[lorster]

Last night a 49 year old male patient was admitted to our med surg unit with R/O PE which was later ruled out. He also had a history of anxiety. Admitting doctor ordered 5 to 10 mg Ativan po Q 4hrs prn. Evening shift nurses questioned it and called the doc on call who quickly changed it to 1 mg Q 4 hrs prn. This morning, the primary doctor comes in and throws a huge fit on the floor. Why didn't my patient get 10 mg Ativan last night???. I explained to her that we have a right to question orders like that and her partner on call changed it. Our pharmacy states max daily dosage should be 10 mg divided over 2 to 3 doses. Also, this patient had taken Ativan only one other time in his life. So...could I get some feedback? I had to write an incedent at the doctors request. Thanks fellow nurses

[grammyr]

I would think that that dose would be WAY too much. I'm not gonna do it.

After the doctor got done throwing the fit, he could give it.

[earle58]

ativan 10mg is something i would have questioned, especially after reviewing his pmh and current regimen. my nurse's note would have reflected the conversation with the md. your actions/questions were appropriate, imho.

leslie

[Pinto]

For that instance that is way too much ativan 10mg sounds more like a Valium dose. If he was an alcoholic and were worried about DT's that could be an acceptable dose depending what his CIWA score was.

[Focker]

How did the smaller doses work for the patient? From your description of the patient that sounds like a lot, from what I could find, PO lorazepam only has 20% first pass metabolism, so 10mg PO is close to 8mg IV (I may be oversimplifying). Like Pinto said, its different if he was an alcoholic. But you can't take meds back once you give them, so why not give multiple small doses titrated to effect, you may end up giving 10mg in the end that way, but you also may only give 1 or 2 and avoid OD'ing a pt. I find it strange to give ativan PO, why not iv? I wonder if the doc meant Ambien? 10mg po is a normal dose for that drug, and may be appropriate in a pt with anxiety to sleep through the night, although not q4 hrs.

[weetziebat]

Ativan 5 - 10 mg. Q 4 hrs. PRN??? Wow! way too much, IMO. No way would I have given that to anyone. Doc wants it, doc can come in and give it herself. Personally think she must have had it mixed up in her mind with some other med.

[DusktilDawn]

You were correct in questioning this order. I wouldn't worry about the incident report, you acted in a manner that any prudent nurse should.

For that instance that is way too much ativan 10mg sounds more like a Valium dose. If he was an alcoholic and were worried about DT's that could be an acceptable dose depending what his CIWA score was.

Exactly why I would have questioned the dose, I would have wondered if she hadn't confused the dose for ativan with valium. We follow a CIWA protocol at my facility, the physician can order a Symptom Triggered Therapy or a Fixed Dose Therapy of either valium or ativan. Approximately 1/2 of alcoholics will have a cross addiction to drugs, so higher/titrated doses may be necessary.

In the OP's situation, the ativan wasn't being prescribed for alcoholism and his history indicated anxiety. Normal dosing for anxiety would be 1-2mg or 2-6mg po in divided doses, not to exceed 10mg in 24hrs.

[casper1]

I would question the order. Does the patient have an Etoh history. I've seen very high doses of Ativan given for DT's.

[suzanne4]

Even with ETOH protocols, the maximum dose is usually 6 mg at ta time, it can be repeated every 30 minutes, but there is absolutely no way that I would give 10 mg.

For severe ETOH withdrawl symptoms, we have given over 75 mg in a day. But it is per a specific and detailed protocol.

[thumperRN]

I've NEVER seen anyone get 10mg ativan po - you might as well knock him in the head with a hammer! - Not to mention that oversedation could mask any other probs the pt was having. You were right to question the order - and don't feel bad about it!