psych clinicals

Dude I can totally understand!!!! My step-grandma had harsh dementia before she finally died and she would bounce from one conversation to another. Since I didn't really like her, I just started avoiding her.

But at the same time (I just wrote an essay on this today, so bear/bare, whichever one it is, with me!) you need to look at what's making you so uncomfortable. You can't be the best nurse than you can be if you have un-examined biases, because it will affect your nurse-patient relationship in a negative way, cause your patient will be able to sense your distress and that'll just freak her out and it'll just make everything worse. Maybe instead of telling your instructor that your needs are not being met, figure out how your needs need to change. Try to look at it from your patient's pov.

As a student, it is about your needs, but it's also about learning how to cope with situations that you absolutly HATE and have a hard time with, because in the end, that's what makes us better nurses! Think empathy! :D I just had one today (stupid in-class essay that was totally unfair, but that's another story).

Maybe spend more time with your patient and try to get to know them better. I don't know anything about schizophrenia except that it has something to do with dopamine levels in the brain (I think!), but maybe someone on here does! Are there usually patterns during a conversation with a schizophrenic?

It sucks that you're having a hard time tho. One of my instructors is the devil and gives us these absolutly INSANE assignments and pretty much sets a bunch of FIRST TERM NURSING STUDENTS up to fail. EVERYONE fails her class, so she ends up having to scale marks by 20%. It's soooooo dumb, but somehow she gets away with it and she's been teaching for like 20 years or something too. It's sick! I hear ya! Hope it gets better!!!

-Fellow nursing student who is currently studying for a bio midterm. Blech.

Wow that was long... sorry!

Forgive the ramble, I hope some of this is useful

I work primarily in psych, and I have to say, I agree to an extent with your instructor. The patients are not in it to meet your needs, nor can (nor probably should) your patient assignment be designed to play to your strengths. One of the hardest things in psych is to learn to deal with the manic patient who cannot stay on one subject, the schizophrenic patient who wanders between various planes of reality, and the borderline patient who has no boundaries whatsoever and seems determined to sabotage him or herself despite the best efforts of all their providers.

What *should* be getting tailored to your needs is the instruction component. If I had my druthers, every nurse would get a taste of dialectical behavior therapy, and lower her stress level by a lot of decimal places when dealing with uber-needy patients in general, and borderlines in particular. And at least a short unit on coping with the schizophrenic patient, and both phases of bipolar. Because even if you are in a primarily med/surg setting, you will still have mentally ill patients to deal with from time to time. If they can't manage all that, at the very least there should be time spent before and after clinical reviewing the disorders your patients have, and strategies that are useful in dealing with them. Which (other than DBT) will largely seem to defy logic, but will help.

Dementia, ideally, should be dealt with entirely separately. In my experience, one deals with the delusional schizophrenic entirely differently than one deals with the Alzheimers patient. After all, if one cannot encode new memories, reorienting them is a futile endeavor that will only frustrate you and them, and it's often best to "play along" with the reality they are experiencing in whatever way will keep them the most comfortable and calm. With someone with schizophrenia, however, sometimes it is worth trying to reorient them (and sometimes it's not, and redirecting is the best you can hope for) and you can actually help them re-establish at least passing contact with consensus reality.

Someone in a serious manic phase like your pt yesterday? If at all possible, I try to get them to exert all that pent-up (or not so pent-up) energy on something either useful or enjoyable, or ideally both. I had one in a group home setting who could ride out a manic phase best if she was allowed semi-free reign to clean the house from stem to stern, regardless of the hour of the day. (Did learn the hard way not to let her clean the fish tank, though. Poor fish.) With another, give her some paint and canvases, or charcoal and paper, and let 'er rip. In both of these cases, though, I'm talking about someone whose swings are at least somewhat modified by medications to the point they don't need to be inpatient every time they swing one way or the other.

What is the goal of a day spent in your psych clinical? Therapy? Working on ADL's? Goal-setting and recap? If I have an idea what they are trying to have you do with your patients, I may be able to offer some suggestions either to try with them or to bring up to your instructor, to see if you can get more out of it.

Re: Forgive the ramble, I hope some of this is useful

Thanks for the insightful comments.

Most of our goal is to see what Psych nursing is about, and how it differs from med/surg. And to practice using "therapeutic communication" - which works a lot of the time, but when a patient isn't oriented to reality, I find it difficut to sit and say, "You seem unable to focus. Tell me about that."

