Which patients are you most scared to take care of?

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Although a variety of patients have brought forth challenges during my time of a nurse, lately I've been finding myself getting very stressed out caring for patients with GI issues.  I've had three patients in the past year with bowel obstructions/bowel perforations who decline no matter what I do.  I've sent them all repeatedly into the hospital.  They've all required surgical intervention.  This really causes me distress, so much to the point that I can no longer sleep at night if a patient hasn't had a bowel movement.  I'm always worried about doing the wrong thing.

Anyone else experience similar things with any patients? Who are you scared of taking care of? 

Scabies, lice, or bed bug patients. They make me itch, I get paranoid about bringing it home, and I go ocd about cleaning everything right when I get home finished with and extremely long shower. Never caught it, and don’t plan on it either. Tiny critters and I don’t play well together.

ANything else, eh, bring it on.

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Specializes in Psych, Addictions, SOL (Student of Life).
11 hours ago, Gillyboo said:

For me, its the ones with schizoaffective disorder. 

Theyre just so violent. I don't like that at all.

I don't care if my dementia patients are violent. I am totally cool with that. It's the schizoaffective ones that scare the heck out of me. Not only are they violent, but they are unreasonable and their bipolar and hallucinations just make things really difficult. 

Doing home care, as a CNA, I have no way of confirming if they are even taking their meds. If they do, they are a lot better. If they don't, its a nightmare. 

 

In twenty years of working psych I have rarely had patients be truely violent. Maybe that's because psych patients are all I see. Plus I have training in how the redirect negative behavior.  I was hit once years ago which was totally my fault (long story) and left psych for  a few years. The problem is that no other specialty captured me like psych. 

While I agree that a psych patient off his/her meds can be scarey think about what the patient is feeling. They often lack the insight to understand why they need them when they are feeling well. That's where long acting injectables have been an absolute game changer. 

Hppy

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Its definitely different working in a facility vs working in peoples homes. 

And in a psych ward, it seems like (IDK this is just what I have seen in the movies) chemical restraints are very common. 

I have worked in home care with 3 clients, all of whom had schizoaffective disorder. One was fine. Totally non violent, and well medicated. 

The next was a late stage alzheimers patient. She wasnt exactly a danger. She just liked to kick people. She even kicked her family. She also squeezed hands and bent fingers back. Her primary caregiver always had scratches and boo boos. Shes been violent for decades, apparently. She did have chemical restraints also, which helped significantly.

The last one was one I couldnt bear. She likely did not take her meds and often admitted it.  She wasnt super violent but she was the scariest of them all. She did throw her keys at me one day. I literally only had her for like 3 or 4 days. Day 2 I offered to organize her papers which she needed me to find stuff in, and she agreed. I asked specifically how I could arrange them. The next day we had put some stuff in a pile up there on her shelves and she threw a huge stack of papers off the bed having apparently either forgotten this 2 hour ordeal the day before where she asked me to put the stuff in order, or just had a conyption fit over it. IDK. She threw a phone at me too. She would cycle between being extra sweet and extra angry and I could never figure out how to keep things just calm. So I opted out. 

Anyways yeah Im the queen of showering and everyone knows my clients actually LOVE me. My approaches are generally pretty creative and positive. 

Ijs. It's different in a psych ward where you can just whip out a chemical restraint at the drop of a hat. 

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Specializes in Critical Care.
On 4/24/2021 at 11:20 PM, SilverBells said:

With that said, if anyone has any suggestions from the list of tasks from my previous post that could be put lower on the list of priorities or better ways of time management, that would be appreciated, thanks

We've been telling you to get a better job, but apparently you would prefer to work 16-20 hours a day salary and do the equivalent of 3 people's jobs!  The only sane answer is to walk away and find a decent job where you are only responsible for one person's work!  There is no way to fix your present job!  It is impossible!  No matter what you say or ask we can't help you.  You have to help yourself by walking away.  I don't see any other option!

I don't understand why you are hanging on so tightly to this job.  You stated you had another job and still worked PRN there.  So you have at least two different nursing jobs you can put on your resume.  I would suggest you make a functional resume, where you give yourself credit for all the things you are doing, that most places hire multiple nurses for.  You've got your MA, you can figure this out! 

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
On 4/27/2021 at 12:16 AM, VivaLasViejas said:

Detox patients. They’re entirely unpredictable and you can’t trust them as far as you can throw them. We used to detox them on the M/S floor, which was horrible because when the DTs hit, they got very scary. I got bitten by an HIV+ patient in the throes of alcohol withdrawals; another guy marched a fully equipped, locked hospital bed across a room while in four-point leathers. They really should’ve been in a specialized care unit with 1:1 or 1:2 supervision and good sedation. Dealing with a patient on the CIWA protocol and trying to manage a team of 5-6 other patients is a special kind of hell that I’m glad I’ll never have to visit again.

