shaken about psychotic patient incident last night.. very long..

[inthesky]

I am still quite a new psychiatric nurse (almost one year). I still get really scared and shaken during incidents of patient violence and restraints. We had a 19 year old patient. It was her psych admit and possibly first psychotic break. She has a long history of abuse and neglect and reports that she hears the devil talking to her. She had been very distant and sedated for her first few days on the unit (probably overly sedated and she had been voicing rightful distress at being "tranquilized").

Yesterday, she just flipped. She was screaming that a plane was going to crash into the hospital and we were all going to die. She had to leave to help give directions on how to land the plane. She was so afraid and truly believed that we were hurting her and preventing her from saving peoples lives. It really cut into me. She threw a chair into a window (luckily plexi-glass) and bit one of our techs. I called a code and security came running with their K-9 unit. It took 6 people to hold her down. Fortunately, 4pts were not necessary. I got the injections ready and called the doc. She managed to sleep a bit so we held on to the injections. I made sure the other patients were safe and did some debriefing. They could probably tell that I was shaken and near tears myself.

We managed to get her to her room and she slept a bit. She awoke and began screaming again. I brought the injections and I just froze up as she was begging us not to do it (we had gotten orders to involuntarily inject and petition). I handed the injections to the other nurse and she gave them. They were given in her deltoid and there was a lot of blood as they were 22 gauge 1.5in needles supposed to be used for the gluteal muscle. She was screaming. I nearly cried again. She eventually fell asleep again. Both techs were in her room so I did the q15 rounds.

We had a new admit (unfortunately this patient had come from another hospital and we had previously accepted her). I received her and got her chart stickered up and ready to go. The nurse was really angry at me for not completing the admit as she was drowning in petition paperwork she had never done before. I honestly was just paralyzed and really wanted to go home and cry. As bad as it sounds (as I was definitely not the only person frazzled), I really needed a hug and some reassurance. It was already an hour after my shift had ended and I felt in a trance. I don't know why I feel so obsessed at how disgusted and disappointed she was with me. I ended up leaving at 1am (my shift technically ended at 1130). I am having trouble shaking it.

I cried all the way home and woke up my boyfriend to cry to him for an additional hour. I could have stopped myself from crying and sucked them up, but I didn't want to. I wanted to release and I feel like the patient deserved a few tears. I took my usual sleeping med. This same nurse called me at 0630 for me to come to work because the AM nurse had called in. I was really disoriented and my eyes were swelled shut from crying. I had finally gone to bed at 0330. I refused to come in and since I was zonked on ambien, I can't remember what I said to her. I called work at 1030 to ask if I had offered to come to work or if they still needed me. Fortunately, someone else had covered. I am hoping that there will not be consequences at the workplace for my lack of team-playerness. I am afraid to go to work tomorrow. I think anyone could be shaken by that event and by the nightmare this poor girl was suffering. I am just disappointed in myself for freezing and not being the team-player everyone wanted me to be. I know that I work in a psychiatric crisis unit and this will happen sometimes, but it breaks my heart and scares me anyway. :crying2:

Thank you all for listening

:icon_hug:

[Whispera, MSN, RN]

I'm so sorry you had this terrible experience, and I'm sending you hugs. I'm also sending them to the patient. Times like these sure shake us to our roots, don't they? I'm glad you felt you could vent your feelings here!

more hugs! >

[NeoPediRN]

