I love the wisdom and experience that so many of you possess, and wanted your opinions on how I handled a situation. I apologize in advance for the length of this.
I'm an recent LPN grad but haven't taken the NCLEX, so I'm just working as a regular MAP cert staff, not a supervisor. Our supervisors are not nurses either- we have a nurse who oversees the residents and gives advice in medical situations (I don't have her number, the supervisors call her).
The other night I went to admin PO meds to a resident- one of the meds was clozapine- and she was unresponsive to verbal and physical stimuli, including an ice pack to neck and chest, with an automated BP of 83/45, P 49. I contacted the supervisors, elevated the resident's legs and kept talking to her. Within 15 mins she was stirring and BP was up to 120/62. Supervisor arrived with manual cuff (I usually bring my whole nursing bag but of course, that was the day I left it in the car)- manual reading was consistent w/ automated. I said I was OK with monitoring the resident but wanted to hold the clozapine just until BP had been stable for 15 mins (still within the time frame to give it). But after 15 mins, the resident was again out and this time the automated BP read 47/25, P 29. My supervisor walked in right as I got that reading and said she was sure it was an error because I had just gotten a normal manual BP 15 minutes ago and there's were no parameters so I should just give the meds. I said I wanted to call and check to see what to do before giving the clozapine. I was thinking that the doctor would be called and maybe they would want to send her to the hospital. My supervisor told me she was calling the nurse and left the room, then came back and told me the nurse instructed the meds be given. I ended up giving the meds and feeling partly petrified that something was going to happen to the resident and partly foolish for refusing to just obey the rules, like I was trying to act like a know-it-all and that they were probably thinking I was obnoxious and thought I was all that just because I had graduated from nursing school. But my intentions were to protect the resident.
My shift ended shortly after, and I worried all night about the resident but I haven't heard anything so apparently she was OK. I just keep thinking, what if she hadn't been OK, if her BP had tanked after the dose of clozapine? I also know that if something had gone wrong with the resident, I would be forever blaming myself for not just calling an ambulance. What would you nurses have done? Thank you for any advice!
I agree, Davey. I think that one of the issues with not having a nurse in the facility all the time to make these judgement calls is that residents get sent to the ER when they shouldn't be and NOT sent when they should. Not putting down my supervisor at all, but sometimes lack of knowledge gives us false confidence. Maybe she had some intuitive way of knowing that the resident was not going to decompensate further, but I don't see how, especially without any hands-on assessment. I feel like nursing school has given me lots of knowledge but also made me realize that there is plenty that I don't know and have no business trying to handle on my own.
We learned about neuroleptic malignant syndrome in connection with certain meds in school but I've never seen it. Her T was 97.7 temporal (sorry I forgot to mention that, I didn't give a very good report in my post!). I remember a high temp as being a classic presentation but don't know about any variations- I'll research it because I should really know more about it since I give a lot of psych meds.
Too bad I don't have you all on speed dial when I'm at work!
There should have been more active involvement from a licensed nurse, plain and simple. A provider should have been called and I agree that ER transfer should have been considered. I also agree that refusing to give medications that you weren't comfortable giving would have been more than reasonable. With that said, I am not criticizing you at all. I am just shaking my head at the lack of involvement/judgment from your superiors.
Specializes in Psych (25 years), Medical (15 years).
12 hours ago, FashionablyL8 said:
Too bad I don't have you all on speed dial when I'm at work!
I must say, fashionablyL8, at this stage of the game, I wish to express my admiration and respect for you.
Having been a member of allnurses for quite a while, I've seen other young nurses like you ask questions, get realistic responses, and run home crying to their mommies because we didn't kiss a boo-boo.
You, fashionablyL8, have taken the bottomline information, used it to learn, and shown gratitude for the experience.
Thank you so much, Davey, I really appreciate that! In this world of fragile egos, it can be difficult to find people willing to tell it like it is, so I really value the honest advice I get here. It annoys me when I watch new nurses get good constructive criticism here and do the online version of flouncing off with their panties in a bunch. I also wonder how they're gonna react when they get their first patient/resident who curses them up and down and insults everything about them ?.
