appropriate behaviors

debRN0417 · Jul 26, 2011

I would think you need to list whatever behaviors the resident actually is displaying as well as whatever behaviors the medication was prescribed to control. Agitation is NOT a good one. You need to be more descriptive- like screaming, pacing, striking out at others, hallucinations (and then say what kind- sees her dead husband or whatever), there's all kinds of behaviors. You should list exactly what it is the resident is doing to make it truly individualized. When the medication was prescribed, exactly what was is prescribed for- I mean what were the behaviors that caused the need for the medication. Those are the behaviors you want to chart on. This will show you if the resident is being controlled on the medication or may need an increase or decrease. Also dont forget to assess and chart side effects- and watch for TD!

pixie120 · Jul 30, 2011

Agree with previous poster, should be descriptive behaviors :

s/sx depression AEB crying, yelling, self-isolating (for AD)

hallucinations, paranoid statements, visual hallucinations for AP

Insomnia (do sleep monitorfor all sleep aides)

S/SX anxiety aeb pacing, repetive health concerns, verbal report of agitation

txdon · Jul 31, 2011

Thanks for the responses. One problem I have is with new admissions who are on psychotropics. We have to fill out behavior sheets upon admission, but often times behaviors are unknown as to why they are taking the medication. Largely in part because the medication is controlling the behavior, so behaviors we put on the behavior sheets are solely based on the type of medication they are on. Recently my administrator said "Hollering at the staff" is not considered an appropriate behavior. This particular resident screams instead of using the call light and hollers at staff. What should be put on the behavior sheet?

Finally, we recently had a dr. who wrote a t.o for a pain medication to be given q 4 hours "while awake". Since we are in the middle of end of month change over, I need to find out just how this should read on the MAR. The medical records manager who puts in the MARS says it should be at 8am, 12p, 4pm, and 8p. My unit manager and I believe it should show 6 times over a 24 hour period 8a,12p,4p,8p,12a,and 4a. If the resident is asleep during any of these times then the nurse needs to initial and circle the medication was held due to resident asleep. This way we are not automatically assuming resident is awake during the day hours only. Any thoughts on how this should be put on the MAR?

pixie120 · Jul 31, 2011

Thanks for the responses. One problem I have is with new admissions who are on psychotropics. We have to fill out behavior sheets upon admission, but often times behaviors are unknown as to why they are taking the medication. Largely in part because the medication is controlling the behavior, so behaviors we put on the behavior sheets are solely based on the type of medication they are on. Recently my administrator said "Hollering at the staff" is not considered an appropriate behavior. This particular resident screams instead of using the call light and hollers at staff. What should be put on the behavior sheet?
Finally, we recently had a dr. who wrote a t.o for a pain medication to be given q 4 hours "while awake". Since we are in the middle of end of month change over, I need to find out just how this should read on the MAR. The medical records manager who puts in the MARS says it should be at 8am, 12p, 4pm, and 8p. My unit manager and I believe it should show 6 times over a 24 hour period 8a,12p,4p,8p,12a,and 4a. If the resident is asleep during any of these times then the nurse needs to initial and circle the medication was held due to resident asleep. This way we are not automatically assuming resident is awake during the day hours only. Any thoughts on how this should be put on the MAR?

On new admits, I look for the "real" psychiatric dx that led to the drug (rule out NEW serequel/zyprexa added in the hospital stay, look at the home meds list, if available). A lot of times cannot find anything specific, SO add what is most likely the behavior, ie

Antipsychotic: Combative with care, delusions, hallucinations, hears voices, (make sure though the med wasn't prescribed for delirium, which should have cleared by the LTC/SNF admit. Ask the families/residents, often times the resident is very aware if they have been taking a med for awhile, and the reasons prescribed. If unable, start with 3 behaviors you think are most likely and then at the 72 hour meeting/review see if it is appropriate still and ask your social worker to chime in. plus ASE of and AIMS

Anti-anxiety: self-reported s/sx anxiety, s/sx agitation/anxiety, panic attack, agitation/pacing plus ASE of

Anti-depression: ASE and s/sx depression, s/sx sadness, crying, self-isolating

Hypnotic: S/s insomnia, hours of sleep for each shift plus ASE of

Anxiolytics (same as anxiety)

There are stickers and sheets that Briggs makes. I also like Workflow or is it Work force? I can't remember.

Surveyors are happy if you at least identify 3 to start and go from there.

NO prn anti-psychs cuz you cannot medicate behaviors (ie Seroquel prn for wandering, bad bad). I get rid of all Haldol except for prn for hiccups UNLESS dx psych prior to hospitalizatin and comes with that as a home med, which is VERY rare, or as a hospice client order (even then I will try to get that med dc).

