I have been working ICU for 8 months straight out of school. Lets not make tjis into a "new nurses should not go into ICU" thred please, that wont help me.I was called last night and told not to come in this morning to the unit. Instead I should goto nursing services and meet with my manager and her manager. Yikes.
1-Last Friday I admittedly made an error (I work ICU). A Patient was admitted from the floor and i wrote an order for ativan 1 mg q 3 hrs, it should have been PRN, i forgot to write PRN. I reported off to the night nurse about the ativan helping with pain/agitation and he realized not to give that much. The patient got several doses 8 hours apart, but the doc flipped when he saw how the order was written
2- Several weeks ago, I had an extremely agitated patient who was also 350lbs. There was an order for haldol 2 mg ivp prn, no time constraint. The nurse who gave me report said she had been moaning all night and nthing could be done, and that she had proabl;y not slept in days and her solution was to close the glass door so she couldnt hear the pt moan. I felt this to be NOT helpful to the pt. I ended up giving some 70 mg of haldol over the 12 hour shift. I looked up the safe dosage and that falls within the safe dose. Some books say 5 mg every half hour, some say 10 mg, then double until you get the desired effect every half hour stopping at 50mg. At no point did the patient have decreased resp[irations or drop her blood pressure. She fell asleep for a few hours but thats it, all in all even that much haldol was not that effective. That was several weeks ago and I guess they were reviewing the MAR and somone flipped. I also asked the other nurses on the unit, including the charge if it were ok that i give that much and noone said anything other then they had not given that much before but it didnt violate the order or the corecct safe doasge. Also They were upset that I didnt question the order for not havinga time constraint, which i will do in the future.
Fallout- Luckily I didnt get fired but now I must verify ALL medications with the charge nurse before I give them. "charge nurse, can i hang some vanc?" crap... and I am not allowed to work overtime because they felt I have worked too much and was too tired. The crazy thing is I am helping THEM out and they cut my overtime completely!!! I am thinking I will find a new job and put my two weeks in ASAP
The patient denied pain actually. She had some wounds that she was scrathing at with her long nails (the family would not let them be cut). she was moaning, and just looked generally uncomfortable. Like i sadi, she had not been asleep in days and proably had some psyhosis, also som mild demntia that was probably aggravated by the setting
i'm a hospice nurse and deal w/dozens of pts who deny pain.
there can be a million reasons on why they deny it.
but you yourself, observed her to look generally uncomfortable.
that is what should have been brought to the md's attn; not necessarily just by you but it just sounds this whole scenario was mishandled.
of course pts have trouble sleeping in different settings and a prn sedative can be prescribed to help them sleep.
but next time, never hesitate to report your findings of pain to an md....esp if she had wounds (were they infected?) and/or a medical hx to support anything that would cause pain. trust your instincts. and best of luck to you. even though the haldol order was totally inappropriate, it was clearly your intent to relieve this woman's suffering. chances are she would have responded much more favorably with proper pain mgmt.
Well, my thought process was haldol must be a pretty damned safe drug if a dosage of 5 mg every 30 minutes is published as safe, as long as side effects arent noticed. the drug guide says 5 mg ivp every half hour is a safe dose, and that seemed to be helping the patient chill out some. If I am sitting in a bed moaning, i would hope someone would address it too. You know sometimes doctors dont really care about patiient comfort because they are not at the bedside watching the patient or hearing their complaints , so they dont really care what happens because overall I suppose it would be safer if noone ever got meds for pain or agitation. And i thought, hey I have an order, and a safe dosage , and ill run it by somone with more experience, and no objections, ok, ill continue.
I have seen a lot of "bootlegging" going on, and pleanty of people in ICUS in the hospitalS (yes plural) at least around here do a lot of chady stuff, people with much more experience then i have. That is a big part of why these docs probably dont realize what their patient's need because some other nurse is pulling phenergan or whatever else from a stash somewhenre and illegaly sedating a patient and the docs come around and see, oh, so and so look pretty confortable to me, ill just write 2 mg haldol prn..... not knowing that some jerk is giving them whatever else so they can read cosmo in peace.
The more I think about it: The only thing I think i did wrong with that haldol order, is not get a time constarint. If the order read 2 mg q 15 min for agitation, Id feel justified in doing it again, UNTIL THE DRUG BOOKS ARE MODIFIED AS SUCH!!!!!!! I WILL GO BY WHAT THEY SAY; and if i have a moaning agitated patient with haldol aloowed to be given in 2 mg increments evry 15 minutes, id give 70 again if thats what it took.
I think that your digging yourself a hole that you may not be able to get out of. The more you post the more inexperienced you sound. n my own opinion the only thing worse than making an error is not being able to except that you made an error or even agree that what you did was an error.
