I work on an acute adult inpatient unit. We have an extremely aggressive patient who is involuntarily committed. He is child like and becomes aggressive when he is told no or doesn't get his way. Otherwise, he is actually pretty likable. He has a behavioral plan in place that says to offer his meds PRN meds PO twice when he is in need, and if he refuses force an IM. this is after trying other options to de-escalate. I understand and agree with this, but the other night staff disagreed while he was being held down and waiting for the nurse to draw up his meds...
His meds were taking a while to be prepared, about 5-7 minutes, which seemed like a while since he was in a physical restraint. The hospital supervisor and security were able to verbally de-escalate him during the time. He was no longer being restrained and had calmed down. He said he would take the meds PO. He began crying and saying "I'm sorry". The director of nursing and the treatment team were the ones who impressed upon staff that the behavioral plan must be followed by everyone. This incident occurred on a weekend and they were not present to clarify the plan at the time.
The charge nurse said "no, it's too late. He's getting the IMs". The charge nurse was in the nursing office during all of this and the supervisor was with the patient. The supervisor disagreed and gave them PO without incident. We had no problems with him after that. Her rational was "...he is agreeable. Not only would it be unethical, but it risks him escalating and disturbing the mileu again".
This caused staff to turn on each other, and everyone was interpreting the behavioral plan differently. We have not heard anything from the DON or treatment team regarding this. Both sides of the argument emailed their perception of the incident to the DON.
My question is:
If a patient becomes agreeable to take PRN meds PO, after originally refusing, can they be forced with an IM? Is that ethical and following least restrictive/invasive treatment?
Well said. I felt like the hospital supervisor and I were the only ones arguing the fact that it seemed like punishment/consequence and that is NOT the indication for PRN Ativan and Haldol! ... It was so frustrating. At one point during the debacle, a psych tech threatened the pt with 4-points!! All the patient was doing was swearing and slamming doors!
Well said. I felt like the hospital supervisor and I were the only ones arguing the fact that it seemed like punishment/consequence and that is NOT the indication for PRN Ativan and Haldol! ... It was so frustrating. At one point during the debacle, a psych tech threatened the pt with 4-points!! All the patient was doing was swearing and slamming doors!
It is perfectly acceptable to set limits on a patient's behavior and have there be consequences. However, 4 points is NOT an acceptable consequence for behavior that isn't an immediate danger to the patient or others. And IMO, swearing and door slamming doesn't exactly construe DTS/DTO.
Is this patient involuntarily committed to your facility for treatment, or for medication? Does he have a conservator? Just because he is committed, does not give you the right to medicate him against his will unless he is a danger to himself or others. In this situation, he had calmed down and was willing to take meds PO, so IMs would be illegal unless there was a special-limited conservator authorizing meds against will or the patient was committed by the court for meds.
That's how it works in my state.
In my state a patient does not have to be an imminent danger to self or others to receive forced meds, if and only if, the patient is IVC and 2 doctors have deemed it medically necessary. (I don't believe we have a court order for meds - just a court order for treatment.) Our docs are certainly not quick to order such but if the patient has refused po meds for several days and is obviously not improving, the forced meds order is put in place. In that scenario, we first offer the po and if the patient refuses, the IMs are given. If the patient complies, it is not a restraint. If the patient resists and a held/restraint scenario is used, documentation follows accordingly.
We have had many a staff person injured - some quite badly - because the docs waited and waited and waited until there was extreme aggression before ordering the forced meds. It doesn't help that we have a new doc every 4-6 months. Our providers are not happy here.
Obviously in the OP scenario, it certainly seems po meds would have been appropriate though I agree with Jules A that it often depends on the specifics.
What is the most concerning to me about the scenario is WTH it took so long for the IMs to be drawn up? That is a big problem and a safety issue for the patient and staff. Hopefully someone is checking into that aspect.
This is not uncommon on my unit. Our patients on our acute hall are highly undermedicated. Many times the hold up is we have to call the doc on call who is at home asleep and they often will order geodon. So yes, while we all jump in and help the primary nurse, it takes entirely too long to override the pyxis and then mix the geodon.
Why aren't these emergency meds already ordered prn when we know these folks are quite sick? Great question. Sometimes our only prn is benadryl or risperdal 0.5mg both po. Say what? It can be maddening. We are slowly making progress in that our day nurses are doing a good job of getting appropriate prn's ordered when the docs are in rounding on patients. However some docs are so conservative that they won't give us the needed meds until the patient goes off.
