another dilemma.. when do i ever learn???

Specialties Geriatric

Published

Specializes in OB, Peds, Med Surg and Geriatric Nsg.

I had a resident which was admitted for altered mental status a week ago. Last night, she was extremely confused, verbally and physically abusive, exit-seeking, and verbalized that she will kill herself if we wouldn't let her go home. MD was called and got an order for stat p.o Haldol (which didn't help at all). Got a call from Behavioral Unit stating that they were contacted by MD about a possible admission. Now, MD wants a direct admit to Behavioral Health, Behavioral Health on the other hand doesn't want to admit said resident pending papers that needs to be signed by POA and its already 10PM. They wanted me to send resident to ER while awaiting for POA to come in and sign the said paperwork. Resident was sent to ER at 2230. I wote a V.O to send resident to ER for eval.

To make the story short, my ass is getting burned today about the said resident. MD didn't want the resident to be sent to the ER but I sent her instead. Behavioral Health told me so. My fault for not making MD aware of Behavioral Health's conditions. Though before I left my 16hour work for the day, I made sure my nurse's note was well documented. Plus there's a red flag because it's a NO-NO to administer Haldol prior to leaving facility since the MD prescribing it is not a psychiatrist. Since when anti-hypnotics limited to psychiatrists only??

Now, did I made the wrong call?

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Specializes in ER, ICU.

Sounds like you did the best you could given a system cluster ****.

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Specializes in Hospice / Psych / RNAC.

Why would you ask for Haldol? It is well documented that that drug is contraindicated in the elderly. It's bad medicine and state surveyors ding facilities for using it here in Hawaii. Sorry about everything else but I just wanted to make you aware that Ativan is a good alternative to suggest for said circumstances.

One of the first things I was taught in school was to not give certain populations Haldol; the elderly are one such group. BTW; Haldol is an antipsychotic (sorry).

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Oh yes, let's dump these patients on the ER because it's well known that they have nothing better to do than babysit difficult patients when nobody else wants to deal with them!

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Specializes in Wound Care, LTC, Sub-Acute, Vents.
i had a resident which was admitted for altered mental status a week ago. last night, she was extremely confused, verbally and physically abusive, exit-seeking, and verbalized that she will kill herself if we wouldn't let her go home. md was called and got an order for stat p.o haldol (which didn't help at all). got a call from behavioral unit stating that they were contacted by md about a possible admission. now, md wants a direct admit to behavioral health, behavioral health on the other hand doesn't want to admit said resident pending papers that needs to be signed by poa and its already 10pm. they wanted me to send resident to er while awaiting for poa to come in and sign the said paperwork. resident was sent to er at 2230. i wote a v.o to send resident to er for eval.

to make the story short, my ass is getting burned today about the said resident. md didn't want the resident to be sent to the er but i sent her instead. behavioral health told me so. my fault for not making md aware of behavioral health's conditions. though before i left my 16hour work for the day, i made sure my nurse's note was well documented. plus there's a red flag because it's a no-no to administer haldol prior to leaving facility since the md prescribing it is not a psychiatrist. since when anti-hypnotics limited to psychiatrists only??

now, did i made the wrong call?

you wrote a verbal order to send patient to er without actually getting a v.o. from the primary md? and you did it because the behavior health told you so? that's a no no. you should have informed the primary md of what the behavior health said and go from there. i would also include the supervisor in this situation and seek her/his advice.

you may have dotted all the i's and crossed all the t's in your charting, but if the primary md refuses to sign your verbal order, then you're in trouble.

i personally would not write any t.o. or v.o without actually getting it from the md. i see some nurses do it in my job but hey it's their license not mine.

good luck and hoping for the best for you.

angel, rn

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Specializes in ICU, PICC Nurse, Nursing Supervisor.

since when is it against the rules to get a order for a anti-psychotic from a primary md ....if that was true there would be a lot of wild patients in the nursing homes....if you have a patient that is threatening to kill themselves and you are having to deal with a lot of bunk about where to send the patient.... then they go to the er. people don't understand that ltc has so many channels to go through to get the right care for the patient that sometimes we can wait to long and the patient has suffered significant harm.

if you feel the patient is going to harm themselves or the patient is sick and the family agrees then send them out . if that patient killed themselves while you are fiddling with paperwork and waiting for whoever to decide where to send this patient ...guess who is in trouble. i doubt the doctor will be standing beside you down at the bon defending you.

. plus there's a red flag because it's a no-no to administer haldol prior to leaving facility since the md prescribing it is not a psychiatrist. since when anti-hypnotics limited to psychiatrists only?? ?
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Specializes in Gerontological Nursing, Acute Rehab.

Agree with the posters above...the doc should've been called re: Behavioral Depts concerns so that he could've given you further orders. Regarding Haldol....from my experience only a psych can order or dc Haldol. We ran into that situation here when a resident with a long standing Haldol order was admitted. Only our psych could change the order.

Right now, it's just a live and learn situation for you. Unfortunately, that's how we learn sometimes. Don't beat yourself up over it...you had the best intentions for the resident. Work with your managers to figure out a way to prevent a situation like this from happening again. But I have to agree with the others who asked: Where was the supervisor when all this was going on?

Good luck to you.

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yeah, agree with above posts. I can see your position but in the end you did write "V.O" when in fact you did not get a verbal order.

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Specializes in OB, Peds, Med Surg and Geriatric Nsg.
Agree with the posters above...the doc should've been called re: Behavioral Depts concerns so that he could've given you further orders. Regarding Haldol....from my experience only a psych can order or dc Haldol. We ran into that situation here when a resident with a long standing Haldol order was admitted. Only our psych could change the order.

Right now, it's just a live and learn situation for you. Unfortunately, that's how we learn sometimes. Don't beat yourself up over it...you had the best intentions for the resident. Work with your managers to figure out a way to prevent a situation like this from happening again. But I have to agree with the others who asked: Where was the supervisor when all this was going on?

Good luck to you.

We have two RN supervisors that night. One got to talk to the POA and helped me decide to send resident to ER. Unfortunately, we had two call-offs that night and both RN supervisors are behind a med cart. If they weren't too busy to be in compliance to pass meds, they would have helped me decide with this situation. This was a first for me and unfortunately I was too busy to get things done. Lesson learned.:crying2:

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Oh yes, let's dump these patients on the ER because it's well known that they have nothing better to do than babysit difficult patients when nobody else wants to deal with them!

I have learned doing psych and long term care not to underestimate a desperate patient or resident, ever!

It's not a dump. It was necessary for resident's well-being to go to another setting that is secure and without access to potential instruments of self-harm or harm to others.

Nursing homes are admitting increasing numbers of SMI patients to get their beds filled. SMI patients can be disruptive and frightening to the non-psych NH population, and a tremendous problem for staff who have to deal with known psych patients using nursing home regulations that are not aggressive enough for psychiatric issues.

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Specializes in ER/Ortho.

Just last week I had an elderly patient who was confused after surg. I work nights, but it clearly showed they gave her Haldol in the afternoon telephone order from Dr. At any rate it is also documented that the Haldol didn't work very well. When I called I asked for Seroquil which by the way also didn't really work well for the pt. either.

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from what i can remember, Haldol is not a great PRN med....need to build a level.....benzos prob a better choice.

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