This is one of the sources i read that day, one saying 5 mg Q 30 min, this one saying up to 200 mg in a single dose, in light of that, it didnt seem liike a lot.
Well, my thought process was haldol must be a pretty damned safe drug if a dosage of 5 mg every 30 minutes is published as safe, as long as side effects arent noticed. the drug guide says 5 mg ivp every half hour is a safe dose, and that seemed to be helping the patient chill out some. If I am sitting in a bed moaning, i would hope someone would address it too. You know sometimes doctors dont really care about patiient comfort because they are not at the bedside watching the patient or hearing their complaints , so they dont really care what happens because overall I suppose it would be safer if noone ever got meds for pain or agitation. And i thought, hey I have an order, and a safe dosage , and ill run it by somone with more experience, and no objections, ok, ill continue.
I have seen a lot of "bootlegging" going on, and pleanty of people in ICUS in the hospitalS (yes plural) at least around here do a lot of chady stuff, people with much more experience then i have. That is a big part of why these docs probably dont realize what their patient's need because some other nurse is pulling phenergan or whatever else from a stash somewhenre and illegaly sedating a patient and the docs come around and see, oh, so and so look pretty confortable to me, ill just write 2 mg haldol prn..... not knowing that some jerk is giving them whatever else so they can read cosmo in peace.
The more I think about it: The only thing I think i did wrong with that haldol order, is not get a time constarint. If the order read 2 mg q 15 min for agitation, Id feel justified in doing it again, UNTIL THE DRUG BOOKS ARE MODIFIED AS SUCH!!!!!!! I WILL GO BY WHAT THEY SAY; and if i have a moaning agitated patient with haldol aloowed to be given in 2 mg increments evry 15 minutes, id give 70 again if thats what it took.
You are making excuses and not seeing the big picture, nor are you answering valid questions.
Did you discuss this plan with the Charge nurse/ADON/Manager before giving that much Haldol? In court, this will be a question that they ask you. Not did you ask other nurses of ambiguous position.
Did you review the Policy and Procedure manual, before giving Haldol like that or speak to the PharmD? The PharmD has a 6-7 year degree in medication information. This is also something that is routinely asked in court.
Drug guides are not adequate. An example of this is that I have some patients that are on Morphine drip. Some are on 1-2mg an hour with their pain managed, some have been on 700-1000 mg per hour for pain management. That is considered an acceptable dose by many drug guides. But if I kick the dose up on a new patient to 100mg/hr from 10mg, though that may be "acceptable" per the guide, I would still be guilty of not behaving prudently. And if I keep kicking up a dose (even the order says that I can titrate), and it has such limited effectiveness that I have to give a PRN 35 times in one shift, as part of prudent practice, I would be calling the physician to get a change of meds. This is good standard of practice.
No one is even remotely suggesting to avoid PRNs. They are just indicating that you need to give them properly. And if the patient is moaning, the reason needs to be assessed. If she was in pain, she needed pain med, not Haldol. If she could not sleep then she needed a longer acting sedative, again, not an antipsychotic like Haldol. And as the family being relieved because she was not moaning, that is not a reason to give Haldol as it just masks the problem, but does not appropriately treat the problem nor necessarily add to the patient's actual comfort.
For that matter, if that much Haldol was needed, the patient could have been placed on a Haldol drip. That way she could have been more comfortable (if an antipsychotic was warranted) and slept better. And there would have been less chance of infection from repeated accessing of the IV line.
VRE comes from overuse of antibiotics for frequent infections. Common sources are URIs/UTIs and IV lines. When you use sedation, you increase the risk of URI's and also, increase UTIs due urinary retention. Repeated access of the IV lines for 35 doses of Haldol, probably doesn't help either.
Pointing out "bootlegging" is irrelevant to the situation. It does not change the fact that YOU made errors that need correction for patient safety. When you play the fingerpointing game, you make yourself look worse, that those you want to point fingers at.
Specializes in Vents, Telemetry, Home Care, Home infusion.
Remember a drug book is only a guideline. Clinical condition, diagnosis, vital signs and clincial response is what one goes by in giving medications along with proper written physician order.
Anytime I have to give 2 or 3 doses of PRN drug in 4 hr interval with exception pain meds, time to relook at entire clinical scenerio and consult with charge nurse or pharmacist.
Remember in court of law "What would a prudent nurse do?" is standard you'll be asked.
Your peers "the prudent nurse" have advised you well.
