LTC incident, what are your thoughts.

[wearyLPN]

This is a unit where I was the only nurse, I had 3 CNA and 61 residents all in various stages of Alzheimer's.

One night I had an issue with a combative resident. After trying the usual nursing measures (Incontinence care/toileting, snack, fluids, redirecting, 1:1, music, photo books, blanket etc) to calm this resident down to no avail, I turned to the PRN meds. The patient had an order for PRN 0.5mg Ativan for increased anxiety/ restlessness. I opted to administer this, at the same time I assessed for pain but was not able to get a response from the resident because the communication was of course words uttered that made no sense, there was no facial grimacing just the combative behavior with the staff. I administered PRN Ativan for the Anxiety/Restlessness and Tylenol 650 mg at the same time in case the resident was in pain and was unable to show/communicate it.

I was written up for this. I am being told I should have tried the Tylenol and then later the Ativan.

Can I not make the choice to address two issues with two separate medications simultaneously? There was no way to verify pain, I thought it best to address it just in case.

Is this a colossal mistake, what would you have done?

[SuesquatchRN, BSN, RN]

I think what you did was entirely reasonable. Whomever wrote you up is a colossal whatever.

[MN-Nurse, ASN, RN]

I know there is very little comfort in this, but the person who wrote you up is a complete effin' moron.

[Old.Timer]

I was written up for this. I am being told I should have tried the Tylenol and then later the Ativan.

If you "should have" tried the Tylenol first then the order "should have" said that. No error made and thus no write up warranted..... none whatsoever.

[AZMOMO2]

I would have done the same thing based on the symptoms. Is there some p&p at your facility that says to assume pain as cause prior to treating with PRN anxiety meds?

[Perpetual Student]

You honestly did nothing wrong. Whoever thinks you did seems like an idiot. Benzodiazepines can be a helpful adjunct therapy when managing pain, so it was win-win to administer it along with an analgesic.

Nursing is both an art and a science. Clearly the person who's giving you a hard time forgot the art part. No two artists are going to do the exact same thing, and that's OK so long as the piece turns out OK in the end.

[KimberlyBSN]

I think what you did makes complete sense and is probably what I would have done. However, from a management pov, by administering both at the same time you couldnt tell if the behavior was coming from a place of pain or from anxiety. Dont think it was a colassal mistake, and with all the non medical interventions that you tried first and then the prn meds I would be more than happy to have a nurse like you take care of any family member of mine! Keep up the good work

[caregiver1977]

I have an aunt in a LTC, and I would be glad that you took that much time with her...

[evolvingrn, BSN, RN]

I don't think you did anything wrong. I will say you are "suppose' to try one prn at a time so you know 'which ' one worked when using prns but in this case.......its tylenol??? and they couldn't adequately communicate pain if the wanted to so agitation may have been their communication. By treating the main symptom "anxiety, combativeness...." you were appropriate and by treating them with tylenol you were being compassionate and trying to let their behavior be communication.. i think you did good. I would write a response to attach to the write up.

[jeckrn, BSN, RN]

Typical for LTC, that is why I do not work there. Unfortunely for every good RN in a LTC facility there are many more how are not and went to the LTC becasue they could not make it anywhere else and end up in management.

Before you jump all over me, I am not saying all RN's are no good and go to LTC because they can not hack it anywhere else. There are many great RN's who choose LTC because that is what they like and are great at. But, LTC from where I am from there are more bad then good; which is sad.

[wearyLPN]

Thanks everyone for the comments. I was asked to write a response to the issue, which I did.

I can appreciate the administering the PRN one at a time to figure out which worked, I guess I was coming from the standpoint (in the moment) that sometimes with someone with dementia you only get one shot to medicate them.

You have given me some food for thought. :)

and thanks for having my back!

[KelRN215, BSN, RN]

I give tylenol with narcs or benzos all the time! We are constantly giving tylenol and morphine, tylenol and valium, tylenol and codeine or tylenol and oxycodone (not the combination pills, we don't carry those but we are smart enough to know that it will help the patient if we give them both). Calling this an "incident" is, in and of itself, ridiculous. PRN meds are ordered for you to administer based on your judgment/the patient's condition. If there is no order that says "do not administer tylenol and ativan together", then there's no way they can say what you did was wrong.