What is wrong with psych nurses?!

[peaceloveandPA]

As some of u know, I do medical consulting for a psych hospital daily and I'm finding so much frustration dealing with psych nurses. For one, I love nurses and appreciate what they do every day and always go to them to get more feedback on the patients.

 

And I HATE to say this word, but most of the psych nurses seem so incompetent. Are they just tired of doing medicine so they go to psych?!

 

Today, MD (psychiatrist) consults me on a pt with elevated BP readings for a few days in the 140s/90s with a history of PKD. So I'm reviewing her vitals and I see that her BP was 173/110 2 days ago. No re-check. No call to the MD. No call to me. No meds given. Nothing.

 

WHAT?!?!?!?!

 

I get that it's not a medical hospital, but there's an MD on call 24/7 who is very capable of giving a telephone order for clonidine. Deal with this sort of stuff every day... I just don't get it.... A psychiatrist is still an MD. A psych nurse is still a nurse. Right?!

 

 

Let food be thy medicine

[LKPAC]

 

A psychiatrist is still an MD. A psych nurse is still a nurse. Right?!

 

I was in agreement with you until here.

[peaceloveandPA]

I was in agreement with you until here.

Why? They should at least know what hypertension is and when to turf.

 

 

Let food be thy medicine

[EMEDPA]

I work at a facility with an inpt psych unit.

the psych docs are fine with psych issues but have forgotten the rest of medicine. the psych nurses call er nurses to start IVs, draw blood, etc.

they call us to consult on whether giving an ordered stool softener is ok at 3 am. 

all they do is pass meds and give IM injections. a tech could do their job and do it better. psych is where the worst nurses migrate to, the folks who couldn't cut it anywhere else. 

[LT_Oneal_PAC]

I work at a facility with an inpt psych unit.

the psych docs are fine with psych issues but have forgotten the rest of medicine. the psych nurses call er nurses to start IVs, draw blood, etc.

they call us to consult on whether giving an ordered stool softener is ok at 3 am.

all they do is pass meds and give IM injections. a tech could do their job and do it better. psych is where the worst nurses migrate to, the folks who couldn't cut it anywhere else.

^ agreed. It' relatively easy work with (usually) street clothes, so the incompetent and the burn out go there. They were the worst when I was a nursing student.

[peaceloveandPA]

I work at a facility with an inpt psych unit.

the psych docs are fine with psych issues but have forgotten the rest of medicine. the psych nurses call er nurses to start IVs, draw blood, etc.

they call us to consult on whether giving an ordered stool softener is ok at 3 am.

all they do is pass meds and give IM injections. a tech could do their job and do it better. psych is where the worst nurses migrate to, the folks who couldn't cut it anywhere else.

Agreed. These nurses can't even do simple wound care... I'm talking like washing the wound with soap and water. Nothing too fancy. Now I find myself writing things like "monitor for a, b, c" and "consult me if..." on each patient because the psych docs are too busy to notice and the nurses are too dumb to notice.

 

Right now, fighting with the state on a case of a schizophrenic because the nurses and docs failed to consult me on a patient who didn't pee for 48+ hours and went into renal failure.

 

2 months and counting until I won't be renewing my contract with them.

 

 

Let food be thy medicine

[cbrsmurf]

Off topic, but a BP in 170s for a pt who is normal in the 140s doesn't warrant a call imo, just a fyi on the next provider visit.  The increased risk of a CVA in a pt without CVD is pretty small in the short-term.  Definitely needs a recheck and measurement everyday for the next week and then If it was still that high then yea, I'd do something about it.  

[peaceloveandPA]

Off topic, but a BP in 170s for a pt who is normal in the 140s doesn't warrant a call imo, just a fyi on the next provider visit. The increased risk of a CVA in a pt without CVD is pretty small in the short-term. Definitely needs a recheck and measurement everyday for the next week and then If it was still that high then yea, I'd do something about it.

