Ok....I work in LTC. We have recently started using a new place that deals with our "psych " pts....now..normally the way this worked was the doc would order a psych consult and then the psych person would come and eval them and make RECOMMENDATIONS for which he would either agree or disagree. Well...with this new one...its a FNP and she is evaluating every single person we have and OMG....I cannot begin to describe how terrible it is....for example....on my unit...i only have about 3 with behaviors that actually cause true problems.....and she has wrote orders for one of mine who is basically a vegetable....to be on the exelon patch and namenda and she ordered ATIVAN too which I got d/cd. one of mine with behaviors was on 0.5 mg of ativan bid with 1mg at hs...which was helping with her....she cut her ativan to 0.25 bid, put her on lamictal 100 bid, cut her risperdal and put her on an extra dose of lyrica.....at hs i give this pt....100mg lyrica, 1mg ativan, 5mg ambien, 0.25mg risperdal, 10 mg elavil ....another pt on another unit is about 80 lbs and she put her on the following at hs....2mg ativan, 1 mg klonopin, lunesta, ambien, vicodin........its unreal.....on top of this...she has loaded almost everybody up on depakote too....ones that have no behaviors at all....i have another one who is pleasantly confused never bothers a soul....on depakote 125 bid for "mood disorder" and since she started depakote....ive caught her chewing on wooden railing in the hall which she NEVER did before. I read the sheets this fnp wrote out....shes putting false info on these sheets.....shes putting on there that she's talked to these pts and they have told her they c/o nervousness...and that they cry intermittently which isnt true. I do the psychotropic meetings every few mos w/ the doc and don and her.....she lied to me to my face in front of them and told me that day nurses tell her that these things go on or that the ones that have problems are "beautiful" ......i told her she was misinformed and the doc just threw his hands up and said " and thats why i want my evening nurse in here. the nurses know more about these people than anybody" .....I told one of the day nurses what she had said and i asked her if it was true...she confirmed that it wasnt true....she told me that the fnp comes in and gets a bunch of charts and sits at the desk for half the day and comes up with all these ridiculous orders and that she never asks the nurses a thing. the doc and all of us nurses cant stand what this fnp is doing to our patients and we have complained to all the above people to no avail. the don and adon back her completely and told us that she is the psych professional and expert and that we are not. And i would be ok with that assumption if i saw a difference in my patients that benefitted them....all i see is a bunch of pts that are turning into zombies...i hold all the meds that i can find supporting facts to hold it. as soon as we get this mess d/c'd.....it comes right back...the whole purpose of our psych meetings is to do reductions.....we do that and she adds 3 to 4 things later on. I am no nurse practioner but my god...im with my pts at least 6 days a week and i think that if anybody knows them ....i do. Does anyone else have any suggestions on this? Or has anyone else dealt with this kind of situation? What helped? what didnt?
Jun 23, '09
Not sure about this one, but I think I would write notes to describe their current behaviors. I am sure that a psych nurse can answer this better than I, since they have the experience. What worries me is what happens if a patient is overly medicated...it just may fall on the nurses.
Jun 24, '09
Get the families on board with you, if they tell you they don't want their loved ones on all of these meds, the prescriber has little choice but to follow their wishes. If this psych nurse doesn't listen to what you tell her about the families thoughts on those meds, "sic" the family on her by encouraging them to call her themselves. Lord knows I've "sic-ed" more than one family on a prescriber! It's our duty to protect and care for our residents, and we must do whatever it takes to get the job done. I can't see how state would be "OK" with that many residents on behavior meds who don't have documented behaviors on the chart. In fact, I think it could get ugly. The very best of luck to you, you have your work cut out for you.
Jun 24, '09
ahh....it is soooo frustrating to deal with this psych mess. at the last meeting i went to I said that i only had the 3 real problem pts which she tried to argue with me about.....then she also said that there was no documentation to prove my side and there was...i told her to go get those 3 charts and she would see months worth of charting on their behaviors. I also told her that 2 of the 3 have most of their behaviors on my shift (evening) so there isnt much charting on day shift but she cant expect that when thats not when they act up. I dont know if she ever went back and looked at my charting but that comment told me that she hadnt looked at it prior to the meeting. Whats even more shocking to me is the DON. A year ago she chewed all of us nurses out at meetings for giving prn ativans/xanax/haldol/ and pain pills b/c she said she didnt believe in those meds. However...we all still gave what the pts needed or asked for. none of us cared about what she believed in, and still dont....but now....if someone asks for a pain pill or what not if it becomes frequent she wants us to get it all put on a schedule....which i can understand to an extent but our issue is overmedication and undermedication. We try to find the fine line that works for each one of our pts. What I have been doing is going thru the md folder on the nights before he is supposed to come in the next day and separating all of his papers including the psych ones...and I read and highlight her "orders" which he must ok before they get carried through and written by a nurse....and if its absurd I put a sticky note on it saying whether or not the nurses, myself included, think the pt needs it......i was successful in keeping certain ones off of depakote and klonopin and ativan that absolutely dont need it for a while.....just by reading off to the doc what she had put on her sheets such as.....the following...she stated she had a conversation with a basically bedridden, completely demented, nonverbal patient....this pt had not spoken in at least 3 years now......she wanted him on depakote for a mood disorder! another one who is basically the same....she wanted ativan, klonopin, depakote....that didnt happen til just last week. she got the DON on her side and somehow they managed to get it ok'd w/ the doc. Im starting to wonder myself if the fnp isnt on all these meds herself....when ive seen her and talked to her...she seems so blank and monotoned. I think she'd be better at working with a younger variety of patients instead of the elderly. If management would listen to the nurses something good could come of this but they refuse to hear us. The nurses on the floor including myself have already talked to some families and told them it would be best if they would just go thru the real doctor and take his recommendations instead of thru the psych company and so far we've got about 6 out of 80 pts families on our side. Thats not much but i guess its a start. this is why I never wanted to go into the psych field to start with..especially with the elderly pts that I have come to adore. I hate feeling so helpless. Its like me and my coworkers are fighting a losing battle here.
Must Read Topics