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?
Specializes in Acute Care - Adult, Med Surg, Neuro.
We teach laypeople do to subQ injections all the time (when they are going home on Lovenox, for example, or insulin injections). I also agree with the liquid Haldol.
We teach laypeople do to subQ injections all the time (when they are going home on Lovenox, for example, or insulin injections). I also agree with the liquid Haldol.
Yeah, family members/family friends/the patient. But unlicensed caregivers paid by the family of a hospice patient? We are asking that person to do a nursing assessment and then give the patient an IM injection of an anti-psychotic drug? Or CNA's/HHA's who work for us - do we teach them to give a hospice patient a SQ or IM of Haldol? Where is the nurse in all this?
There is a liability issue I'm still not clear about - haven't heard back from the BRN.
For now - we are going with Haldol cream and not using IM or SQ.
Isn't a PICC line a bit drastic? Especially to send the patient out who is dying. I am a hospice nurse and this just doesn't sound right. Any RN can place a sub-q port, why would they send a terminal patient 70 miles away for that? A port is nice allowing for frequent med administrations with only one stick but if you are not able to place a port the haldol CAN be given sub Q and if you can give insulin, you can give haldol SQ.
Isn't a PICC line a bit drastic? Especially to send the patient out who is dying. I am a hospice nurse and this just doesn't sound right. Any RN can place a sub-q port, why would they send a terminal patient 70 miles away for that? A port is nice allowing for frequent med administrations with only one stick but if you are not able to place a port the haldol CAN be given sub Q and if you can give insulin, you can give haldol SQ.
This was a different patient. He had esophageal cancer and lived 18 months. He had a CADD Pump initially - with a Sub-q port infusing Morphine Sulfate and then we switched to Dilaudid. He was pretty emaciated and we ended up having to respond every day or so, sometimes in the middle of the night, to change the site as it would go bad. In our trouble-shooting, we decided to do a PICC line for this particular patient. It is not the norm for our hospice patients.
When we admitted this patient, he was in excruciating pain and bedbound. We were able to get his pain under control with the CADD Pump via the PICC. He then was able to get up out of bed, he started to eat, gained some strength, still stayed very thin. He was well enough to take rides out in the woods with friends. Enough to take his granddaughter to the fair.
I don't think that care givers would fall under the Nurse Practices Act because of the fact that there is no remuneration, i.e. no duty to act. If you are working at a facility and a can gives a shot and they are not licensed to do so, there can be serious consequences, which may be why there is a problem with the school nurse teaching unlicensed personnel to give insulin injections. But, family members give meds at home all the time - insulin, allergy shots, rectal valium for seizures in peds patients etc. There are even patients being sent home on inotropic drugs, which we normally only see in the ICU. If patients can be sent home with a PICC and start their own antibiotic infusions after a consultation with a home infusion nurse, I'm not sure I see the problem. Is your problem the fact that the med is IM or that it is Haldol in addition to the myriad meds this patient is on?
.. Is your problem the fact that the med is IM or that it is Haldol in addition to the myriad meds this patient is on?
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?
From my original post ^^^^
Is it against the Nurse Practice Act to teach someone not affiliated with our hospital, unlicensed, and hired by the patient to give an IM injection?
Is it fair to the caregiver to put him/her in this position of assessing and giving an IM anti-psychotic?
State practice acts generally do not enumerate specific acts that are permitted to unlicensed personnel such as CNAs -- that is why they are unlicensed. Their duties are not specified. Rather, the practice act defines the scope of what a registered nurse may delegate. That's why so much time is spent in nursing schools on the discussion of delegation to unlicensed personnel and why it is covered on the boards. States do vary somewhat as to what can be delegated to unlicensed personnel. My understanding is that IM injections are generally allowed, if the proper guidelines and supervision requirements are followed. See, for example, Oregon State Board of Nursing Board Policy on RN Delegation at http://www.oregon.gov/OSBN/pdfs/policies/nursedelegation.pdf. Other states allow delegation only if the CNA has undergone special training, such as Virginia's Medication Aid training. But the limitation is on what the nurse can delegate, rather than on what the CNA can do.
.. But the limitation is on what the nurse can delegate, rather than on what the CNA can do.
Thanks - that's what I was trying to say. What I can delegate - to an unlicensed caregiver hired by the family of a hospice patient at home.
In my original post:
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.
Specializes in Complex pedi to LTC/SA & now a manager.
I was taught delegation/skills teaching to a family is not the same as a paid, non-related unlicensed caregiver. Unless the unlicensed caregiver is an employee of the same agency as the nurse.
The provision you quote above applies only to facilities. You may want to check out the implementing regulations, California Code of regulations Title 22 which might have more to say about the delegation of nursing care by an RN to unlicensed staff. California nurses are very strong politically and have argued against delegations that are typical in other states. There was also a big Supreme Court case in California a few months ago allowing unlicensed school personnel to administer insulin shots to students. It was quite controversial and the nursing board argued that it should not be allowed under the practice acts. I am not sure what the reasoning of the court was . . . .
I am also a school nurse so was involved in the insulin issue as well. We lost but it may go on to the Federal Supreme Court.
You are right, California does have more strict thoughts regarding scope of practice. Which may be why I'm extra-cautious as I was taught the same thing JustBeachyNurse stated:
I was taught delegation/skills teaching to a family is not the same as a paid, non-related unlicensed caregiver. Unless the unlicensed caregiver is an employee of the same agency as the nurse.
0.adamantite
233 Posts
We teach laypeople do to subQ injections all the time (when they are going home on Lovenox, for example, or insulin injections). I also agree with the liquid Haldol.