Wow, really? Does everyone agree with this? U don't think that a pt with hypertension and polycystic kidney disease needs to be put on an ACE? Or that a BP in the 170s doesn't need a recheck the same day?

 

 

Let food be thy medicine

[cbrsmurf]

Anything over a systolic of over 160 should be rechecked on the same day imo, just to make sure it is an accurate measurement. A bp of 170 does not warrant acute treatment in a pt without renal or cv disease as it may just be a transient increase. In your pt who has pkd (which i missed when reading your post) I would want to be notified and monitor for a day or two and treat if it was still elevated.

[peaceloveandPA]

Anything over a systolic of over 160 should be rechecked on the same day imo, just to make sure it is an accurate measurement. A bp of 170 does not warrant acute treatment in a pt without renal or cv disease as it may just be a transient increase. In your pt who has pkd (which i missed when reading your post) I would want to be notified and monitor for a day or two and treat if it was still elevated.

Got it!! That makes sense. I ended up putting her on lisinopril since her BP was elevated since admission (4-5 days)

 

 

Let food be thy medicine

[Derbingle]

At our ED we have psych holding unit, VS done q8 minimum as many of the patients have unknown or undocumented medical hx. PAs round daily at any time, but at least once in 24 hr. Many of us document daily "notify MD or PA for HR, SBP, temp > or < xyz" (whatever parameter you decide) to help cover yourself in case of problems.

 

Some of the psych nurses simply sedate the patient and are done with it. They may let them sleep for hours and dry up with no PO intake. So I also tell them to ambulate them TID and give fluids. We arent psych but hosp wants ED, (not psychiatrist/MD) to manage pts medically. I agree a simgle sbp 170s isnt worrisome if its asymptomatic. But if you arent rounding and are relying on pysch nurse to determine what is symptomatic, could result in problem as described above. Why wouldnt they measure it again?

[peaceloveandPA]

Yeah, the problem is I only see them on admission and for consults as ordered by the MD. I will follow up or write parameters if they have a medical history or something needs to be followed. The MD is supposed to review their vitals, review ROS daily but I know that never happens with certain attendings. I've seen one of the docs round on the whole hospital (60 pts) in one hour tops.

 

Also, the techs are usually taking the vitals (bad idea?) and it probably didn't register in their head and they failed to alert the nurse. But that nurse should at least review everyone's vitals, in my opinion. It's a big cluster fuck and changes are a-coming....

 

 

 

 

Let food be thy medicine

[ventana]

170 sbp------- not very worrisome.....

 

would be nice to get a recheck with them seated, not talking blah blah blah on getting a good BP

 

But really what is the risk of a 170 sbp for a 5 day hospitalization.....  Honestly I would NOT start a new med if they had a PCP that was invovled in the care - I would call the PCP and ask if they had prior readings, and what they had tried (if anything) in the past......

 

We are just to quick to put on meds for little reason......   HTN is not made one a single measurement, PKD and htn is a PCP issue not an inpatient issue with a single elevated BP when the patient is "freeking" out and amitted for psych....

 

 

 

now to argue that point - there is some interesting studies that show that meds started when inpatient the patient takes more seriously and their complaince goes up.......

 

 

but on the flip side..... if they are non-compliant and you put them on a med and do not follow up - "they get d/c the next day" did you really help them?

 

 

 

Hence, call the pcp - talk with them even if just briefly.

 

 

 

 

And if a nurse called me from a psych ward for an "emergency BP of 170" I would educate her that this is not an emergency (look up HTN crisis to learn more)

 

 

 

Tough call - as the post was about nurses - if they had a thought and realized it was not a big deal - fine......  if they just didn't notice or care - not fine......

[peaceloveandPA]

170 sbp------- not very worrisome.....

 

would be nice to get a recheck with them seated, not talking blah blah blah on getting a good BP

 

But really what is the risk of a 170 sbp for a 5 day hospitalization..... Honestly I would NOT start a new med if they had a PCP that was invovled in the care - I would call the PCP and ask if they had prior readings, and what they had tried (if anything) in the past......