I am closing this thread for a time out period to allow OP time for reflection on our members wise words as too close to the situation to hear advice.
thanks for all the input. In light of OTHER circumstances at work such as a hostile work environment etc, I think its best for me to put my two weeks in and find another job (not in that order). When you find yourself being challenged by the ntechs, and the charge nurse shuts you up when you complain about it, and then is all to happy to write you up, then I think its likely I wont be having an easy time. especially with my having one foot back in orientation. It may not be but it sure feels like a punishment. I dont see how verification of antibiotics, eye drops, scheduled PO's is going to help me. But whatever.
went into work this AM and left after a half hour saying i was sick. Leaving two coworkers to triple, and i dont care. I have been the one to triple, I have never called in, i have been stepping up. I have been the one to help out others even when I am behind. Its not appreciated.
Last weekend was horrible. I had a charge nurse and a group of people make me feel like crap all weekend, then i had a nurse assistant yell at me for asking her to help me move a 300 lb patient close to the time she was leaving, and when i complained about it, the charge nurse shut me up. She then wrote me up for the ativan. Then I get called off yesterday and am reprimanded, told I have to verify my meds. Sorry, i dont feel that unsafe... I looked the meds up, and gave them with the appropriate dosing guidelines. administering within recomended dosaged while wathcing for s/s of adverse effects. My mess up was of course the time constraint, again I feel like only an"outsider" me and a few others would have to answer for that. My drive to be a good employee there is gone. It doesnt make a dofference. People call in left and right and look out for themselves and get along better then i do. I need a new job, and quick. I have an interview Tuesday.
excellent idea to close to allow op time for reflection.i am worried about this situation...bc this op stated she'd have no problem administering 70 mg of haldol again. i am worried bc it sounds like the main concern was to "silence" the patients moans...and not treat the underlying reason of "why" they are moaning.one of the posters talked about eps developing with haldol use. eps isnt pretty and the patients are often left with them for life.pillrolling, lip smacking, shuffling gait etc etc ...these can be socially ostracizing for the patients. you can given cogentin all ya like after the fact but ...it will not do alot once eps has developed. and again....haldol isnt treating the underlying condition.
always think "what brought this patient to me?"- was it the wound infection and pain----if so treat that...and the moaning will reside.
what brought the patient to the hospital?- treat that!.in alot of icus....they are staffing with huge quanities of new grads who share this same op problem. she went to other nurses who obviously have minimal experience also that didnt stop this problem dead in its tracks. so...alot of this can be laid upon that same nm's shoulders who wrote the op up,.. who obviously isnt providing enough experienced nurses for resources for this new grads who are there to learn in her icu.when she hired thi new grad op...she accepted a responsibilty...both to the op and to the patients to make sure she /he had plenty of resources to pull insight from. was this nm more concerned over the budget(cheaper new grads) ...and not focusing on assuring her unit/ patient population had the safety / benefit of new and experienced nurses.?
my advice.....in an icu.....be very very leary of sedation. sedation to maintain intubation is one thing...you have abgs to draw every so often that can validate your oxygentaion or you can pop an etco2 monitor on. if...a patient is not on a vent.......it is walking a thin thin thin line when you opt to sedate. in a situation like that....always first just treat the problem that brought that patient to you....and when sedation is involved document that you clarified with the pharmacist(time date and name)...and ask the charge nurse to give a dose ever 3rd dose.....that way.....they cant say they were not aware.mistakes will be less likely to occur then. give yourself time and just use this a learning experience.i feel for you ..i do. i have a feeling from your posts that their isnt a huge resource pool that you can go to at your icu.....and that isnt your fault. i work as a icu nurse and charge nurse in a icu @ times....and it is my job...it is my job to check behind my nurses...esp the new grads who do need insight at times like this.so this op here....isnt the "sole" problem here.when that hcf hired him/her into that icu they accepted a responsibility to assist them until they reached the "expert stage" on benners stages of development. you cant fault him/her 100% for this....this op is probably tracking right along on benners stages of development where he/she should be. we'd all love it if all new grads could be spit outta nursing school as a "expert pratcitioner" on benners stages of development.
well i beleive I said what the problem was. The pat had okay abg's, the patient had been up for days and was getting icu psychosis. They were generaly agitated and i beeleiev they were given ativan and it made her worse , as ativan tends to do sometimes with older patients.
