Ativan and getting punched in the face

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Hi all!

Situation. So I'm a new nurse, just out of school. My background is psych but I figured I'd give the ER a try to get some medical experience. Anyhoo, I'm in the observation area and I've got a patient with a kidney stone and appendicitis and an annuerysm. He's got an extensive mental health history of violence as well as narcotic addiction. But I firmly believe he's hurting. He doesn't have much ordered, even for a regular person, and he's acting up, getting more and more agitatied. He's a big dude so I call the doc to get some Ativan on board before we have an incident. My patient has developmental issues also so talking to him will get us nowhere. The doctor says he doesn't want to write an order for anything to calm this guy down because he said it's "not therapuetic" and we need to use other ways before resorting to drugs. I was basically just told to order security if things start getting bad. Now I've been in mental health and people getting hurt when someone goes off the chain isn't therapuetic either. But maybe I'm new. Is this response from a doctor out of the ordinary?

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Specializes in Critical care.

Not out of line in some situations, no.

Not every pt responds favorably to every med, Ativan included. I see little problems become huge problems due to the 'wrong' med, sometimes. So, if this doc has seen enough of the same, then that explains her or his bias (or the doc is just an idiot and is going to get someone hurt) :)

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Specializes in Hospice.

With that list of diagnoses, delirium is a real possibility - Ativan would be like setting a match to gasoline. I've learned the hard way to be very judicious with benzos.

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Specializes in Emergency.

It sounds like he's got a lot going on pain wise. I'd try going down the analgesia route before sedation.

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Specializes in PICU, Sedation/Radiology, PACU.

Why was he getting more agitated? I'd be agitated too, if I had a kidney stone and appendicitis and wasn't getting appropriate analgesia. It sounds like this patient needed some pain medication, not a benzo. Treat the source of the agitation (pain), and you'll treat the agitation.

Also, giving a benzodiazepine in the ER when the patient is still being evaluated and diagnosed can be tricky, as you may end up masking symptoms. For example, a mental status change may brushed off as a side effect of the ativan when in fact it's a result of a stroke.

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Specializes in CVICU, MICU, Burn ICU.
Why was he getting more agitated? I'd be agitated too, if I had a kidney stone and appendicitis and wasn't getting appropriate analgesia. It sounds like this patient needed some pain medication, not a benzo. Treat the source of the agitation (pain), and you'll treat the agitation.

Also, giving a benzodiazepine in the ER when the patient is still being evaluated and diagnosed can be tricky, as you may end up masking symptoms. For example, a mental status change may brushed off as a side effect of the ativan when in fact it's a result of a stroke.

If I could "like" this twice, I would.

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Specializes in Family Nurse Practitioner.
My patient has developmental issues also so talking to him will get us nowhere.

Definitely address the pain or hunger if that is ever a complaint with this population as a priority but also please take pause to consider your quote above. While I agree when a patient with developmental or cognitive deficits has already escalated it can be very difficult to safely manage so it is crucial to be aware and prepared however based on my experience with neuropsych patients it is so important and very often successful to attempt to provide support, encouragement and distraction techniques. Patients with developmental delays, TBI etc. can also be very difficult to safely medicate so that is also something to keep in mind and imho Ativan prn as monotherapy in the EDs, detox excluded, is overused, often ineffective and can have disastrous results.

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I mean I agree with the delirium thing but when I called the doctor about getting more pain meds, because yeah I'd like to treat the pain for this guy, the doc wouldn't write me anything stronger than 1 MG of morphine which even on those little old ladies sometimes doesn't do it and this guy is obese and 6 foot 4. Hes not the type of TBI who would be content with a busy blanket if you know what I mean. The doc wanted him on Tele and he ripped the wires off twice and was throwing things around his room. The whole situation just upset me because it just didn't seem right to not treat the pain and then provide the nursing staff nothing to address the agitation that would inevitably occur. I was just worried about someone getting hurt. This patient has a history of narcotic addiction but even addicts are in pain when they have all of that going on. I don't know. It just didn't seem right. I charted everything to cya if you know what I mean, because there was a real possibility of something going down with this guy.

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Specializes in Pedi.
I mean I agree with the delirium thing but when I called the doctor about getting more pain meds, because yeah I'd like to treat the pain for this guy, the doc wouldn't write me anything stronger than 1 MG of morphine which even on those little old ladies sometimes doesn't do it and this guy is obese and 6 foot 4. Hes not the type of TBI who would be content with a busy blanket if you know what I mean. The doc wanted him on Tele and he ripped the wires off twice and was throwing things around his room. The whole situation just upset me because it just didn't seem right to not treat the pain and then provide the nursing staff nothing to address the agitation that would inevitably occur. I was just worried about someone getting hurt. This patient has a history of narcotic addiction but even addicts are in pain when they have all of that going on. I don't know. It just didn't seem right. I charted everything to cya if you know what I mean, because there was a real possibility of something going down with this guy.

1 mg of morphine is how much we give to 10 kg children. Seriously.

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Specializes in Medical-Surgical/Float Pool/Stepdown.
I mean I agree with the delirium thing but when I called the doctor about getting more pain meds, because yeah I'd like to treat the pain for this guy, the doc wouldn't write me anything stronger than 1 MG of morphine which even on those little old ladies sometimes doesn't do it and this guy is obese and 6 foot 4. Hes not the type of TBI who would be content with a busy blanket if you know what I mean. The doc wanted him on Tele and he ripped the wires off twice and was throwing things around his room. The whole situation just upset me because it just didn't seem right to not treat the pain and then provide the nursing staff nothing to address the agitation that would inevitably occur. I was just worried about someone getting hurt. This patient has a history of narcotic addiction but even addicts are in pain when they have all of that going on. I don't know. It just didn't seem right. I charted everything to cya if you know what I mean, because there was a real possibility of something going down with this guy.

Honestly this is when you have the MD come to the bedside and see if they want to go a round with the patient!

In my experience, (I would think ED MD's would have waaaay more exposure though) MD's are really not realizing the safety aspect and the true dangers of a physically aggressive patient until they get hit by the patient or see the patient aggressive. Once the MD does take a punch however, they are usually more receptive to appropriately medicating. :up:

FWIW we work closely with our security and they aren't punching bags either. I feel like (although often necessary) restraining an agitated patient that could have been treated safer with other modalities only causes more harm for all involved.

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Specializes in Psych, Addictions, SOL (Student of Life).
With that list of diagnoses, delirium is a real possibility - Ativan would be like setting a match to gasoline. I've learned the hard way to be very judicious with benzos.

Yeah but a small dose of good old fashioned Haldol can work wonders.

Hppy

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The patient's pain was not being sufficiently addressed. You, the nurse, are the patient's advocate. It is your responsibility to advocate for the patient's needs, and if the physician is not responding appropriately to your concerns to use the chain of command to obtain appropriate medical care for the patient. A kidney stone is a very painful condition without the pain of appendicitis in addition. You said you charted to CYA: I assume you truthfully charted your pain assessment and the patient's description of their pain and it's severity, and your intervention (following the orders as given and involving security if needed), or are you saying you charted something else? How did you chart the patient's response?

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