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:
I have not read this entire thread . I am sorry at the emotional trauma you felt. short story.
I worked years ago with one of the most amazing Rn's she was compassionate always advocated for her patient . Her only Achilles heel was, her inability to give an IM injection during an emergency situation.
We accepted this was the one things she could not do so when she would make the decision that an injection was necessary one of us would go draw it up and administer it for her. She always stayed with the patient as she had wonderful rapport with them. I never faulted her for her this. None of us did.
In non emergent conditions she was able and ready to give her own injections. Sometimes we need to accept others as they are: including our co-workers in their strengths and their known weaknesses.
thank you so much for sharing! I'm really glad that this RN received support and acceptance from her colleagues. Unless she had seniority, she might have gotten the same dreadful managerial meeting I did at my workplace. The post on here are really helping me find perspective.
Specializes in critical care; community health; psych.
These patients are sick and in need of our compassion but in a severe psychotic break, they (and staff) are most in need of protection. It is extremely frightening to confront a violent psychotic patient. I'm sorry Sky that this happened to you. I understand that you are fully aware of the consequences of your reaction. You may need some safe space to process this and decide whether it's something that will happen again.
As others have said, this is the time when everyone looks to the nurse to regain control with quick decisive action. Nurses on a psych unit also have the dual role of local law enforcement in a manner of speaking. I'm trusting the people I work with to help keep me and our patients safe, and I them. It's absolutely integral.
Thanks for the article. In my opinion, if a patient is coherent enough to decide which method he prefers, then he doesn't need any of them.
We'll ask the patient if he wants to lay down in the resting room (open room without any door) and ask him what medications he would take. I guess this is my most common 'emergency'. The patient comes up to us and reports severe agitation or just appears to be escalating. "Would you like to lay down and enjoy some quiet?" "Would you accept the shots? (and explains what they are)" "ok, I'll get the orders and get them ready in (time period)" "thanks so much for your honesty and coming up to us"
In my opinion, if a patient is coherent enough to decide which method he prefers, then he doesn't need any of them.
I'm not sure I'd agree with this based on my experience. Coherent and able to remain safe aren't always the same thing. There are many times and situations when they can make the choice to take a PO rather than IM and some times when they actually pick the injection.
We'll ask the patient if he wants to lay down in the resting room (open room without any door) and ask him what medications he would take. I guess this is my most common 'emergency'. The patient comes up to us and reports severe agitation or just appears to be escalating. "Would you like to lay down and enjoy some quiet?" "Would you accept the shots? (and explains what they are)" "ok, I'll get the orders and get them ready in (time period)" "thanks so much for your honesty and coming up to us"
I don't really see the diffence in asking what medication they would take or the route. Your patients must be a very different acuity than the majority of mine. Definitely spotting and intercepting behavior before it escalates is the key but there are still times when its all we can do to prevent them from assaulting staff with a chair or bashing their own head into the brick wall so "ejoying some quiet" while laying down and waiting for an injection rarely happens.
Definitely spotting and intercepting behavior before it escalates is the key but there are still times when its all we can do to prevent them from assaulting staff with a chair or bashing their own head into the brick wall so "ejoying some quiet" while laying down and waiting for an injection rarely happens.
I totally agree - but I've seen it happen. Pts who don't actually require the level of intervention offered (not saying the case inthesky presented didn't) who are compliant with staff direction, given excessive levels of restriction, restraint or medication - I've seen patients walk into seclusion on staff request.
How contradictory is that?
The point about coercive medication is that it seems to be the first-response - often the only response.
Many times I've employed therapeutic control by hands-on non-restraint holding - ie linking arms or sitting close but protected; and engaging in talk down for an hour or so.
It provides a protective environment for the pt and others and is much less confrontational.
If this fails after a significant period then other options such as enforced medication are considered.
Of course this approach depends on skilled staff availability and not all places have that.
(Did that sound arrogant to refer to myself as 'skilled staff'? .. well, I am anyhow!)
I totally agree - but I've seen it happen. Pts who don't actually require the level of intervention offered (not saying the case inthesky presented didn't) who are compliant with staff direction, given excessive levels of restriction, restraint or medication - I've seen patients walk into seclusion on staff request.
How contradictory is that?
The point about coercive medication is that it seems to be the first-response - often the only response.
Many times I've employed therapeutic control by hands-on non-restraint holding - ie linking arms or sitting close but protected; and engaging in talk down for an hour or so.
It provides a protective environment for the pt and others and is much less confrontational.
If this fails after a significant period then other options such as enforced medication are considered.
