Pt threw a bedpan...

Angeljho, MSN, NP · Mar 10, 2015

@NanikRN,

These types of incidents are happening more and more in the acute care setting. Hopefully in the future, there will be a better way to deal with psych emergencies in acute care. All of these dnp programs and no changes to practice in this area as of yet.

kungpoopanda · Mar 10, 2015

Really? The patient is mentally ill.
I've had tables thrown at me, juice thrown at me (my favorite scrubs were stained), been spit at, spit on, and almost punched (luckily it didn't connect). If the patient continues to escalate, then you have a behavioral emergency on your hands. Usually these problems can be solved with very good verbal intervention.

I was assaulted by a patient who assaulted staff before me and after me. He was not a psych patient but he was allowed to continue his behaviour without consequence. At no stage was he medicated or restrained or charged. I was left with injuries that required surgery and I now suffer chronic pain. The worst thing was the ordeal that I had to experience to claim workers compensation. That was just as traumatic. So you;ll have to forgive me if I seem quick to shut violent situations down before anyone is left with life altering injuries.

Angeljho, MSN, NP · Mar 10, 2015

What happened to you is tragic. No one should have to experience that at work. As you have indicated, not all patients who have violent episodes are psych patients. Anyone can be aggressive and I believe those type of people (the people who become violent without any history of violence or psych issues) are the most dangerous.

NanikRN · Mar 10, 2015

I was assaulted by a patient who assaulted staff before me and after me. He was not a psych patient but he was allowed to continue his behaviour without consequence. At no stage was he medicated or restrained or charged. I was left with injuries that required surgery and I now suffer chronic pain. The worst thing was the ordeal that I had to experience to claim workers compensation. That was just as traumatic. So you;ll have to forgive me if I seem quick to shut violent situations down before anyone is left with life altering injuries.

I wanted to like your post to show my support but-- liking something like that just seems wrong.

Thank you for sharing your story. I have to admit that your experience is what I fear happening.

I am sorry that you had to experience it.

I am unsettled by the general lack of indignation and apathetic attitude I see on my unit about this episode

Tenebrae, BSN, RN · Mar 10, 2015

I never said the behavior was okay. I don't know where you got that from.

You stated that the patient has a mental illness, to which I replied there are very few mental illnesses that prevent a person from knowing right from wrong and thats a fact.

I stated that in our country, any violence directed at medical and nursing staff may result in charges being laid.

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.

Oh seriously we are going to get into a pissing match over who is more qualified to do a pysch eval?

You make this statement based on one post on the internet..... You are correct in that I have two years four months experience as a registered nurse. I have about 16 more years from working in community mental health and having to try and do fun things like preventing patients stabbing their doctors, or jumping of motor way bridges, self harm, suicide etc the experience also included trying to get the tertiary mental health services to come out and hospitalise the seriously psychotic patient whose command hallucinations are telling them that they need to kill their parents.

Tenebrae, BSN, RN · Mar 10, 2015

To be honest, if a patient is throwing objects and biohazards at me, I am not too concerned with whether the situation is traumatic for them. The OP stated the patient was definitely A&O. This is assault. Having a mental illness does not negate the reality of the situation or that it is traumatic for the caregiver, who is, in fact, a victim at this point.
I do agree with keeping calm and modeling calm behavior and staying at a safe distance. I tend to take a "mom" approach. I know my gut reaction would have been to frown at the patient, say "That is NOT okay!" and get the tech and myself out of the room, then rally the troops to go in together, clean things up, discuss acceptable behaviors with the patient and go from there. If the patient continues to be agitated then a code for agitated persons would be called. In acute care, de-escalating by mental health protocols is ideal, but unfortunately we are rarely tossed into an ideal situation and often times the quickest route to safety involves restraints and meds.

This poster nailed it.

Here.I.Stand, BSN, RN · Mar 10, 2015

I agree completely about needing better ways to deal w/ psych emergencies. That said, this was not a psych emergency. It was an assault with projectiles--some of which was excrement.

@NanikRN,
These types of incidents are happening more and more in the acute care setting. Hopefully in the future, there will be a better way to deal with psych emergencies in acute care. All of these DNP programs and no changes to practice in this area as of yet.

Red Kryptonite · Mar 10, 2015

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

I'm completely serious about the dog. We've always trained our cats and dogs not to go in the house that way. It works and it doesn't take more than a couple times.

heron, ASN, RN · Mar 10, 2015

Here's the thing: I agree with pretty much everything written here. For me, it boils down to one size does not fit all. For me, the bottom line is that we are professional caregivers. Our conduct has life or death consequences. Bad decisions lead to dead and damaged people on both sides of the stethoscope.

You see a fat, middle aged frequent flyer[COLOR=#000000] [/COLOR]complaining of a backache, who vomits in triage and is visibly sweating heavily. Whaddya gonna do? Right - you keep her calm while you figure out whether she's having an MI. Frightening her into a full code will send your shift sideways fast, not to mention probably kill her and put your other patients in more danger than they needed to be.

It also seems to me that a decision to tie someone down, drug them against their will, then send them to jail could also have significant legal consequences. Acquiring a basic skill set in the recognition and management of problem behaviors seems only sensible risk management.

I agree with filing charges against patients that are legally competent to make their own decisions. For me, the problem has been differentiating between them and those truly not able to make a responsible decision. Not every delusional and dangerous person walks in wearing a tinfoil hat. I would imagine good triage people learn fast how to tell the difference.

In fact, I think most of us have some practical experience in differentiating between some kinds of obvious mental illness and the sociopaths gaming the system. What behavioral specialists (aka psych nurses) offer to us medical types are tools for managing uncontrolled behavior in a way that doesn't depend on getting violent to work. Seems like that's when most people are likely to get hurt. Why let it get that far if you don't have to?

First, do no harm - and yes, I include harm to us, too.

I also think that patients shouldn't be held responsible for the behavior of management and their insurers. Those are important issues, but they're separate from the question at hand: how do we - or should we - respond when attacked by a patient?

It's too bad that HIPAA precludes learning more detail about the situation in the OP. I'm curious to know more about the context of that assault. I wouldn't know how to get that without violating privacy, though. We'll never hear the whole story.

Glycerine82, LPN · Mar 10, 2015

Alert and Oriented? I'd file a police report for assault.

Confused/demented.... them's the breaks

NurseOnAMotorcycle, ASN, RN · Mar 10, 2015

Had a patient attack a nurse by putting her into a chokehold because we wouldn't give him narcotics. Four people had to drag him off of her. She was unmarked. Despite video evidence and four witnesses, the police called it harassment instead of assault because she had no marks on her. Therefore he was not able to be tried as assaulting a nurse on duty: an automatic felony here.

The moral of the story is that calling the police for an assault doesn't automatically get the results we expect it to. They have their own definitions for protocols just as we do with our patients. Most of our team, because we work nights in the ER, has some kind of non-striking martial arts (aikido, judo, jujitsu, etc).

Glycerine82, LPN · Mar 10, 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.

Sorry I had to comment.

You are supposed to show them and say "NO"! but NOT actually rub their noses in it.... that's animal abuse.....

Cat's don't learn from negative reinforcement, you may think you're training them by doing that, but they will learn to use a litter box no matter what you do, it's in their nature.

If they go outside the box after the fact, it's because there is a problem of some kind.