Psych Unit?

Recently my Medical/Oncology unit has felt more like a psychiatric unit. This past week we have had patients screaming, throwing things at nurses and other people, threatening anyone that comes in the room, being verbally abusive not only to their nurses, but to the people that need to be constantly sitting with them. In the past week I can’t even tell you how many times we have had to call security in order to keep not only the patients safe from themselves, but the staff safe as well from the abuse they might take. Part of our jobs as nurses are to protect our patients, but it becomes a difficult task to protect them from themselves when they try to abuse us.

As nurses we are trained to deal with escalation to an extent, but when there are several of this type of patient on the unit at the same time, it makes it extremely difficult for us as nurses to deliver effective care to all of the patients equally. We do our best, but of course those that are more stable and less acute patients are sometimes left more to their own devices than we as nurses would like. It frustrates us as nurses to no end, and shows how lacking our healthcare system is in dealing with the psychiatric patient. One of the most acutely psych patients was realistically just on our unit awaiting placement. Which means there was no where for him to go because either the places for him to go are completely full, or they are not accepting that type of patient.

Has anyone had to deal with a patient that was just absolutely crazy? How did you deal? Do you have any recommendations or comments to share with us? Good or bad are always welcomed, we can learn from others bad experiences.

 

~Niki

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Difficult Questions

The other night I had an interesting question come from a patient, I had no idea how to answer that question, so I said I would ask someone and get back to the family member.

A little background on what happened. A patient came up from the ED, who had recently been diagnosed with something that would kill her. So she and her family members came up to my floor as we are the oncology unit and deal with a lot of comfort care patients. The patient seemed to be doing quite fine considering her diagnosis, but what one of her family members asked me was what threw me off guard. She looked me square in the eye and asked me how do I make this kind of phone call. I had never been asked that question and I had no response for it. I excused myself and said I would ask some people and get back to her. So I left the room with my head spinning and asked both my clinical coach that night and the charge nurse. They were both seasoned oncology nurses, and both gave me looks that they didn’t know how to answer that question. The charge nurse said that it was probably best to just relay the information, not sugar coat it, and make sure that the sense of urgency was understood should the patient pass quickly as she very well may have.

I was at a bit of a loss for words, and when someone was looking to me for guidance, I was unsure how to proceed. Has anyone had this experience before? Does anyone have some advice on how to proceed in this type of situation?

 

~Niki

Limit Setting

Something that has been both a struggle for me in my personal and professional life is setting limits with people. I have a very hard time saying no, especially when it is someone who is in pain or is in the hospital. 99% of people are in the hospital because they need to be, not because they want to be, but every once in a while there is a patient that is there because they want to be and are seeking medications or other services they could not otherwise obtain.

Saying no is a skill I am still learning, but setting limits is something that I needed to learn early on in nursing. I remember the first time that I needed to set limits with a patient I failed miserably. Fortunately my instructor was with my so she was able to give me some pointers, but I remember feeling like such a doofus that I was unable to steer the conversation the way I wanted to and that I allowed the patient to walk all over me. I had never had to assert myself before so this was totally new and foreign to me.

Now I am better at setting limits with my patients, but I still have a long way to go before I feel comfortable doing it. I still struggle with it every time I have a patient that is difficult, but I am getting better at it.

How do you guys handle setting limits with difficult patients? Or any patients for that matter? Was this something you struggled with? Let me know in the comments below.

 

~Niki

Guilt, Anxiety, and Frustration

I have been struggling quite a bit more on night shifts than I have on my day shifts. While on day shift it was really busy, I always felt like I was connecting well with patients and the work load was always chaotic but manageable. I am not struggling so much with the actual work, but more with my mental state. My anxiety and “hermit tendencies”, as I like to call them, when I go home, have dramatically increased, which doesn’t make anything better.

In the last few days there was also an event at work, that although it was not directly my fault I still feel a great deal of guilt associated with it. I realize that I am being unfairly harsh on myself, but I just can not help but feel like I am totally responsible for that. I don’t want to go into too much detail about it, but initially the medication was hung incorrectly and as I caught the medication error later, but I feel I should have taken other steps to correct the situation. I however had not ever dealt with this situation before, so I followed the lead of my mentor and charge nurse on the proper protocol for this particular situation.

That being said I of course take responsibility for my own actions and realize that I should have listened to my nursing intuition for this particular situation, and notified the MD as well.  The PFO or pre formatted order was set up in such a way that it appeared that we should be able to titrate it according to the order set, but then the medication error element of it should have shot up little red flags to notify the MD, which my sleep deprived little brain failed to see as red flag warnings.

There are a couple of elements that I think factored into this particular situation that made it less than ideal, which is why I am still beating myself up about it. One being the craziness of the shift (those full moons I didn’t believe in before I sure believe in now). I was unable to even think about sitting down to chart until 1am, and this particular evening I was unable to even make it to my lunch/break period until 5am, which is 10 hours later and 3 hours later than I normally go. All of which are fine for me, it just goes to show how insane that particular shift was.

