First some background. I work at a private psychiatric hospital. Most patients have insurance paying for their stay, but about 30% of our patients are indigent and their treatment is paid for by the county under a special program called "healthcare district". Many of those are homeless, frequent flyers (they visit us often). It provides for an interesting mix. We are a short-term facility, most length-0f-stays are less than 2 weeks. Our goal is to stabilize patients in crisis and get them into either an outpatient treatment program or another in-patient facility that is designed for long-term. We have a very high turnover; during one shift I once had 6 discharges and 2 admissions. But that's part of why I love this job: I see many different patients, many different diagnoses. So here's how my most recent shift unfolded.
I start the morning at 6:45, doing the narcotic count on the automated machine with one of the night nurses. I am working on my favorite unit that includes the PICU (Psychiatric Intensive Care Unit) where patients are the sickest. After we count together & verify everything is there that should be, we go into the lounge and do report. The night nurses go over each patient with us, giving a brief run-down on the patient's diagnosis, what crisis brought them to us, their treatment and their medications. Patients may have special precautions as well: suicide, aggression, detox, seizures, SIB (self-injurious behavior) etc. This takes about 45 minutes. I am responsible for 10 patients today (my typical number). After report, I head to the med room and start pulling meds for all my patients using the Medication Administration Record. I use the automated machine to dispense each drug and put them into labeled cups. This takes at least 30 minutes, sometimes longer. Part of my responsibilities as I pull each drug is to confirm that it's an appropriate dose, verify last dose given, check patient allergies, and verify drug packaging that it's the right medication. Once the pharmacy tech loaded the wrong dose of morphine into the pocket and 3 patients were given 10x the correct dose. Really. So it is important to check.
A word about diagnosis. Most of our patients fall into one of 3 categories; MDD (major depressive disorder), schizophrenia, and bipolar. Sometimes we also get personality disorders like borderline. Borderlines, in fact, are the patients I have the most trouble dealing with. They are highly manipulative, extremely needy, childish and emotional people. They delight in playing staff off against each other; "you're the best nurse I ever had, not like that rotten bitch last night that wouldn't give me a blanket and stole my meds. And you should've heard what she said about you..." The diagnosis du jour seems to be schizoaffective disorder, I think because it incorporates elements of both schizophrenia and mood disorder. Of course, psychiatric diagnosis is a difficult thing. It's not like you can take a blood sample and measure the "insane" level.
Patients start eating breakfast at 8:30. I have two diabetics that need to have their blood sugar tested before this time and insulin administered. I find the techs and ask for these values, then give the appropriate dose of insulin. As the patients start eating, I bring the medications into the dining room, only two patients at a time to minimize confusion and reduce errors. Before I give meds, I check patient arm bands to make sure I've got the right person. Since I don't work full-time, I usually have a brand-new slate of 10 patients every time & I don't recognize any of them. I am walking among them to give these, since I'm on the open side. On the PICU side, we sometimes have to give meds from the dutch door for safety. But often we walk among patients there, too. You have to use your judgement and trust your aides to protect you. A good aide is your most valuable resource as a nurse.
About 9:00, the charge nurse sits down with the psychiatrists (we have 3) and goes over each patient's status and treatment plan for the day. I'm not in charge today so I get to skip this meeting, which often takes an hour.
As I'm making my way down the hall with some meds on one of my trips, one of the patients stops me. He's wrapped in a blanket, naked underneath, heavily tattooed and with a shaved head. I recognize him from report; we are all on high alert about him. He's on the open side & really needs to be in PICU, but he was admitted last night & there was only an open bed available. (We stay full almost 100% of the time.) He takes my elbow and tries to steer me into one of the rooms, stating that he desperately needs to talk to me. Um....no. I insist we talk in the hall. He's acutely psychotic and paranoid, hyperverbal and angry. He frightens me & that doesn't happen often. I know from report that he is an athlete and was arrested with a firearm. I use all my therapeutic skills to talk down his anxiety but still feel pretty unsuccessful. After I manage to seat him for breakfast, I tell the other nurses that we must move him over to the PICU side with a higher level of observation and security. We move him, and within ten minutes, his behavior escalates. He's angry at being moved & his paranoid delusions are intensifying. He accuses the other patients of things. He begins shouting and making aggressive motions and statements. We get a syringe ready of a medication to calm him. The psychiatrist (thank goodness he was there), 3 of us nurses and an aide walk him down to his room. After about 15 minutes of negotiation and some hands-on, we administer the shot. (I think the only reason we were successful is because of the presence of the doctor. It's interesting to me how often patients completely defer to him.) Once he's sleepy, the aides get him to put on some pajamas and crawl into bed. The doctor writes orders for more medication once he's awake.