Nursing is my 2nd career (I'm 30, background in computers and theatre tech). I work on a m/s floor as an aide, mostly with geriatric patients, and I love it - that's where I want to spend my time. We do have psych pts, but to me, the main focus is healing them physically. And if the pt acts out or starts throwing ice cream at me, I can leave the room. I find it hard (for me) to work with patients where I don't feel like I'm doing anything useful. I know that as a student, we're only in clinical for a short time, so we can't measure our pt's progress, but on m/s it just feels like I'm doing something.

I noticed that you said "encode new memories" - that's a phrase that I haven't seen turn up in lectures yet. Can you explain that a little more? Is it a schizo thing? I really appreciate your input.

-catherine

Re: Forgive the ramble, I hope some of this is useful

Pardon me for jumping in... heh. But, what I interpreted the "encoding" bit to mean was that patients with dementia are physically incapable of forming new memories. That is, their brain functioning makes this impossible. However, people with schizophrenia have difficulty separating real memories, or reality in general, from "fantasy," or delusions. They CAN learn, with a lot of practice, therapy, and drug therapy, to get much better at differentiating between what's real and what isn't. People with dementia, on the other hand, simply do not have the ability to do this, and attempts at redirection, etc, will do absolutely no good and only serve to frustrate the health care provider and the patient.

Hope that is what firefly meant, sorry for jumping in!

Re: Forgive the ramble, I hope some of this is useful

Oh boy, did I get long-winded here. I didn't even know there *was* a character limit for replies, and apparently I exceeded it by about 100%! Splitting this in two, now.

And to practice using "therapeutic communication" - which works a lot of the time, but when a patient isn't oriented to reality, I find it difficut to sit and say, "You seem unable to focus. Tell me about that."


Not only is it difficult to say that, it's probably not horribly useful to either of you. With a sufficiently delusional person, the answer is apt to be something like a dissertation on the consistency of the pudding filling their skull. Sadly, I did not just make that up. For someone who is jumping around because they are in a manic phase, who has insight into their condition, what they might tell you is, "I'm manic today, duh." Also, not hugely useful.

Let me see if I can come up with a reasonable facsimile of a conversation with one or two of the persistently delusional people I work with regularly. Name totally fictional.

Sue: Can I talk to you about something?
Me: Sure, what's up?
Sue: I'm really concerned because I saw my mother drive by today and she didn't recognize me.
Me: Sue, do you remember that your mother passed away last year?
Sue: Oh yes, I know, but she's been reincarnated.
Me: Well, if she just got reincarnated, she'd be a baby, right?
Sue: I guess not, because she was driving a car.
Me: Oh. Well, what makes you think she didn't recognize you?
Sue: I waved to her and she didn't wave back.
Me (ok, her issue is "oh crap, my mother didn't recognize me," and it's abundantly clear she's not going to accept it wasn't her mother, so I won't argue with her, but I also won't agree with her. Meanwhile, I'll suggest something that may help allay her anxiety, that could actually be true of whomever was driving the vehicle.): Well, it's pretty sunny out today. Maybe the sun got in her eyes and she didn't see you?
Sue: Oh, maybe that's it.
Me: What if you write her a note, and say something like, "Hi, Mom. I saw you today, but I don't think you saw me. I miss you. How are you doing?" or something on that idea?
Sue: Maybe. So what is for dinner tonight?
Me: We're making lasagna and peas, with ice cream for dessert.
Sue: When I was a kid, my sister used to make these great lime coolers in the summer.
Me: That sounds good, why not ask her for the recipe, and maybe we can make it sometime?
Sue: I don't want to take my Zyprexa anymore. It hurts my back.
Me (giving up on the previous two topics): Your back hurts? We should talk to your doctor about that. For now, why not continue taking it, because sometimes things get worse if you stop a med suddenly.
Sue: My doctor came to my home yesterday and told me I don't have to take it anymore.
Me: Sue, while your doctor is a really nice guy, I find it very hard to believe he made a house call. Can I call him to confirm this?
Sue: Maybe I'll just wait until my appointment on Tuesday.
Me: That sounds like a good idea. Want to help me start dinner?

One obvious difference is that my focus is ADL's, not therapy, which gives me some handy re-focusing tools like housework, meal prep, budgeting, and so on. For the ones with poor boundaries, I often have to remind them repeatedly that I am not their therapist, in fact. But the tactic of getting them to elaborate on whatever they are talking about to find out the meat of what is bothering them (e.g. "mother didn't recognize me" probably her mind's way of dealing with the emotion of "I miss my mother," so I try to suggest something to allay the anxiety, and give her something constructive to do that may help with her grief), that tactic is similar.