 

We are just to quick to put on meds for little reason...... HTN is not made one a single measurement, PKD and htn is a PCP issue not an inpatient issue with a single elevated BP when the patient is "freeking" out and amitted for psych....

 

 

 

now to argue that point - there is some interesting studies that show that meds started when inpatient the patient takes more seriously and their complaince goes up.......

 

 

but on the flip side..... if they are non-compliant and you put them on a med and do not follow up - "they get d/c the next day" did you really help them?

 

 

 

Hence, call the pcp - talk with them even if just briefly.

 

 

 

 

And if a nurse called me from a psych ward for an "emergency BP of 170" I would educate her that this is not an emergency (look up HTN crisis to learn more)

 

 

 

Tough call - as the post was about nurses - if they had a thought and realized it was not a big deal - fine...... if they just didn't notice or care - not fine......

Hmmm.. Interesting, and good to know. I can assure u that these nurses probably just didn't notice/didn't care from my experience with them over the past 10 months... They know very, very little.... I put her on a med based on high BP over a weeks time. Mind u, this is a very calm-appearing but depressed pt, not an anxious/psychotic one. Seeing as her PCP is the naval hospital, she really doesn't have just one PCP that knows her. And getting in touch with someone at the naval hospital is like jumping through hoops. Most of the navy docs will tell u they won't talk to u.

 

Interesting take.. Did I help or hurt her? I am not sure, but after being consulted on her, I kinda felt "obligated" to do something more than document all those high readings and then just say "refer to PCP after discharge" which I still counseled her to do. She seemed like a compliant pt who would follow up.... She was actually there voluntarily seeking help for her depression.

 

 

Let food be thy medicine

[Febrifuge]

What got my attention was the diastolic of 110, honestly. That's kind of a no-brainer; check that s#!% again and if it's still high, you call.

[dannydude57]

I feel you,

 

I was an RN in the ED before P.A. school. One afternoon, I get this telephone call from a RN in our attached inpatient psych facility to notify us that they are sending someone over for "respiratory distress." I ask for vital signs, especially SpO2 and respiration rate. The reply was "we did the morning vitals and they were fine." The vital signs were never repeated. So I asked them "how they knew this patient was in respiratory distress?" I was told that "the doc did an ABG and told us he was in respiratory distress. We'll bring him over when we get a chance." Guy arrived, breathing even and unlabored, SpO2 high 90's. He was sick, but not in distress. 

 

I wish it was an isolated example, but it wasn't. I'm as flabbergasted as your are, brother. 

[Derbingle]

Maybe Create a standing order for your consults (to be performed daily)as long as the pt remains inpatient, indicating the call back parameters sbp, temp, pulse spo2 > < with vital sigh q8 or what ever you like. make them walk them and drink fluids. You are making recomendations and psych doc is suppose to implement but ignores you recs, just make them orders yourself. If he considers your recommendations and chooses to ignore them, kinda puts it on him. At least will help discover problems. Lots of info in repeat VS. RN must carry out the orders, meds, fluids, whatever, VS too. ps use a short acting Bp med vs starting long term therapy just nudge them dowl a liitle. Clonidine ? They can get long term meds out-patient. Youre consulting so protect you! How much longer at this job? Want to come to a crazy ED? You could pratice psych and learn evrything else too :) ps see my previous post of trials in starting ER!

[primadonna22274]

Wow, really? Does everyone agree with this? U don't think that a pt with hypertension and polycystic kidney disease needs to be put on an ACE? Or that a BP in the 170s doesn't need a recheck the same day?

 

 

Let food be thy medicine

In the dirty south we don't even blink until the SBP is 200 and DBP is 120.

Truth be told, there is little value in chasing BPs if the patient is asymptomatic IN THE SHORT TERM. Of course we want long-term BP control to reduce end-organ damage but that won't happen in a weekend. I like to think the nurses would have consulted you if the patient was symptomatic.

That said, where I trained the psych nurses were top-notch and in that hospital the floor nurses were questionable...but of course I was on Geri psych and the rest of the hospital was empty.

