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?

[morte, LPN, LVN]

This is exactly what i do, and what i suggest other nurses that i may be supervising do. good grief.

[CrunchRN, ADN, RN]

If you had the MD orders allowing this then how can they rwite you up? Ridiculous. Who did you **** off last week?

[catlvr]

I agree that you did the right thing for the patient...if you had given the tylenol, and it had no effect, then your patient may have become increasingly agitated and possibly fallen. Unless you facility has a policy about this, I cannot see how it warranted a write up. (And it drives me nuts when mgmt goes straight for the write up instead of an educational discussion so that everyone can understand the situation!)

[caliotter3]

I would have done the same thing you did. Person who wrote you up should find better things to do to occupy their work day.

[MomRN0913]

She SUBJECTIVELY wrote you up, there was nothing OBJECTIVE about that write up. She FELT? Well, if someone goes against her FEELINGS it does not mean they are wrong.'

I would have done exactly what you did.

[caliotter3]

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!

People who are working under the circumstances that you describe do not have time to go piddling around with the least effective option when they see a need for the better option. If anything, you might have been criticized for the length of time you put up with the interfering behavior before you took action. I guess none of the rest of us better go to work at your facility since we wouldn't like being written up for using our own judgement. Hang in there.

[sweetpatoodie]

I think the bigger issue here is why the hell you were the only nurse with 61 Residents!! This is totally unacceptable. This can not possibly be in compliance with the Federal regulations!!

As far as what you did was perfectly acceptable in fact Congratulations for being a proactive nurse with a brain and taking control of what seems like an impossible situation. Who ever wrote you up must be completely incompetent! They should be thankful they have such a wonderful employee that takes action.

I am so sorry you work for Morons.

[CoffeeRTC, BSN, RN]

If it was an 11-7 shift..that might be okay staffing.

I hope you didn't sign that right up! Yes...I do see the argument of trying one prn med to see what works, but 90% of the time in this environment...both will work together to get the right results. Often times it could be agitation and discomfort/ pain. Yeah, the agitation could have been caused by the pain, but treating them both makes sense. Makes even better sense when you are the only nurse for that many people and you already tried the non pharm interventions. The only thing they might be able to get you on is if you charted what you did prior to the meds.

[newstudentrn]

I guess I may not have connected the agitation and pain, but that shows my inexperience. I am thinking that I would've tried the ativan and if that didn't help, then move to the tylenol. I feel like ultimately as long as you are being safe, those sorts of decisions are legally within your scope to handle. Your decision making is what you get paid for. They should allow you to do what they hired you to do and use your clinical decision making skills. If they had a specific way they wanted those types of situations handled, then they should have written protocols that you are trained to follow. Otherwise, it is your decision which prn meds to give.

[Morainey, BSN, RN]

I think you made a good call, especially with 60 other residents to take care of and AFTER trying all those interventions.

[Guttercat, ASN, RN]

My guess is it's a facility covering its butt.

Chemical restraints, are a big deal; State regulations regarding the use of them in LTC facilities (especially alzheimer units) are highly scrutinized.

State comes marching through and they will want to see a record of following facility protocol to the letter. If it wasn't, they will want to see a paper trail of how the bad nurse was "corrected."

[Munch]

I don't get what the problem is. The dose of ativan was on the low side and Tylenol is pretty benign(unless the patient has a liver problem or just received a dose of tylenol which he obviously didn't...if he did it would have been charted and you would have known to not administer the tylenol). The person who wrote you up gave you the explanation that you should have tried the tylenol first and then the ativan? What if you did just try the tylenol first and then the patient got more and more agitated and harder to control? .5 of ativan is a relatively low dose, it might not have worked very well. AND like you said you tired many non medicinal interventions before administering the medication. I would try to appeal the write up and go to the supervisor of the person who wrote you up. I would have done EXACTLY the same thing as you. I have had patients on my neurosurgery/neurology floor who have been out of it from a brain injury who haven't been able to articulate their feelings. They've had standing orders for IV ativan as well as morphine or dilaudid. I have actually administered both(my boss says we are allowed to if the patient can't articulate how they are feeling and they seem agitated..we can't read minds). How are we to know if they are agitated because they are in pain or agitated because they just are OR both. My boss says if both the medications are in the orders and enough time has lapsed between doses then we can give both at the same time. Then again I work in a hospital not at LTC facility and the rules might be different.