Incorrect medication prep

[ARN1992]

So I'm almost off orientation and I made my first medication mistake. A patient arrived with complaints of cardiac related symptoms, but has a history of stroke. The dr went in to see him and determined it was all anxiety. She order PO Ativan. Doesn't sound like a problem, right?

Well the nurse I was orienting with knew this patient and told me I shouldn't have given to PO med because stroke units will usually make a huge deal of this and get jcaho involved. Because of his stroke history and the fact that he was being sent to a stroke floor. CT showed no signs of a stroke, and the patient had an NIH of 1. He seemed to have tolerated the medication, but it was the end of my shift so idk what the stroke floor will say. I'm so nervous. I know better than to give stroke patients PO Meds, but this guy was in the grey area. And I'm afraid I'll get in a lot of trouble. Anyone else have experience with this?! Please help

[nrsang97, BSN, RN]

Sounds like there was no real reason to hold off on po medications. I am not sure why the nurse you were working with felt that po meds weren't indicated, but if a bedside swallow screen was done then he was ok to take them. We don't stop giving po meds to every stroke patient unless they have swallowing issue.

[EmergencyRN22]

As long as the pt passed a swallow eval - po meds are okay. You may need to reasses frequently if any changes in pt condition.

[Fiona59]

Ativan is sublinqual, it dissolves in the mouth under the tongue. How is that a swallowing risk?

Yes, I'll admit my ignorance here

[CamillusRN, BSN]

Ativan is sublinqual, it dissolves in the mouth under the tongue. How is that a swallowing risk?

Yes, I'll admit my ignorance here

No ignorance - it's a valid question.

I was taught to never put any medication in someone's mouth (sublingual or otherwise) if they weren't alert enough to maintain a patent airway without assistance (field/prehospital) or failed a swallow challenge (bedside). This was d/t the risk of aspirating the secretions produced by the gustatory-salivary reflex - production of saliva d/t something being in the mouth.

[jadelpn, LPN, EMT-B]

But the bottom line is that if you have a written order for PO Ativan, and the MD has seen the patient (and assuming that part of their assessment would include speech/swallow) and as the nurse are seeing no signs of swallowing difficulty...I am not sure that I would hold the med or ask for IV Ativan. If the policy is different, then I would reconfirm with the MD that they want this patient still on a strict r/o stroke orders, and if so, you need to keep patient NPO. Then let the MD decide.

Sounds a little political to me--with all the jhaco/stroke nurses having a cow business. MD's have an option to pick and choose what parts of a whole stroke order set they would like to follow based on their own assessment. If the condition changes, then that is another whole thing. But presenting to the MD was a low stroke risk, and seemingly able to swallow.

[iluvivt, BSN, RN]

MunoRn gets right to the point...I love your posts!

[Nurse Beth, MSN]

A couple of bothersome things about your experience-

The doctor assessed the patient in person and ordered po Ativan. Is your preceptor suggesting the doctor is in error? Or that you should be expected to know not to follow the doctor's order?

Your preceptor was acting out of fear (probably for herself) and then blaming you. Using the scare tactic of "Joint Commission will get involved" is not the best way to communicate a concern to a new nurse.

Patient safety was not compromised, and that should be the focus and intent of your learning.

Sorry you had this experience. You did everything right and you are really performing at a high level (are you a new grad?) by considering the CT results and the NIH eval. Good job :)

ps A simple bedside swallow screening is performed at our facility on R/O strokes. Makes it all very clear cut.

[That Guy, BSN, RN, EMT-B]

D a bedside swallow study. If they tolerate that, they can tolerate PO meds more than likely.

[Altra, BSN, RN]

What is the protocol at your facility - all r/o CVA patients are NPO until a formal speech eval? Or is a dysphagia screening by the bedside RN part of the order set?

And please file this away in the back of your brain: do things, or don't do things, on the basis of whether or not they are clinically appropriate for your patient -- NOT on the basis of whether or not another nurse will be "annoyed".

[CamillusRN, BSN]

And please file this away in the back of your brain: do things, or don't do things, on the basis of whether or not they are clinically appropriate for your patient -- NOT on the basis of whether or not another nurse will be "annoyed".

^^ Haha! Yes, this! Kudos for straight up saying what we were attempting to hint at!