I look at anti-anxieties for potential fall risk and doses of all meds esp Depakote, Anti-psychotics the hospitals often double AP, forget the AD and add fall risk drugs just for fun. Takes a while to weed it all out and get the right meds for your patient.

pixie120 · Jul 31, 2011

Oh for pain med, give pain med every 4 hours while awake, start 0600, 1000, 2 pm 6 pm and 10 pm and get the doc to write an order that says may hold any med if resident asleep or if the resident wants to be awakened at 0600 and 10 pm, add that into the order (best practice would be to have a "prn" 0200 med and add may hold if resident asleep). My real question here is why not a long acting pain med so the resident CAN sleep?

CapeCodMermaid, RN · Aug 6, 2011

NO prn anti-psychs cuz you cannot medicate behaviors (ie Seroquel prn for wandering, bad bad). I get rid of all Haldol except for prn for hiccups UNLESS dx psych prior to hospitalizatin and comes with that as a home med, which is VERY rare, or as a hospice client order (even then I will try to get that med dc).
I look at anti-anxieties for potential fall risk and doses of all meds esp Depakote, Anti-psychotics the hospitals often double AP, forget the AD and add fall risk drugs just for fun. Takes a while to weed it all out and get the right meds for your patient.

We use PRN antipsychotics IF there is a standing order for the same medication. We use a lot of Depakote as a mood stabilizer and standing orders for po Haldol. If someone is a short term resident, we try not to be changing their meds around...especially the psychotropics. If they are going to be with us for several months, we try to get them on the best med regime we can that manages their symptoms with the fewest side effects.

Of the 117 residents in the building....107 are on some sort of psychoactive drug....89 are on at least one antipsychotic...and no, they aren't old people with dementia...they are psychotic people.

Nascar nurse, ASN, RN · Aug 7, 2011

txdon - i think I would call the Dr. back and clarify the tylenol order. They recently announced that they have lowered the daily tylenol limit to 3000mg/day and if the resident would actually be awake and take it at night they will be over the 3000mg limit. Let it be the Dr. choice, not your mistake.

pixie120 · Aug 7, 2011

We use PRN antipsychotics IF there is a standing order for the same medication. We use a lot of Depakote as a mood stabilizer and standing orders for po Haldol. If someone is a short term resident, we try not to be changing their meds around...especially the psychotropics. If they are going to be with us for several months, we try to get them on the best med regime we can that manages their symptoms with the fewest side effects.
Of the 117 residents in the building....107 are on some sort of psychoactive drug....89 are on at least one antipsychotic...and no, they aren't old people with dementia...they are psychotic people.

Definetly your population is different, and yes, we try not to rearrange their meds. We are just trying to fix the medications that were all mixed up during the hospital stay, to get back to either pre-hospital SNF med list, or home list. I just personally haven't had a reason to truly give a prn antipsych. Depakote is a wonderful mood stabilizer, Haldol causes lots of TD/EPS especially in the elderly plus is a fall drug. I also agree, if short stay resident, try to get to the correct med list but the hospital rarely has it written correctly, in my 20 years, I haven't yet found one discharge list of meds, from a hospital, that was even remotely correct for the previous home meds/Assisted Living/Adult Family home and they tend to forget antidepressants and add in random antipsychotics for short term delirium (which is an off label use) which has, of course, cleared by the time they admit to skilled nursing. It takes at least a good hour to get to the actual med list and that is if the patient or the family has the home list or bottles of meds for me to look over, compare and do a full med reconciliation. Haldol prn and a new dose of Seroquel without the routine dose of Celexa and nuerontin makes for a very unhappy patient. Maybe it's just our local hospitalists that make these errors? But it is every hospital, without fail, on every admit......if I am lucky, I have the assisted living med list prior to the admit so I have a good idea what the home meds were before I see the wacky hospital list, not to mention the thousand bowel meds the hospital thinks we should do in addition to our house protocal bowel program... like what IS Guar Gum, anyone ever see what this is? HOuse formulary at one hospital, and the hospitalist adds it on/leaves it on for every admit, my pharmacy has no idea what this is, why do hospitalist not understand that SNF's have their own bowel programs?

CapeCodMermaid, RN · Aug 7, 2011

There is no reg which states your doc has to okay what the hospital doc wants. We use different meds than the local hospital so our docs tell us to us what we have.

Never heard of guar gum as a laxative. I know it's used as a binding agent in some cheap ice creams.