[peaceloveandPA]

In the dirty south we don't even blink until the SBP is 200 and DBP is 120.

Truth be told, there is little value in chasing BPs if the patient is asymptomatic IN THE SHORT TERM. Of course we want long-term BP control to reduce end-organ damage but that won't happen in a weekend. I like to think the nurses would have consulted you if the patient was symptomatic.

That said, where I trained the psych nurses were top-notch and in that hospital the floor nurses were questionable...but of course I was on Geri psych and the rest of the hospital was empty.

Did a rotation in Geri-psych... Very interesting. Here most of the nurses are military wives and pretty sure they could give 2 shits about their job. (Most of them)

 

 

 

 

Let food be thy medicine

[primadonna22274]

Did a rotation in Geri-psych... Very interesting. Here most of the nurses are military wives and pretty sure they could give 2 shits about their job. (Most of them)

 

 

 

 

Let food be thy medicine

My humble opinion is that the geriatric psychiatrists retained their medicine skills quite well because of the nature of their patient population. My mentor told me "only BAD psychiatrists forget their medicine". I almost chose psych because he inspired me so but ultimately I am an internist at heart.

[EMEDPA]

In the dirty south we don't even blink until the SBP is 200 and DBP is 120.

 

of course you worked in the "stroke belt"

 

http://en.wikipedia.org/wiki/Stroke_Belt

 

in Haiti they don't even tx htn until the bp is > 180/110. that's the WHO standard...although honestly I fudged the guidelines and treeated plenty of folks >160/100.

[cbrsmurf]

You don't have to treat short term non-emergent HTN --

 

 

I don't think anyone has mentioned that yet in this thread.

 

 

It should be reiterated at least 5 times.  

 

 

At least.

 

 

;)

[Febrifuge]

You don't have to treat short term non-emergent HTN --

 

 

I don't think anyone has mentioned that yet in this thread.

 

 

It should be reiterated at least 5 times.  

 

 

At least.

 

 

;)

Well, there's one then. :)

 

Short-term, no - but the repeat vitals will help establish short-term vs SHORT term, y'know?

 

And if there are two SBP's above 100 a few months apart (now I'm going off on a tangent about the Urgent Care, not inpatient) the thing is I want them followed up because I don't know the BP hasn't been regularly or even constantly that high in the interim. If they're sitting in front of me and look and sound fine, no, I don't worry. But if I've never seen someone before, they came to see me because of a weird headache, AND their SBP is high... I dunno, man, that sounds like a job for the ED to me. If nothing else, they can check and re-check q15 minutes for 2 or 3 hours, which I can't really do without going outside my group's concept of what the UC is about.

[nebaker]

I work at a facility with an inpt psych unit.

the psych docs are fine with psych issues but have forgotten the rest of medicine. the psych nurses call er nurses to start IVs, draw blood, etc.

they call us to consult on whether giving an ordered stool softener is ok at 3 am. 

all they do is pass meds and give IM injections. a tech could do their job and do it better. psych is where the worst nurses migrate to, the folks who couldn't cut it anywhere else. 

 

As someone who works as a mental health tech while in the process of applying to schools, I can testify firsthand that this is exactly what happens with the nurses on the unit. I've actually heard them having conversations about how they only desire to work in psych due to how easy it is. Their only direct interaction with patients is passing out meds, yet they are the ones reporting to the psych doctors; the entire system is an absolute mess IMO.

[peaceloveandPA]

Ok... here's another example. Got a medical consult for a "sore throat" on a patient who was admitted 4 days ago....

 

I ordered cepacol lozenges prn, and ordered rapid strep on admission "call PA with positive result." Cepacol was not given once. Rapid strep was not performed. I asked the patient "did anyone swab your throat?" She said "No. The nurse looked at my throat and said it wasnt red so she wasnt go to do what you ordered." Granted these are psych patients, so can't really trust if that was what actually happened, but really?!

 

Sorry, just venting.