Hello everyone,

Since I am so new in this profession, just graduated, passed the NCLEX and my 4th.day on the floor, I know I got tons to learn.

My question is in connection to my previous post about the hospice pt.that i have. He has an order for ativan .5 mg 2 tabs q hs, this was ordered because of his severe agitation few weeks ago. it helped, he was calm and less anxious. Now another order came 2 days ago for fentanyl patch 12 mcg q 72 hrs... since we started the patch a day ago, he was very lethargic and looks very sedated. My question is, do i still have to give the routine ativan? I am so not comfortable giving it but i have to give it otherwise, what would be my reason of holding it? can i call the hospice nurse and discuss this? how should i tell it?

Your insights are greatly appreciated.

thanks alot.

Hello everyone,

Since I am so new in this profession, just graduated, passed the NCLEX and my 4th.day on the floor, I know I got tons to learn.

My question is in connection to my previous post about the hospice pt.that i have. He has an order for ativan .5 mg 2 tabs q hs, this was ordered because of his severe agitation few weeks ago. it helped, he was calm and less anxious. Now another order came 2 days ago for fentanyl patch 12 mcg q 72 hrs... since we started the patch a day ago, he was very lethargic and looks very sedated. My question is, do i still have to give the routine ativan? I am so not comfortable giving it but i have to give it otherwise, what would be my reason of holding it? can i call the hospice nurse and discuss this? how should i tell it?

Your insights are greatly appreciated.

thanks alot.

Very good of you to ask questions when you are new. I would never have a problem holding a benzo scheduled or otherwise for a lethargic patient.

Talk to the hospice nurse and tell her what you said in your post. She will probably advise you to hold the ativan if the patient is too sedated. But that is not much ativan, she might not have you hold it. Talk to her. She is the expert with a patient in this condition.

You can hold the med for reasons you stated; just circle it and chart why you held it. Get the med changed to a PRN since you may still want it. When opiate free people go on the patch they will snow for a few days and usually come out of it.

If he doesn't come around you need to get an order to take the patch off and do something else. Just because he's hospice he shouldn't be in a drug stupor.

Never be afraid to ask questions. I graduated in 2010 and passed my licensing exam Feb 2011 and I know I have a lot to learn as well. Personally, I'd put it on hold and call the hospice nurse. Her experience will guide you in what to do next.

Ativan is a very potent benzo.. I would hold..

however does the order read more like this.. this may give you more latitude in holding.

Ativan 0.5 mg -1mg po qhs for agitation

You still of course have to comply with whatever your facility/agency's policy is for holding medications.

If he isn't agitated due to the fentanyl then well maybe you shouldn't give it...

I'd have to see the original order... But trust your gut and nursing judgement.

Very good observation! A lot of nurses don't know the difference between Claritin and Benadryl (random).

Kuddo to you for asking questions! :redbeathe

What is the dx?

Is this pt transitioning (dying)?

My suggestion is to call the hospice nurse. They can make an extra visit if needed to assess the pt. I'm assuming you work in LTC. I have 9 hospice pts in an LTC and make extra visits PRN when the nurse has a question about the status or change in condition of a pt. The hospice nurse can use this visit as a teaching moment for you, the pt, and the family. Hospice is there to compliment the excellent care you are already giving.

Good luck and welcome to nursing!

Hello everyone,

Since I am so new in this profession, just graduated, passed the NCLEX and my 4th.day on the floor, I know I got tons to learn.

My question is in connection to my previous post about the hospice pt.that i have. He has an order for ativan .5 mg 2 tabs q hs, this was ordered because of his severe agitation few weeks ago. it helped, he was calm and less anxious. Now another order came 2 days ago for fentanyl patch 12 mcg q 72 hrs... since we started the patch a day ago, he was very lethargic and looks very sedated. My question is, do i still have to give the routine ativan? I am so not comfortable giving it but i have to give it otherwise, what would be my reason of holding it? can i call the hospice nurse and discuss this? how should i tell it?

Your insights are greatly appreciated.

thanks alot.

I'm glad you are thinking about these things instead of blindly giving the med just because it is an ordered med. HOWEVER, I have to ask why you didn't ask your precepting nurse? You say this is you 4th day on the floor, please tell me you aren't on your own yet.

If a medication is not ordered as a prn, you need to report the lethergy to the physician. The order may be changed to 1-2 prn qhs. Once the patient has been on fentenyl for a while, they may need the order changed again to qhs.

Kuddo to you for asking questions! :redbeathe

What is the dx?

Is this pt transitioning (dying)?

My suggestion is to call the hospice nurse. They can make an extra visit if needed to assess the pt. I'm assuming you work in LTC. I have 9 hospice pts in an LTC and make extra visits PRN when the nurse has a question about the status or change in condition of a pt. The hospice nurse can use this visit as a teaching moment for you, the pt, and the family. Hospice is there to compliment the excellent care you are already giving.

Good luck and welcome to nursing!

Yes, yes, yes! This was a great answer.

Remember, that the Fentanyl is probably just kicking in around the second day. If you hold it one day, you will still need to remember that maybe the next day when they are getting used to the new med, then they will need it or maybe he won't need it at all now that the pain is being managed..maybe a prn dose.

Holding the Ativan until you have a chance to consult with Hospice is the appropriate thing to do, you can always give it sublingual if necessary. One caveat, does the pt. have a dx of seizures? If so the Dr. may not want to stop the Ativan abruptly.

Yes this all can be confusing. Remember hospice is adjunct in many ways. If your role is the primary nurse and you have orders to give meds that you feel are not appropriate at this time, and your orders do not give you prn "choice", you can call the hospice nurse and tell her what you see and how you feel the orders need change. Now, dependent on the hospice and it's relationship with your facility and the particular patient, a hospice nurse can come in and eval and call the MD to get new orders, but if there is delay, a call and a brief discussion of the issue to make sure you and hospice are on the same page might be all that is needed, and then you can call the MD noting discussion with hospice in order to facilitate prompt action. Hospice (should be) able to pull up a chart on a laptop, it's just that your specific nurse may be off an hour away and if the situation is not critical to the point of emergency trip to this patient, these things can be handled.

You know if you have a good hospice nurse when between the two of you you've got that patient's particular trends down tight, and you feel you can call and be relaxed and have someone to collaborate with! If your place never notices that the hospice nurse even has been there excepting for progress notes left in a facility binder, then you don't have a good hospice nurse.

Hello everyone,

Since I am so new in this profession, just graduated, passed the NCLEX and my 4th.day on the floor, I know I got tons to learn.

My question is in connection to my previous post about the hospice pt.that i have. He has an order for ativan .5 mg 2 tabs q hs, this was ordered because of his severe agitation few weeks ago. it helped, he was calm and less anxious. Now another order came 2 days ago for fentanyl patch 12 mcg q 72 hrs... since we started the patch a day ago, he was very lethargic and looks very sedated. My question is, do i still have to give the routine ativan? I am so not comfortable giving it but i have to give it otherwise, what would be my reason of holding it? can i call the hospice nurse and discuss this? how should i tell it?

Your insights are greatly appreciated.

thanks alot.

I think this is a great question and alot of the other posters added great points. I also wanted to point out that depending on how lethargic your patient is, giving them something to swallow isn't a great idea (not sure if this person has a peg tube, but assuming if they dont). I would consider them at risk for aspiration, since the order is for tablets. Since the fentanyl patch seems to be working, you could call the doctor to get the order changed or even change the route it is given, just in case you happen to need it.