And like I said, if you can give me a real contraindication for giving that amt of haldol besides the esatblished fact that the order was improper, or you have not given that much, id love to hear it. I havnt heard anything that makes me think its too much . "we have never given that much before" doesnt mean anything to me. I gave the drug, observed for s/s of hypotension/decreased resp,. and ekg changes, noted none, and gave more, all way under some of the dosing guidelines I have seen which inculde a ceilinge single iv dose of 200 mg and uo to 700 mg a day in some literature. I am trying to understand. But I cant yetr
went into work this am and left after a half hour saying i was sick. leaving two coworkers to triple, and i dont care. i have been the one to triple, i have never called in, i have been stepping up. i have been the one to help out others even when i am behind. its not appreciated.
last weekend was horrible. i had a charge nurse and a group of people make me feel like crap all weekend, then i had a nurse assistant yell at me for asking her to help me move a 300 lb patient close to the time she was leaving, and when i complained about it, the charge nurse shut me up. she then wrote me up for the ativan. then i get called off yesterday and am reprimanded, told i have to verify my meds. sorry, i dont feel that unsafe... i looked the meds up, and gave them with the appropriate dosing guidelines. administering within recomended dosaged while wathcing for s/s of adverse effects. my mess up was of course the time constraint, again i feel like only an"outsider" me and a few others would have to answer for that. my drive to be a good employee there is gone. it doesnt make a dofference. people call in left and right and look out for themselves and get along better then i do. i need a new job, and quick. i have an interview tuesday.
np2be......was the ativan issue not addressed by the nm?why did this charge nurse write you up after it was already addressed by the nm? do not be lifting tugging on any 300 lb patient by yourself.ask that cn or other nurses to help ya...you only have one back!
i know you looked up the meds......and .....i know what those drug guides say. but most of the mid-high doses of any sedation drug is given for to treat the primary problem that brought that patient in to the hospital.like dt's, acute psychosis secondary to schizophrenia etc etc. a ggod rule of thum is ...if you have to give more that 3 ivp's in a 4 hr period...they probably need to be on a drip of some sort...and take the leagal burden off of yourself and shift it back to the physician and call him/her back and tell them you have given 3 doses and it has been ineffective.but take that burden off of you and shift it back to them.
i have seen places where nurses feel so bad about theirselves they try to "not let go of a coworkers mistakes".if you feel your nm is not truly being supportive to you....and they have now set you up for failure no matter what you do/dont do...you can find another job. but ...just remember...your first loyalty is to ensure that patient is safe....that is your # 1 priority. your second priority is to treat the issue for which they are admitted (their infection etc etc)...your third priority is to treat the issues that are secondary to the admission diagnosis ( such as pain , depression , anxiety) as long as it doesnt interfere with your #1 priority or your #2 priority.hope this helps.....and np2be....i think everyone here that has posted knows you really want to do a good job and take great care of your patient. but with sedation...you have to be soooooo careful. some of these patients metabolisms are so outta whack that these drugs may stay in their system for a long long time ....and it may suddenlt hit them all at once and make you have sudden airway issues....so unless that sedation is treating your reason for admit...dont go give over 3 ivp's in a 4 hr period before you shift that burden back to the md and let them know its not working!
and like i said, if you can give me a real contraindication for giving that amt of haldol besides the esatblished fact that the order was improper, or you have not given that much, id love to hear it. i havnt heard anything that makes me think its too much . "we have never given that much before" doesnt mean anything to me. i gave the drug, observed for s/s of hypotension/decreased resp,. and ekg changes, noted none, and gave more, all way under some of the dosing guidelines i have seen which inculde a ceilinge single iv dose of 200 mg and uo to 700 mg a day in some literature. i am trying to understand. but i cant yetr
i tell ya....you have seen what haldol does to the older folks.it isnt pretty when granny is now not only anxious but she now has the strength of superman and caught her second wind!so haldol just sucks imo, the eps that can occur are awful.
you say " i am trying to understand but just cant yet"......thats why i feel like you nm has failed ya. i love having new grads in my icu...love them. but when we hire them we owe them a resposibility to ensure they have adequate mentors to clarify things with. it is also my job to frequently check on them as charge. thats my job.....and i feel like someone like the nm and the charge nurse has failed you....bc they didnt check on ya...and they were not there as a resource to you.so i do...i feel like they failed you and kinda set ya up for this.new grads are great in a icu....but when they are hired that hcf owes them and the patients the responsiblity of ensuring the framework of support for them is there.if they dont...the hcf has failed in their duty to not only the patients...but also to this op here. you went to that hcf to gain experience...where was that cnurse when ya needed her?or that nm?
leslie :-D
11,191 Posts
i'm a hospice nurse and deal w/dozens of pts who deny pain.
there can be a million reasons on why they deny it.
but you yourself, observed her to look generally uncomfortable.
that is what should have been brought to the md's attn; not necessarily just by you but it just sounds this whole scenario was mishandled.
of course pts have trouble sleeping in different settings and a prn sedative can be prescribed to help them sleep.
but next time, never hesitate to report your findings of pain to an md....esp if she had wounds (were they infected?) and/or a medical hx to support anything that would cause pain. trust your instincts. and best of luck to you. even though the haldol order was totally inappropriate, it was clearly your intent to relieve this woman's suffering. chances are she would have responded much more favorably with proper pain mgmt.
peacefully,
leslie