Working in psych is a whole other world. I also work in pedi psych and understand the emotions you're feeling right now. You experienced the psychiatric equivalent of a medical code. If your patient is about to go into respiratory arrest you have to intubate even if your patient is crying and scared. You have to look at it this way or psych nursing will get the best of you. You are providing a safe place for your patient to have a break down. She isn't competent to make decisions for her safety so you have to make them for her. My medical director told me that psychotic breaks and long tantrums affect your brain similar to the way a seizure affects it. You actual burn brain cells in a psychotic state and the quicker you can break it the better off your patient will be. No one wants to get a shot and I'm not sure why the other RN didn't give them to her in the gluteal muscle but at least she got them. You have to be strong enough to react in a crisis. Your patients are counting on you to be there for them and to help them when they're losing control. If your patient was coding you wouldn't be able to stand there frazzled so you have to think of this the same way. The most important thing to realize is that this isn't something you did to her. You didn't cause her to break down, but you were right there for her to help snap her out of it. Psych nursing can be extremely frightening but it can also be very rewarding. The most important thing you can do as an RN post team control/restraint is to gather the group involved in the restraint. Everyone needs to be able to air their feelings and lean on each other for support, especially if you know other team members were frazzled. Also remember that you're responsible for the milieu. The counselors are counting on you to maintain control and direct the situation. They need to feel safe too and feel like they have an RN they can rely on in a crisis. Then afterwards it's good to get everyone's thoughts on it and if there's anything that could've been done differently (usually not, when a kid is going to go into crisis they are going to go into crisis no matter what you offer as de-escalation)...it's also a good time to talk about handling future crises. Your nurse manager should get everyone together to discuss it, at the very least. Take a deep breath and find some comfort in knowing you did your job and kept your patient safe. Remember that you always have to be able to give the injection if your patient is in a crisis, no matter how you feel about the situation. It's the not so fun part but it's about safety. Restraints are always draining, you're not alone.

[RochesterRN-BSN, BSN, RN]

Unfortunately this is part of working in psychiatry. I have worked on a 30 bed adult psych unit and work now in the psych emergency room. I have to say that this is a pretty regular occurance, at least in my experience in both settings. Your patient is out of control and needs to be able to look to staff to give her the control she is unable to give herself. The nurse who is assigned to a patient and has a repore with that person needs to be heading the crisis, doing the talking and if possible giving the meds. It is hard sometimes but you know that you are doing what is best for that patient and need to not forget that at any time during the crisis. The more calm you can remain the better off you will be. I have found that in a large number of cases after the patient starts to come out of their acute psychosis, once meds have reached a therapeutic level, that patient will thank you. Working inpatient, where I was with patients throughout their stay, I had a lot of them approach me and thank me for keeping them safe and being so kind and helping them through a really scary time. They appologize for their behavior and are genuinely grateful for how you helped. This is the good stuff! Why we do what we do! So try to think about it that way. It does get easier the more you are involved in a psychiatric crisis. If you find that it doesn't get easier maybe psych nursing is not for you. It's okay if its not. Not everyone is cut out for this. It's very different then med nursing. But don't give up too quickly. If you love caring for them give it a chance. and try to remember you are doing what is needed for that patient and patients look to you for stability and a calm in their unstable and out of control time.

As far as the size and location of the shot she got........when I worked inpatient at a different hospital we always gave them in the hip or thigh areas. However where I work now, in a psych ED.......this hospital has a separate ED for these patients.....we give the IMs in the deltoid all the time......22 and 23 guage. Some patients just bleed more no matter what size you use....many causes for this......many patients are ETOH abusers and this thins the blood and also I find the level of agitation of the patient can make it bleed more as they are so tense and tightening up the muscle you inject into and not completely still. Just like they don't calm a child crying during a LP in medicine because the cring creates more pressure so that the fluid will be coming out faster and the sample can be obtained more quickly and the procedure over more quickly. Same concept. We always bring in a bandaid to put on after. And put some pressure on it for a minute if you can.

[Jules A, MSN]

I'm also sorry you are so upset and glad you felt comfortable to share it with us. Please consider talking to a professional about your reaction because it really sounds like you took things hard. This is the way psych is and I worry that after a year working in psych that you are still this traumatized. Wishing you well.

[Jolie, BSN]

I don't have any experience in psych, and greatly admire those with the patience and desire to practice this type of nursing.

What concerns me about your post is that it sounds as if the unit was staffed with 2 relatively inexperienced RNs, who needed (but didn't have) the guidance and support of an experienced nurse to get thru the shift.

Is it possible to discuss with you manager having a back-up person to call in the event that you have an unusual or especially challenging situation in the future?

