Made an uh oh

[momo_2013]

I work at a SNF with mentally disabled adults. Today one of our residents had a bad day and was all over the facility trying to fight with other residents and kicking the walls and punching the walls and doors. The morning nurse gave the pt an oral ativan at 0900 because he was "acting funny." While on my shift he was acting like I stated above. This resident always ends up having days like these and is a tall strong man. The resident had an order for ativan PO Q 12h and ativan Im Q 12 H. Now we all know how quickly things can go from bad to worse so after trying to redirect him with no success I know the safest thing to do was give him a PRN. Well I was in tough **** because it was barely 6pm! I wasn't to sure on what I could do? So I called the DON on what I should do and there was no answer. So I went ahead and gave him the injection. The DON called back and I explained to him the situation and he said okay. Now that I'm laying in bed I'm realizing did it count for both medications? Since she gave the PO at 9am I wasn't able to give any ativan IM or PO until 9pm? The pt was fine after I left my shift at 10pm. In fact he was still pacing the floors until 10pm and eventually went to sleep. Does this need to be reported to the dr? I can't sleep and feel like complete **** on how stupid I was..

[Meriwhen, ASN, BSN, MSN, RN]

You may be OK, If there were two seperate orders (and not a "if can't/won't take PO give IM" order) then the shot would be under the seperate IM order. And if you felt that the PRN was necessary AEB the patient's behavior, then you had justification to give it.

If in doubt, call the DON or MD for guidance (plus the MD could always give a verbal order if needed).

Usually, most facilities have a policy that gives you a window of 30-60 minutes to give a med (e.g., if the med was scheduled for 2100, facility policy may let you give it between 2000-2200). Since policies vary among facilities, check for your facility's specific policy.

I think you acted appropriately and should be fine. I hope your facility agrees with me.

[MrChicagoRN, RN]

I think you did what was indicated for this patient's needs, but the orders probably need to be updated/clarified.

[nurse lala, BSN, RN]

I have a few thoughts.

The order is ambiguous and open to interpretation, therefore a call to the MD is indicated. To clarify all that is needed is the addendum, "Not to exceed 2mg q 24 hours" for example or "NTE 4mg/24h". Right?

Secondly, benzos are known to lower inhibitions. They are anxiolytics given for anxiety. I am questioning the value in its use in calming an out of control individual. If the individual is punching walls and trying to fight residents, isn't a stronger medication indicated, such as haldol? One mg of ativan seems to be inadequate and inappropriate.

Last thought, he was acting funny. I sure hope you all looked for a cause in a change of behavior. Sometimes something as simple as a UTI can trigger a vulnerable adult. Abuse also needs to be ruled out: sexual, pyhsical, emotional. Drugs perhaps? Something triggered this fellow... If he is verbal or can communicate, it is important to process with him what happened so you and he can learn and grow.

I would love to hear the outcome.

[angelabLPN]

I agree, I would interpret that as 2 separate orders. I too would have asked, I was always the nurse calling our Pharmacy to check things, as I am still new myself lol