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?

[CrissiQ]

There was no way to tell, what was causing the patients discomfort. Was it pain causing anxiety, or anxiety causing a pain? Most likely both were at the heart of the problem. You did the right thing and were written up by a dumb a*$ who was looking to make you life difficult.

[NurseLoveJoy88, ASN, RN]

You did nothing wrong. Last night I gave a cocktail of tylenol, oxycodone, and ativan. It worked and my resident was content.

[CathRN]

Ahem,,,,,I know I'm going to get flamed, so here it goes...... I am a state surveyor. I would not flip out over seeing a resident getting Ativan for behaviors, that is what is prescribed for. What I look for is the documentation that other interventions were attempted, what responses, etc. State is not there to "punish" facilities or staff. We are, most of the time, the residents last voice. We advocate for the resident.

To the OP, from the information you provided, I can't see that you did anything wrong. As I stated above, I would be looking for the documentation of all attempted interventions and the response to them. Meds are prescribed for a reason. Yes, it could look like a chemical restraint, but not if the other interventions are documented.

A lot of the time, when a facility gets "tagged", it is because of the lack of documentation. Nursing 101 is....is it isn't documented, it didn't happen."

Thanks for reading.

[nerdtonurse?, BSN, RN]

I don't understand what you did wrong. I do that all the time. If I have a non-verbal patient who I can't tell if they're in pain, nauseated, or just nervous, I hit them with Zofran and either Tylenol or morphine, smallest PRN dose; if I'm leaning toward nerves or psych issues, I may do Zofran and a small dose of Ativan. When they go to write you up, request specific instructions in writing as to what they want you to do next time...and watch them stutter.

Last I checked, mind reading was not required by the BON. If this crazy stuff is all they can come up with to write you up, you're doing good.

And I'd suggest looking for a job somewhere where the average IQ of the boss is higher than the outside temperature...*grin*

[leslie :-D]

Ahem,,,,,I know I'm going to get flamed, so here it goes...... I am a state surveyor.

why would you get flamed?

not only did you provide insight, you vindicated the op.

i for one, appreciated your input.

leslie:)

[CathRN]

Thank you Leslie, I was just saying that I would get flamed since I'm a state surveyor. We are used to getting all kinds of "flames" from the staff at the LTC facilities.

Again, Thank you.

[KelRN215, BSN, RN]

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.

I am also from MA and had the same thought as you when seeing PO Ativan referred to as a chemical restraint. I give doses higher than 0.5 mg PO to CHILDREN routinely!

[fltnrse2, ASN, RN]

Dear Weary LPN,

After reading you posting I respectfully would not support you and who ever wrote you up.

Now remember I am taking your information for face value. If you had no signs or symptoms of pain I would have medicated the patient with ativan. I also have a problem with whom ever told you to try a tylenol first when the patient was exhibiting symptoms warrenting the prn of Ativan. The only thing that would make me give tylenol (assuming the prn is for pain) were sign/symptoms of pain.

Fltnrse2

[Nascar nurse, ASN, RN]

Thank you Leslie, I was just saying that I would get flamed since I'm a state surveyor. We are used to getting all kinds of "flames" from the staff at the LTC facilities.

Again, Thank you.

Sorry for the thread hijack - just a side note. As a 25+ year veteran of LTC, I have worked with some really really nasty surveyors that clearly get their kicks out of making the staff feel like crap - the kind I want to scream at and dare them to do this job just one day and let us pick them apart. I have also worked with some very fair and objective surveyors that are just there doing their job just as I am doing mine. They don't seem to take a great pleasure putting me and my staff thru he!! and belittling us at every little turn. I see the surveyor's job as a pretty thankless job but I'm glad the good ones are around and you can serve as a wealth of information for us out on the front lines. Don't worry about being flamed. :)

[saintplatypus]

I don't understand why the powers that be felt what you did was write up material. If they felt it was the wrong decision I could see giving you a "teachable moment". But not a reprimand. I understand their reasoning that intractable behaviors in dementia patients often is a sign of pain. But I understand your decision as well.

Had you just given the Ativan they may not have even made issue at all.

IMO, nurses have tough choices sometimes, and often we don't have another nurse nearby to discuss situations with to get another point of view. We must feel secure in our choices. What they did would make me feel insecure next time I had to make a decision regarding care.

[CapeCodMermaid, RN]

Dear Weary LPN,

After reading you posting I respectfully would not support you and who ever wrote you up.

Now remember I am taking your information for face value. If you had no signs or symptoms of pain I would have medicated the patient with ativan. I also have a problem with whom ever told you to try a tylenol first when the patient was exhibiting symptoms warrenting the prn of Ativan. The only thing that would make me give tylenol (assuming the prn is for pain) were sign/symptoms of pain.

Fltnrse2

Since residents with dementia are most often unable to express their pain, it frequently exhibits itself as an increase of behaviors. Giving tylenol is certainly an appropriate intervention. I read a study once of an alzheimer's unit with 40 residents. Many had behaviors on a daily basis. The residents were all given tylenol 650mg in the morning upon arising and in the afternoon. The behaviors significantly declined.

[morte, LPN, LVN]

Since residents with dementia are most often unable to express their pain, it frequently exhibits itself as an increase of behaviors. Giving tylenol is certainly an appropriate intervention. I read a study once of an alzheimer's unit with 40 residents. Many had behaviors on a daily basis. The residents were all given tylenol 650mg in the morning upon arising and in the afternoon. The behaviors significantly declined.[/quote)

Yes! How many of US, past a certain age, lol, don't have an ache here or there on an ongoing basis? Why should the patient be miserable when we can make them more comfortable? We are not talking about zonking them out on high dose antipsychotics for pete's sake.