The imposition of chemical restraints...

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My place of work has a MSDS nurse who tries to instruct us on the use of PRN medications. We have a certain resident who has in the past had psychotic episodes, and we have IM ativan to give and once, when the patient was throwing themself on the floor, IM haldol. Other than that, the POA isn't very cooperative and has blocked efforts of routine benzodiazepine and /or antipsychotic administration. Said patient has suspected BPD, but was only on an antidepressant and that didnt manage the mania of course. Well, until recently we got an antipsychotic commonly used to treat BPD and now that it's been a few weeks, the effect is kicking in and things have been going great. Has some bouts of agitaton, and I give prn po ativan to this person and it has worked fine if I catch it soon. My problem is that now the MSDS nurse has given us direct care nurses a side note to give PRN norco to this patient 2x a day. I assess pain in this patient by asking "do you have any pain?" And get a yes or no answer. No probs. Other nurses where I work will just give the med, no question. So by the time I have a shift, said resident will be physically dependent, even if she has no pain. What would you do?? Please note this resident has dementia and can't advocate for self.

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Specializes in Emergency Room, Trauma ICU.

I guess I'm not sure what you're asking here. What are your concerns with the pt having norco?

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I want to move this to LTC. Accidentally posted in general nursing. Decreased LOC, physical dependence... and for what? We are not assessing pain in this resident. If we were, we could start out with utilizing the prn tylenol order. The MSDS nurse is acting as physician. Told us to give norco routinely, 2x a day. If a regular order was needed, then they could call MD and get that set up. It's not needed, though.

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Specializes in Hospital Education Coordinator.

someone needs to communicate with the MD. Can you really do prn ativan, legally, as a restraint? I assume you are asking if it is ok to give Norco if pt. is not in pain. I would still want more clarification from the physician.

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someone needs to communicate with the MD. Can you really do prn ativan, legally, as a restraint? I assume you are asking if it is ok to give Norco if pt. is not in pain. I would still want more clarification from the physician.

There is a sheet which is off the chart, but where the nurses can see: "Give prn norco to x resident @0800 and 2000 every day". This is what they do at this place for some reason...

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If it's PRN it's up to your nursing judgement, or if the resident asks for it. No other nurse can tell you that you "have" to give it. I am not beholden to some dumb sign the MSDS nurse put on the chart telling us when she wants us to give a PRN med.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I want to move this to LTC. Accidentally posted in general nursing. Decreased LOC, physical dependence... and for what? We are not assessing pain in this resident. If we were, we could start out with utilizing the prn tylenol order. The MSDS nurse is acting as physician. Told us to give norco routinely, 2x a day. If a regular order was needed, then they could call MD and get that set up. It's not needed, though.
thread moved....:)
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If it's PRN it's up to your nursing judgement, or if the resident asks for it. No other nurse can tell you that you "have" to give it. I am not beholden to some dumb sign the MSDS nurse put on the chart telling us when she wants us to give a PRN med.

I'm not either. I hate this idea of giving the Norco as if it's scheduled, when it's not. Especially when it's not needed this often anyways. I just wanted to know if it's like this at other LTCs?

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Specializes in LTC, assisted living, med-surg, psych.

The MDS nurse should contact the prescriber herself if she wants Norco given to this resident BID. Otherwise, a pain assessment needs to be done and documented each time the med is given.....the other nurses shouldn't be giving it to the resident automatically.

As for the psych meds, I don't see them being used as a chemical restraint. They could be considered such if they were being used to sedate the resident for staff convenience. But there's nothing wrong with using an anti-psychotic routinely to treat mania and agitation, nor is it bad to use Ativan judiciously for anxiety/agitation when the resident is driving him/herself crazy.

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Specializes in Hospital Education Coordinator.

I do not work in Long term care, but wonder about the Norco order. You would have to assess for pain and then document if the intervention was effective. How can you do that if the patient does not admit to pain? Are you using an evidence-based scale to evaluate non-verbal patients? Another issue is that the nurse is having to decide if the patient has a condition that requires treatment. That sounds medical to me. All in all, I think the situation does not pass the smell test. (Fishy)

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Thanks for your perspectives. I'm saying I'm happy about the prescribed routine antipsychotic med. It seems to be working and improving this residents symptoms/quality of life. They used to do the same thing with prn po ativan that they are now pulling with the norco "give po ativan to x resident q 0800 and 2000". But it was never prescribed that way. Only left as a note by this MDS nurse. The management knows she's doing this. Other nurses where I work will just go ahead and give the norco without assessing. I didn't mind giving the ativan, bc she does have anxiety that is apparent during almost every shift. There were times that I don't give it, based on my findings, though. The MDS nurse order (ha) for bid norco annoys and bothers me even more. The new grad nurse on my shift got sooo upset that I didn't give a po prn ativan, even when I didn't assess a need. At all. I explained everything to her and she was very nasty with me.

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Specializes in LTC,Hospice/palliative care,acute care.

Your MDS staff can be an excellent resource.They tend to be able to see the bigger picture and often cath things we miss..Ours will often make suggestions. I am a big believe in OTC pain meds especially for residents who can not always reliably verbalize their needs but as you said in one of your posts start with plain old Tylenol or ibuprofen and work up from there.I would assess the pattern of the agitation and the use of the PRN's.Any time you are giving a med at close to the same time almost every day someone needs to talk to the physician about scheduling the med routinely.

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