Once again I cannot believe how long it has been since my last post. The weeks and months seem to be flying by me at the moment, and work is keeping me busy.
So a catch up before the main focus of this post. I worked Christmas Eve and Christmas day and all in all it wasn't so bad. Everyone was in good spirits, we had several Father Christmas' visit and we got half the unit on home leave for the day.
I had a very welcome three day break in Cornwall over the New Year which left me feeling refreshed and ready to work.
Last week I started on a new ward. It is an adolescent unit. I have so far worked for long days there and it is the reason for my post title.
The first two days were spent looking after a teenager who had been involved in a gang-related fight. It is a whole different world to the one I grew up and live in, though not unfamiliar because of the kids my mother works with.
He would swing from being polite and well mannered to being angry and refusing to cooperate. On several occasions he left the unit unaccompanied which is against our rules as we are unable to ensure their safety if they do that. Despite reprimands, explanations and assurances he wouldn't do it again he did. He would also try some of the most unbelievable lies to get permission to leave the ward, and then would become angry when we wouldn't let him. He was never verbally abusive to me and I never felt threatened by him, I actually quite liked him. Soon his anger would blow over and he would be cooperative again, now allowing us to do his antibiotic. I made him a hot chocolate and got him a packet of biscuits after one particularly difficult argument and as I sat watching him dunk his biscuits I realised that despite the bravado he is little more than a boy. He has had a really difficult home life, has been excluded from several schools, is now involved with a gang, I'm fairly sure carries a knife and is in trouble with the police, he also has some degree of mental health problems and anger issues. He is not accepting the help he is being offered and it's really sad to think where this young man may end up, because beneath that hard outer shell he is a nice boy.
On my third and fourth days I looked after a young woman who has had many previous admissions for confusion post seizures, and she has been non compliant with her medication. We had a registered mental nurse (RMN) (which makes me giggle) to watch over her, which makes my job a lot easier. Initially I didn't have a lot to do with her and was busy with three other patients but as the afternoon wore on I became more concerned about her behaviour which didn't seem like confusion you may have post-seizure but a lot more like psychosis. I was told she has presented like this before but it still didn't seem right to me. She had delusional thoughts; that she was a witch was the most common. She was having auditory, visual and tactile hallucinations; people calling her name, a man trying to strangle her. She was convinced she was dying and would not believe any reassurances that she wasn't and didn't have cancer, AIDS, wasn't having a heat attack. She became increasingly distressed and said she wanted to kill herself.
Although she had been seen by CAMHS and psych in A&E there wasn't really any plan for her, and fortunately at this point we had a brilliant psychiatric doctor come and review her. She straight away recognised our concerns and finally someone seemed to be taking this more seriously. She prescribed a very small dose of Lorazepam to try and help with her anxiety as she was highly agitated and distressed. This was given quite late in the day and the night staff reported it really helped calm her and she went to bed.
The following day we had more members of the mental health MDT assess her and the decision was made to transfer her to an adolescent mental health unit for assessment and observation. Unfortunately my patient didn't want to go and with her parents permission she was sectioned under Part 2 (I believe) of the mental health act - a process that I had not encountered before and took several hours, needing two different doctors to assess her and signs a document and the the Approved Social Worker to complete the last part.
We then had to wait over an hour for transport. When they were scheduled to arrive my patient was ready and had been persuaded and accepted the move to another hospital. Unfortunately the hour and fifteen minutes we spent waiting for transport saw her agitation increase and once again she refused to go. I was concerned she was going to try and leave the unit and was becoming a little aggressive, but we managed to persuade her back to her bed (having wandered up and down the adjacent children's wards with her) and when transport actually arrived (and I made them get rid of the trolley they wanted to strap her to!) she actually went quite peaceably.
So as my title suggests those four days were a very steep learning curve for me. At this point I would like to thank MMW for her blog. The knowledge and insight I have gained from reading it really did help me with the care of a patient that was totally outside my realm of professional experience.
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14 comments:
Wow, thanks Angela :o)
I was actually going to pop over to Mental Nurse and recommend this post as childhood and adolescent mental health is a topic of discussion there at the moment, and Z has just started working in this area also. But that last paragraph makes me feel embarrassed to do so now!
I'm a little confused though - if it was believed that she was suffering from confusion post seizures why was there a RMN there in the first place? And how come the RMN didn't recognise that she was suffering from psychosis? And a trolley?? They were actually going to strap her to a trolley?? Blimey, I think I've been caught in a time warp, back to the 50's.
Thanks for sharing such interesting experiences.
Hi Angela
As Mr Man's Wife says, I am indeed an RMN who's just joined CAMHS.
You were quite right to send the trolley away. If a patient needs restraining, it has to be done by hand, not using any kind of mechanical restraint such as strapping them to a trolley, and it has to be done by staff who are trained to do it.
