Should we teach unlicensed caregiver . . . . .

[Spidey's mom]

Hi - something came up this week with a hospice patient who is home and her caregiver and I'm not comfortable with it.

Our patient is getting more agitated and combative. Her diagnosis is CHF and co-morbidities include diabetes with right leg pain due to insufficient circulation. She's on anti-psych meds and anti-anxiety meds - dosages just increased a few days ago. Long-time caregiver (prior to hospice) sometimes has to deal with hours of agitation and hasn't called us.

We've dealt with that - encouraging her to call. We also have a new order for Haldol 4 mg IM for agitation that doesn't respond to her cocktail of meds. The nurse has given one dose so far and it worked well. Now the powers-that-be think we should teach the caregiver to give an IM of Haldol prn.

I'm uncomfortable with this for 3 reasons. One - Nurse Practice Act:

A health facility licensed pursuant to subdivision (a), (b), or (f), of Section 1250 of the Health and Safety Code shall not assign unlicensed personnel to perform nursing functions in lieu of a registered nurse and may not allow unlicensed personnel to perform functions under the direct clinical supervision of a registered nurse that require a substantial amount of scientific knowledge and technical skills, including, but not limited to, any of the following

1) Administration of medication.

(2) Venipuncture or intravenous therapy.

(3) Parenteral or tube feedings.

(4) Invasive procedures including inserting nasogastric tubes, inserting catheters, or tracheal suctioning.

(5) Assessment of patient condition.

(6) Educating patients and their families concerning the patient's health care problems, including postdischarge care.

(7) Moderate complexity laboratory tests

Two: Can you imagine a layperson doing an assessment to decide about giving prn Haldol and then giving an IM injection to a combative and agitated elderly women? Is this even fair to the CG? Or the patient.

Three: Um - isn't this what hospice nurses are for??

So, I'm asking for advice here.

Have any of you taught a caregiver to give an IM injection of a drug such as Haldol? Do you think it is against the Nurse Practice Act? Do you think it would be unfair to do this to the CG or patient? Do you think this is the nurse's job?

Thanks!

[chopwood carrywater]

Unfortunately the Haldol cream went by the wayside HERE years ago.

Even a sub-q on an agitated woman by an unlicensed caregiver who is simply a very nice homemaker who helps out this woman and has for year seems inappropriate to me.

We are a small hospice associated with a small rural hospital. In order to get a port, we'd have to send the patient 70 miles away to a bigger hospital. We don't do ports up here.

We have sent some longer-term hospice patients out for PICC line placement. Of course hospice has to pay for that.

I really appreciate the comments! Keep them coming.

The sq port I am referring to is very easy to place. If you look them up on the Internet you see what I am talking about. They can be placed in areas where it might be harder for the pt to remove. They are great for home use where caregivers/pts are less comfortable with sq injections. I love them.

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[Spidey's mom, ADN, BSN, RN]

I have taught many skills to FAMILY caregivers who are willing to learn, however, I would never attempt to teach nursing skills to unlicensed paid caregivers. That is an entirely different matter legally. Family members may learn whatever skills are needed to provide care but HHAs, CNAs etc are limited by state practice acts as to what care they are allowed to provide. If you are uncomfortable or unsure what can or can not be taught to paid caregivers, contact your education department or risk management.

That's my point - people keep bringing up teaching family members but this is a paid caregiver, not a family member.

Thanks - funny thing is our hospital is so small I'm not even sure who our risk management person would be and doubt they'd know much about hospice regs or state regs.

[Spidey's mom, ADN, BSN, RN]

The sq port I am referring to is very easy to place. If you look them up on the Internet you see what I am talking about. They can be placed in areas where it might be harder for the pt to remove. They are great for home use where caregivers/pts are less comfortable with sq injections. I love them.

Sent from my iPhone using allnurses.com

Thanks - I'll look that up.

[MomRN0913]

A paid unlicensed caregiver is ok. If they are with an agency, that's one things. If it's a person they hired privately who works under no one , it's as if you are teaching a family member.

From what I have seen these paid unlicensed care givers are much better at performing these duties being it's not their own family. They are hired to administer care and that's what they do, probably better than I've seen most families give. I've had patients well into their 100's only who made I to their 100's due to the excellent care rendered by their hired caregivers. They literally kept them alive .

You can teach an IM injection to a son and one to a paid caregiver and the son could very well not demonstrate competency but the caregiver could return a perfect demonstration.

Anyways, have you considered a haldol suppository?

[Spidey's mom, ADN, BSN, RN]

Our patient died peacefully this morning (11/2) about 0245.

We decided not to have the caregiver do the IM Haldol.

After looking at the sub-q Cleo .. . it is the same device we use for our CADD Pumps when we do a sub-q infusion of morphine sulfate or dilaudid. Two of our patients right now have these devices. Never thought of it for a PRN med.

We are looking at reinstating our Haldol cream. Our IDT meeting next week should be interesting.

I thank you all for your input. It really helped.

[SaoirseRN]

It might be easier to give the haldol sub q. Perhaps placing a sub q port would make it easier and safer for pt and caregiver. Typically our orders start with 1 mg sq every 2 hrs prn and may be titrated up and even scheduled if needed. Sent from my iPhone using allnurses.com[/quote'] I second this idea about the subcut route with a port. Perhaps with the additional instruction that the caregiver should let the nurses know when they have had to give it?

EDIT: sorry, should have read the last comment. Disregard.

[Spidey's mom, ADN, BSN, RN]

I second this idea about the subcut route with a port. Perhaps with the additional instruction that the caregiver should let the nurses know when they have had to give it?

EDIT: sorry, should have read the last comment. Disregard.

No apology necessary. I welcome the advice. We have to discuss this at IDT next week and I had many qualms about it and you all have helped me.

[SaoirseRN]

In that case, we frequently use subcut "ports" (we call them infusers) for people receiving care in their homes. Often the nurses will even pre-draw and label the medication so there is less likelihood of dosing error. Without the need for needles it's a great system and easy for most family members to grasp.

[SuesquatchRN, BSN, RN]

We stopped using the cream because it's expensive to compound. And my agency is all about the census and bonuses.

[Spidey's mom, ADN, BSN, RN]

We stopped using the cream because it's expensive to compound. And my agency is all about the census and bonuses.

Thank God we aren't about census - we don't have enough nurses to worry about that. And I've never heard of a bonus.

[Orca, ADN, ASN, RN]

And I've never heard of a bonus.

Every place I have ever worked, "bonus" meant finding out that you were still on the payroll when you arrived for work every shift - unless you count the cheap trinkets they gave us for Nurses' Day.

[curiousauntie]

What about liquid haldol? We have it in our comfort kits and it works wonderfully. 2mg/ml. We usually start with 0.5ml/1mg. I personally wouldn't want to try to stick a combative, agitated pt. IM or SQ.