psych nurses....Please HELP!!?

[the new girl]

as some of you may already know i work on an adolescent unit in a psych hospital. as with any job in psych it can get very frustrating... not to mention depressing. well the staff and i are dealing with a big problem right now. we have a male patient who has been diagnosed with schizophrenia. he's 15. he has been seen by several psychiatrists, who all agree that he needs to be treated rather aggressively (medication). he can be assaultive, although he keeps to himself most of the time. he has to be watched like a hawk, because he likes to sneak in the shower room and annoy the other male patients, and he'll walk up and poke at his peers, which evokes a fight about 75% of the time. he has strange repetitive rituals, he will not touch door handles, or the drinking fountain... he refuses to take oral medications, because he is convinced that he's not mentally ill, and he doesn't need them, and that the meds. will cause terrible side effects. he demands ativan rather than cogentin for the "shaking" he experiences, despite the fact that i have read through the side effects of ativan with him, and told him that for the problem he's having, ativan isn't going to help as well as the cogentin. he refuses to bathe, and the other boys complain about it, so he has to be assisted, and usually the staff ends up as wet as him. he was on a schedule of prolixin dec. injections q 2 weeks which was the only way that he was actually getting any medication on a regular basis. (he would flat out refuse, or cheek the p.o. meds)

it is so sad to watch a boy drift away like this. you can see it in his eyes.

here's our problem. his mother refuses to believe that there's anything wrong with him. she is angry with everything that we have done, nothing seems good enough. she was angry that he was getting the prolixin dec. and i believe she told him he didn't need it. we can't do anything without a fight. we are treating her, as much as him.

don't get me wrong, i know if he were my son, i may be in denial...but i truly feel that we are doing a dis service to him by not treating him as prescribed. i wish for once she would let her guard down, and listen when we try to tell her that we are all on the same side, we all want what's best for him.... to get better.

any advice as to how to handle this situation??? any words of wisdom or ideas would be appreciated. thanks!

[Nurse Ratched, RN]

Is he there on a voluntary basis signed in by his mother or other legal guardian? Based on her attitude, it sounds like he is there on a court-ordered basis. Orders can be obtained to force meds via IM injection and the like. If he is there by court order and the mother is causing more harm than therapeutic benefit by encouraging his belief that he is fine, then can you have his vistation restricted until such time as he is more stable?

As for the Ativan, does he have any previous addictions issues?

[the new girl]

he is court ordered to be there, and I don't believe he has had any addiction problems in the past... as he is so paranoid about meds anyway. That's why I am concerned, he actually wants the Ativan, and asks for it by name, and if he doesn't get it, the mother calls to put pressure on me, she can get very verbally assautlive herself. And I forgot to mention something in the original post. She's a NURSE herself!!! So this is a woman who should understand Schizophrenia, and the need for meds.

[mageean]

If he is legally detained, he can be treated WITHOUT his consent ( in the UK anyway). Additionally I would ask the authorities to prevent his mother (legally) from interfering with his plan of care and if necessary have her temporarily removed as next of kin.

[sanakruz, ADN]

Many schizophrenics suffer from almost intractable anxiety- Give the ativan as orderd.

This child needs aggressive polypharmacy to get his symptoms under control- If some thing doesnt work try something else while he's an inpt.

He also needs therapy and education as does his Mom- People do recover from schizophrenia- But the first step has to be admitting it's a real disease and accepting help.

Is he getting an antidepressant? Bet its indicated...

[the new girl]

The last couple of weeks with this woman has been terrible. She keeps trying to tell US that it's ADHD. She also is trying to find something physically wrong with him, which has not worked... He's physically stable. Something else that has me bugged.... He doesn't really seem to like the hospital food, but when mother comes, she feeds him tons, and I mean LOTS of junk food, and then he vomits and she puts it in our lap, as if to say, "what's wrong with him now?" I don't doubt that he has anxiety, he refuses his antidepressant however, and Ativan is just a quick fix to a much larger picture. She demands to have his labs drawn, and then an hour later, will approach another doctor and insist to have them drawn again. I'm stumped as to what she thinks..... That they will change in an hour?? He's not diabetic.

I did give him the Ativan tonite, but that's the last thing in the world that I want for him, to be dependant on it.

[the new girl]

I forgot to add that he gets individual therapy and family therapy numerous times a week. Mother loathes father, and that makes it difficult. Dad wants him to take his medication, is supportive of his treatment thus far, and even attends a support group for people with mentally ill loved ones. When this patient has been given any kind of patient education on schizophrenia, he aggressively rips it up, and even destroyed a video on the illness. Mother refuses to even look at it, because "he's not mentally ill"

[StuPer]

Sounds almost Munchhausens (spelling?) by proxy, from this distance anyway. She really sounds like a negative influence on him and therefore theraputically can be removed from the situation.

As is fairly common in psychotic clients, the family dynamics are hopeless. Is it just me, but I thought family therapy would be better started after the client had stabalised on medication... but hey maybe thats just me. The other thing I wanted to ask was, what kind of nurse is his mother?... does she have training in Mental Health or is she using the care of her child as experience?

To be frank while the mother is destroying everything your trying to do medically and theraputically, you haven't got a hope in hell with this client. Maybe you could as a team start documenting everything she is doing and how it affects the client, by building up a body of evidence, you'll have something to approach the psychiatrist with.

regards StuPer

[the new girl]

She works in a regular acute care (medical) hospital. I don't know if she's ever worked in Psych, but she still believes that SHE knows, and we do not. She insists on 3rd and 4th opinions, but these physicians tell her the same thing. I wonder if she isn't hoping for them to find something medically wrong with him. And I'm glad you mentioned Munchausen Syndrome because I've been wondering that myself... I'm glad I'm not the only one who suspects this.

[sanakruz, ADN]

Munchausens By Proxy is extremely rare. Unless she is poisoning him in the junk food i doubt that's it.

Sounds like she is in major denial. The genetic loading for this kids illness probably comes from her side of the family- iF YOU LOOK i'LL BET YOU FIND OLDER RELATIVES OF THIS WOMAN WITH SERIOUS MENTAL ILLNESS.( WHOOPS)

Ignore the bold type... too lazy to redo.....

NAMI info should be given to this poor mom.

The least of this kids problems are benzo dependance right now. Can one of the docs get the dad to sign a consent for a depo inj?

[Orca, ADN, ASN, RN]

Treating patients is difficult enough without family members who want to dictate the course of treatment. It sounds like mom wasn't doing too well by doing things her way if the boy wound up court committed to the hospital. It sounds like perhaps the psychiatrist ought to give the mother an ultimatum: Either stop badgering the staff about the medication regimen, or take him home and deal with it herself.

I hate to be that confrontational, but sometimes enough is enough.

[the new girl]

That's exactly what I thought, as she fights us every step of the way. She also is trying to get us in trouble now, saying he's being treated innappropritely, like we're abusing him. This of coorifice gets LOTS of attention now, and we have to be even more careful, as if that's possible. She still swears there's nothing wrong with him, that he isn't mentally ill. I think she needs to go back to school, and review Psychology. The consideration of discharging him to home, HAS been discussed, and there are opposing views, as he has hurt her in the past (physically) and it would come back on us, for letting him go. Wouldn't a discharge AMA be possible??? She won't let this rest, and appears to be determined to make our lives hell until she gets her way.