I may link to this post on our weekly round-up of psych-related blog posts that we do every Saturday, if that's okay.
MMW: Don't be embarassed at all, my words were sincere :)
Z, welcome to my blog :) Please feel free to link my post.
My patient had previously been admitted to our ward with this post-seizure "confusion" and had had an RMN in the past because she could be aggressive - though from everything I was told I too questioned why they were bringing an RMN in if it was merely post-ictal "confusion".
The RMN was actually very good and did recognise the psychosis. Unfortunatly when a young person is admitted to our unit they are under a Paediatric nurses care, the RMN is there simply to watch the patient - and if they're one of the "good" ones they will do observations for us as well! I was told on the second day that my RMN was there to watch over the patient and not to be involved in any discussion relating to or planning of her care. I disagree with this as I feel the RMNs offer a wealth of experience that I do not possess and that they should be involved in decisions relating to this patient's care, and in this situation I listened to my RMN and did invovle her in the MDT discussions.
However I also recognise that sometimes we do not have "good" RMNs. (To clarify the RMNs all come from external nursing agencies.) I have encountered several RMNs who I would not want looking after me, or my patients, with some of the worst communications skills I've encountered (something I feel should be a strong point) - for example the 11 year old suicidal young man that I looked after, the RMN kept telling him that he was "wasting our time".
Because ultimately the professional accountability lies with the ward nurse assigned to the patient that day I can understand not wanting to involve too much the external agency nurses when we are unsure of their skills - however condescending that may be. Ultimately if a mistake is made my registration is on the line as I was the named nurse that day.
Back on track again. I believe that this patient was referred to CAMHS previouslhy but consent wasn't gained so it was never followed up. Other nursing saff who knew her said she had been like this previosuly when in hospital, and I feel as an outsider was perhaps that she'd been unwell for a while and people had just assumed this was seizure related and not picked up on the developing mental health problems.
Regarding the stretcher, I'm not sure their intention was to strap her down as a means of restraint - I think it was a mistake on the part of transport not realising she was able to walk independently, however I told them it was not appropriate to come onto the ward with it as she was already agitated and whether they intended to use it or not it would frighten her more.
The other thing that I will mention in light of Z reading is the hesitency to use medication. The people we spoke to from the CAMHS team were very reluctant to use any form of medication, despite how unwell and agitated she was, as was the consulant psychiatrist who saw her. It was only because we had an on-call psychiatry SHO assess her in the evening that we were able to have anything prescribed as Paediatrics were also hesitent to do anything.
One final thing I didn't mention in my post was age. She was 16 in the last school year, so out of compulsory education. This is a very "grey" age and no one wants to take responsibility. We would usually only take young people up until the end of Year 11 but Adults were refusing to accept her (despite being seen in adult A&E) as she was known to us, Paediatrics tried to get out of taking her, especially in light of her mental state not feeling she was an appropriate admission for our unit.
I was told we were very "lucky" to have had her transferred to an adolescent mental health unit so quickly as they usually stay on our unit for days just being watched or "sat on".
I don't believe I ever blogged about my experiences with the 11 year old boy, it was in my "away" time - however I did mean to. I'll see if I can drag up the memories and post about that when I'm off on thursday.
He didn't happen to be tall and thin did he?
What a bloomin' horrible thing to say to a child - or anyone - who is suffering so badly.
Hi Angela
Regarding medication, it's pretty standard practice in CAMHS to use minimal or even no medication. The reason is because there's very few psychiatric meds that are licensed for use in children.
Hi Angela,
just floating in on the back of my mental nurse buddies from over the blogosphere (*waves at z & MWW*). Nice posts (as in well written). I'm usually quite opinionated but, for now, just wanted to say hi - your blog is tagged for future reading :o)
Just an afterthought:
You're absolutely right about there being some very good agency RMNs out there, but also plenty of rubbish ones. If I were a cynical person, I'd suggest it was because some of them see being an agency RMN as a well-paid job where you don't actually have to do very much.
In my opinion, psychiatric observations should not be done with a mobile phone in one hand and a copy of Heat magazine in the other.
Hello Mr Ian, welcome to my blgo and thank you :) Please feel free to be opinionated!
MMW: It was a lady! With some of the poorest communication skills I have encountered. I will definitely blog about this in the next few days otherwise I'll end up explaining it all here!
Z: With regards to medication the vast majority of medications used in daily paediatric pracice are not licensed for children, something which surpsises many people. (Going off on a slight tangent here) However when you think about it what ethics commitee will be persuaded to allow clinical drug trials on babies and children? So instead of medications "tested" on children, we use medications that we calculate/guestimate based on our experiences with adults and anecdotal evidence - which I think could be argued equally as unethical.