I go back to finishing my medications. Once that's done, I have two discharges to process. The social worker hands off the chart to me. I detail the patient's medications on their form, make copies of certain things for the patients and ask the aides to ready all their belongings. If they brought in valuables, I get these out of the safe. When all this is ready, I sit down with the patient and go over their discharge instructions and ask for their signature. Sometimes this is smooth, sometimes not. Once a while, patients are unhappy with what the doctor chose to prescribe for their discharge & they refuse to leave (usually, they want Xanax. Xanax is probably the most-abused prescription drug that we see). Once in while, we can't locate a belonging. But eventually, the patient is either picked up by a family member or another agency and they are discharged.
During all this time, about three patients have asked me for what we call "PRN" medications. These are medications that are only given based on need, and the patient has to ask for them. Things such as pain and anxiety medications. For each one, I have to verify what I can give them, whether enough time has elapsed since last dose, and then pull the medication out of the machine and administer it.
The psychiatrists are busy making rounds and writing new orders on each of their patients. It's my job to "take off" those orders; I read the order and then either update or add to the medication record. If it's a non-medication order, such as "patient's family may visit during non-visiting hours today" or "vital signs must be taken every 4 hours", I alert the techs and update the white board. If lab tests are ordered, I fill out the lab request sheets and file them. The doctors see each patient once a day; often I have new orders on all 10 of my patients. Usually a newly-admitted patient will have multiple items ordered.
Meanwhile, another patient on the open side begins to have a meltdown. He's obviously cognitively-impaired, beyond being in a psych crisis. From reading his chart, I know that he's brain-damaged from a lifetime of drug abuse, starting when his parents shared their drugs with him as a small child. If you ever want a good cry, just open one of our patient's charts and read the history. He is demanding to be discharged immediately, in his child-like way, and won't listen when we explain that the doctor must examine him and ensure he's not going to walk out the door and run into traffic. He is pacing and his voice is getting louder. Attempts to talk him down fail, and he refuses the medication offered. The aides start to stand closer to him and we ask him to walk through the doors with us to PICU. He refuses and we spend about 10 minutes negotiating, which fails. He must be restrained and carried over to the PICU side and by that point, he is getting physical with the staff and yelling non-stop. Two of these in one morning feels like too much, but it's not the first time. Once he's on PICU, his behavior doesn't lessen and again, we must inject him with anti-anxiety medication. He is crying because he doesn't like needles; this really gets to me, but I understand the necessity for his safety and I do my job. But I feel an intense sadness when I think about how he got here & where he's going. Because he was restrained, I have to fill out a special form documenting exactly what we did, why, and for how long.
Unfortunately, I have a new admission that was just walked onto the unit and witnessed all this. It's her first psych admission and she's only here for MDD (major depressive disorder). Her eyes are wide, watching this unfold and I have to quickly explain what's going on & reassure her that she's in a safe place and this won't happen every day. Probably. I take report from the admissions nurse and then review her paperwork that documents exactly why she was admitted and what her history is. The techs take her vital signs and examine her belongings, confiscating things like razors and scissors. We document her valuables and lock them up. I sit down with her and do a full assessment and history and answer her questions about what's going to happen. As part of my assessment, I have to take her in a private room and have her strip for a search. For the safety of all the patients and staff, we have to make sure that nobody comes in hiding drugs or a weapon (both of which have happened).
Sometime during the morning, I review vital signs taken on all my patients by the techs. If something's amiss, I address it. If a patient's blood pressure is too high, I call the doctor and get an order for new medication. Many of our patients are detoxing from drugs/alcohol (about 30%), and based on their vital signs, we administer extra medications because elevations suggest withdrawal complications, which can lead to seizures if untreated. I also spend a few minutes asking each patient key questions. I do these in a conversational way, starting with "how are you today?", but eventually I find out if they are suicidal and/or if they have auditory or visual hallucinations.
Meanwhile, our aggressive athlete in PICU has woken up and is pacing amongst the other patients. He's still psychotic but is not threatening. The aides watch him carefully. He has about 4 medications in him, each one alone would put me to sleep for all day. But he's still hyperverbal and paranoid.
Pretty soon it's lunchtime and again, I am checking blood sugars on my diabetics. After that's done & I give a few medications due at noon and some PRN's, I can finally take my 30 minute lunch. It's 12:45.