After having had a tough couple of weeks, I am trying to remain optimistic, but I am just afraid most of the time to go back to work now because of the acuity of the patients that have been on the unit so far. It is not a nice feeling to go to work and feel like you’re going to have a panic attack or something before you even start your shift. I am also frustrated by the fact that I feel like the acuity of the unit has gotten to be high lately. Each of the patients are not necessarily medically sicker, but they require more interventions and attention so other elements of my care feels like it is slipping. I also feel that there are a lot of admissions that all need to be done at once, and all of that paperwork takes time.

There are a couple of things I have decided I am going to try as a result.

  1. Probably the most difficult for me as I am working nights and tend to want to eat junk, is to try and eat healthier meals. I don’t mean like all of a sudden I am vegetarian or anything, but try to eat more vegetables and less junk/processed foods.
  2.  Another issue that I was being great with on days but am sucking with on nights is exercising regularly. I keep telling myself that it can wait and I am tired now, but realistically that is when I should be getting up and out. I know motivation when I’m tired is such a challenge so I am going to try and just get outside and walk even if its only 10 minutes, thats better than 0 minutes :).
  3. I am also going to try mixing up my schedule as that was a suggestion from another fellow nurse that I had not previously thought to do.
  4. I am also going to continue to ask for feedback from others to see what worked for them and what hasn’t. All suggestions are welcome as there is no way to know what works until after you have tried.
  5. I have also started baking again, something I love to do, but I have let it fall to the side as I have been tired.

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Hopefully some of these changes will allow me to feel more like myself again. I know it is unrealistic to try and implement these all at once, but I feel if I set a goal to try at least 1 per day that should help. Has anyone else had a struggle like this, or is still struggling? What did you do to help you move through it?

Let me know in the comments 🙂

~Niki

 

Dealing with Difficult Patients

The other night I had a particularly difficult patient. On top of being in acute alcohol withdrawal, this individual also had an extensive psychiatric history and history of previous substance abuse. This is a winning combination that leads to a busy night. First this patient had been getting better during the day, and for the beginning portion of my shift, this patient was fine. Then as the night progressed and my other patients drifted off to sleep, the patient began to escalate. Everyone that is a fall risk in the hospital has a bed alarm on so that we as nurses know that patient is getting out of bed and can run in there to prevent any harm or falls to the patient. This patient was setting off the bed alarm at an increasing rate. I was giving this patient Valium 10mg every hour as that was how his PRN (as needed) order was ordered. The patient was not responding to Valium, and I even tried giving a dose of Ativan, which had a temporary fix for about an hour before the patient was climbing out of bed again.

12 hours worth of this is enough to make anyone lose their mind, but as nurses we need to keep our cool and treat each patient with the respect and courtesy everyone deserves. There are a couple of ways that I have found that work for me when I do this.

  1. Remembering what the patient is here for and that patient safety comes first. I will be the first to admit after the 203 time the bed alarm rang I was tempted to just turn it off. But this of COURSE would be dangerous for the patient, and neglectful of me, so of course I did not do this, but just taking the extra moment either before running into the room to steady the patient, or after settling them back in to remind yourself that they don’t know any better and are there because they need your help is a good way to keep yourself sane.
  2. Speaking with your coworkers about it. Just allowing a little bit of your frustration to leak out and have someone who understands validate your frustration can help relieve some of it.
  3. Speaking up and knowing when to ask for help. We are nurses. We are strong. We are patient. We are also human and have our limits, so knowing when to ask for help is crucial. On my particular unit we all work as a team, so my fellow nurses would occasionally run in there as needed when I was running behind or with another patient. I of course reciprocate as needed when my patient load is not as crazy, and someone else has a difficult patient.
  4. After work activities. Make sure that your shift doesn’t totally get to you! I know this probably sounds ridiculous with the above story I just told, but have a glass of wine or cocktail with friends and just vent it out. Especially with some nursing buddies, they can relate and maybe even give you advice about how they deal with it. I included a picture enjoying some time out with friends. Or just do whatever you enjoy doing to blow off some steam.

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This is just one example of a difficult patient and they come in many different forms. What’s the most difficult patient you have ever had? Leave it in the comments

~Niki

Tough Calls

Yet again as I continue on my journey into the nursing profession, I had a first time experience that truly didn’t sit well with me, but is something that we find to be a norm in our society. I had to discharge my first long term patient, which is emotional and trying. In addition to  discharging this particular patient, I had to discharge him/her to the street because he/she had no where else to go. His/her family wouldn’t help him/her and he/she didn’t have the funds to go elsewhere so he/she was unable to put him/herself up in a hotel or motel.

