Saturday, September 30, 2006

Damn it, Jim. I'm a nurse, not a lawyer!

ER: "I'm calling to give you report on Mr. x."
Ok, one moment, let me get the intake form....
How old is the patient? (used to verify the correct unit he will be admitted to)
Ok, and who was the psychiatrist who cleared him? Has he been cleared medically?
Did they sign the voluntary? Who has power of attorney? Well, was crisis involved? I think you'll need to get a 302. No, I CAN'T just take them based on a psych history. Please check with your nurse supervisor, she should have the protocol. That's what I'm trying to tell you. Because it is illegal. No, we have to have a copy ON.OUR.CHART. We can accept a fax until they bring in the original. Yes, we have a bed, please call back when you get in touch with the son.
Four-point leather restraints, IM Haldol/Cogentin/Ativan.
DEM attending calls to inform me that the son is "legal guardian", and he is signing the 201.
Does he have durable power of attorney?
He is the legal guardian.
But there is no DPOA?
A judge signed him as his guardian, that is acceptable.
Do we have proof of this claim?
He said he'll bring it in this weekend.
We can't hold someone here on a statement that someone is allegedly responsible. He will need to be 302'd.
The family is refusing involuntary commitment.
...what the f...?
Well, I'll look into this further, I do know we were expecting him today, but our rules work just a leeeeetle bit differently than do yours.
(For instance, restraints - either mechanical or chemical - are NOT as easy to just slap on to any old body we feel is a wee bit testy.)
[In addition, the ER has a tendency to get voluntary signatures in a not-quite-full-disclosure manner. "Here, you need to sign this paper so we can admit you". Or, "This will allow us to treat you for three days, then you can decide if want to go". Don't even get me started.]
Call placed to the director of our program, my nurse manager, and the social worker. Messages left.
Five minutes later, but what to my wondering eyes should appear...
Yup. Accompanied by three security guards, the daughter who is NOT to have any information shared, and a handful of ER staff to assist this unruly gentleman into his new digs.
Where is the son? The guardian? The man you are accepting direction from?
Argh! This sucks on so many levels. I have a foley that should have been placed an hour ago, a dressing to change, readminister medications that Miss P. had cheeked earlier, and 15 or so notes to chart.
In the interest of patient safety, we do place him into a room, assign a 1:1, place a call to the on-call shrink just in case we need PRNs, and goddamnitineedaciggerettenow.
Two calls returned, both with an emphatic NO to the legality of 'guardianship' for this whole shabang. Well, guess what, they sent him on over anyway, so now what? ::gritting my teeth::
You need to obtain the documents.
well.duh. um... how? (and just when did this become my job anyway??) ???
As luck would have it the social worker is familiar with the family, esp. the son with the super powers that transcend state law, and Mr. x is spending the night tucked away in a nice cozy bed down the hall.
Why can't this ever be easy?

Saturday, September 23, 2006

Therapeutic Communication

Shifting from LTC to inpatient psych hasn't proved to be much of a challenge, but I do find myself needing to approach my residents/patients/clients in a different way. For starters, the majority of our interventions and planning begin with "approach in a calm, non-threatening manner", which is a given. What I hadn't anticipated was the absence of touch.
While an elderly demented patient might benefit from a warm hand on the shoulder as you gently guide them out of the garbage and into the sensory room, your average schizophrenic will tell you directly, "don't touch me", if you're lucky.
At 0600 yesterday, as I began my final rounds administering the synthroids and checking the blood sugars, I gently woke the lofty dutch woman whom has enjoyed her 23 days at the all-inclusive resort we call "gero". She was quivering and tearful, and I asked what was wrong. She was up for discharge, and was frightened. She had been slowly weaned from her 4mg of klonopin, and the cymbalta did not work. So far, it appeared as if the zyprexa and trazodone were helping her a tiny bit; the panic was less frequent, she was sleeping (although she denies this) and an axis II dx was being considered.
I asked her if I may sit down. She said yes, and began to talk more than she has in the past three weeks. She is lonely, the staff had decided early on. She states she is unable to enjoy any hobbies or outings with friends, she just can't concentrate. She denies SI, although there is a hint of a passive death wish. She laughs when she tells me her house is "very, very clean". She wonders if a pet might be a good idea. She is picking at her gown, the sheet, the edge of the paper souffle medicine cup. Tears are welling up in her eyes. I feel detatched. On the one hand, I want to reach over and hug her; on the other hand, I wish she'd just snap out of it. Call bells are going off, bed alarms are screaming, and I have to go tape report. She has until monday to decide if she's going partial or if we have to 304 her to a more long-term program. She doesn't belong with the psychotic patients, she is just wound too tight. I've seen much worse. Why is she here, and why for this long? Meanwhile, Mr. OCD with diabetes insipidus in the next room has taken himself to the bathroom, urinal in hand, to try his luck at the spring water in the porcelain reservoir. She can tell I'm distracted, and I hate that I am. I acknowledge her concerns, state that I am needed to tend to some urgent matters at the moment, and tell her we can discuss this more after breakfast. I forgot I wasn't going to be there at that time. After I took care of the risk-for-water-intoxication gentleman, I returned to let her know I'd stop by at the end of shift instead. She reached out and grasped my hand. I was taken aback, in a big way. People don't touch here. Unless we're wrestling someone down, but that's another story. I didn't have time to sit with her. She began to plead with me. My heart went out to her, yet I had many other (more important) tasks to tend to. There are limits to be set, boundaries to enforce, levels of caring that one has to be careful not to breech. This is mental health, not a nursing home, and... well, shit. What do you do? In the hour that followed we started an IV, sent one patient medical, did two bladder scans and a straight cath, and documented all the 1:1 and chemical restraints.
I did return to tell her I was off, I hoped she would participate in group, and ensured she contracts for safety. She wasn't paying attention, because she needed 2% milk, not skim, she preferred cranberry juice to apple, and she needed to know why all she ever got was decaf coffee and tea. Did she have to sit at this table with those people, why aren't they allowed to eat in their rooms, and what inane craft did they have planned for today? Did her son call yet (make sure she gets it), did that social worker ever bother to schedule the family meeting, and make sure I get the wet towels off the floor and change her linens. And by the way, her toast was cold.
Axis II, indeed.

Friday, September 15, 2006

Initial Consultation

Welcome to my first post - of sorts.
While I blog regularly elsewhere of my life in general terms, I have felt the need to express my views on things of a more professional nature.
That is to say, that I will not be providing intentional, methodical, relevant education in any purposeful manner, but the occasional random reader might find my thoughts to be mildly amusing. At the very least, an adequate way to waste valuable time.
Through blogging, I have a found a rich fabric of others who share similar views to my own on a variety of topics. What I lack among my real-life contacts, is an acceptable vehicle for which to unload work related issues from my short term memory; hence, this medium shall be my talk therapy. My feedback loop.
Although I am a nurse of 16+ years, and I hold myself to high professional standards with a responsibility to all of my clients/patients/families/peers, et al. - this blog is NOT to be considered reference material, peer-reviewed, or helpful in any way. Many of my posts could be considered offensive to some, humorous to others, or simply extraneous to the masses.
Descriptions of people, places, or events will be modified to protect identities. Any similarities to actual situations are completely coincidental. The information contained herein is for entertainment purposes only, and not a substitute for a proper evaluation. I am full of good advice, use at your own risk. Side effects may include uncontrollable drooling, somnolence, ambivalence, and a burning sensation when you urinate. Use of this product should be limited to a PRN basis; more frequent dosing may lead to idiopathic dementia, which should improve after discontinuation. If bothersome dryness should occur, please consult your physician.