Pt threw a bedpan...

heron, ASN, RN · Mar 9, 2015

@newboy: thanks, that description was much more helpful than scornful condescension.

Speaking of which, I'm sure you're aware that a psych dx does not always equal inability to control behavior. As I pointed out before, we have no real idea about what really went on in the situation described in the OP, so it's hard to say whether the patient's behavior was r/t a manic episode or simply a deliberate decision to bully staff.

We also don't know what medical priorities might have been in play. And I'm pretty sure that you're not qualified to determine those.

One of the best nurses I've met in 40+ years in the business was the psych liaison nurse on my AIDS unit. She was able to talk one of our patients into restraints when he started acting out in dialysis. She is an expert at navigating the interface between psych and physical medicine and taught us a lot. She did not accomplish this by sneering at our ignorance.

Angeljho, MSN, NP · Mar 9, 2015

@newboy: thanks, that description was much more helpful than scornful condescension.
Speaking of which, I'm sure you're aware that a psych dx does not always equal inability to control behavior. As I pointed out before, we have no real idea about what really went on in the situation described in the OP, so it's hard to say whether the patient's behavior was r/t a manic episode or simply a deliberate decision to bully staff.
We also don't know what medical priorities might have been in play. And I'm pretty sure that you're not qualified to determine those.
One of the best nurses I've met in 40+ years in the business was the psych liaison nurse on my AIDS unit. She was able to talk one of our patients into restraints when he started acting out in dialysis. She is an expert at navigating the interface between psych and physical medicine and taught us a lot. She did not accomplish this by sneering at our ignorance.

I've reread my earlier post and I do apologize for how I came off. I see a lot of, "Oh no, the patient is acting up, let's get an order for restraints or seclusion and meds" in my practice. Nurses are relying too much on restrictive practices and not on their skills - at least on my unit anyway. It's no excuse for how I came off, though; and I apologize. Every behavioral crisis is different so it's hard for medical units to have a clear algorithm of what to do during such situations. However, please also understand that A+O does not mean free of psychosis at the time of behavioral escalation. As you said, we have no idea of what went on.

heron, ASN, RN · Mar 9, 2015

@newboy: thanks, and yes, medical nurses tend to have a very limited repertoire of responses and rely heavily on rapidly regaining control of an already out-of-control situation.

The psych manifestations of physical disease and the physical aspects of psych disease are two of the most fascinating aspects of nursing, in my view. That psych and medical nursing seem so mutually exclusive has always bothered me.

Here.I.Stand, BSN, RN · Mar 9, 2015

My hospital's behavioral response team includes security and leather restraints for when said behavioral emergency has escalated to physical aggression, in addition to the psych RN who helps w/ the deescalation. Of course an upset pt is not physically or chemically restrained as a first resort, but staff safety is the #1 priority. This patient assaulted a tech. Having a psych diagnosis (especially something like bipolar, which some nurses have--and manage not to assault people on the job) does not absolve one of consequences. If someone on the street were to throw objects and feces at someone, he/she would be held accountable. Hospital staff shouldn't be expected to willingly accept that behavior, either.

I never said the behavior was okay. I don't know where you got that from. I said there are protocols when addressing a psych patient. Hospitals are now starting to implement behavioral emergency response teams which consists of psych nurses and - depending on the time and hospital resources - social workers or psychologists. This prevents events where staff are quick to grab restraints and IM antipsychotics - experiences that further traumatizes these patients. And determining whether the patient knows right from wrong is not your job, because I'm pretty sure you're not qualified to do psych evaluations. Just saying.

AJJKRN · Mar 9, 2015

So here's what I'm not understanding from the side of the mental Heath nurses. No disrespect intended but when someone with a mental health diagnosis needs acute care nursing are they being admitted and treated on an acute care floor or on a mental health floor? I'm thinking us acute care nurses are seeing our fair share of patients with mental health diagnoses way more than any mental health nurse could even imagine. As someone duly pointed out, many people with certain mental health diagnoses, nurses being included, are still in control of their actions and know right from wrong. We have tons of patients that do not have any known mental health diagnosis and this does not stop them from crossing boundaries such as throwing feces at someone to prove their point and showing a temper-tantrum! It's called customer service these days! Now it might be a different story if the patient had just covered themselves from head to toe in mustard from the mustard packets they had stashed in their room (true story). Having a mental health diagnosis in no way means a person can act any way they want or get treated any differently than any other person on the face of the earth while they are A&Ox4...that is like saying it's ok that the alcoholic got behind the wheel while intoxicated and killed another person or persons because they have a disease...A&Ox4 or not while drunk shouldn't fly as any excuse.

heron, ASN, RN · Mar 9, 2015

I don't think anyone advocated for total permissiveness. What I understood from newboy's posts and the responses to it was way more nuanced than that. It's not an either/or, black/white issue.

The psych viewpoint is that there are better and more effective ways to handle behavioral outbursts than (essentially) beating the patient into submission. Recognizing the early signs and intervening early are learnable skills.

The medical viewpoint is that some situations don't allow for such niceties, control is critical NOW.

The human viewpoint is that behavior has consequences.

The challenge is not to pick one but to integrate each approach so as to have a variety of tools for dealing with a given situation.

Pangea Reunited, ASN, RN · Mar 9, 2015

Code gray is combative person.
If an A&O patient threw that at me or a coworker I'd have trouble not reacting like I do with a dog who poops in the house. I'm a great believer in rubbing their noses in it to prevent repeats. At the very least I'd tell the tech, in front of the patient, that they are not to return to that room.

I hope you're not serious about the dog...

Kooky Korky, BSN, RN · Mar 9, 2015

Well that entirely depends on the pt's complaint and acuity because you have to take more than the action into account. The main factor is whether or not the pt is mentally equipped at that moment to understand what they are doing.
A fully independent dental pain patient? Buh-bye! Security will be escorting you out.
A septic/delirious patient? Even more so with an demented total care patient.
In this case, the patient is alert/oriented, but what is complaint and the acuity of their condition?

Sorry, but there is no excuse for committing assault and battery upon a staff member. It's illegal to do it to cops, illegal to do it to ER staff. It should be illegal to do it to any staff person, anywhere, any time.

After I deloused, I'd be calling police.

imintrouble, BSN, RN · Mar 9, 2015

Sorry, but there is no excuse for committing assault and battery upon a staff member. It's illegal to do it to cops, illegal to do it to ER staff. It should be illegal to do it to any staff person, anywhere, any time.
After I deloused, I'd be calling police.

Throwing poop is an assault. My facility would do everything possible to stop me from making that call, but I'd call the police too. Maybe, just maybe, that patient would think twice before assaulting another nurse.

wannabecnl · Mar 10, 2015

My cousin was a relatively new nurse when she answered a call bell and found the patient exposing himself to her. She told him to shut his d*** pants and not ring again until he actually needed something. I can only imagine what she would have said in OP's story; Press Ganey scores or no, I suspect she would have had some choice words!

Julius Seizure · Mar 10, 2015

Flying feces might qualify as a tornado.

I think we could call it a $*!% storm!

NanikRN · Mar 10, 2015

Omg. I just wrote a long reply and lost it all!!

I dont have much else to say about pt. pt is in acute care, extended stay r/t placement issues. Most interactions involve cursing at staff. Psych has been involved but I'm not sure of outcome

Pt was angry at response time from tech. Tech was in alone and she wisely chose to leave room when pt threw bedpan i do not know what the nurse said to pt, if anything

Ive never had this kind of incident happen to me and wanted to hear whT others have to say

Not much at all was said on my shift.

Thanks to all responders