BID Order Questions

[ShonaRN0522]

hi everyone. i am a new nurse, and am finding that i am doing a lot of second guessing myself these days! here is one i could use some advice on. the other night, i had a patient with a hx of alzheimers who had just had his hip pinned. he became very agitated and began digging at his dressing and wound up pulling his dressing off, tried to pull his staples out, and was becoming violent and mean to any staff that tried to get close to him. i called the dr. who ordered restraints and 0.5mg haldol po bid prn. i managed to get him to take the pill, and he calmed right down, therefore, i did not put the restraints on him. 3 hours later, he was right back to square one. he pulled out his iv, tried to yank his foley out, and pulled the dressing off his incision again. he had it bleeding and once again was becoming violent to the staff. this time, i did put limb restraints on him. i was also advised by one of the seasoned nurses to go ahead and give another 0.5 mg of haldol, which i questioned and was told it was ok to give it because it was after midnight, and therefore the start of another day. the order was bid, so i went ahead and gave it again. did i mess up? am i going to get a med error? the patient eventually quit yelling and fighting, and rested for a few more hours. i am just worried about getting in trouble...thanks for any advice!

[oldladyRN]

In my mind, there are a couple of things wrong with this picture.

First of all, was the order for 0.5 mg or for 5 mg? With the patient population I've cared for, 0.5 mg would be the amount you might sprinkle on a mosquito. That seems a terribly small dose to me, but there may be kidney issues, liver issues or other medications on board that necessitated a dose that small. I just can't imagine a dose that small being effective.

Second, I would have never given another dose just because it was after midnight and the sun was coming up on a new day. I would seriously question the other nurse's advice. Check your facility's P&P on medication administration parameters. It could mean that the medication is to be given every 12 hrs as needed, or twice daily as needed while the patient is awake. The policy and procedure for that situation is what's going to cover you if something happens.

Please continue to advocate for this patient's safety and healing.

oldladyRN

[Isitpossible, LPN, LVN]

just a student so i dont know BUT i know BID is twice daily, but shouldnt it be spaced like 12 hrs apart (or at least 8?)

[meandragonbrett]

BID for a PRN medication is a bad order. Plain and simple.

[elkpark]

Actually, my biggest concern about this scenario is that you got an initial order for restraints, didn't use them because the client calmed down with the po Haldol, and three hours later, when the client became agitated again, you applied restraints. I was a CMS surveyor for several years, and I can tell you that CMS would consider this restraining someone without a physician's order, because of the time that had passed and it being a new, different episode of agitation. (It's probably a violation of your state rules/regs also -- it would be in my state, but there is some variation from state to state.) PRN restraint orders have been "outlawed" for many years, and you are expected to get a physician's order for each use of restraints at the time they are needed.

You need to familiarize yourself with your individual facility's policy on prn orders and how frequently they can be given when the order states something like "BID PRN." But, again, the bigger concern here for me is the use of the restraints.

[ShonaRN0522]

Happy New Year Everyne! Thanks for the comments and advice.

I've looked in the P/P manuals, and I've asked every nurse I work with for their opinion, and still have not come up with a straight answer! I've decided to not worry about it anymore. If I get an error, I guess I'll just have to look at it as a learning experience and move on.

Thanks!

[ShonaRN0522]

Never even thought about the restraints being a problem....Yet another screw up with this patient I suppose. *sigh* I didn't want to use soft restraints on him, and by waiting, I was trying everything possible before going the restraint route. I kinda wish my facility had a longer preceptor program. It would be nice to have a go to person that I could go to in order to prevent these problems.

[Plagueis]

As meandragonbrett posted, 0.5 mg Haldol PRN BID was a bad order. It should have been more specific, such as every 8 or 12 hours, for instance. The MD should've been contacted for clarification.

[elkpark]

I didn't want to use soft restraints on him, and by waiting, I was trying everything possible before going the restraint route.

I understand your concerns about the restraints (and you're right!), but, in this situation, you essentially used the original restraint order like a "prn" order which, for restraints, is strictly forbidden.

Well, you'll know better next time! :) Everybody has to learn this stuff. Best wishes --

[starletRN]

The restraints issue might be different depending on the area. In our facility a RN has to reevaluate the need for restraints and document it on a flowsheet q 12 hours. Our restraint flowsheet has a space where you can document that a patient is temporarily out of restraints. A new doctors order has to to be on the chart daily for restraints.