Psychiatric Emergency! Fumbling Syringes?

[Angeljho, MSN, NP]

Hello all!

I work on a high-acuity psych unit. I deal with psychiatric emergencies on a near daily basis (fights, physical assaults, threats, destruction of property, etc). Emergency STAT IMs are given out all the time like candy lol. I almost pricked a security staff member when I was administering emergency STAT IMs the other day. I feel so torn up about it . The problem is fumbling syringes in my hands when administering the injections. Usually haldol, ativan, and benadryl are given. On occasion, I'll mix the ativan with the haldol and give the benadryl separately so I'll only deal with 2 syringes. But some doctors stress that the medications be given in 3 separate syringes. If another nurse is working with me, one nurse will hold the syringes while the other administers each one by one. If I'm working alone, I'll ask an extra security staff to hold the syringes while I administer. However, this is not always the case because in most cases I work alone and the entire security staff is struggling to keep a fighting patient still. I wish there was some policy or technique on how to address this. It's just not simple to administer 3 injections. I'm hoping other nurses here can enlighten me on their techniques?

[Meriwhen, ASN, BSN, MSN, RN]

It can be hard to keep both your focus and your cool in the midst of a code, especially if it's one of the wilder ones. What I have found helps is to not let yourself be rushed: just because everyone's got a limb in hand doesn't mean you should blow through these shots as fast as you can. Stay focused on what you are doing and briskly (which is not the same as rushing) give the medications. Don't feel pressured or compelled to rush by people yelling "Hurry up!" or whatever else.

I don't know how new you are at doing this, but it does get easier with experience.

Safety trumps everything, and rushing increases the risk of a needlestick--Hep C runs rampant in psych patient populations so needlesticks are something you want to avoid at all costs. In addition, rushing increases the risk of injury for the patient: the shot may be placed in the wrong muscle, it may not make it into the muscle period, or it may accidently go into a vessel and become an IV shot.

[Davey Do]

What I have found helps is to not let yourself be rushed: just because everyone's got a limb in hand doesn't mean you should blow through these shots as fast as you can. Stay focused on what you are doing and briskly (which is not the same as rushing) give the medications. Don't feel pressured or compelled to rush by people yelling "Hurry up!" or whatever else.

I don't know how new you are at doing this, but it does get easier with experience.

Safety trumps everything

AMEN!

I such Circumstances, I tend to talk my way through the Process as it occurs, mainly to the Patient, but is also meant for all those present: "Now I am giving you this injection. It's to help you and is better administered if you relax" sort of thing. This technique seems to cause a focus on the Medication Administration Process and helps me to focus on what I'm doing.

[sharpeimom]

What both the above posters said. Ignore the pandemonium around you as much as you are able. Though some may be telling you to

hurry or to give it, the ultimate goal of all concerned is safety. A little extra time taken won't matter. Stay safe. Just because your patient is screaming and yelling, that his limbs are being held down, changes nothing. I talked to the patient and explained what I would do or was doing, why I was doing it and that it was necessary and that the medicine really would help him calm down. I never quite knew how much, if at all, was sinking in, but it at least made me feel as though I was trying.

No matter how busy I was as the shift progressed, I went back and checked the patient and spoke with him if he were calm enough.

No matter how many times you face that situation, that feeling never completely goes away. Almost, but not entirely. It will get easier.

[MrChicagoRN, RN]

AMEN!

I tend to talk my way through the Process as it occurs, mainly to the Patient, but is also meant for all those present: "Now I am giving you this injection. It's to help you and is better administered if you relax" sort of thing. This technique seems to cause a focus on the Medication Administration Process and helps me to focus on what I'm doing.

That's exactly what I was going to write.

Take your time, speak calmly to the patient, explain what you are doing, why you are doing it, and what the medication will do to help them regain control. Then explain what will happen next, and what is expected from the patient.

Things go much better when everyone remains calm and in control.

Has your team been CPI trained?

[WantAccel.BSN, BSN, RN]

Can you put the capped needles in your scrub pockets? I've done that when I have more than one injection to give at a time, and it's worked pretty well for me.

[BSNBritt]

Personally I've never had a provider tell me to place all three meds in different syringes. Where I was trained we always mix the two and leave the Benadryl in its own.

[RNcashy89]

Not sure if this will be directly helpful to you. If I interpret what you are feeling correctly, its a form of performance anxiety. In my graduate year I was giving probably my 10000th IMI one day when one of the more intimidating psychiatrists came into the patient's room and decided to wait and watch while I administered the drug. I turned into MR Bean! And that was just a standard, voluntary depot admin - so don't feel bad, its natural. What I realized was that I was insecure about my administration technique. Insecurity, as you know, doesn't necessarily spawn from any factual deficiency - it grows from a belief you have, about yourself. You clearly have some questions - so get a senior, respected colleague to scrutinize your knowledge and technique in a non-emergent situation where you can pause, evaluate, question, etc etc. I tell people all the time to stop fearing scrutiny! Its the best tool in the box for personal development. So at that time I asked a senior staff member to go through an injection with me - not only was I doing everything perfectly, I was able to teach the CN a thing or two! It was such a confidence boost that now, regardless of the pandemonium or drama, I am confident enough to execute that procedure.

[NursKris]

On my unit we give all 3 meds in 1 syringe...1 shot and done!!

[marshmallowstar, BSN, RN]

On my unit we give all 3 meds in 1 syringe...1 shot and done!!

Be careful with that, benadryl and haldol will participate out, I've seen it happen.

[Juryizout]

Over the past year at my facility, I have probably given over 400 shots, 3 separate syringes of your basic cocktail. Once in a while, it's Geodon. What works for me is to label all three in case somebody should get pricked, grab my band aids, alcohol preps and place them in one of our removable med drawers. Then I assign someone to the scene to be the holder. If we are short-staffed, I'll use a CNA or security and they are always ready to help.

I concur with the previous posters: yeah, they are holding limbs, but you are about to put a needle in someone, take the time you need.

[mikenmim]

Does your agency use syringes with retractable needles. My preference is Vanish Point brand. The needle retracts while it is still in the patient. This dramatically reduces chances of a stick. Also, talking to the patient may seem like the most humane approach but the situation is already out of control. It is unlikely that your efforts will matter once you are at this point. No amount of reason is likely to work. Best to focus on the task at hand. Security does their job and nursing does theirs. Get the job done and let the patient sleep. Things will get better.