[hsieh]

how would you rate patients as needing more "skill" to successfully deal with? for example: which of these patients does a nurse need to be most skilled to deal with successfully? agitated mentally ill, agitated personality disorder, chemically dependent, agitated dementia, or "normal" person? i would say:

most skill needed: agitated dementia
then: agitated mentally ill
then: agitated personality disorder
then: chemically dependent
least skill needed: "normal" person

[cougarnurse]

To me, it all depends on the situation. Have seen some 'normal' ones get quite agitated. Your ranking is good, though.

[kimmiejs]

Originally Posted by hsieh

how would you rate patients as needing more "skill" to successfully deal with? for example: which of these patients does a nurse need to be most skilled to deal with successfully? agitated mentally ill, agitated personality disorder, chemically dependent, agitated dementia, or "normal" person? i would say:

most skill needed: agitated dementia
then: agitated mentally ill
then: agitated personality disorder
then: chemically dependent
least skill needed: "normal" person

In my opinion dealing with a family member that feel guilty or have other issues to deal with. Recently I had a patient that had been recently placed in a nursing home by her daughter because she was too busy being the "Volunteer of the Year" to help her aging mother so she could live in her home and not be placed in a nursing home. Soon after being placed in the nursing home she fell and broke her hip and had an ORIF. She did not do well from the surgery and they were unable to extubate her after surgery. Her daughter stood at her bedside in the ICU asking her "Why she was doing this to her and why she was trying to make her feel guilty"? She definitely had issues.

[stillearning]

Skill, in any arena of nursing, is often a matter of infra-structure -- meaning, in what sort of setting is the care to be delivered?

The diagnoses you cite, could all be managed by a skilled CNA if the setting was a well-organized psychiatric setting with clear policies for care, good medication-management, exceptional nurse/physician assessment and solid community programming.

But, alas, the care is all too often delivered in a nursing home that is understaffed, care is poorly planned, interventions are not strategic and medications are added symptom-by-symptom! This is a set up for chaos no matter HOW skilled the individual care giver may be!

Think of it as a two-by-two table. . .
In the lower left quadrant are those patients whose care requires little diversion from the protocols always in use (in other words, little creativity). Additionally, patients here are UNlikely to experience a rapid change-of-condition in the near future -- they may be sick, but they're stable. -- THESE PATIENTS REQUIRE YOUR LEAST SKILLED CAREGIVERS.

In the upper left quadrant are those patients whose care requires significant diversion from the protocols always in use (in other words, thoughtful, change-care-as-you-go, creativity). Still, patients here are UNlikely to experience a rapid change-of-condition in the near future -- they may be challenging, but still, they're stable. -- THESE PATIENTS REQUIRE YOUR MORE SKILLED CAREGIVERS -- people who can THINK on their feet!

In the lower right quadrant are those patients whose care also requires little diversion from the protocols always in use (in other words, we know what to do for them). However, patients here are VERY likely to experience a change-of-condition in the near future -- this instability can make a big difference if the caregiver can not respond to the change. -- THESE PATIENTS REQUIRE CAREGIVERS who can spot the change AND know what steps to take!

Finally, In the upper right quadrant are those patients whose care constantly requires reinvention and re-thinking! Additionally, patients here are frequently experiencing a change-of-condition -- they are both sick and unstable -- THESE PATIENTS REQUIRE YOUR MOST SKILLED CAREGIVERS -- nurses who can assess what's going on and adjust the care accordingly!

This is a grid I have used many times to help make patient assignments! Hope you find it useful!

--p

[Sylvia321]

Originally Posted by hsieh

how would you rate patients as needing more "skill" to successfully deal with? for example: which of these patients does a nurse need to be most skilled to deal with successfully? agitated mentally ill, agitated personality disorder, chemically dependent, agitated dementia, or "normal" person? i would say:

most skill needed: agitated dementia
then: agitated mentally ill
then: agitated personality disorder
then: chemically dependent
least skill needed: "normal" person

I've never worked in a nursing home,yet I have had all of the above on a regular med/surg unit. Your synopsis is good. In the majority of facilities I've worked in, optimal assistance is not available. CNAs are floated or canceled, also unfortunately, many CNAs are not trained well. Other than CA. staffing is poor, leading to increased problems dealing with the above patients. One to one on a med/surg unit is not realistic. They all can be a challenge to deal with.

[TriageRN]

Different folks need different skills. For instance, say I have a highly demented pt who keeps getting OOB, can't remember what you told them two minutes ago let alone know where they are, keep tugging and pulling out IV's and Caths....well, they don't take as much social skill out of me as they take lots of running around and help from others. They can certainly be handfulls!!!

Some of my most challenging pts are the elderly from very posh assisted living homes that get every need of theirs done by an aide and can't really do anything anymore for themselves! They call non stop for things they can and NEED to be doing for themselves, complain that you have taken and hour to get to them when it was three minutes, start spouting "I paid for this service, and earned your complete attention" (yeah, and although tempted, I don't say "no medicare did..and I am paying out the nose for it...and I won't even get it when I am older!"). They are a social challenge as well as task oriented challenge too!

