LTC incident, what are your thoughts.

Sparrowhawk · Jan 17, 2012

Jeez aren't they write up happy....are they so bored they have to split hairs on what meds to give first????

Forever Sunshine, ASN, RN · Jan 17, 2012

Both of those medications were appropriate to give. Alzheimers patients can't appropriate communicate pain and sometimes they communication through.. acting out. Acting out is also indicates anxiety. Making it appropriate to give the ativan.

I would have refused to sign that write up.

leslie :-D · Jan 17, 2012

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."

ding ding ding ding - we have a winner (me thinks).

this is the only remotely plausible explanation...

because nothing else makes sense.

the state wants to see chemical restraints used as a very last resort.

still, it remains bs.

mgrs can become excessively paranoid when it comes to state surveys.

and, it's just not realistic to administer the apap, reasses an hr later, then maybe give the ativan...

while being the only nurse for 61 residents.

fwiw, the only other etio i might have considered, is if he needed mom/laxative...irrelevant to situation, i know.

write your response (to the writeup) as you explained it here.

(you can also note in your response, that you find the writeup unwarranted.)

sorry this happened to you.

leslie

Roy Wachter BSc LPN · Jan 17, 2012

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?

THERE WEREN'T ANY MISTAKES made at all from the info provided.

This incident illustrates one of the major reasons why I will never work in LTC again.

61 Residents 1 Nurse is that legal in the state you are working in?

Good Luck and BlessYou and maintain your altitude.

Forever Sunshine, ASN, RN · Jan 17, 2012

But when a patient is agitated and combative. Good luck getting anything PO in them. It will most likely get spit back into your hair.

These corporate state hogs don't really put the idea of safety of the resident, other residents who happened to be around said residents and staff. If we let this patient continue to be combative, someone could get hurt. And then the facility has a bigger problem on their hands.

Creamsoda, ASN, RN · Jan 17, 2012

I would have done it. Tylenol is not even a narcotic or sedating. They needed the ativan. You were entirely within your right judgement to give them both.

Jaimie.RN · Jan 17, 2012

How you supposed to get an agitated person to take a tylenol without getting your fingers bitten off? Or kicked or smacked? Were you supposed to have your 3 cnas hold them down and give it rectally? You did the right thing. It's stupid.

Jaimie.RN · Jan 17, 2012

The real problem is probably that state thinks it's okay that you have 61 residents ( i have 44 myself) but get upset that the one who is flipping out got some ativan. Big deal. Maybe if you had a safe patient assignement you'd have time to sit and give tylenol then something else later. Alas, I cannot do 2 things at one time, nor can any other human being. They bring us admissions during med pass. You chose to do the admission, your meds were late!!!!! You passed meds and let admission orders wait, that patient didn't get their meds the next morning cause pharmacy is slow and you put the orders in at 11 pm! HOW CAN I DO 2 things at the same time!!!! I am not a magic person. Nor am I a mind reader. called the hospital pharmacy and the doctor for dosages on d/c meds from the hospital, no one would tell me what they were. I can't write orders guessing. If they write me up for not adding those meds on, I will scream. I called OUR pharmacy, the HOSPITAL pharmacy, and the doctor! No one gave me any doses. I think in LTC manages expect way too much of us while giving us more work to do than any person could possibly do.

DixieRedHead, ASN, RN · Jan 17, 2012

Who ever wrote you up for this obviously doesn't have enough to do. As far as I can see the only thing you did wrong was you waited WAY too long to give that ativan. Chemicals are your friend.

mazy · Jan 17, 2012

How you supposed to get an agitated person to take a tylenol without getting your fingers bitten off? Or kicked or smacked? Were you supposed to have your 3 cnas hold them down and give it rectally? You did the right thing. It's stupid.

This is a good point. In addition, a patient that agitated due to pain would probably not have gotten any relief from Tylenol, and so waiting to see how it worked would have meant another hour of escalating behaviors.

Agree with Dixie also. The important thing would be to deal with the behaviors medically before they get out of control in order to better assess what's going on and the needed interventions to follow.

I would have done exactly the same thing.

CapeCodMermaid, RN · Jan 17, 2012

Where to begin??? Ativan, at least in Massachusetts, is NOT considered a chemical restraint. 0.5 mg po?? I'd have given it and the tylenol, too. You did what was appropriate at the time using your nursing judgement, and since you were the one there, I'd have questioned why you were written up for following an MD order. It wasn't your first intervention. You tried everything else and then used a perfectly legal medication.

60 residents at night....do you work for Kindred? My nurses never have more than 39 on a long term floor on 11-7 and they have 3 or 4 aides and a supervisor.

For the poster who said LTC's were horrible (I am paraphrasing) and filled with bad RNs.....take another look. I have plenty of nurses who could work on a med surg floor any day. They have better assessment and time management skills than any nurse I've seen at the hospital who has 5-7 patients, an aide, transport, lab techs, IV teams, and plenty of docs around.

Been there,done that, ASN, RN · Jan 18, 2012

61 residents,, in Various stages of dementia?

And you actually had time to try those other measures?

My first reaction would have been, check the pulse ox(as restlessness a sign of hypoxia).. then I would have gone straight for the Ativan.

The morons on THAT particular ivory tower... need a reality check.