Posts Tagged ‘Forensic Nursing long-term care’

Focus assessment of injury in a long-term forensic hospital setting

February 27, 2007

Keeping patients from harm is paramount to professionals in health care. In Psychiatric Mental Health Nursing, patients causing self-harm is the usual, but in a long-term care facility there are far more injuries sustained than those of self-harm. The facility where I work has a very active Recreational Therapy department including activities of basketball, volleyball, ropes course, weight training to mention a few. In addition to this the campus is sprawling across approximately 10 acres with some of the patient living areas (cottages) lying quite a distance from the main building where most of the programming and meals occur. This setting and therapies set the stage for many diverse injuries than for those of self-harm including sprains, bumps, bruises, falls during inclement weather and the like.
Nurses in this setting must have great competence in assessing for musculoskeletal injuries. Performing problem-focused assessments are a reality in this setting. The nurse must have skills in assessing each and every joint, skin lesions, edema. This is compounded by assessment for chief complaints of syncope episodes, and a whole inventory of other complaints.
The psychiatric patients (some with co-morbid mental retardation) are not always reliable in their reports, or are unable to describe their signs and or symptoms. With this being said it is imperative that Psychiatric Mental Health Nurses remain competent in their assessment skills, whether it is a comprehensive admission health history and physical assessment or a problem-focused assessment.
I challenge administrators in psychiatric facilities to offer continuing education to their Registered Professional Nurses in an on-going fashion to keep their skills current. I would be interested to learn how other facilities maintain the competence of their nurses.

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GI problems and the psychiatric mental health patient

February 20, 2007

I am going to illustrate a specific example and then request advice as to how to improve communication of assessment data to the attending.

The patient is a 45 year old African American male with an Axis I diagnosis of Schizophrenia, Chronic Paranoid and Axis III of Cerebral Palsy (CP), hypertension, gastritis, and urinary hesitancy.

Mr. M. is quite debilitated from his CP compounded by extra pyramidal side effects from his psychotropic medication. He is, quite to his embarrassment, incontinent of bowel and bladder. Very recently he began having tarry stools and his H&H; dropped significantly. Even though his stools were negative for blood it was obvious he was loosing blood. This is when he was worked up for and diagnosed with the gastritis. He was prescribed medication for the gastritis, his H&H; improved, but he continued to have frequent diarrhea stools.

Nursing staff vigilantly assessed volume and visualized the color and consistency of the stools. Auscultation of the abdomen found hyperactive bowel sounds, but little else. As the days went by skin integrity became a legitimate concern. Daily, and sometimes multiple times, during the day nursing reported frequency of bowel movements to the attending psychiatrist and to the onsite internist. The problem seemed to be that the local consulting gastroenterologist had little patience or desire to work with the mentally ill and dismissed the patient. As the problem grew worse finally a successful appointment occurred and the patient was diagnosed with Crohn’s disease and treatment was prescribed.

How could the nurses have better articulated the distress that this patient was enduring?

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Nursing Process implementation in long-term forensic nursing care

February 16, 2007

I have cared for “criminally insane” patients during my 28 years as a psychiatric mental health nurse in the acute care setting. Those patients with impending revocation of a conditional release, pre-trial evaluations, incompetent to proceed, and NGRI, but now I am working in a long-term care state hospital that is greater that 90% forensic. Of those about 43% are shorter stay patients that are incompetent to proceed. In this population regaining competence is touted to be the primary focus of care and treatment.
My professional dilemma is implementation of the nursing process at this organization. My observations show less than adequate assessment, absent planning, fairly good intervention/implementation, and non-existent evaluation.
As an administrator I see opportunity to make dramatic change in this department. I see opportunity to elevate the nursing professional practice to a level that could be the benchmark. I see an opportunity to introduced evidenced based practice into this interdisciplinary yet medically driven organization.
My charge is to create, implement, educate, and mentor the advancement in nursing practice in this organization. My quandary is and my question posed is; Does anyone have input into methods or approaches that will expedite and facilitate this paradigm shift?

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