Of course this approach depends on skilled staff availability and not all places have that.
(Did that sound arrogant to refer to myself as 'skilled staff'? .. well, I am anyhow!)
I totally get and agree with you on this. Sadly I know a few nurses that would rather "snow" them instead of taking an extra few minutes to try other interventions. Fortunately I'm not one of them but the more experience I get the more I can respect the times when a forced injection is the safest thing for the patient, my other patients and my staff. Things can change on a dime and I've seen incidents that could have been avoided or lessened by quicker intervention. I'm working with a volitile population on a locked unit so I'm sure that makes a difference also although I have a friend that works in geriatric psych and swears those old folks can throw a mean punch, lol.
I know this thread is an old thread but IntheSky, I think what you did was very brave and the right thing, lots of people don't take stands like you did and just follow the same routine over and over without questioning it, without thinking of other ways.
I don't know how strong the possibility is of you seeing the girl ever again but I think she will remember you and what you did and that someone acted in a caring way towards her which was rare in her life and that gave her hope for her future.
I hope you don't get desensitized as you progress as others in your field do, please stay the same for you and your patients.
Thanks for the article. In my opinion, if a patient is coherent enough to decide which method he prefers, then he doesn't need any of them.
We'll ask the patient if he wants to lay down in the resting room (open room without any door) and ask him what medications he would take. I guess this is my most common 'emergency'. The patient comes up to us and reports severe agitation or just appears to be escalating. "Would you like to lay down and enjoy some quiet?" "Would you accept the shots? (and explains what they are)" "ok, I'll get the orders and get them ready in (time period)" "thanks so much for your honesty and coming up to us"
This hasn't worked in my experience. I work in an acute stay psychiatric hospital with an adolescent, adult, and pediatric unit. I've tried offering patients that were escalating a time out, or a PO med, but it's never really panned out. Most of the time the patient was too agitated to accept time in the quiet room. When I've offered a PO med and the patient's accepted, they 99% of the time do not take the med when I bring it. Looking back I think I've learned that when you get the order, give the IM. No patients like it, obviously, and most will beg you not to do it, but it's for their own safety (and the safety of others).
The way I see it it's like this: Give them a shot that hurts and end it there, or let the situation go on that much longer and risk more?
The ideal situation would be to de-escalate a patient before it gets to this level, but hey- this is psych and that's not always possible.
I know it sucks. I've had to give an IM to a screaming naked 9 year old (he was trying to strangle himself with all his clothes, even his underwear) who begged me not to do it. It made me feel bad, but not so bad that I wouldn't do it to stop him from trying to hurt himself.
Having just started in the field myself (working 5 mo), I feel for you. It's never easy when they're that agitated... you can't help but have an emotional response. On the other hand, though, your patients and fellow nurses depend on you to be able to keep them safe. This means medication IM in some situations.
Think if you were seriously sick in the ER and you needed CPR. The ER nurse steps back and says the situation is too much for her. You feel bad for her because who enjoys giving chest compressions, but it's the job and she needs to be able to do it.
I would take some time to seriously consider whether you'll be able to handle these situations in the future. I've found even the most experienced, conscientious psych nurse can miss the signs of escalation and have a patient go bizerks. So it's a situation you need to be prepared for. Working in a clinic can be good, because there's less of a chance for someone to do that. However, that is really restricting your work prospects. Are you prepared for it? Especially if you go for your NP, I'd hate for you to go through all that schooling and then be stuck in job you don't feel comfortable in.
:crying2:
but the more experience I get the more I can respect the times when a forced injection is the safest thing for the patient, my other patients and my staff. Things can change on a dime and I've seen incidents that could have been avoided or lessened by quicker intervention. I'm working with a volitile population on a locked unit so I'm sure that makes a difference also although I have a friend that works in geriatric psych and swears those old folks can throw a mean punch, lol.
;)
lpnflorida, LPN
1,304 Posts
Inthesky,
I have not read this entire thread . I am sorry at the emotional trauma you felt. short story.
I worked years ago with one of the most amazing Rn's she was compassionate always advocated for her patient . Her only Achilles heel was, her inability to give an IM injection during an emergency situation.
We accepted this was the one things she could not do so when she would make the decision that an injection was necessary one of us would go draw it up and administer it for her. She always stayed with the patient as she had wonderful rapport with them. I never faulted her for her this. None of us did.
In non emergent conditions she was able and ready to give her own injections. Sometimes we need to accept others as they are: including our co-workers in their strengths and their known weaknesses.