Haldol with Ativan and Cogentin

Specialties Psychiatric

Published

I understand there was a previous topic about this but it was already closed and I thought I just want to bring this topic to light in case if there are any new information and tips from our experienced Psych Nurses.

Last night was my second shift on my own (after a 7 shift orientation in my Psych Facility) and we experienced a Code White right before I was leaving. So I stayed an extra hour and a half and participated and observed how the Security and Nursing Team deals with it.

Prior to calling the Code White the patient was already getting agitated and the nurses already started calling for medical restraint order, preparing the physical restraint, and calling for security assist (mind you this patient has been getting more and more aggressive and started to threaten both staff and other inpatients).

The doctor ordered 5mg of Haldol, 2mg of Ativan mix and I believe it was 1 or 2mg Cogentin. My questions are:

1) Is there a specific way of pulling Haldol and Ativan out of their vials? A specific order?

2) Why did we opt for Cogentin and not Benadryl?

3) When someone is really aggressive and just would not settle specially for a needle...how do you approach the situation (as in how do you go about giving the needle)?

4) How do you go about handling a Code White (aggressive patient) in your facility?

(Just a side note, we tried to deescalate the situation for some time hence the amount of time I stayed after my shift was done but he just was not settling down. We offered him the medication and told him exactly what they were prior to giving it to him and he was just inconsolable).

Thank you very much for the feedback.

Meriwhen, ASN, BSN, MSN, RN

4 Articles; 7,907 Posts

Specializes in Psych ICU, addictions.

1. Doesn't matter, as long as the Cogentin is given alone--it's not really compatible with mixing. You can give Haldol and Ativan separately or mix them.

2. Could be facility/prescriber preference. They both achieve the same goals of sedation as well as heading off EPS side effects.

3. To be honest, if things have escalated to the point that a code has been called, the medication you are giving has probably been ordered by the prescriber as an emergency psychiatric medication that can be given without the patient's consent, d/t the patient being an immediate danger to themselves or others. And as a code has been called, you more than likely have lots of staff there that can hold down the patient down for you if necessary. Of course, that should be the last resort: every code should not be a mad rush at the patient. Some patients, once they realize that the shot is going to happen no matter what, will cooperate. Others...

This really is a judgment call that you can make once you have solid psych experience...but depending on the patient's condition as well as the prescriber's OK, during a code you could offer the patient the opportunity to take the meds PO instead of IM. Tell them that they will have to take this medication and they have the choice of shots or to take it by mouth. Some will choose PO and take it willingly...or at least cooperate with you. But it's not a choice that you'd offer to every patient...like I said, that's a judgment call that comes with experience.

4. Too many variables for me to give a cover-all answer. Generally we try to recognize and head off signs of escalation as early as possible so it doesn't reach the point of a code. Sometimes we may ask if they want a PRN, or we just pull the PRN and say, "here, take this."

electricblack

74 Posts

Specializes in Psychiatric Nursing.

Thank you for the reply it was definitely informative. Another question would be if it is an emergency situation which a code white usually is... Can you give the needle in the same area just a few inches away or do you need to turn the patient to give the next needle to the opposite end of the muscle. And is there an order which needle do you give first and last?

Meriwhen, ASN, BSN, MSN, RN

4 Articles; 7,907 Posts

Specializes in Psych ICU, addictions.

You can give the shots in any order.

Depending on how...cooperative...your patient is, you can give them in the same area or switch sides. If releasing the hold on the patient will cause more trouble than it's worth, just work with whatever you got.

jessie5881

1 Post

1.) Most people in our hospital always pull the shots up separately, but its personal preference the Haldol and Ativan can be mixed. But when things are hectic in a code, you wouldn’t want to accidently pick up the wrong one and mix it. That is why I pull them up in three, just so I don't forget which one is one is which.

2.)This is preference of the doctor. Maybe they did not want to over sedate the patient since they were getting the Ativan and Haldol. Maybe Benadryl makes them worse as it does some people. Could be many things. We usually give Benadryl in a code situation because usually we want them sedated along with the EPS control.

3.) If a patient is actively agitated and aggressive, we call a code and if the presence of large group of staff does not settle them down in about 10 seconds we take them down as a group to prevent the patients and ourselves from becoming injured, and take them to our seclusion/restraint room and bring the shots to them. If the patient is calm enough we always give them the opportunity to take the meds by mouth. Sometimes, when we have someone becoming increasingly agitated but not combative and he/she won’t take po meds, we get the orders for im meds and get a group of staff gathered and then hold the patient down for the shots on the unit, and then they get up lay down in bed and are usually fine, but those are usually patients that are confused or delirious and not behavioral.

4). I guess I answered this question some in the last one, but when we call a code 6 (our version of code white) depending on if it was expected and we had warning that the patient was agitated, we would have the other patients cleared out of the area to prevent them from getting injured or from becoming agitated also. Then a bunch of people show up to take the patient to seclusion with the gurney if that’s what the charge nurse and/or doctor wants, the med nurse for the unit would be getting shots ready or getting an order from the doctor to do so if not already ordered.

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