Medication administration vs Patients wants

[Notmarvin]

I am a brand new RN of two weeks and have run into an issue I cannot get a clear answer on. I work on a very challenging Med-Surg unit and have had one day of orientation with a preceptor and am now pretty much on my own. I have a pt who has been admitted for many months and waiting placement. My MAR shows she has dozen of meds scheduled between 0800 - 1100. I have worked with her for the last two days and each am she refuses all meds and demands to take them around 1030. I have been charting refusals and have dispensed the meds as 'patient request' at the later times. Other RNs on the unit say this is how she does them, they leave them bedside and she takes them as she pleases. I am uncomfortable with this as that I cannot keep track of when she takes them. I can recite the medication admin rights in my sleep but does patient desires trump those rules? Should I omit the am meds and refuse to give them when she asks for them late am, or give them when she will take them? Hoping to keep my license long enough to pay off my student loans I would love any help!

[sharpeimom]

Sometimes a patient isn't being difficult for no reason. I don't care who watches me take my pills or if someone wants to check my mouth afterwards, but I would have one thing I am adamant about and it will sound odd. My neurologist has ordered Keppra 1000 mg split into two doses, or at least that's the usual timing. I, however, have balance problems and if I take 500 mg. in the morning, not only am I very dizzy but I have even greater trouble walking safely. Solution? Take 1 1/2 pills at 8 am and the other half with my lunch. It's not written on the Rx or the bottle or anywhere, but that's what we agreed on. If I were admitted by my PCP, I doubt very much that he'd remember to adjust the order, so I'd end up asking you to call my neuro. That would make me totally safe to walk unaided using my cane, sit up without having my head spin, and I wouldn't throw up.

Sometimes there is a good reason for wanting a change besides wanting to be in control or being nasty.

[tokebi]

A good thing to do in this scenario is walk the patient through your point of view. "Ms/Mrs/Mr Patient, I understand you don't like this but, I am a licensed nurse. I know your dose of XXXX may not seem terribly critical, but in a hospital, it is my job to ensure that the medications that you're getting here don't interfere with the ones you take at home. That means charting the type of med, dose, and time that you took it. As a licensed nurse, it is my legal and ethical responsibility to ensure that when I chart that you took a med, you took that med. I cannot chart that you took the med unless I actually see you take the med."

"At home, you are responsible for your care. At a hospital, you're still responsible, but so am I and the doc and the plethora of other medical professionals who care for you. That means that I, as a responsible medical professional, must ensure that the meds are taken, the IV pump is right, the diet coming up from the caf is correct, and a myriad of other activities that you don't have to worry about at home."

I can never find the right words in confrontational situations. I'm saving this script so I can use it when I get belligerent patients. Thank you SoldierNurse!

[martymoose, BSN, RN]

1. Seriously, one day of orientation for new grad???? And here we have arguments on pt outcomes???

2. Obviously the pt has been doing this( I would see it as manipulative, because I'm sure you aren't the first staff who has tried to insist pt take meds at assigned time) for a long time.

3 where I am, it would be no problem to get the times changed, but pt would be informed this is when you take your meds. Otherwise i am marking you down as refused, and notifying the MD.

4. with electronic charting- it is marked as a med error if not given on time or refused.

5. anyone ever think that this might be why pt can't find placement- as being a difficult pt?

[Ruby Vee, BSN]

The only time the exact timing matters is for antibiotics, which should be given exactly as pharmacy determines, meds that are given several times a day, and meds that should be specifically given with meals or between meals.

Look through each med for that patient. If any of them must be given at exactly prescribed times, explain to the patient why. For anything that's just "daily," let patient take it when she wants.

Timing matters for antibiotics, but please don't leave that up for the pharmacy to determine. If the order says give them every four hours with the first dose STAT, give the first dose STAT and then give them every four hours. Let the pharmacy change their times . . . some pharmacies will time q4h meds for 8-12-4, nevermind that you started at 6. A pharmacist isn't always -- or even often -- the person determining the times. It's probably a pharmacy tech . . . and you know better than the pharmacy tech when the second antibiotic is due.

[morte, LPN, LVN]

yup, being picky, the doc should order "dose stat, and q4 hours from that time" but they won't, it will be up to nurses to fix.

Also, have seen doctor's orders "may leave meds at bedside".