In San Diego, we don’t get truly cold below freezing weather, but we still get weather that is chilly and not something you would like to be stuck outside with. This happened to be in December in San Diego, and just before a day where it decided to rain. One of those rare days I find to normally be a treat, but on this particular day, my joy of the freshness rain brings was dampened by the cold wetness it would bring to someone newly homeless being sent to the street to survive. I had this patient more than one day in a row so we were able to prepare him/her the day before that he/she would be discharging the next day and told him/her we would give him/her a list of shelters and to contact whoever he/she could to see if he/she would have a place to stay. My mentor that day tried to find a place for the patient to go if everything else fell through, and then we realized once we found out there was no where for the patient to go, other than waiting in lines. He/she had come in to the hospital in September a much warmer month, and didn’t even have pants or a sweatshirt with her. My coach decided that if no one else had anything to offer up, she would buy something for the patient so there was at least one substantial set of shoes and a sweatshirt to somewhat protect from the cold.

At the last moment a family member was able to pick the patient up from the hospital, but they were unable to bring the patient home with them. It struck me as a sad reality that from our standpoint, we housed this individual for several months and now he/she was going to the street to fend for herself.

There are some things I take for granted that I shouldn’t. I can provide food and shelter for myself, had not become a struggle for this individual. It seems we are missing a part in our social structure if we have people that need to go to the street after leaving the hospital. Especially if they didn’t come from the street to begin with. Understandably we as a hospital and from a medical standpoint can not house people simply because they have no where else to go, but it just felt like such a horrible thing for me as one human being to have to tell another I’m sorry you’re medically clear so you can not stay here, and quite frankly it is not my problem where you go after this. I didn’t have to say that last part but I was in with an administrator who had to do that and it was such a shocking harsh reality to hear someone say that. We as nurses care for people not only as a profession, but fundamentally most of us have a heart that truly want to help others. Period. End of story.

I had never felt as terrible about doing something as I did that day. It saddened me and broke my heart. For the first time after beginning my career I went home and cried about something I had to do at work. A place I am sure I will go again, but hopefully next time I can help make the outcome just a little bit better.

What’s the toughest thing you’ve ever had to endure in your nursing career? We all have those stories that just stick with us, and if you would like to share your story please do so in the comments below.

 

~Niki

 

 

Dealing with Death

When working in a hospital, death is inevitable and unescapable. How does that old saying go…There are 2 things in life you can’t escape, death and taxes…or something to that effect. **There are some graphic details in this so if you would rather not be exposed to that please stop reading now 🙂

In this field that its truly inevitable, especially when working in a hospital…on an oncology unit…that also cares for other end of life patients.

The first patient i ever encountered that had passed on was during a night shift in nursing school. The patient was not mine on this particular night, but several of the other nurses on the unit encouraged me to go in to that room so my experience was not on my own. As  I walked into the room, you could feel the energy was just different. The patient was still laying in the bed the blankets tucked to his/her chin. He/she just looked like he/she was sleeping with the exception that his/her skin had taken on a yellowed waxy appearance. I helped one of the CNAs to prep the patient for transportation downstairs to the morgue. Placing someone into a glorified plastic bag after they have passed seems eerie like there should be more to it than that. We enter the world with people celebrating and anticipating our arrival, it seems like there should be more to the end than tears of loved ones and a body bag, but thats just my outside opinion.

I also accompanied the patient to the morgue where the security guard was a little over zealous and showed me all of the different things stored in the morgue. I did not realize and came to the rude awakening that more than deceased patients were kept in there. Not to go into too much detail, but I was not prepared for biopsies, amputations, and fetuses from fetal demise for any number of reasons, in the room in a cabinet. They were in jars and many in plastic bags that just looked like something you would find in a refrigerator, which made me uncomfortable for many reasons, but mostly because it seemed like they should be in something a little more substantial.

I definitely went home and had to have a couple of cups of soothing tea before I was able to go to sleep that morning. The image also stuck with me longer than I like to admit and I had a few nightmares about it before learning how to cope with it.

I had another experience in nursing school, but this experience was at the VA. After the patient passed he/she was prepared to be brought to the morgue, but at the VA they drape the patient in an American flag, and have a mini ceremony/procession. They ring a bell and announce that a Veteran is leaving as he/she passes through the hall. The medical personnel can move into the hall to show their respect as the patient passes through.

This was a MUCH different experience than my first one. This patient’s passing felt much more like a celebration of the life of this patient and his/her passing. I felt like this was a lovely way to not only honor the patient, but give the family closure. The family not only gets closure from this, but also the staff who have cared for the patient for the many months he has been there.

The important thing to note from all of this, is that different hospitals do different things when it comes to death, and each person deals with it differently. Being respectful of everyones wishes helps family members of patients feel supported. Finding healthy coping mechanisms for healthcare personnel is essential for not feeling burned out.

What are some of your coping mechanisms for dealing with patient deaths? Any other questions comments or concerns? Please leave them in the comments 🙂

~Niki