Psychiatric Nursing Differences?!

[medsurgrnco]

I just started my new psych RN position, and am surprised at some of the differences from med/surg. Seems none of the nurses actually assess the patients (other than a few questions) and no one uses double-checks to make sure they are giving the medications to the correct patients (who do not wear namebands or allergy bands). I think I'll really like psych, but am pretty appalled at the laxness of other nurses. Is this typical of psych?

[42gameover]

Now our patients are wearing name bands. As far as assessments go, I've been under the assumption that if the assessment form lists an item then they expect me to assess it. Apparently others only assess medical areas if there is a reason to do so.

This makes sense to me. If a thorough admission assessment is done, and you follow up daily with inquiries regarding pain/distress (we try to do this religiously) and evaluate/ask about side effects -- well, combine all this with your own observations and interactions with the pt and you should be able to pick up any real problems.* Remember, too, that many psych pts are wary of being touched -- a big difference from med/surg.

But I'm wondering if you're communicating your concerns to your own colleagues? They'd be the best ones to advise you. (I'd love to have you working with me; Nursing Ed's not always available for our medical questions.)

*On my own unit we do VS daily or more often, but we're an acute care unit; no doubt long-term facilities would not do VS as frequently.

[medsurgrnco, BSN, RN]

Yes, I've asked coworkers about their assessments as well as asking a supervisor regarding the expectations. And I continue to assess areas that most other nurses do not, as it is on the form, it doesn't take long, I believe somebody should be assessing those areas (other than the NP original physical) as some patients stay more than a couple of days, psych patients do sometimes have medical issues or can develop them, and I always ask patients if it is ok to assess areas that involve touch. Only one patient has ever refused an assessment by me, and that patient also refuses them from others. Doing a more in-depth assessment can communicate to patients that you care about them, if done sensitively. Too many nurses cut corners, so I don't base my nursing care on what others do.

[ScarlettRN]

I have no idea why a psych assessment would have lungs/abd sounds. When our patients are admitted, they are seen by an NP, who does the head to toe assessment. We still do narrative charting in my dinosaur of a hospital, and unless there is a medical reason to auscultate something, I am not addressing physical anything. I monitor VS, signs and symptoms of withdrawal, etc.

Very strange to have to document that other stuff daily.

[medsurgrnco, BSN, RN]

If your assessment form doesn't list any physical assessments, then that implies it is not expected at your facility. But if physical assessment areas are on the form and you don't assess them, and the patient has a problem...?? I've worked in med/surg long enough to know the unexpected does occur, and that the higher-ups then look for a way to blame the nurse.

[nursebabygirl 08]

Hey all you psych nurses out there,

you guys are great because i know that i could not be a psych nurse myself. I am amazed at how you guys stay so composed during a confrontation. I remember in my rotation in the hospital i forgot that when you talking to the pt that you're not supposed to let them sit in front of the door:uhoh3: well he started talking about my neck and it being pretty and other uncomfortable things.. boy was i glad that he decided to get up and walk out of the room. I think with me not being able to see physically what happeningwith the pt can be more of a challege, so my hats off to you psych nurses!!! Like tony the tiger says "yourrrrr great:yeah:

[aloevera]

we always do a physical assessment along with a psych....especially when a pt. is detoxing....many problems arise.....a psych pt. doesn't always tell you what meds he has taken or not taken and it is wise to do a phys. assessment before calling doc for orders....

[nursebabygirl 08]

I've noticed a lot of psych drugs can cause heart disturbances such as haldol. Do you think that i pt on such drugs be placed on telemetry?

[sarmedic70]

WIth Psych patients, if they are stable and have no other medical conditions, then they are going to get their weekly vitals (BP, RR's, ht/wt, waiste measurements, temp, et al)..........periodically, and at scheduled intervals, they will also get glucose checks.....we have monthly checks and weekly checks on vitals..........additionally, we have the standard labs drawn for those on certain medications (i.e., Depakote, et al)...............other than that, if they have no complaints of medical issues, we just do observations (especially for any EPS s/sx).................For those with med/surg issues (NG tubes, et al), then, as needed, other assessments are done.................. I am also a medic. It is kinda the same situation, you focus on the obvious things first and foremost...............then once you deal with that, then you can go onto further assessments as warranted.......... With med/surg patients, OB patients, post-partum patients it does require the thorough assessments because it is required.............but with psych patients, it is a little different. However, a good psych RN will still ALWAYS be observant and in tune with any changes in the patient's condition be they complain or not, and then take it from there.

"nursebabygirl08" Thank YOU so much for your kind words and appreciation for us psych nurses............I don't know what your specialty is, but I also like to thank you in that I don't think that any specialty in nursing is all that easy and it takes special nurses to be able to special things..............if that makes sense........and we all should be appreciative for what each and every one of us do.......we are all for the patients regardless of our specialty area...............So thank YOU!!!!

Have a great weekend, everybody......................

:-)

[pinkiepie_RN]

If your assessment form doesn't list any physical assessments, then that implies it is not expected at your facility. But if physical assessment areas are on the form and you don't assess them, and the patient has a problem...?? I've worked in med/surg long enough to know the unexpected does occur, and that the higher-ups then look for a way to blame the nurse.

At my facility and I'm sure at most others, patients are considered "medically cleared" before they are admitted. This is possibly why physical assessment data isn't gathered unless there is an issue. Charting is also done by exception.

[wonderbee, BSN, RN]

Our unit is a dumping ground for the local medical facility. Our docs have been strong armed into clearing patients who had no business being released. We do not have the time or the resources to take care of these kinds of patients. Our nurses do not have the same experience or focus as the med surg nurses. Yet, we are required to care for them. They do not get the same attention for their physical needs as they would get in a medical facility. These people do not fare well with us. Medical clearance should not be taken lightly but we are left with the reality.

If we're listening to abdominal sounds and breath sounds, assessing for skin breakdown because they are bed bound, chances are this patient is too sick to be with us in the first place.

[42gameover]

If we're listening to abdominal sounds and breath sounds, assessing for skin breakdown because they are bed bound, chances are this patient is too sick to be with us in the first place.

That's very true, and most psych facilities are simply not made for pts like that (even though the ER will still send them). We are not allowed to use medical beds on my unit, we are not allowed to have grab bars or handheld sprayers in showers, we have no specialized rooms for pts with contagious illnesses, we are not allowed to have any medical equipment which must be plugged in -- on the rare occasions when this is temporarily essential, that pt is placed on constant observation for as long as such equipment is required.

I leave one or two hours late every shift as it is, sometimes more -- and I don't think I'm alone in that. We carefully address what medical issues we have (ie, impaired kidney function, diabetes, HIV, broken limbs) but if every patient required a physical every day -- eek, I would never have time to do that for 15 (or 17 or 19) patients. If RNs find that they're fudging paperwork because this is the expectation, then they need to sit down with their managers and alert them that these expectations are out of line. We have no such paperwork and JCAHO has never given us a problem.

[nanacarol]

Two things come to mind here, first, what are you using to determine if the nurse is doing a physical assessment? I can check skin, breathing, GI, cardia while I am holding a therapeutic "get to know you" conversation. As someone else mentioned, if the patient is presenting with only psychiatric concerns, the initial full assessment has ruled out for the time being, any medical concerns and if the patient makes a complaint of a medical nature then I bump it up. Reserve your final conversation or judgement for a while. Speak to the unit manager about med admin safe guards like pictures and reminding med nurse to follow protocol when passing meds, psych patients when unstable are very good at pretending to be who they aren't and medications change

sometimes daily. nanacarol