Followed MD Order--Now Do I Look Incompetent?

[LaurenBoog]

I feel that I may have made an error in judgement and made myself look incompetent to my supervisors. In the interest of not stirring up any drama at work, I want to post the situation here in order to gain insight about what you all think.

I am new to the ICU, but not a new nurse.

I took care of a patient going through ETOH withdrawal. This was my second day of having the patient. The patient was originally admitted to a step-down unit, but later transferred to ICU with uncontrolled withdrawal symptoms.

The patient slept through most of the first day. I titrated the sedative drip down. Towards night shift, the patient became less groggy. The next nurse kept the sedative drip on the same level overnight. The next day, I knew that the MD would want the patient transferred back to the floor (no other medical issues requiring ICU care). I decided to stop the sedative drip and begin giving Ativan, so that I could give the MD an accurate picture of how the patient would tolerate the Ativan. The patient was cooperative and nonviolent but restless and impulsive when awake. The patient was in a vest restraint.

The MD came in that afternoon and as I suspected, wanted the patient transferred back to step-down. I shared my concerns with the MD that I felt that the patient may require higher levels of Ativan than are safe to give outside the ICU. The MD saw the patient awake, restless, but also A & O x 3. I decided while waiting for a room assignment to give the patient the max dose of Ativan our protocol allows just to see if that would help the patient stay calm. I gave the patient the max PO dose three times in the next three hours, but it didn't help the patient's restlessness. The patient had now learned how to un-snap the vest restraint!

I called report to the step-down RN and I was honest in my report (i.e. patient is able to unsnap vest restraint despite receiving the max dose of Ativan). Immediately after speaking to me, the receiving RN called my charge and protested the assignment, stating that she felt the patient was too high of a fall risk to come to step-down. (BTW, my charge nurse and my assistant supervisor were already aware of the situation). I paged the MD and had him come down again to re-assess the patient and see if he still felt that the patient was stable to go to step-down. At that time, the MD saw the patient again attempting to remove the vest restraint and get out of bed. I informed the MD that the patient had receivied the max dosage of Ativan for the past 3 hours. The patient was still A & O x 3. The MD stated that he still wanted the patient to transfer to step-down. We placed wrist restraints so the patient could not unsnap the vest restraint.

I did end up transferring the patient, but the situation became a mess. The charge RN of the step-down unit made some angry comments to me when I was transferring the patient. The receiving RN paged her nurse manager, my nurse manager, my nurse educator, and the MD to have a meeting about the appropriateness of the patient being transferred to step-down. (The patient was not transferred back to ICU). My nurse educator spoke to me afterwards and said that a patient receiving such high doses of Ativan should never leave the ICU. She called it a "learning experience" for me. I felt like she was frustrated with me. I have never had any issues with my educator before; she has always been supportive.

It has been several days but I am still upset over the situation. I am a sensitive person and I do not feel confident about being in the ICU already. Now, I feel that I have a target on my back and that my supervisors will not trust me to make good decisions. I am angry because I feel that I was talked down to by my nursing educator. As I said, I am not a new nurse. There is no protocol at my hospital for when a patient receiving high doses of Ativan can or can not leave the ICU. It is entirely MD judgement. I know that there are risks to giving large doses of any sedative, but I felt that I did all I could by sharing my concerns with the MD and having him come back and re-assess the patient. Theoretically I could have refused the MD order, but I was not 100% convinced that the patient needed ICU care. Even though it was against my better judgement, I followed the MD order.

Thank you to anyone who read this long and winding post. All comments or suggestions are appreciated.

LaurenBoog

[blondy2061h, MSN, RN]

It honestly sounds like the step down unit just didn't want a difficult patient. I am not sure what kind of ratios your step down unit has, but at my facility we would never have a patient holding an ICU bed just to get ativan for etoh withdraw.

[athflying]

I was going to say the same thing. My floor we can have 6 pt's with one of them being ETOH constantly climbing out of bed, cursing, swearing, etc....I would think they would give a 1 to 1 sitter before holding an ICU bed.

[mentalhealthRN]

Well being a nurse that worked in a detox center and a psych nurse--granted not ICU or anything---I will tell you the things that come to mind..... first off if it were me I would pull that RN Educator and let her know that this situation is bothering you as you feel like you did what you could within your scope-- you not only let the doctor know your assessment findings and personal thoughts and concerns you had the doc actually come and see the patient. Ultimately the doc has the say legally--RNs practice under them. Yes if its a resident maybe getting the attending involved can be appropriate--but if you are already dealing with one--they do have the final say legally--which is why you document to cover yourself. That RN can be mad but RNs practice under MDs. Yeah I have had a doc tell me to give what was a way beyond normal dose of an IV med and I wouldn't give it and asked him to come and administer it--he did and understood my concerns. Inform the educator that you did all you felt you could do within your scope and that you did as the MD told you to do. She needs to take things up with the doc if she has an issue with his clinical choices.

