Should I or shouldn’t I have given Ativan?

[Nurse Pure-Spring, CNA, LPN]

Hello! I’m a new nurse about 3 months of practice. And a few nights ago I gave a PRN Ativan 0.5mg to one of my long term care patients. He is mentally ill but stable enough to function and wheel about the facility. Often nights he will roam the facility at 2-4am and ask out of context questions to staff on third shift. I am a first shift nurse and I had gotten report a night or two before and the nurse mentioned this patient was up and roaming and had been on his call bell quite often. He had previously fallen from his inability to ask for help during transfers as well. During my HS med pass before third shift arrived, I noticed the last PRN Ativan was in the blister pack and administered it. This patient was already in bed and was showing little to no behaviors or anxiety at the time. Yet, I knew once midnight and on came it would be a different story. So I administered it. Once administered I felt complete guilt as to whether or not I should have given it to keep him safe and let him get a night’s rest or had I given it to just give it. I have been at war with myself ever since and I spoke with my PCP about this - to which he mentioned it was completely fine and that I did the best thing to 1) keep him calm and safe and 2) allow him to get some sleep.

Can anyone illuminate this conflicting self-issue and give an explanation of why guilt is there? Is it necessary to inform my DON? Am I overthinking?

Thank you so much.

Nurse PurseSpring

[FolksBtrippin, BSN, RN]

You may be feeling guilt because you did not want him bothering you and you know it isn't right to give an anxiolytic for your own convenience. But, just because you didn't want him bothering you, doesn't mean he didn't also need the ativan.

If he's up all night every night it seems to me he does need something at night.

Does he have an HS med for sleep? Is he sleeping during the day? Is he sun downing? Let your guilt go, but keep pressing to find a solution for the patient.

["nursy", RN]

I think you are way overthinking it. The order was there. The PCP said it was fine. Patients need sleep or their confusion will get that much worse. I agree with FolksBeTrippin, there may be a better solution, but there's absolutely no reason to feel guilt. But your actual question was "why is guilt there?" I don't know the answer to that, but it worries me that you are feeling guilty for something so inconsequential. One day you WILL make a mistake, (cuz unfortunately we are human and we all make mistakes) and I cannot imagine how you will react to that when you feel this bad about a non mistake. Maybe it would help you to talk to someone (therapist?) to get this sorted out before something happens that will really overwhelm your ability to handle it.

[Kooky Korky, BSN, RN]

You say the order was for PRN Ativan. I'm assuming it was ordered PRN for agitation, which the pt was not displaying at HS. Technically, it seems not quite right that you gave it, but I do understand your thinking that he would become more and more agitated as it got later and you were trying to prevent a problem. (or maybe he was in bed but not resting calmly)

You have already talked to the doc about this, so try to quit beating yourself up.

Perhaps the doctor would change the order from a straight PRN order to a scheduled HS med that would allow him to get needed sleep instead of him being up all night. That would be a kindness to the man, I think.

He should still keep a PRN order, too, but you all will need to be careful to not give him too much. The PRN must be worded properly to prevent it being given too close to any scheduled sleeper or sedative. He needs to be watched very carefully, especially because he has already fallen.

Move forward. He is stable, doc says you did OK, forge ahead.

[RNNPICU, BSN, RN]

So you gave a medication to prevent him from waking up at 2am and walking around confused. Let me ask you this... is roaming the facility from 2am to 4am healthy sleep? Is it something you would want to do every night? Is it something that is normal behavior? Would you want to have sleep interrupted like this? Does he feel rested after roaming around for 2 hours in the middle of the night?

What is the guilt for? Your patient was calm and able to sleep. Perhaps it could be a good time to discuss if he may need a sleep aid or a scheduled dose of ativan at night and not just a PRN. Would you want a loved one consistently waking up at am to 4am, not sleeping? How wold you be feeling if day after day you had interrupted sleep? Probably pretty awful., so again, why the guilt?

[rac1, ASN, BSN, RN]

I would have waited until midnight when he became agitated to administer it, but that's just me. For the most part I tend to be "by the books." I think it's because of how you're feeling now - I am led very much by internal feelings and I think I would feel like I administered it outside the prescription since he was resting comfortably at the time. Technically, that is chemical restraint, which is not permissible for a patient that is resting comfortably. That is how I would see it in my mind, for this patient (for me - not saying you did wrong, just explaining that I get your feeling guilty over it because I think I would too).

I would have given the patient melatonin or trazadone or something else PRN if they had it available before administering ativan HS - if possible.

[canoehead, BSN, RN]

I suppose it "should" be administered once symptoms begin, but if you might ward off symptoms altogether, that's an even better result. Technically its a medical call, not nursing, but no harm done, and the patient benefitted. Now that you know Ativan helped, the physician knows, and you can collaborate on getting this guy a good sleep every night.

[Lostsoull]

you are not a doctor next time tell a doctor before what meds you dec8de to give id be a bit annoyed if i was instead of him even if it wont do harm

[Rose_Queen, BSN, MSN, RN]

1 hour ago, Lostsoull said:

you are not a doctor next time tell a doctor before what meds you dec8de to give id be a bit annoyed if i was instead of him even if it wont do harm

The patient had an order for a dose as needed.

[Pepper The Cat, BSN, RN]

When dealing with sundowning, increased nighttime agitation, etc., it is better to give something before the escalation starts. I've worked with a lot of sundowning pts, and while sometimes it takes time, we have been able to find the best time to given meds to prevent agitation.

After all, we don't wait until the blood pressure is high before giving meds right? Meds are given to keep the blood pressure under control.

So why not give the Ativan to provide a restful sleep?

[nursex23, BSN, RN]

I think you feel guilty because you didn't assess him and make the determination yourself that he needed a PRN. You saw it and administered it but did not consciously think to "he needs this Ativan because..." While care does need to be exercised with PRNs, I honestly think you made the right call. You got in report that he's been up and wandering at night and even fell because of it. I'll bet that if you didn't hear that, you would have not given him Ativan. Or if, let's say for example, the PRN was for constipation, you wouldn't have just given it because you didn't get in report that he was constipated. I think subconsciously you were thinking "up at night, wandering, fall, Ativan, safety." I think it just scared you that you gave such a strong medication without checking yourself but it sounds like the patient really did need Ativan.

Nothing needs to be reported and you did nothing wrong in this case but next time I would just slow down and think "does my patient need this medication right now?"

The fact that you are worried means you care deeply about your patients and that is a wonderful trait to have as a nurse. ?

[BSC_RN]

I know this is an old post, but I’m too familiar with administering Ativan and have argued with other nurses about what warrants “agitation” til I’m blue in the face ? in my opinion, you did the right thing! You used your judgment based on what you knew about the patient’s behaviors the previous two nights. An elderly man who is up roaming the halls in the middle of the night is showing signs of agitation. Was he up and doing that yet? Apparently not, but the best predictor of future behavior is the past ... and he would likely be doing the same thing had you not given the med. I know people will disagree, but I think giving the man the med and assuring he gets a good night’s rest was much less of a risk than not medicating him and having him roam the halls and potentially fall. The doctor had it ordered, you using your judgment and gave it, no harm done!