets discharged or not.

[Hygiene Queen]

I did clinicals in nursing school on a psychiatric medsurg unit. It was a unit for people with both active medical issues that would likely otherwise land them in the hospital and active psych issues. It was a weird mesh of psych unit and medsurg unit in that it had regular patient rooms with o2 set ups, beds, and vital sign machines, but also had psych unit aspects like group therapy rooms. Often times the medical issues were directly related to the psych issue. I remember a manic depressive patient who tried to poison himself and went into multi-system organ failure. I remember a few anorexics on tube feeds or TPN. I remember a man with schizophrenia who, despite having a warm home, spent a cold night outside and had to have several toes and fingers amputated. There were also patients who just happened to have major psychiatric issues and medical issues, though the two might be unrelated, one always influenced the other.

It was an awesome learning experience, but I could never do that full time. Those nurses have my utmost respect as some of the hardest working in the hospital. It was full of challenges. Paranoid schizophrenics with central lines? Oxygen tubing on a suicidal patient?

Occasionally they got regular psych overflow, but never medsurg overflow. It was such a unique, and need unit that it was nearly always full. I should clarify also that stable psych patients who were well controlled on meds went to regular medsurg units. THis unit was for patients who definitely needed acute psych care as well.

I think that would be an awesome job!!

I work in geriatric psych and like the fact that there are still plenty of medical issues to deal with.

I think it's a nice mix of both.

[elthia]

We have taken care of psych pt's on my floor many times and it's very difficult. If they need a 1:1, then we have to pull an aide off the floor, often we have to decide which aide is the "best fit", which means the most efficient aide goes in the room and the laziest aide works the floor. Because the most efficient aide is going to have the best rapport with the psych pt.

A lot of the times the psych pt was in the ICU post surgery, and has been off their meds for awhile, which makes me furious thanks surgery service!!!, so they cannot help the way the are acting. Even if they had great impulse control before, now they don't. OR they are s/p overdose and have a cocaine induce MI, etc. We have had a couple of people who are s/p suicide attempts while the spouse was stationed overseas in a war zone, that was a terrible situation.

It's challenging, and often it's best to have psychiatry to consult early and give suggestions. Try very hard to be nonjudgmental, and to make sure that nursing is all on the same page. Borderline and Bipolar are notorious for staff splitting and are extremely frustrating. It's hard to balance giving them the medical care they need when they obviously need pych care too. I have an easier time taking care of Schizophrenic and schizoaffective pt's even when they are paranoid than a borderline...sometimes you have to recognize your own limitations with psych, take a mental deep breath just do the best you can.

[xtxrn, ASN, RN]

Oh my God...... the vast majority of hospitals do not have units dedicated to psych patients needing medical care....where are they supposed to go?

It's not their fault that their brain chemistry is out of whack. How many of your co-workers are on psychoactive meds? And you don't know it? How many of their family members are 'horrible' psych patients?

There really should be some sort of screening before nursing school to see who can't stand psych patients, because no matter what specialty you choose, there will be periodic psych patients.... maybe have the manic bi-polar pregnant woman just drop the kid at the bus stop.... it will give the local media something to do, and keep her from being an inconvenience to psych-prejudice nurses.

Not wanting to WORK psych as a full-time specialty is one thing - nobody wants you there :) But to globally trash a segment of humanity who has no responsibility for their brain malfunction is pathetic.

And yes, they can tell you don't like them. If that matters.....

[MyGranniePanties]

Having been on the other side of the fence I'll throw in my 2cents.... Through a series of events I ended up in the ER while waiting for a psych bed to open in a hospital. I was there 2 days before my social worker found me a place to go. I slept in the hallway because they do not have psych rooms and wouldn't staff people to sit with psych patients in private rooms. They wouldn't allow me to bathe, brush my teeth, or allow me 5 steps from my bed. Another lady near me had been there 5 days... Same thing. No bath for F I V E days!

My social worker had to fight my nurses to allow me to take medicine that I needed because they "forgot" to bring it to me. She was the only one sympathic to the issues. She would bring me water and food, take me to the restroom, bring me blankets, etc because the nurses were too busy with their other patients.

I was there for anxiety and depression, I would really hate to see how someone more ill might have been treated. It also makes me scared that I will need medical treatment as a psych patient one day.

Until I read this post I thought maybe it was just my hospital, but now I dunno....

[xtxrn, ASN, RN]

Having been on the other side of the fence I'll throw in my 2cents.... Through a series of events I ended up in the ER while waiting for a psych bed to open in a hospital. I was there 2 days before my social worker found me a place to go. I slept in the hallway because they do not have psych rooms and wouldn't staff people to sit with psych patients in private rooms. They wouldn't allow me to bathe, brush my teeth, or allow me 5 steps from my bed. Another lady near me had been there 5 days... Same thing. No bath for F I V E days!

My social worker had to fight my nurses to allow me to take medicine that I needed because they "forgot" to bring it to me. She was the only one sympathic to the issues. She would bring me water and food, take me to the restroom, bring me blankets, etc because the nurses were too busy with their other patients.

I was there for anxiety and depression, I would really hate to see how someone more ill might have been treated. It also makes me scared that I will need medical treatment as a psych patient one day.

Until I read this post I thought maybe it was just my hospital, but now I dunno....

Nope- it's pervasive. And, what some nurses don't know (either for their own age, or that of their friends/family) is that a lot of psych disorders don't show up until the early to mid 20s- and there aren't always warning signs. And what about PTSD- where the symptoms are because of having some type of major trauma happen to them? It's very sad.

I had medication interactions that made me really loopy. I was treated like dirt at an ED here. The abuse by the nurses was horrible- but who believes someone with PTSD???? Nobody. So, even though I'd ask to be taken elsewhere (someone else often made the 911 call), i was taken to H*!!....eventually, I'd just stay at home and hope I'd be ok. Once the medications (not psychiatric BTW) were adjusted, I no longer had the symptoms that required going to the ED. I had decided it was better to stay home and die in peace and with some dignity than be tormented.... if anybody wants a list of what they did- PM me.

[colleennurse, ASN, RN]

Awe it makes me sad when people "don't like psych patient's". I work on a behavior medical unit, so I guess my hospital is fortunate to have such a unit. Someone else said it, people with mental health issues know if you do not like them. They don't chose to be that way, who would? Hope you can remind yourself that they are people too and that the behaviors they have are symptoms of thier illness. Good luck.