Ok, here's the situation. We have an adolescent on our unit who is pretty sick (psychotic). Mother brought him in a few days ago and basically said do what you have to do to help him. Yesterday he was awake and starting to get a little agitated, requiring frequent redirection, but no aggressive behavior towards himself nor others so I gave him a PRN dose zydis 5 mg PO before the end of my shift. I came in tonight and found out that later that day the day shift had to put him in restraints because his behavior escalated further. They also had to give emergency med because he was trying to chew the restraints and bang his head, etc. So I'm reading the docs progress note and he spends 2 pages ranting about the nursing staff not medicating him quickly enough (which I understand the staff was unable to reach him during this ordeal) and then rags on the night shift for not giving him the PRN IM zyprexa he ordered a day or so after he ordered the PRN zydis.
Here's the problem: The doc wanted us to give the pt. the IM med. Appearantly he thought the new zyprexa IM order eliminated the zydis order.
Now unless I'm way off, you NEVER medicate a patient with IM meds unless the patient requests IM, or he requires an emergency med and refuses the PO form, or he is under a court order to take his psych meds or receive IMs. In other words, you HAVE to start with the LEAST invasive method which would of course be the PO form of a med. Per the floor director, we can skip the POs for an adolescent and force the IM when the adolescent becomes agitated.
Here are my questions: Why on earth would adolescents have a different set of rights when it comes to med admin? Or am I wrong in thinking that adults can't be forced to take IM meds without offerring the POs first? Does anyone have a link which can support or refute what I'm thinking?
Tread carefully. In your effort to be patient advocates you are pushing into getting fired territory. You may even be endangering your license.
If you believe the MD or the unit director have made errors of judgement or transgressed law or policy of your institution, you have the option of writing a complaint to various coverning bodies. You can refuse to follow a Dr's orders if you believe them to be endangering(not inconveniencing) the patient. Your institution will have guide lines for you to follow in that case. If they don't contact your state nursing board.
However the MD has the unlimited license, you don't. There are plenty of cases where it is fine not to offer a po alternative. If in the physician's judgement a medication is more effective in a particular case if given IM then that is how he orders it and how the nurse is required to administer it. If the MD orders a med given IM then that route is part of the order. You are not empowered to alter physician's orders.
I'm not sure why the lot of you are not facing serious disiplinary action. A case could be made for you practicing medicine without a license.
You are not empowered to alter physician's orders.
I'm not sure why the lot of you are not facing serious disiplinary action. A case could be made for you practicing medicine without a license.
I'm not quite sure where you get that we did anything wrong nor where we altered any physician orders. The first incident had a PO ordered still; the 2nd we called the psych director (who happened to be on call and was very familiar with the case) and got a PO with absolutely no argument. I simply explained that the patient was willing to take the PO and we were uncomfortable with giving an IM. We didn't give a med without an order. And like I said...I'd prefer to be on the stand any day defending why I requested POs in lieu of IMs rather than justifying why I gave IMs to a patient (who was perfectly willing to take a pill) and as a result hit the vagus or a blood vessel in the struggle.
As for IMs being the first and only line; that hasn't been my experience in the Fed system, CA state prison, nor private medical nor psych floors. I'm sure some areas do allow it, but IMHO that is one lawsuit away from changing when a pt. who is not out of control, nonetheless is getting IM has an adverse affect from the IM intervention.
Here's the problem: The doc wanted us to give the pt. the IM med. Appearantly he thought the new zyprexa IM order eliminated the zydis order.
...
Here are my questions:
Better question: Are they ticked at you?
You did exactly the right thing. If the 5 mg Zydis didn't work, or he continued to escalate and you weren't there for that, how can you be held responsible? The PRN was ordered, you gave it appropriately.
If the doc thought writing a new "zyprexa" order negated the previous one, he should think again. His order should have started with d/c zydis if he didn't want the zydis order followed. Period. End of story.
The adolescent is in deep trouble. Lucky he has you (and probably one or two more like you!) on his side.
To me, it isn't about rights when it is an urgent or emergent psychiatric situation. You can the order. You had the parent's consent (presumably). If somebody documented mother's "do whatever you need to do" documented, then you had that, but you didn't need it. You were practicing your profession professionally.
Now stop beating yourself up! (And does it say you are coming back to Texas???? Can I interest you in a job where I'm working????)
You did exactly the right thing. If the 5 mg Zydis didn't work, or he continued to escalate and you weren't there for that, how can you be held responsible? The PRN was ordered, you gave it appropriately.
If the doc thought writing a new "zyprexa" order negated the previous one, he should think again. His order should have started with d/c zydis if he didn't want the zydis order followed. Period. End of story.
The adolescent is in deep trouble. Lucky he has you (and probably one or two more like you!) on his side.
To me, it isn't about rights when it is an urgent or emergent psychiatric situation. You can the order. You had the parent's consent (presumably). If somebody documented mother's "do whatever you need to do" documented, then you had that, but you didn't need it. You were practicing your profession professionally.
Now stop beating yourself up! (And does it say you are coming back to Texas???? Can I interest you in a job where I'm working????)
Yeah, we're moving back to TX (Sugar Land area) specifically. In spite of this one doc (who believe me when I say he is a problem child--he wrote a 6 page rant on the RNs because they wouldn't restrain a patient and cath him for a urine sample, not to mention his frequent 11p-3a patient rounds) I absolutely loved my job--when I did the crisis role. I never thought I'd say it, but I think I enjoyed it more than when I worked with the vets in Waco. I hated to leave, but we just couldn't afford a home. So if y'all can hire me as a traveler...have car will travel. Just need a few weeks to settle into the house.
Yeah, we're moving back to TX (Sugar Land area) specifically. In spite of this one doc (who believe me when I say he is a problem child--he wrote a 6 page rant on the RNs because they wouldn't restrain a patient and cath him for a urine sample, not to mention his frequent 11p-3a patient rounds) I absolutely loved my job--when I did the crisis role. I never thought I'd say it, but I think I enjoyed it more than when I worked with the vets in Waco. I hated to leave, but we just couldn't afford a home. So if y'all can hire me as a traveler...have car will travel. Just need a few weeks to settle into the house.
:kiss
I don't think they do the traveling thing, although a couple of our nurses work weekend doubles and just stay the in-between night in a local hotel.
Seriously, travel from the Houston area to the Dallas area just won't pay, especially since we are doing about $3/gallon out here. (And we're sitting on our own oil! sheesh!)
We do have a psych ER thing that's pretty cool. I worked it a couple of times--I am now a fulltime float since they "collapsed" the child/adol psych ER and those nurses opted for the 12 hour shift style. Since I do weekend doubles I didn't make the cut....
Anyhooo. I know you know this--you told me before and now I'm relearning it from experience.
A lot of nursing, maybe especially psych nursing, is about doing the best we can do and then leaving after our shift. We see so much that isn't quite right. Our best practice may very well be to do the best we can, document to protect ourselves and advocate for our patients and keep our hind ends out of the line of fire.
My heart is with you in your situation. Those 11p-3a round-makers need a good dose of Li or Neurontin (or maybe some ECT? LOL I can think of a few places to put those 'trodes!).
We nurses have to support each other, protect each other, cajole each other, love each other.
If nurses don't do it for nurses, I think it won't get done. And I guess this is off topic.
Thunderwolf, MSN, RN
3 Articles; 6,621 Posts
Your an excellent patient advocate. Just document clearly with rationale. But, it doesn't make it any easier for you. I feel your pain.