I did a lot of detoxing before CIWA and didn't find it too difficult.  As soon as the vitals start trending upward you get some Librium down the hatch (or inject it).  The problem with CIWA is that there is no provision for vital sign changes.  You have to wait for more advanced signs and then give Ativan.  I found CIWA to be woefully inadequate.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
On 4/27/2021 at 8:28 AM, The0Walrus said:

I'm mainly a psych nurse. I like picking up extra shifts at the hospital and will pick up shifts in any of the med surg or PCU units, but I would say the patients I fear most when I have to take them are patients in the psych unit that want to fight the nurse because of voices in their head. Even worse is when you medicate them and they apologize. The reason I get nervous about those patients is you have to be very careful when dealing with them and medicating them at the same time when the patient is going through a psychotic break and they're trying to fight you you're being careful as possible with the patient while trying not to get hurt yourself. It's a tough balance.

If you're allowed to four-point them and you have enough competent personnel it's usually not too bad.  If you don't have adequate resources then, yes, it is quite the balancing act.

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Specializes in retired LTC.

What is CIWA???   Unfamiliar abbrev.

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Specializes in Critical Care.
40 minutes ago, amoLucia said:

What is CIWA???   Unfamiliar abbrev.

Clinical Institute Withdrawal Assessment for Alcohol

Basically a detox scoring system with standard orders for ativan, haldol or librium to treat patients in alcohol withdrawal.  Back in the day the protocol included scheduled ativan 1 mg po q 6 hours and then PRN based on CIWA scale, and it worked very well.  But then they took away the scheduled ativan and things started to get out of hand.  By the time the CIWA scale was high enough for ativan, it was difficult to stabilize them.

My worst nightmare patient was a detox guy on a 13 hour shift thanks to fall back of daylight savings.  Had to use 4 point restraints,  so agitated, thrashing, needed a sitter in the room on top of that, and liberal ativan and, of course, no sitter available!  It was such a horrible night, I made it a point to take vacation every fall back weekend I was scheduled after that!

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Specializes in retired LTC.

TY re CIWA.  All I knew was CWA = Communication Workers of America. HUGE national union, very powerful union. ATT, Bell, civil service, employee members. A bit different, I think. 

 

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Specializes in Community Health, Med/Surg, ICU Stepdown.

I used to do CIWA almost every day. But in our protocol we could give Ativan once an hour. Some really out of control pts were on a different scale called RASS (Richmond agitation and sedation score) where we could give Ativan or valium every 15 mins and keep increasing the dose. One shift I gave a pt 280mg of Ativan plus phenobarbital and he was still hulking out, took the bedframe off the bottom of the bed and chucked it at the glass door. He got restraints, tx to ICU and precedex drip. 

Docs said more meds better as long as they are not too sedated, more agitation leads to more pt and staff injuries and more seizures. Most docs ordered good protocols and supported us, which was nice. But etoh withdrawal pts were still some of my least favorite, besides meth intoxication or withdrawal. After a while meth destroys parts of your brain and the pts were irreversibly emotionally labile cognitively impaired. Very sad and hard to deal with. I felt sorry for them but also for us staff constantly getting attacked and berated. 

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Specializes in Critical Care.
47 minutes ago, LibraNurse27 said:

I used to do CIWA almost every day. But in our protocol we could give Ativan once an hour. Some really out of control pts were on a different scale called RASS (Richmond agitation and sedation score) where we could give Ativan or valium every 15 mins and keep increasing the dose. One shift I gave a pt 280mg of Ativan plus phenobarbital and he was still hulking out, took the bedframe off the bottom of the bed and chucked it at the glass door. He got restraints, tx to ICU and precedex drip. 

Docs said more meds better as long as they are not too sedated, more agitation leads to more pt and staff injuries and more seizures. Most docs ordered good protocols and supported us, which was nice. But etoh withdrawal pts were still some of my least favorite, besides meth intoxication or withdrawal. After a while meth destroys parts of your brain and the pts were irreversibly emotionally labile cognitively impaired. Very sad and hard to deal with. I felt sorry for them but also for us staff constantly getting attacked and berated. 

I feel part of the problem is that they don't transfer these patients to the ICU soon enough, where they can be on a precedex drip till they are over the DT's.  But as you said, some patients have such an irreparably damaged brain whether due to drugs, alcohol or traumatic brain injury, that you are always at risk of injury if they decide to become violent and you can't reason with them.  I'm fortunate I wasn't seriously injured, but we know other nurses have been.

Some nurses really like psyche and I've been told it's easier than med-surg or critical care, but some of these patients are violent and may attack you.  I've been told you are taught how to take them down.  I don't want to deal with that and don't want to be someone's punching bag! 

But definitely be aware of your surroundings and stay near the door when dealing with such patients.  Also the violence is not always because of mental illness or drug/alcohol abuse.  Sometimes it is just angry violent people that will lash out if they don't get their way.  I remember an older nurse in NYC that should have already been retired was attacked by such an angry man who wanted pain meds and was being discharged, so he grabbed an IV pole and started attacking her.  By the time coworkers and security could get to her she was critically brain injured.  It hit the news, but I never heard if she lived or recovered.  I still wonder and hope she is OK.

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Wow thats a lot of severe violence! Yikes! 

How does a caregiver keep their composure during that kind of an episode, I wonder? 

And are initially violent types ever weaned off of the sedation? 

I have so many questions now. 

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