Just another night in the psych ward

I know I should really be keeping up with this blog. I'd like it more for my own personal memories since there are probably tons of nursing student blogs out there. So....prioritize blog!

Anyway, last night was quite interesting. I was feeling pretty ready to go in to the psych unit yesterday, as things are sort of slowing down a bit around here with Thanksgiving break being an entire week (!) off but I was quickly reminded of how things go around there once I arrived. All but two of the beds were filled on the 17-bed unit and that probably meant we would also have two intakes throughout the evening.

After day shift report, me scribbling down every word I could, the two nursing students from the day shift walk in to the nurses' station. One of them tells me that so-and-so would be an interesting patient to take on, that she is showing some signs of experiencing internal stimuli. The other one tells me not to take D. as a patient since he stinks. Literally stinks, apparently, and is passing gas like noboby's business. Ok, great.

I decide to ask a newer nurse who is an alumni of my school if she'd mind if I follow her today. She says she doesn't mind and I watch her get all her meds ready for the evening. She sends me out to take some vital signs and I get a reading of 210/125 with a pulse of 111 on this guy. This person was a big guy with major depression who is detoxing from alcohol. What my preceptor really wanted me to do was to complete a full "Tranxene assessment," which includes taking vital signs, checking for tremors, diaphoresis (sweating), orientation to person, place, time, and situation, etc. I go back out and finish the assessment and he gets a high score, indicating that he needs 30 mg of the med. Preceptor, RN is really worried about him. Twenty minutes later we take his vitals and he's got a BP of 145/85. Nice, not great, but he's feeling better.

I take on my own patient for the first time since the summer (and that was only 3 days!) and for the first time in the psych-mental health unit. Ms. V. is my patient and the first thing I did was a one-to-one with her. Ms. V is hearing voices and she's hyperverbal with some pressured speech. She related some interesting stories about what the voices say, and they mostly talk about her. There are at least 2 of them, sometimes more, and they tell her to kill herself. They ask her what she's doing at the hospital, what she thinks she'll really get out of it. They wonder out loud in her head who she thinks she is. The voices come from the bushes, from the windows, from the vents. It seems to me that white noise sets them off but once they get going, she can't stop them. They make her cry and say mean things about her. This is the first time I've ever been faced with someone who is suffering in this way. She looks worried, scared; she admits that she never thought she'd be a crazy person. I realize that it could be any of us.

I did try redirecting her thoughts, asking her what the purpose is of listening to them. Reminding her that they are not real, that they are a malfunction of her brain at this time. That it is all chemical and physiological and that I am so happy she is here getting help. That her meds may be able to help her. I try to be a good student nurse but run out of words somewhere. I know she is looking to me for help. I want to grab a hold of something for her, I want to reassure her that it will all be ok....but I can't because it might not be.

"explorative" journal

This is my first "explorative journal" assignment for my Psych-Mental Health rotation. So, that being what it is, this is kind of school-ish and leaves a lot to be desired as far as blog entries go. However, I am so very exhausted and at least wanted to post something about my first couple experiences there, that this will have to do for now. Next week will be my third week in the acute psych unit.

Here you go:

During my first clinical week for Psych-Mental Health Nursing, I experienced a wide variety of experiences and interactions with both clients and nurses in {deleted} Hospital. After listening to the report for the day shift, the “mid” shift began at 3 pm. Following a very experienced nurse for the first couple of hours was an eye-opening experience for me. I had not known what to expect before coming, but did have phrases from lecture echoing through my head such as, “Never touch a psychiatric patient,” and pictures from the schizophrenia videos especially were running rampant through my head. All of the material from lecture, videos, and my notes were beginning to come to life for me.

Talking to my first client felt daunting at first, especially since “D.*” was a very depressed person with fibromyalgia who was experiencing some severe medication side effects, which I quickly found out about. I asked her if it was okay that I sit next to her and she responded that I could. When I asked her how she was doing, she immediately began to tear up and then cry, rubbing and pulling at her face with her hands, and saying that she is having so much pain in her face. She was experiencing tingling, throbbing, and stabbing pain in her face and neck, I found out after probing her a bit more. She was sure it was from [her medication], which she had just started as a new medication that morning. I tried to find out more about her and tried a few more open-ended questions such as, “Tell me a little about what it has been like for you since you’ve been here.” She was able to expand a lot about her experiences in the unit, as she had been admitted before. Her affect brightened considerably when talking about her three children, and by that time the pain in her face and head seemed less of a factor at the moment.

The experience with D. seemed to go rather smoothly, and I found myself utilizing some the therapeutic communication techniques from both this class and another nursing class. I felt slightly proud of myself that I was able to get at some of D.’s underlying feelings and issues, and that she was pretty open with me at the time. However, I also realized that I did not ask her for a pain rating which may have been important information to relay to her nurse. After the experience, I did go to her nurse about her complaints of pain and the possible medication side effects. Her nurse at first seemed not to take the information seriously and I questioned my tone of voice during the interaction. Perhaps I was not assertive enough or did not seem worried enough about her pain when speaking with her nurse. Then again, maybe I was “just” a student nurse who is still far from recognizing important signs and symptoms of medication side effects. One important question raised about this experience is: Is a side effect of Zoloft increased fibromyalgia pain? Is there any research about this? Could it be that strange pains like D.’s is a common side effect even for patients without fibromyalgia? Searching the Davis Drug Guide and even delving into the CINAHL research database through the college would be ways of finding out some of this information.