I also wanted to say that you sound like an amazing nurse. You’re brand new and you were in a difficult situation but you did everything right. Good critical thinking skills (legs up, trying to wake her with the ice pack, etc), calling for help at the appropriate time, etc. Your supervisors failed you, but you’re going to be great, I can tell.
Specializes in Psych (25 years), Medical (15 years).
1 hour ago, Curious1997 said:
NMS has pretty evident symptoms.
Yes indeedie, Curious:
"Symptoms of neuroleptic malignant syndrome usually include very high fever (102 to 104 degrees F), irregular pulse, accelerated heartbeat (tachycardia), increased rate of respiration (tachypnea), muscle rigidity, altered mental status, autonomic nervous system dysfunction resulting in high or low blood pressure."
I've known of only three patients in my career diagnosed with NMS, the first one being a patient at Anomaly State Hospital in the early '90's.
I was called on to assess a patient who was experiencing what was believed to be flu symptoms and I had just recently learned what NMS was. I informed the medical doc of my belief, and it was confirmed.
Another patient, in the early 'aughts at Wrongway, was also diagnosed with NMS. However, this patient's symptoms, I learned, were not to a T.
"Symptoms of neuroleptic malignant syndrome usually include very high fever (102 to 104 degrees F), irregular pulse, accelerated heartbeat (tachycardia), increased rate of respiration (tachypnea), muscle rigidity, altered mental status, autonomic nervous system dysfunction resulting in high or low blood pressure."
I've known of only three patients in my career diagnosed with NMS, the first one being a patient at Anomaly State Hospital in the early '90's.
I was called on to assess a patient who was experiencing what was believed to be flu symptoms and I had just recently learned what NMS was. I informed the medical doc of my belief, and it was confirmed.
Another patient, in the early 'aughts at Wrongway, was also diagnosed with NMS. However, this patient's symptoms, I learned, were not to a T.
As I said,
because some of the symptoms were consistent.
Correct me if I'm wrong Davey, but isn't NMS most common on initiation of antipsychotic therapy? My understanding is that this is a chronic patient in a residential setting and is likely to have been managed on clozapine for a while. Can NMS develop at any time while using the drug?
A BP that low and a heart rate low from the baseline you just got, means either the machine was wrong and you should confirm manually or it's a medical emergency.
I do hope in your documentation you included that you notified and utilized the chain of command.
Specializes in Psych (25 years), Medical (15 years).
1 hour ago, TheMoonisMyLantern said:
Correct me if I'm wrong Davey, but isn't NMS most common on initiation of antipsychotic therapy? My understanding is that this is a chronic patient in a residential setting and is likely to have been managed on clozapine for a while. Can NMS develop at any time while using the drug?
Good questions, Moon!
Yes, the majority of NMS in patients occurs with the initiation of antipsychotic therapy. However, NMS can occur anytime during treatment.
A case in point was the patient at Wrongway I mentioned who was diagnosed with NMS in the early 'aughts. I had worked with this patient as a client in a community mental health center from 1996 to '02.
This patient was approximately the same age as me, so they were probably in their 40's when the NMS symptoms appeared. The patient had been receiving psych med therapy for more than five years, and it's probably safe to say they had been receiving treatment for somewhere in the area of 20 years.
That's interesting about your pt at Wrongway, Davey (btw I love the names you come up with ?). It's good to have information about these rare syndromes because if nobody recognizes them, they don't get treated. I remember that old physician's saying, something like "if you hear hoofbeats think horses, not zebras"- but zebras do still exist. Come to think of it, there's even a training we have to do on clozapine, and it never mentions NMS.
I did document what I could at work, and when I got home also documented a thorough narrative of the event for my own records, just in case.
Unless it happens again and the resident is actually taken to the hospital, I guess we'll never know what happened that night. I'm just glad that there was no bad outcome, and I learned a lot from the replies here on how to handle similar situations in the future ?.
Davey Do
10,666 Posts
In reading your last post with more symptoms, Neuroleptic Malignant Syndrome (NMS) came to mind, fashinablyL8.
The patient needed to receive an involved assessment by a qualified medical professional.