Second thing that comes to mind........not sure what the person was there detoxing from. Just ETOH? Not all addicts are honest about what they use and sometimes don't even know what they are taking--things laced, using other drugs while drunk and can't remember things, etc. There could have been w/d from something else that wasn't being accounted for. Also it is a good chance that this person could have had co-occuring mental health issues. I have found it's even harder for those that suffer from anxiety disorder to detox because they have even worse anxiety then those without that disorder.

I have also seen some cases (rare) where Ativan can make people worse. The person could have been having a severe akestesia (severe inner restlessness) reaction--if you have ever had this reaction as it can come from a few meds--its enough to make you want to crawl out of your skin! I had it from a fast IV push of Phenergan and it was aweful.

I agree that this person was a safety risk. Maybe a better option might have been to send the person to psych to finish the detox. I am guess you don't have a medical/psych unit--if you did that would be good too. The other thing could have been to bring in a consult of a doc that specializes in detox. Maybe there could have been something else going on medically, psych wise, or a another med could have been better.

You don't always have all the info from these folks when you think you do.

I will give you a good example. I got a call to the detox from an impatient hospital psych unit asking for help. They had a patient--a female that they had admitted and were treating her for what they thought was a first psychotic break and had diagnosed her with a new schiophrenia dx. After a whole week of anti-psychotics, benzos, hallucinations and violent behavior landing her in restraints often she was getting worse and not better. They were at a loss. Teh girls dad came in and tells the staff he just found out she had been smoking pot laced with Formeldahyde!!! Yeah! crazy! It had caused the psychosis and they anti-psychotics apparently are not suppose to be given as they will make the person worse. They wanted suggestions! So they were treating the girl totally wrong based on not having all the info. So if things aren't going as you expect--question things. Drug addicts lie. Its part of the disease.

Good luck to you --hopefully this might help--at least give you some insight--you did what you could.

[purple10]

I agree with the other posts. You did what you needed to do and did what you were told to do. its up the MD to decide if the pt is moved (even if the pt is climbing the walls). Im sure the MD got an earfull from the other nurses. I wouldnt worry about it.

[BacktoBasics]

I work in an adult ICU too. I think you did everything appropiately. You let the physican know of your assessment in the morning, the patient was put up for transfer, you let the physican know again of the "change" in patient condition, the physican reassessed, and still approved to be move out of the ICU.

Basically the patient was too much for the floor to handle, and the floor should have accomindated the nurses assignment instead of alerting management for an inappropiate admission. The patient was stable; no longer needing the ICU. Just because a patient is confused or a fall risk, doesn't constitute the patient staying in the ICU.

I think it was perfectly okay to tranfer the patient even though he was on the "max dosage" of ativan. It didn't even touch him. I think because management knew, they had to put someone to blame for it, and it happened to be you, the nurse.

[caliotter3]

Do not work in that area, but agree with previous posts. The receiving floor was complaining about a difficult patient. What you did seemed appropriate to me.

[ckh23, BSN, RN]

I agree with the others. I don't understand how the step down unit can try to refuse a patient because they are too much of a fall risk. If that were the case many people would never leave the ICU.

[rgroyer1RNBSN, BSN, RN]

I agree with the other posts, i have been an Icu nurse in sicu for 5 years give or take and have no clue as to why you would take up an Icu bed with an etoh, unless he had poisioning and had been on a vent or dialysis.

[shoegalRN, RN]

I work Stepdown from time to time and our hospital will admit all ETOH w/d to the Stepdown unit. They are never admitted to our ICU.

And they come up from the ER with restraints and ETOH w/d protocol. And if they are violent they get a 1:1. I've given enough Ativan IV to sedate an army on just one pt.

I think you did the right thing. There was no reason for this pt to stay in the ICU. He was no longer on the vent, nor was he on a pressor, so he was stable enough to be moved to Stepdown. The Stepdown unit just didnt want a difficult pt. And I think it was completely out of line for the Stepdown RN to page all those people in hopes of getting the assignment cancelled. Instead of paging the NM to try to get the assignment cancelled, the RN should have been asking for a sitter for that pt instead.

Just because the pt was a fall risk and trying to get out of bed is no reason to take up an ICU bed.

Just my opinion.

[OttawaRPN]

You did nothing wrong. You followed md order and you followed protocol - if they have some unwritten rule about Ativan dosing that is their problem, not yours.

They are using you as the scapegoat b/c they don't want a difficult patient so deflecting the blame on you.

Stand up for yourself, it's their insecurities, not yours.

[silentRN]

You did the best you can do. I wouldn't sweat it. The next day no one probably even remembered. Plus, in my opinion, it seems like all nursing educators talk down to everyone!