Timing matters for antibiotics, but please don't leave that up for the pharmacy to determine. If the order says give them every four hours with the first dose STAT, give the first dose STAT and then give them every four hours. Let the pharmacy change their times . . . some pharmacies will time q4h meds for 8-12-4, nevermind that you started at 6. A pharmacist isn't always -- or even often -- the person determining the times. It's probably a pharmacy tech . . . and you know better than the pharmacy tech when the second antibiotic is due.

[NurseGirl525, ASN, RN]

There could be a ton of different reasons why she wants to take them at her times. She is probably very educated about her meds if she takes that many. I know I am. I will also usually talk to my doctor about when I take my meds especially if it is different than what is on the script. I take a variety of meds due to epilepsy and fibro. I take different meds at different times because of what works best for me. All meds have varying side effects and I don't want to dose myself on too many meds at once that will either make me sleepy or dizzy. Some may make me feel weird or slow me down. She probably has a routine in place and has been questioned so many times about it, she gets tired of having to explain every day. Why don't you talk to her and find out her reasoning and if it is safe just have the pharmacy adjust the times? I used to be a pharmacy tech and yes we just put times down to take meds.

[SoldierNurse22, BSN, RN]

I can never find the right words in confrontational situations. I'm saving this script so I can use it when I get belligerent patients. Thank you SoldierNurse!

No problem! I was hoping someone would be able to use what came to me in a moment of desperation, standing in front of a patient as a young nurse and wondering how to respectfully explain to them that I wasn't trying to infringe upon their independence, but that I had a job to do. Most people can relate to having a responsibility and are at least somewhat appreciative of your help. Invoking those two factors whilst explaining the "why" portion of your job that most patients simply cannot fathom (how many people go to work and find themselves responsible for the lives of 5-7 other human beings?) can really change the tide of the conversation. :)

[toomuchbaloney]

Our job is not to confront or argue with patients regarding their medications, it is simply to administer them in a safe fashion and observe for expected results or absence of untoward effects.

Our job is to advocate for our patients, not advocate for a task or our convenience.

If your patient has a reason that they prefer to take medications in a timing or manner different from the provider orders simply notify the provider and document. Easy smeezy. If they have no reason and are just being difficult, do your level best, for 5 minutes, document and move on. Notify the provider. If they are not competent to make a reasonable decision regarding their medications and behavior is limiting ability to administer medications via a particular route, notify the provider to develop a reasonable plan to resolve the issue.

I am very cool with orders to leave meds at bedside or similar when dealing with patients who are competent and active participants in their care.

[loriangel14, RN]

Our philosophy at work is that if the patient was at home they would be taking them whenever they pleased.Usless it's drug that the timing is critical for we just change the times on the MAR as per the patient's preference.

[martymoose, BSN, RN]

If it's been this way for months, why hasn't anyone else had the times changed? Im sure the general consensus here would be NOT to leave the pills on the table for safety reasons.

Your employer sounds pretty awful, but I understand why you're there- I'm sure there's nothing else available. :-(

[chillnurse, BSN, RN, NP]

if they are with it and its not 15 bottles of percocets then I'm fine with letting them take them like that. saves the staff time.

[nurseprnRN, BSN, RN]

I am very cool with orders to leave meds at bedside or similar when dealing with patients who are competent and active participants in their care.

Come on, people, take back your turf-- or at least recognize that it's yours. Notice that in the following I very purposefully do not use the word "order," because we are not in the military and the physicians are not our superiors.

This is not part of medical standard of care, and a physician cannot prescribe it because it is unsafe. Well, a physician can prescribe it, but no nurse is obligated to implement that in the plan of care.

This is because of a radical concept: Nursing standard of care is what rules over this sort of issue. It's not a matter of drug dose, route, indication, or frequency (those are medical), but a matter of safe administration of oral medications to an awake and competent patient. That and its associated safety issues fall under the purview of nursing, not medicine. Physicians are not trained or experienced in the administration of medications in the way nurses very explicitly are.

If a nurse can negotiate with a patient to handle medications safely/get them rescheduled to suit patient preference as described above, then fine. Otherwise, it's, "Sorry, I can't just leave them here," take them away and chart as refused.

As a recap: A physician can prescribe meds to be left at bedside for the patient to take whenever he damn well pleases, but the nurse is under no obligation to follow that prescription because it is unsafe and against nursing standard of practice for medication administration. The nurse should go up the chain of command to get that prescription changed or modified, or to have the physician explain to the patient why these medications will no longer be prescribed while he's in the hospital if he refuses to take them properly. People get discharged from the hospital for declining to participate in their plans of care (medical and nursing) all the time.