Hrm. For someone who's really manic, I usually don't even try to direct the conversation. It's generally just not a happening event. In a therapeutic context, I suppose I might suggest my artistic client narrate what she is drawing or painting and ask questions about what it means to her. Half the problem, though, is their mind is racing so much faster than their mouth can catch up, though the hands can sometimes come close.

Part two

We do have psych pts, but to me, the main focus is healing them physically.

That is certainly true. But you will probably need to cope with their mental health as well. A particularly challenging example would be someone with borderline personality disorder who self-injures regularly, and re-opens the wounds. Telling them not to do it will accomplish nothing, and may even escalate the behavior. DBT prompts may help if they are already familiar with them. Restraints may temporarily solve the problem, but you can't possibly keep them restrained until a 6cm-deep gash heals completely. And if the reason they are in a SNF is to keep them reasonably safe and monitored until that gash can heal, keeping that person from re-opening it will be a high priority, which means finding strategies to help them cope with the symptoms that are leading to that behavior.

I find it hard (for me) to work with patients where I don't feel like I'm doing anything useful. I know that as a student, we're only in clinical for a short time, so we can't measure our pt's progress, but on m/s it just feels like I'm doing something.

And that is one area where psych is really, really hard. It's not just you! Because sometimes the disease is progressive and they won't get better, only worse, or else they'll seem to get better for a few months, and then experience a massive decompensation. And sometimes they surprise you. One client I came close to despairing of, thinking I'd soon be attending her funeral when she managed a successful suicide attempt ... is now doing better than most of the others, holding a job, going to school, and generally making me frequently drop my jaw and gaze in amazement. And some others that seemed for so long to be maintaining at least a somewhat functional baseline ... suddenly start doing things like throwing away all their belongings, and camping out on the sidewalk. It's profoundly frustrating at times, and I find I have to focus on how I can help this person make this day, or this hour, or even this minute and then the next more tolerable.

I noticed that you said "encode new memories" - that's a phrase that I haven't seen turn up in lectures yet. Can you explain that a little more? Is it a schizo thing?

No, more of an Alzheimer's thing. "Encoding" is what the psychology of learning folks call the process of the brain storing memories. With Alzheimer's, it's the part that does this that is most affected, then progressing to remove already-encoded memories in a more-or-less reverse order: newest memories get wiped first, oldest last the longest.

So, for example, if it's 3am and the lady down the hall with fairly advanced Alzheimer's is yelling for her husband, it's both pointless and cruel to remind her he is deceased. She will either get mad at you for "lying," or go into the initial stages of grief if she believes you ... and in five minutes will not remember it at all. It can be far more effective to find out what would be a reasonable place for him to be (at work? milking the cows? ran to the store?) as far as she is concerned, and go with it.

With someone with schizophrenia, not only can they encode new memories, sometimes they've got memories like steel traps! Any time I start to doubt that, someone quotes me something I said or did over a year ago and brings me up short. *g* So while they may not be willing to buy into your attempts to reorient them, as in the fictitious/composite conversation above, they can retain the thread of the conversation and may respond to reality checks (calling the doctor to verify a med change), or redirection, or something.

I really appreciate your input.

No problem. I like to ramble, if you hadn't noticed. *g*

Incidentally, I'm a 2nd (or possibly 3rd or 4th, depending on how you count stuff, mostly assorted types of office work, plus 8 years as a waitress) career CNA and mental health worker at 36. So we're in somewhat similar shes, in that respect, anyway. :-)

Re: Forgive the ramble, I hope some of this is useful

I just came across this post... I'm a nurse on a pulmonary/medical stepdown and we don't usually get psych patients, but I have a personal interest in psych... I just wanted to tell you that I really admire your style, even if the conversation was fictional... I am inspired, completely. Thank you!

Re: Forgive the ramble, I hope some of this is useful

::blush:: I have to confess, since it is a composite of a bunch of conversations I've had with a few clients with schizophrenia, some of those responses are things I thought of after the fact, thinking, "Oh, this might have worked soooo much better than what I actually said." :-)

Re: Forgive the ramble, I hope some of this is useful

Still, it sounded fantastic and I loved it!