Don't worry about declining the extra shift. They shouldn't have called you in the first place. You are not obligated to work extra shifts. Use voice mail and caller-ID to screen your calls so that you are not disturbed by them.

Take care.

[inthesky]

thanks guys!

To respond to some of the posts:

-psychotic episodes burn brain cells? it actually makes sense. fascinating

-the other nurse was a very experienced nurse. I wanted to watch her do her thing and be there for back up (call code, call the doc, draw up the meds), but apparently she felt like she was by herself

-a tech expected me to help lift the patient in bed. this sounds ok except she wanted me to get in a corner in between the wall and the patient. >_<. isn that breaking one of the fundamental rules psych>

-these occurrences in the unit I work in are very rare and this was the worst one I have seen. This is the only patient I have ever witnessed to receive involuntary shots. Most patients I have seen in that spot will agree to the med because they are scared of their panic as well. When I was a student nurse, I saw some 4pts done. I stayed out of the way (as I was expected to) and watched others in action.

-i was nearly terminated today for this. My work is notorious for ganging up against co-workers and going to the manager. Everybody knew about it at work today.

-I think I can overcome this and it would not be the first time I was told I could not do something pertaining to nursing.

-I'm really upset that I nearly got fired. I have no mistakes to my record and I am known to have very good patient rapport and be conscientious. I guess that is why I'm on my second chance.

:sniff:

[jpRN84, BSN, RN]

Hello,

I'm sorry to hear that you had that experience, but that's the nature of the specialty we are in. Don't take it personally. I used to do that unknowingly doing it, and once I realized that, I was able to better handle being in psych nursing. The fact that you almost got terminated over that incident is ridiculous, you didn't do anything wrong, personally I would confront the other nurse you were working with and ask her why she reported you. Clearing the air with your co-workers is always a good thing to do. I hope you are doing well and I wish you the best of luck in your career in psychiatric nursing!

:-)

[Mr Ian]

Before you confront - be sure it was that nurse who reported. I'd also let things cool off before anything gets stirred again - since you've been 'warned'.

Don't lose your compassion. It's a psych nursing trait that is sadly abandoned by most in favour of the institutional approach.

As for burning brain cells:

Grey matter in the brains of people with bipolar disorder is destroyed with each manic or depressive episode. This was the finding of an MRI study of 21 patients with bipolar disorder, a mental illness marked by successive episodes of mania followed by deep depression.

http://www.bioedonline.org/news/news.cfm?art=3473

[Jules A, MSN]

The fact that you almost got terminated over that incident is ridiculous, you didn't do anything wrong, personally I would confront the other nurse you were working with and ask her why she reported you.

But I read this as she "nearly cried again" when she balked at giving a PRN and had to give the needle to another nurse. At my hospital this absolutely would have required an incident report and very likely a follow up before the nurse would be allowed to return to the floor. Maybe my facility is different but not a week goes by when I haven't had to give an unwanted IM and imo it is dangerous to the patient and staff if the nurse isn't able to do this quickly and safely.

[NeoPediRN]

But I read this as she "nearly cried again" when she balked at giving a PRN and had to give the needle to another nurse. At my hospital this absolutely would have required an incident report and very likely a follow up before the nurse would be allowed to return to the floor. Maybe my facility is different but not a week goes by when I haven't had to give an unwanted IM and imo it is dangerous to the patient and staff if the nurse isn't able to do this quickly and safely.

Agree with this 100%.

[Whispera, MSN, RN]

What did management do that indicates you were nearly fired? Maybe you're over-reacting?

"nearly cried again" could imply you were close but didn't one time or both times. I can understand feeling emotions about the situation. The thing is, did you show it? I agree with others, sometimes you have to tough through the emotions and just give the meds. I've been on the floor injecting into a port. I've injected through clothing. Sometimes you just have to do it. It's in the interest of the patient to do for him or her what he/she can't do alone. And you must at least act confident in what you're doing so the patient can feel trust that you know what you're doing. That's what we do as psych nurses.

That being said, I'm still sad you had to go through this. It's definitely a learning experience, isn't it?