Patient asking for ativan hours in advance regularly, prn for anxiety.

[EarthwormRN]

I have this patient who asks for ativan every day at 7pm. I was told by my supervisor that I need to offer alternative ways to calm her down before giving her the ativan, such as offering food, water, one on one, back rub, visualization etc. Well this patient refuses to take part in the other methods and sternly says I wouldn't ask for it if I didn't need it. But at 5 oclock, she will say bring me an ativan at 7, and I think how does she know she will be anxious at 7 o'clock? The only time she doesn't end up getting the medication is if she doesn't ask for it, if she does, she bullies me until I cave and I cave pretty easy. I talked with a fellow nurse on a different shift about how "pain is what the patient says it is" but is anxiety what the patient says it is as well? I think yes, but i wonder what my supervisor thinks. How should I go about this situation?

[amoLucia]

Can you just get the order changed to 7 pm as a standing order? My guess is she feels it relaxes her for sleep. She's getting anxious just about getting the med....

Is it a low dose only given once at nitetime? Or is it a high dose given freq during the day? I understand the supervisor's position re PRN anxiolytic drug usage - but maybe she's feeling the muscle relaxant effect and it helps her for some some mild achey-pain issues at the end of the day. Maybe 2 Tylenol EX at 7 pm could be an alternative?

Maybe this issue needs to be brought up at care conference?

[Pangea Reunited, ASN, RN]

It seems like you're complicating a simple situation. She has an order for ativan and she requests ativan. If she's not anxious about anything else, she's anxious about getting her ativan "on time". There you go!

[montecarlo64, ASN, BSN, LPN]

I agree with amoLucia...Best solution is to get an order to make it routine @ 7pm...You won't need to do, nor document, non-pharmalogical interventions prior to the administration of the medication. And, if this patient continues to have a daily prn at the same time for the Ativan (or any other prn), state surveyors might question as to why the doctor has not been notified of a continual problem. I remember an issue with a patient requesting prn tylenol at least once a day for "c/o headache". State came in & reviewed the chart and determined that the facility failed to notify physician of this condition, plus the patient had previous history of ovarian cancer. This could have been a symptom of mets to brain or some other brain disorder, but it wasn't. Upon further patient assessment and tests, everything checked out ok; but, she was mildly MR, aging, and was saying "headache" for any aches and pains or just not feeling up to par. Good luck:)

[Mommy&RN, BSN, RN]

I can tell you right now at noon that I will need a Dose of Xanax at bedtime tonight.

[jadelpn, LPN, EMT-B]

Why make this into a power struggle? If the patient has an order for ativan, then she has an order. If it is PRN then perhaps getting it changed to routine at 7pm would make the patient less anxious. Or a PRN for sleep and/or anxiety.

There are many patients who can't sleep well, or sleep like babies, and even if you check on them religiously, some will say "I had NO sleep last night" even if you tell them they snored all night.

She should not need to participate in any other relaxation stuff should she choose not to, and to suggest otherwise can be considered a control issue. To dance around the fact that this patient is requesting to be medicated is absurd. Maybe the patient believes she will forget unless she asks for it when she remembers--which really is smart, as apparently it is a huge issue to attempt to get the medication if she remembers closer to the time--per your "the only time she doesn't get it is when she doesn't ask for it" and "she bullies me until I cave" statements----why is that even happening? Very unecessary. If she has a PRN, she has a PRN. If you need to get an order change in the best interest of the patient, then that is what you need to do. Why make the patient stress over an ativan?

[montecarlo64, ASN, BSN, LPN]

"She should not need to participate in any other relaxation stuff should she choose not to, and to suggest otherwise can be considered a control issue."

Jadelpn: It is a state required regulation to provide non-medication interventions prior to administering a prn medication in a LTC or SNF. Failure to do so can result in a citation for "administering medications unnecessarily". Yes, this patient has the order & has every right to have her prn; however, the nurse must provide (and document) other interventions, which were ineffective, first...Yes, it's sad but true...Nurses must provide for their patients while protecting themselves...I agree, this patient should have a routine order to bypass the interventions.

[jadelpn, LPN, EMT-B]

Wow. I am unfamiliar with LTC, and seems bizzare that you all have to do that each time a resident wants a PRN. So in other words, if the resident has a prn sleep med, you have to see if they can fall asleep any other way first? Unreal. I can see if a facility chooses to just medicate everyone into oblivion, and I am sure there may be those type of facilities out there, however, what a task that would be for the nurse.

[montecarlo64, ASN, BSN, LPN]

Yes. That is correct. Non medication interventions would include: offer food & fluid, reassurance, offer bathroom, dim lights, etc...All have to be documented ineffective prior to the administration of hypnotics and anti-anxiety...Also pain interventions to include: repositioning, ambulation (if able), cold/warm cloth, back rub, etc...This is why routine meds are so much easier. LTC regulations are very rigid:(

[tewdles, RN]

It seems to me that the policy encourages reassessment of the plan EACH time the plan is actualized. Typically the plan would be developed in a team conference which includes the patient or advocate and only changed if there is a problem or at the next conference.

What you describe doesn't sound like a problem with the patient plan of care, it sounds like a process problem. In that the process/policy promotes inefficiency and delay in providing the service the patient requires, has ordered on the POC, and has requested.

At minimum this is poor customer service.

Perhaps you could present the situation in that light to your management team?

[BrandonLPN, LPN]

Jadelpn: It is a state required regulation to provide non-medication interventions prior to administering a prn medication in a LTC or SNF. Failure to do so can result in a citation for "administering medications unnecessarily". Yes, this patient has the order & has every right to have her prn; however, the nurse must provide (and document) other interventions, which were ineffective, first...Yes, it's sad but true...Nurses must provide for their patients while protecting themselves...I agree, this patient should have a routine order to bypass the interventions.

I'm gonna disagree with this. Not true at any LTC facility I've ever worked at. Maybe you're facility is just really, really micromanaged.

We don't have to try a nonpharmological intervention before giving an ordered PRN medication. If a pt requests a PRN medication and there's a valid physican's order for it, then we can give it. Easey-peasey-lemon-squeezy. Don't make it more complicated than it is.

Of course, there's reasons our nursing judgement might tell us it's not appropriate to give a PRN at this time. Maybe they received some scheduled medications that might react. Maybe we strongly suspect they're drunk. But just saying "I don't think they're really painful/anxious" isn't a good enough reason.

[psu_213, BSN, RN]

We don't have to try a nonpharmological intervention before giving an ordered PRN medication.

And even if some state has a regulation that non-pharm. interventions must be done first, then chart "Resident refuses food/drink, resident refuses back rub, resident refuses to participate in visualization. Pt states 'the only thing that works is ativan, give it to me now.'" (or whatever exactly the pt said) I know it is a pain in the rear to chart this every time, but if you are required to try such things first and the pt refuses, then it has to be done.