But my most most CHALLENGING pts are the ones that can't speak for themselves or won't...and let a overly dominating relative take over their care! Trying to be nice, get my job done safely and well, trying to actually establish a pt/nurse relationship with the actual pt, being driven by a taskmaster family member non stop, getting yelled at for nothing..and typically something I can't control or out of my scope, and not finally screaming at them is a big Challenge!

[Ricu]

Originally Posted by stillearning

Skill, in any arena of nursing, is often a matter of infra-structure -- meaning, in what sort of setting is the care to be delivered?

The diagnoses you cite, could all be managed by a skilled CNA if the setting was a well-organized psychiatric setting with clear policies for care, good medication-management, exceptional nurse/physician assessment and solid community programming.

But, alas, the care is all too often delivered in a nursing home that is understaffed, care is poorly planned, interventions are not strategic and medications are added symptom-by-symptom! This is a set up for chaos no matter HOW skilled the individual care giver may be!

Think of it as a two-by-two table. . .
In the lower left quadrant are those patients whose care requires little diversion from the protocols always in use (in other words, little creativity). Additionally, patients here are UNlikely to experience a rapid change-of-condition in the near future -- they may be sick, but they're stable. -- THESE PATIENTS REQUIRE YOUR LEAST SKILLED CAREGIVERS.

In the upper left quadrant are those patients whose care requires significant diversion from the protocols always in use (in other words, thoughtful, change-care-as-you-go, creativity). Still, patients here are UNlikely to experience a rapid change-of-condition in the near future -- they may be challenging, but still, they're stable. -- THESE PATIENTS REQUIRE YOUR MORE SKILLED CAREGIVERS -- people who can THINK on their feet!

In the lower right quadrant are those patients whose care also requires little diversion from the protocols always in use (in other words, we know what to do for them). However, patients here are VERY likely to experience a change-of-condition in the near future -- this instability can make a big difference if the caregiver can not respond to the change. -- THESE PATIENTS REQUIRE CAREGIVERS who can spot the change AND know what steps to take!

Finally, In the upper right quadrant are those patients whose care constantly requires reinvention and re-thinking! Additionally, patients here are frequently experiencing a change-of-condition -- they are both sick and unstable -- THESE PATIENTS REQUIRE YOUR MOST SKILLED CAREGIVERS -- nurses who can assess what's going on and adjust the care accordingly!

This is a grid I have used many times to help make patient assignments! Hope you find it useful!

--p

Hi P,

Excellent tool. Thanks for posting. I like it more than some other scheduling tools/methods that I've been forced to use because it requires us to look specifically at the patient and his/her needs and then at the skill sets of the staff available. Other tools I've used rated some the patients medical care needs; number of IV medications, tube feedings, POD" on a scale from 1-4 but failed to consider time consuming tasks like frequent dressing changes, bed changes, frequent toileting, education time, etc. None of them considered the ablity of the staff on any given day. Frequently we "fudged" the numbers in order to get another nurse for the shift- some useful tool, right? I'm grateful that I rarely deal with such matters now.

R

[hppygr8ful]

I work in a high acuity psych hospital and I would have to say that all of the patients mentioned can be difficult - where I come from I usually have 18 patients. I am the rn I have a PT or LVN for meds and if I'm lucky two mental health workers. Of all the patients listed I would say the hardest would be aggitated mentally ill depending on the the type and level of mental illness. are we talking sociopath, schizophrenic, bi-polar, borderline personality disorder etc... I personally find borderlines the most difficult because they
have few or no boundaries.

The trick is to manage the level of aggitation so that it does not get to a point of crisis.

peace and namaste

hppy

[cassioo]

Originally Posted by hppygr8ful

I are we talking sociopath, schizophrenic, bi-polar, borderline personality disorder etc... I personally find borderlines the most difficult because they
have few or no boundaries.

The trick is to manage the level of aggitation so that it does not get to a point of crisis.

peace and namaste

hppy

Then put them on a few street drugs and make them pregnant and in labor just a barrel of fun.

I used to work on a neuro unit those closed head injury teenagers were about as fun.

[hsieh]

Originally Posted by hppygr8ful

I work in a high acuity psych hospital and I would have to say that all of the patients mentioned can be difficult - where I come from I usually have 18 patients. I am the rn I have a PT or LVN for meds and if I'm lucky two mental health workers. Of all the patients listed I would say the hardest would be aggitated mentally ill depending on the the type and level of mental illness. are we talking sociopath, schizophrenic, bi-polar, borderline personality disorder etc... I personally find borderlines the most difficult because they
have few or no boundaries.

The trick is to manage the level of aggitation so that it does not get to a point of crisis.

peace and namaste

hppy

i consider mentally ill to be like schizophrenia. symptoms are delusions, hallucinations, and APATHY. i consider the other diagnosis to be behavioral. i guess you would call dementia also a mental illness AEB eventually becomeing totally unable to care for oneself. to me behavioral is kind of like - if a tree falls in the forest and nobody hears it does it then not make a sound? meaning behavioral has a lot to do with iteracting with your envionment. if you're alone in the middle of nowhere a 500 miles from the nearest person or place and you don't have transportation how are you going to act?