Another experience I had with a client was with “A.*,” a young man of 25 who was admitted only about 20 hours prior to my conversation with him. He drank excessive amounts of alcohol the night before and his friends took him to the emergency department when he began talking “nonsense” and apparently brought up some suicidal thoughts more than once. While talking with him, he was extremely nervous and just could not sit still. In trying out some of my therapeutic communication techniques, A. seemed to be very focused on his being released in order to get schoolwork done, as he was under a lot of pressure and in a master’s program. Some of the strengths of our communication were that I believe he opened up relatively quickly and we discussed ways in which he can better handle his high stress and schoolwork that did not involve alcohol or marijuana, which he admitted to occasionally using to excess. He talked numerous times about how “this stuff” (group and individual counseling) “doesn’t work,” and I realized I almost wanted to talk him into it. After our conversation I realized that instead of being silent and listening to him continue about that, maybe I should have asked him some open-ended probing questions about what he thinks it is about counseling that “doesn’t work.” I also noticed that I began to feel that he was actually trying to convince himself, and not me, that he could and should go home and just pretend the experience did not happen. I could have even been bold and stated that it seemed that way to me.

One question I had after my interaction with A. is: What are some of the ways of communicating differently with people of higher educational experiences versus people with much lower levels of education? I will have to search through some communication techniques resources in order to fully expand my knowledge of this aspect of client care. This, to me, is something I know in my gut, but still need and want concrete techniques to try when dealing with people of differing educational levels.

Overall, my first week’s experience at this unit was trying, complicated, and informational at the same time. It turned out that D.’s nurse did recognize the problem with her and gave her a PRN for her head/face pain and D.was feeling better by the time I talked with her later in the evening. I was glad to have five days between the first week and the upcoming week to process all that happened and the ways in which I can improve some of my communication techniques. I was able to go back through some of my lecture notes and begin to piece together the information with real-life experience for the first time, which makes the experiences meld together a bit better. Next week I’d like to work on better communication with both the clients and the staff.

*First name letters have been changed.

(fake) Mental Status Exams in the Afternoon

I keep wanting to catch up on some of the things that have happened so far, but I'm short on time (like any good nursing student) so I'll focus today on this last week.

I have finished the lecture part of my psych-mental health class!!! This is amazing and I almost felt like it would never come. We had 4 major exams every other week for the first 7 weeks, and they were just plain difficult. The first focused mainly on psychopharmacology and I think we all thought it couldn't get any worse. But that turned out to be, at least for me, the least of my problems in this class so far. That was really rote memorization and the other tests proved much more difficult for me, with lots of "select all that apply" questions with built in answers that, I swear, in some instances, could've gone either way. But apparently our professor loves questions that are just as tough, if not tougher, than NCLEX questions. I know I should be grateful that I am being prepared early for this test-of-all-tests, however, some of these questions were ridiculous.

I should also be grateful that our school has about a 97% NCLEX pass rate, and for the accelerated students it's more like 99%. Could I possibly be that 1% that doesn't make it? Blah. It feels so far in the future that it's hard to even imagine being anywhere near ready for it.

This week I start my clinical experience for psych-mental health in an acute care psych ward of a major hospital in town. I'm on from 3:30 to 11:30pm so that means I have to get in there at about 2:45 in order to be ready for report, which starts at 3pm. We had an orientation to our clinicals for two very long days last week, in which we sat in a giant lecture hall for 8 hours for most it, until the last couple hours which were spent doing simulated mental health status exams with professors acting as patients with certain diagnoses. We had to come up with their diagnosis, and follow through with the interviews for 30 minutes. My "patient" had PTSD and was "sleeping" when I arrived in the "clinical area." The first interviewer (not me) decided to wake her up by touching her on the shoulder at which time she jumped up flailing about trying to punch and kick at us (kinda). After the "patient" settled down, we got into the interview and she seemed relatively stable other than flashbacks. It turned out well, and the initial interviewer showed great nonverbal skills and therapeutic communication techniques. I basically got to watch that part and take notes on the client's speech patterns and nonverbals. So far that has been one of the best learning experiences during classes.

My First Blog

I had thought about blogging about my student nurse experience for a couple months, and since I am a bit of a procrastinator, here I am. Almost five months into my nursing program, here comes my blog.

A bit of background. I started nursing school in June of 2009. I'm in an accelerated second-degree bachelor's program and recently started the fall semester after a less-than-hectic summer of basic nursing classes. So far, it has been interesting, to say the least, relatively difficult, and my schedule has been pretty much jam-packed since fall started.

Yesterday my clinical group for a Health Promotion class went to a government-funded low- to no-income home where we had to brainstorm about clinics we can set up to help people in the community. Some ideas are blood pressure clinics, a sock drive for the homeless, nutrition information, and, my personal un-favorite, a foot-care clinic. Our clinical instructor is basically making us do a foot care clinic for either low-income folks or the homeless. So we thought we'd do a sock drive in order to be able to give people decent new socks who may not be able to buy socks for themselves. I know how important foot care is, but have a hard time with feet, and really need to look inside myself and remember the beauty of helping others in this way. It is a basic need that many, many people really don't have the means or understand the importance of. So many problems can arise from improper or neglected foot care. However, I need to get over the gross factor and see beyond my superficial view of the whole thing.

Much more to come.