My personal feeling is that if a child needs a medication then they should have it, we regularly give medications that children need despite them being unlicensed. However I also believe that psychiatric medications are a somewhat different kettle of fish, that the need for them really needs to be weighed up and that our adolescent unit is not the appropriate place to begin treatment. The Lorazepam was used minimally and with good effect (it's something we use regularly with younger children pre-operatively), though the CAMHS lady nearly had a fit when I told her she'd been given medication overnight "They aren't anti-psychotic medications are they, we really didn't want her to have anything like that".
Z, regarding your last comment I totally agree! I think some people see it as easy money, especially at night (more money for less work). We always make sure we don't put out too comfy a chair for them to sit on, otherwise we find them snoring when we go in to to do our obs!
Please make your own typing error corretions to my posts as I have given up!
MMW: Oooooh, you meant was the boy tall and thin (just looked again at the post you linked!), not the RMN! No, the boy was short and well, not thin. But he was only 11! He may lengthen out in a few years.
Random trivia, tall, thin young men are also the most likely group to suffer a spontaneous pheumothorax. *nods*
About drugs in adolescent psychiatric units: at the unit I attended in 2001, almost every patient (ages 11-16) was on Seroxat/paroxetine, and at least one, who was sectioned, was taking some very heavy duty old generation anti-psychotics. It was common practice if someone was agitated to pin them down and inject haloperidol or benzodiazepines such as flunitrazepam or lorazepam; sometimes both.
On the subject of RMNs watching over patients on non-psychiatric wards: I required medical treatment when I was an inpatient in the adolescent unit, and the nurses on the general ward were obviously not used to patients having a psychiatric nurse with them - they were scared of me, and got very upset whenever my RMN went to the loo and they had to watch me for a minute!
Dear Anonymous, thank you very much for your comments and welcome.
Fortunatly my patient was fairly co-operative with regards to taking medication, perhaps because she regularly took anti-epileptic medication at home or because she was frightened and wanted to feel better.
Having a patient with an RMN is becoming more commonplace on my unit, but I think a lot of the fear comes from a lack of understanding and experience - people usually fear the unknown. I'm sorry you had nurses who were frightened of you - they could have at least hidden it better if they were unable to control that! It can't have been very pleasant knowing the person sitting across the room from you was afraid of you and didn't want to be there.
It's an interesting comment. I think that we often don't realise how transparant our feelings are, especially if the nurse is making assumptions about the emotional and mental state of their patient.
Hello - same "Anonymous" as earlier! Perhaps more training is required on psychiatric disorders for general or paediatric nurses (though I'm aware that there's enough for student nurses to learn as it is). I don't know whether all nurses do a psychiatric placement, or whether it's just those wishing to become an RMN.
I can understand the nurses' and HCA/HCSW/auxiliaries' anxieties, especially if they had't been around psychiatric patients very much. From their point of view, they didn't know me and whether I might be violent, they didn't know how compliant I was likely to be with treatment, and they might have been worried about what would happen to me, the other patients, and the smooth running of the ward if my mental health suddenly deteriorated.
Funnily enough, it didn't really upset me too much that the nurses on the ward were apprehensive. At least on that ward I could be sure I wasn't going to have to put up with the much worse and scarier attitude many of the psychiatric nurses had. For some patients, however, I can imagine that it would be really difficult to cope with the situation.
I'm enjoying reading your blog and finding out what it's like from the other side of the medicine trolley.
Thanks again for your comment Same Anonymous (SA).
during my training we had about 30 hours of lectures on mental health across one week. We were never put on a practical placement, though I know some nurses who trained elsewhere who were, something I felt would have been beneficial.
I think part of the fear comes from the misguided belief supported by the media that psychiatric patients are violent by definition.
Adult nurses and paediatric nurses are never taught any restraint techniques. If we were ever needed to restrain a violent patient we would have to call security up to the ward, where as RMNs do receive training. This is something I feel is a failing on paediatric nursing as in reality we restrain children on a daily basis for medical procedures. I won't say too much regarding this as I've just decided this will be the feature of a forthcoming blog post! But my point was that I believe some of the fear comes from not knowing what to do, or perhaps knowing you aren't supposed to do anything when faced with a violent patient.
During the first day there was a point where my patient began screaming (that was the moment she chose to throw herself backwards, fortunatly we managed to catch her and lower her to the floor before she cracked her head on the sink!). When I came out of the cubicle a short while later a colleague told me that another family had voiced concerns about their safety. The cynic in me wondered if this was genuine fear or just them being nosy and trying to get find out what was wrong with her.
They were reassured that the patient wouldn't be here if she presented a threat. The truth is probably that she would be there because it takes such a long time for anything to happen, but she'd have a security sitting outside the door. That security guard would probably say the same as the one who came up to us that day. "She's a girl though. I can't do anything." That's a great help.
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