Why aren't these emergency meds already ordered prn when we know these folks are quite sick? Great question. Sometimes our only prn is benadryl or risperdal 0.5mg both po. .
At one of my previous workplaces, we would always encourage the MD to write a set of IM PRN orders in addition to the PO PRN orders (e.g., we'd have Haldol/Ativan PO PRN and a matching set but IM PRN). Almost all of them understood why we wanted them and would do so. The POs were always offered first, and it was uncommon for us to resort to the IM form...but it was good to know that they were there.
Of course, the fact that the other set of PRNs were IM didn't necessarily mean we could give automatically them without patient consent.
Meriwhen (sorry, I'm on my phone and can't quote):
I think what you describe is good, safe practice. I wish I understood why getting those meds prescribed at my facility is such a struggle.
We had talked about implementing an agitation protocol as part of the admitting order set but our medical director never valued it enough to inform the providers. We have asked the provider on call as a patient is escalating, "can I initiate the agitation protocol" and we would be met with the equivalent of "huh?" Very frustrating when obviously we are trying to manage a safe milieu after hours with no provider on site.
Specializes in Hospice, corrections, psychiatry, rehab, LTC.
I have never given a PRN anxiolytic injection to a patient who was calm and rational. When the patient deescalated, he no longer met the criteria for administration of the IM medication. The attitude of "I went to the trouble to draw this up, so by God he's getting it" is unprofessional and irresponsible. The patient could potentially file criminal charges against this nurse, or at the very least file a complaint with the state board of nursing.
At one of my previous workplaces, we would always encourage the MD to write a set of IM PRN orders in addition to the PO PRN orders (e.g., we'd have Haldol/Ativan PO PRN and a matching set but IM PRN). Almost all of them understood why we wanted them and would do so. The POs were always offered first, and it was uncommon for us to resort to the IM form...but it was good to know that they were there.
I should also add that getting the IM copies were good to have for non-emergent reasons as well: a patient who's too nauseated to keep pills down, a patient known to cheek or regurgitate meds, the occasional odd patient who prefers the IM over PO for whatever reason (thinks it works faster, difficulty swallowing pills, has a needle fetish, whatever...I pick my battles, so if this patient really wants these meds IM, IMO they can have them. I'd rather they willingly get the med in them in some form and calm down).
I have never given a PRN anxiolytic injection to a patient who was calm and rational. When the patient deescalated, he no longer met the criteria for administration of the IM medication. The attitude of "I went to the trouble to draw this up, so by God he's getting it" is unprofessional and irresponsible. The patient could potentially file criminal charges against this nurse, or at the very least file a complaint with the state board of nursing.
I've worked with more than a few less than empathetic, burned out nurses and I have not seen this in practice nor does it seem any of these posts endorses such behavior.
The patients I have had on a meds/objection plan or in an emergent situation have the right to take the po meds vs the shot up until I have actually put the needle into their muscle.
I've worked with more than a few less than empathetic, burned out nurses and I have not seen this in practice nor does it seem any of these posts endorses such behavior.
Sadly, I have.
If it wasn't the "they're already drawn up" reason, they sometimes gave a patient IMs to make an example of him/her so other patients would see what would happen if they decided to act out as well.
Specializes in Hospice, corrections, psychiatry, rehab, LTC.
Sadly, I have.
If it wasn't the "they're already drawn up" reason, they sometimes gave a patient IMs to make an example of him/her so other patients would see what would happen if they decided to act out as well.
I once had a colleague who medicated patients preemptively so that she wouldn't be bothered during her shift (nights). I learned this when I covered night shift during one of her absences (I worked swings and I stayed over when she called off). A young female patient came out of her room into the hallway and she sat quietly in a chair. The psych tech asked if I was going to medicate her. I told her no, because she was calm and she wasn't bothering anyone. The tech then told me about the night nurse's routine of giving IM medications to patients at bedtime and then charting that they were agitated.
I reported this information to my nurse manager. The night nurse wasn't employed with us for much longer.
Abbyrose
12 Posts
Well said. I felt like the hospital supervisor and I were the only ones arguing the fact that it seemed like punishment/consequence and that is NOT the indication for PRN Ativan and Haldol! ... It was so frustrating. At one point during the debacle, a psych tech threatened the pt with 4-points!! All the patient was doing was swearing and slamming doors!