Over sedated? Grrrrrrrr

[ShayRN]

There is a nurse that works on dayturn that consistantly states we are "over medicating or oversedating" the patients. I am all for using as little as medication as possible, but when they need sedated then they should be sedated! I admitted a gentleman who had severe restlessness. (I thought it was terminal restlessness.) Gave him IM Haldol 5mg and 1mg Ativan PO. He continued to throw his legs over the side rails, struggled to sit up, beligerant to his wife, you know how it goes. So after an hour or so of redirecting and the above medication given I called the doc and asked for an Ativan subq drip. Started it at 0.25mg/hr with a .5mg bolus. He was asleep within 30 minutes. His wife was crying as she left thanking me for getting he husband to sleep for the first time in 3 days. The next morning the LPN who had the patient woke him and he wanted coffee, toast and something else and ate all three. He slept the rest of the morning and she reports he would fall asleep when she was talking to him. Her solution? No, not turn the drip down, even though nights had increased it to 0.45mg/hr. She had the doc give an order to DC IT! AHHHHH! Then, she "got too busy" to start the new order of PO Ativan 1mg po now. He fell 2 hours after she stopped the drip. She STILL didn't start the PO medication. It was another 2 hours before the PO ativan was given. THEN, she went home. I must admit, I was not at all nice when I said, "you did WHAT! Did you READ my progress notes? Do you KNOW what this poor guy went through last night?" She said, well yeah, but he is too sleepy. AHHHHHHHHHHHHH, ever think he is sleepy because he hasn't SLEPT in 3 days? That if PO medications can manage these symptoms he wouldn't be INPATIENT in CRISIS! The thought is he has a UTI (Temp, with chills and a suprapubic cath.) So how about this? Lets give him a couple of days of sedation while the Cipro takes care of the infection? THEN we can D/C the drip? I then said to her, you know, whatever you see in the daytime? Multiply that by 10 and thats what happens when the sun goes down. So my night last night was spent trying to keep him in bed. Trying not to get hit. Trying to redirect him that he wasn't in Europe during the war. You get the drift. Luckily, the doc was still there and after sitting in the room watching him for 15 minutes he saw for himself that the man needed sedated. However it now took a higher dose to get him calm (and 6 hours.) Any advice on how to handle this in the future? (Besides of course, not losing my temper next time:nono:)

[al7139, ASN, RN]

Grin and bear it.

Everyone is an expert and everyone has an opinion about sedation/pain meds, etc. I am of the opinion that if I am spending the majority of my shift in the confused/belligerent patients room trying to prevent a fall or other complication, that person needs aggressive therapy. I think you are right in your situation to request a drip or IV meds to keep this pt calm. So what if they slept all day? It sounds like they were arousable, but tired, and the really confused patients can hurt themselves or you without help.

On my unit we try very hard to be as conservative as we can with meds, but sometimes it is just not possible. I cannot tell you the many different attitudes I have encountered regarding narcs. I try to be as unbiased as I can in my care of the patient regardless of others, and am occasionally faced with the nurse who has the anti-drug attitude. All I can do is treat the patient the best I can on my shift, and document what I do and the results.

You did not say, but I am willing to bet the wife was not happy that your coworker got the drip discontinued, and noticed the difference in your care and the other nurses care of her husband.

Luckily, the attending realized that the drip needed to be restarted after his observation of the patient.

Also, the other nurses excuse that she was "too busy" to carry out this simple "now" order is not acceptable unless she had a 2 hour code (unlikely). On my unit she would be written up and disciplined for neglecting to carry out the order in a timely manner.

Amy

[Sabby_NC]

My suggestion is ongoing education in treating restlessness, agitation etc with this LPN.

Reasons for symptom managment and what they mean.

Idea on titration of medication and reasons for this instead of just D/C IV, SQ etc.

Thank you for being a great advocate for this poor man in turmoil.

You win my smiles this morning. :)

[hospicenurse]

Go to the nurse manager, explain the situation. Is this LPN new to hospice? Perhaps some teaching is needed for the nurse, and perhaps the whole team. This would be an excellent opportunity for the team to learn more or get a refresher about treament of agitation/restlessness. And then sometimes you have a nurse who just doesn't get it - those folks need to move on to an area that better suits them.

hn