After lunch, I have 3 patients with 13:00 medications that I give. Then I finally start my nursing notes. I will work on these off & on the whole afternoon. It's required for each patient, and it's a synopsis of their care and behavior during my shift. It details things like their mood and affect, their attendance at group therapy, their sleeping and eating, and their medication compliance. I also assess their suicidality and their aggression risk. It's a form with checkboxes but also a narrative paragraph is required. I also take another admission during the afternoon so that both of my two discharges are replaced.
The afternoon from about 2:00 to 5:00 is the slowest part of the day. Most nurses eat their lunch then, but I can't wait that long. I work really hard to get things done in the morning so that I can eat earlier. During the afternoon, I sit down with the aides and go over each of my patients, asking about their behavior and participation in unit activities. Again, I give requested PRN's as patients come up to the nurse's station. As the afternoon progresses, issues come up and I handle it. One patient was found eating toilet paper in the bathroom; this is a known problem for him. Patients that eat unusual things are called "pica". Some patients, as a result of brain injury, will eat almost anything. Others eat particular things because it distracts them from their internal anxiety; that's the case for this guy. I redirected him verbally (that means talking to him about what's bugging him & asking him to stop), gave him an anti-anxiety med and kept him out of the bathroom. A patient threw up in her bed & needed some anti-nausea medication. A patient was found in tears, curled on the floor; I ended up spending over 30 minutes talking to her about her treatment plan and her medication orders and finally got her off the floor.
A word here about what we call "drug seekers". Many of our patients have a history of drug abuse and like their PRN's. Some will readily ask for anti-anxiety medication right after a rousing card game in the day room. Some nurses are stingy with the meds, but I simply follow the doctor's orders. If it's allowed every 6 hours, then I give what the patient asks for and record it. It's there for the doc to review and address as needed. But I also always ask why the patient thinks they are anxious and offer them conversation. Some take it, some don't.
A process server comes by and serves court papers to one of my patients, admitted involuntarily. When patients are brought in by the police, they have a court hearing at ASH (Austin State Hospital) after their admission to decide what to do next. We bring them over to ASH for that. The social worker appears with them to report on the patient's treatment and discharge expectations.
One of the social workers tells me a funny story. In group therapy that morning, the patients were asked which animal they were most similar to, and why. One of my patients said "a bear". When asked why, he simply stood up and started taking off his clothes. He's very hairy.
At 5:00, things usually pick up and get busy. The patients eat dinner at 5:30 and some medications are given before dinner. Visiting hour starts at 6:00. Our head psychiatrist makes rounds again at this time, and often the medical doctor will make his rounds then. If I patient has a medical problem (like a sore toe), the psychiatrist will write a consult for the medical doctor to examine him. The psychiatrists try to confine their treatment to only the psych needs. But in a pinch, they do both. If someone needs something simple, such as a laxative, they'll write the order. Of course, doctors making rounds at this time means that new orders are written and have to be taken off. During all this, I'm trying to get ready for shift change; get my notes ready for report and finish all my nursing notes on each patient for their chart. If I have time, I squeeze in dinner. I hate to arrive home at 8 pm hungry and I never go to bed on a full stomach. So I bring my little Kashi frozen dinner and eat it as fast as I can.
Shift change is often a time for patients to become anxious, unfortunately. There is extra activity at the nurse's station and it's visiting hour. So often there is a mini-crisis (or major, once in a while). The worst I've ever witnessed was when a young male patient jumped over the dutch door of the PICU, grabbed a pen and tried to stab an aide in the throat with it. Luckily, his aim was bad and he only grazed him. As often happens, the patient had fixated on the aide and it became part of his delusion that the aide was a bad person, or out to get him. The most amusing fixation that's happened to me so far was when a patient wanted me to leave with him as he was discharged and get married. Really. Unfortunately, I'm just not into bipolar, hyperverbal guys. But seriously, I don't want to give the impression that I view myself as above the patients in any way. All of us have issues, I like to say that all of us are crazy. Some just are in crisis and need a hand. The patients are truly not different from me, they are just in a temporary state with some limitations for their own protection. Many of us are drawn to psych because we've been there. If you talk to the nurses and staff, you'll find things in our pasts that led us down this path; it's usually not accidental.
Finally at 6:45 the night shift appears, we do the narcotic count again and then sit down to report. Hopefully we're not interrupted during that, because all the nurses are in that one room and if something happens with a patient, one of us is going to have to come out and address it. If all goes well, I'm able to walk out and go home after my 12 hours.
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