Re: Forgive the ramble, I hope some of this is useful

This was an interesting post to read. I'm not a nurse (yet), but I'll have a B.S. in psych this December, land I plan on beginning a nursing program next spring. Right now, I work as a mental health tech. at a group home for mentally ill adults. The focus there is to get our clients back to the point where they can live independantly, so, most of our clients are relatively high functioning. However, I'd say about 1/2 at any given time have some form of delusional or hallucinatory disorder - usually schizophrenia, but some have things like severe depression with psychotic features, etc. I'd have to say that the "schizophrenic side" of things is absolutely fascinating to me, and I love working with them. Gah. I'm rambling!

Anyway, you seem to really have a handle on the psychiatric end of things. What type of work to you do exactly? What's your training. I'm curious about the psychiatric side of nursing. Eventually I would like to be a psychiatric nurse, possibly even a psych NP or CNS. :)

Also, a question for the original poster: What type of schizo was your patient diagnosed with? Disorganized type? To me, that is the most fascinating, but I can understand would be very difficult to work with... Good luck!

Re: Forgive the ramble, I hope some of this is useful

I'd have to say that the "schizophrenic side" of things is absolutely fascinating to me, and I love working with them.

Me, too. And in general, give me Axis I disorders ANY day over Axis II. *g*

What type of work to you do exactly?

I work a couple of different jobs. One is psychosocial rehab - I'm a residential assistant in a program for people who have their own apartments, but have a history of having difficulty maintaining homes in the community due to their psychiatric illnesses. I med monitor (I'm not a nurse, so I can't *give* them their meds, I can only remind them, unlock the cabinet, watch them take them, and then sign that I saw them, or that they refused, or whatever), do ADL coaching and skills training, DBT-prompting with those who have borderline personality disorder, and some days function largely as a taxi driver.

The other job is as a patient care tech (basically CNA plus pulse-ox, ECG, and glucose fingersticks) at a hospital, where I started out as a sitter, and still do sit from time to time. Most of the patients I sit for are either on suicide watch or have dementia, though some have delusional disorders or self-injuring behavior rather than suicidal behavior/ideation.

My training? Well, I minored in psych (though these days I wish I had majored in it, little did I know at the time). Most of my training has been on-the-job and in-services over the last three years that I've been working in these two places. Then last year I went and got my CNA primarily so I could do more with the patients I sit for than just watch them (hugely frustrating when they want to be put on a bedpan, say, and I was not allowed to do it as "just a sitter," meanwhile everyone on the floor is too busy to come do it right away).

Re: Forgive the ramble, I hope some of this is useful

DBT prompts may help if they are already familiar with them. Restraints may temporarily solve the problem, but you can't possibly keep them restrained until a 6cm-deep gash heals completely. And if the reason they are in a SNF is to keep them reasonably safe and monitored until that gash can heal, keeping that person from re-opening it will be a high priority, which means finding strategies to help them cope with the symptoms that are leading to that behavior.

I am only a nursing student, first year, PN. My goal is to go into Psychological nursing. After my BSN I want to get my Master's in Psychology and go from there... possably my PhD.

This conversation is fascinating and will be stored in the back of my mind for reference for some time to come, I'm sure.

My question is with the abreviations DBT and SNF. Could you explain, please? Sorry for those who know what that means and have to hear it again.

Thank you.

Re: Forgive the ramble, I hope some of this is useful

Sorry. I didn't mean to slip into a bunch of acronyms!

SNF is the easy one: skilled nursing facility. Sort of a catch-all for the various types of rehabilitation centers, nursing homes, convalescent homes, etc., that are out there.

DBT is dialectical behavior therapy. The nutshell definition is that it is a type of cognitive-behavioral therapy with a Zen-like mindfulness meditation component, used primarily in the treatment of borderline personality disorder but also useful in other situations. Here are some links with more information for the long version:

http://www.priory.com/dbt.htm

http://members.aol.com/njacbt/dbt.html

http://www.borderlinepersonality.ca/dbt.htm

This last one includes the most specific information related to the types of prompts I was talking about, that relate to the elements of distress tolerance, self-soothing, and interpersonal effectiveness. The big complaint most have with DBT is that when they are in a state of emotional dysregulation, they are too wound-up to remember any of these skills, so having providers who can prompt them to try one or more of them can go a long way towards averting problem behaviors.

I'd probably snap too. :) There's a guy I work with who tried to refuse working in the Alzheimer's ward because, he says, his grandmother lived in one and he'd be uncomfortable there, though his tone made it sound more like he simply didn't want to deal with dementia patients. I told him (somewhat politely) to get over it, and that's evidently what the DON told him as well.